Study shows higher rates of neonatal mortality with planned home birthsBMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c3551 (Published 02 July 2010) Cite this as: BMJ 2010;341:c3551
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Mayor reports (News, 2 July 2010) a meta-analysis(1) has linked
planned home births with a twofold higher rate of neonatal mortality
compared with hospital births. Closer inspection calls this finding into
1. The quality of studies in any meta-analysis is critical but no
assessment was reported. Studies were observational and many were not
matched adequately for confounding risk factors.
2. Misclassification errors are also a concern. Neonatal mortality
data came mainly from small studies, with most weight from one larger
retrospective study on birth registry data for Washington State(2). Here,
some unplanned home births, more likely to have poor outcomes, may have
been misclassified as planned home births as birth certificates did not
distinguish between these.
3. Differences arising from relatively small numbers should be
interpreted with caution as lack of statistical power can give rise to
systematic errors. Differences in neonatal mortality were based on 32
deaths in 16,500 planned home births and 32 in 33,302 hospital births(1).
This lacks the power recommended by the GRADE quality assessment tool(3)
(being phased in by NICE) which suggests 200-400 events are needed. In
contrast, perinatal mortality was based on 229 deaths amongst 331,666
planned home births and 140 among 175,443 hospital births, thus no
Unfortunately Wax and BMJ chose to focus on the neonatal mortality
findings. Outcomes given less prominence were no significant differences
in perinatal mortality, and in neonatal deaths with planned home births
attended by certified midwives. Mothers planning a home birth were
significantly less likely to have a preterm or low birthweight baby. All
the outcomes should be viewed within the overall poor quality of the meta-
analysis, however. Professional journals have a responsibility to report
the findings of studies in a balanced way, highlighting methodological
1. Wax JR et al. Maternal and newborn outcomes in planned home birth
vs planned hospital births: a metaanalysis. American Journal of Obstetrics
and Gynecology 2010;203:x.ex-x.ex.
2. Pang JWY et al. Outcomes of planned home births in Washington
State: 1989-1996. Obstetrics and Gynecology 2002;100:253-9.
3. GRADE Working Group. Grading quality of evidence and strength of
recommendations. BMJ 2004;328:1490-1494.
Competing interests: No competing interests
The findings in this study, that planned home birth increases a
baby's (albeit very small) risk of dying compared with a hospital birth
plan, has received a great deal of media attention, and numerous medical
professionals and birth groups have spoken out to defend home birth
legitimacy and advocacy in the UK.
Surely then, particularly in light of studies such as this one
published in Canada last year, 'Caesarean section on maternal request:
risks and benefits in healthy nulliparous women and their infants' by LS
Dahlgren et al, which found that an elective pre-labour caesarean delivery
in a nulliparous woman at full term "decreased the risk of life-
threatening neonatal morbidity compared with spontaneous labour with
anticipated vaginal delivery", it is time to review current attitudes
towards caesarean delivery on maternal request.
This Canadian study included almost 40,000 births, and even though
the comparison used breech presentation as a healthy elective caesarean
surrogate (which is arguably a more complicated delivery than a cephalic-
presenting fetus) to compare with the healthy onset spontaneous labour
group, the caesarean group's babies still had better outcomes.
Similarly an American study, also based on intent to deliver and not
just actual delivery, 'Maternal Outcomes Associated with Planned Vaginal
Versus Planned Primary Cesarean Delivery’ by EJ Geller et al, found that
planned caesarean delivery had less chorioamnionitis (2.2% versus 17.2%),
postpartum hemorrhage (1.1% versus 6.0%), uterine atony (0.6% versus
6.4%), and prolonged rupture of membranes (2.2% versus 17.5%) for the
mother but a longer hospital stay (3.2 versus 2.6 days). There were no
differences in transfusion rates.
If a healthy woman's maternal request to give birth at home is
acceptable, then given the (two examples of) improved outcomes cited
above, her request for a prophylactic caesarean delivery at 39+ weeks
should be acceptable too.
Competing interests: No competing interests