Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study
BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d7400 (Published 25 November 2011) Cite this as: BMJ 2011;343:d7400
- Birthplace in England Collaborative Group
- Correspondence to: P Brocklehurst, National Perinatal Epidemiology Unit, University of Oxford, Oxford OX3 7LF, UK peter.brocklehurst{at}npeu.ox.ac.uk
- Accepted 11 November 2011
Abstract
Objective To compare perinatal outcomes, maternal outcomes, and interventions in labour by planned place of birth at the start of care in labour for women with low risk pregnancies.
Design Prospective cohort study.
Setting England: all NHS trusts providing intrapartum care at home, all freestanding midwifery units, all alongside midwifery units (midwife led units on a hospital site with an obstetric unit), and a stratified random sample of obstetric units.
Participants 64 538 eligible women with a singleton, term (≥37 weeks gestation), and “booked” pregnancy who gave birth between April 2008 and April 2010. Planned caesarean sections and caesarean sections before the onset of labour and unplanned home births were excluded.
Main outcome measure A composite primary outcome of perinatal mortality and intrapartum related neonatal morbidities (stillbirth after start of care in labour, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus, or fractured clavicle) was used to compare outcomes by planned place of birth at the start of care in labour (at home, freestanding midwifery units, alongside midwifery units, and obstetric units).
Results There were 250 primary outcome events and an overall weighted incidence of 4.3 per 1000 births (95% CI 3.3 to 5.5). Overall, there were no significant differences in the adjusted odds of the primary outcome for any of the non-obstetric unit settings compared with obstetric units. For nulliparous women, the odds of the primary outcome were higher for planned home births (adjusted odds ratio 1.75, 95% CI 1.07 to 2.86) but not for either midwifery unit setting. For multiparous women, there were no significant differences in the incidence of the primary outcome by planned place of birth. Interventions during labour were substantially lower in all non-obstetric unit settings. Transfers from non-obstetric unit settings were more frequent for nulliparous women (36% to 45%) than for multiparous women (9% to 13%).
Conclusions The results support a policy of offering healthy women with low risk pregnancies a choice of birth setting. Women planning birth in a midwifery unit and multiparous women planning birth at home experience fewer interventions than those planning birth in an obstetric unit with no impact on perinatal outcomes. For nulliparous women, planned home births also have fewer interventions but have poorer perinatal outcomes.
Footnotes
The Birthplace in England Collaborative Group includes co-investigators, researchers, project staff, and coordinating midwives who contributed to the research programme. Members are listed in appendix 9 on bmj.com.
Contributors: Members of the writing committee for this paper were Peter Brocklehurst (professor of perinatal epidemiology, National Perinatal Epidemiology Unit (NPEU), University of Oxford; professor of women’s health, Institute for Women’s Health, University College London (UCL)); Pollyanna Hardy (senior trials statistician, NPEU); Jennifer Hollowell (epidemiologist, NPEU); Louise Linsell (senior medical statistician, NPEU); Alison Macfarlane (professor of perinatal health, City University London); Christine McCourt (professor of maternal and child health, City University London); Neil Marlow (professor of neonatal medicine, UCL); Alison Miller (programme director and midwifery lead, Confidential Enquiry into Maternal and Child Health (CEMACH)); Mary Newburn (head of research and information, National Childbirth Trust (NCT)); Stavros Petrou (health economist, NPEU; professor of health economics, University of Warwick); David Puddicombe (researcher, NPEU); Maggie Redshaw (senior research fellow, social scientist, NPEU); Rachel Rowe (researcher, NPEU); Jane Sandall (professor of social science and women’s health, King’s College London); Louise Silverton (deputy general secretary, Royal College of Midwives (RCM)); and Mary Stewart (research midwife, NPEU; senior lecturer, King’s College London, Florence Nightingale School of Nursing and Midwifery).
JH, DP, and PB drafted the manuscript. PB, AM, CM, NM, AM, MN, SP, MR, JS, and LS were involved in the conception and design of the study. PB, JH, DP, RR, and MS were part of the project management team that coordinated data collection for the study. DP, LL, and JH wrote the statistical analysis plan; DP conducted the main analyses; LL conducted the propensity score analysis and provided statistical advice; and PH provided statistical advice. All authors had access to all data sources, contributed to the interpretation of results, commented on the report, and approved the final version for publication. PB is the guarantor.
Funding: This study combines the Evaluation of Maternity Units in England study, funded by the National Institute for Health Research Service Delivery and Organisation (NIHR SDO) programme, and the Birth at Home in England study funded by the Department of Health Policy Research Programme (DH PRP). The funders had no role in the study design, data collection, data analysis, data interpretation, or writing of the report. The views expressed are not necessarily those of the funders.
Competing interest: All authors have completed the Unified Competing Interest form at http://www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work .
Ethical approval: Approval was obtained from the Berkshire Research Ethics Committee (MREC ref 07/H0505/151) and did not require consent to be sought from participants.
Data sharing: No additional data available.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.