Where to give birth, at home or in a hospital? Does it matter? (29 Jan 2013)

>>Good afternoon. Hello and welcome to
this lunch hour lecture. I’m very pleased to
introduce Peter — Professor Peter Brocklehurst,
with his lecture entitled “Where to give birth: at
home or in a hospital? Does it matter?” Thank you very much.>>Thank you. So, that was a bit
loud, wasn’t it? Good afternoon, I’m Peter
Brocklehurst, I’m professor of Women’s Health here at UCL. I’m director of the
Institute of Women’s Health. My background is an
epidemiologist although I’m not going to give lots
of statistics today. I’m going to show you
some tables but hopefully, I’ll explain them
clearly enough. I’m going to talk safety
of planned place of birth. I’m going to stray from
the title a little bit, not just restricted
to home birth but talk about other birth settings
outside the hospital in the UK. You may be aware that this
is still a very controversial and hotly debated issue. Most Sunday newspapers
have something about home birth
in them most weeks. And there’s very little
you can do about home birth without getting a lot
of media attention. So, I felt I will declare my
conflict of interest in this in a moment but I thought I’d
talk about Maternity Care Policy and I’m talking about England, I’m talking about
the UK initially but predominantly,
about England here. I’ll talk about the big
piece of research that we did which is going to form the
bulk of this, about the safety of planed place of birth. And I’ll talk a little about
interpreting the evidence and what we do with
that evidence, and how we handle evidence
in our decision making around place of birth. So, first of all, I need to
declare a conflict of interest. I was specifically asked this
question when I was presenting in the Netherlands so I thought
I better come absolutely clean and say that I was born at
home but it was by accident which sort of gets me out of it. It wasn’t a planned home birth,
my mother was told she wasn’t in labor so she went back home
and promptly have me in the bed. So, I can sort of feel that I’m
on both sides of the fence here and mutual in terms
of the debate about planned place of birth. So, a little bit about
maternity policy in England set by the Department of Health. You may be aware– some of
you may be aware of this, this was the National
Service Framework. The maternity standard which
came out from the Department of Health of England
in 2004 which stated that every woman should be able to choose the most appropriate
place and professional to attend her during
childbirth based on her wishes and cultural preferences and any
medical and protective needs she and her baby may
have and that options for midwife-led care will
include midwife readiness in the community or
on a hospital side. And a care was to be provided in
a framework which enables easy and early transfer
of women and babies who unexpectedly
require specialist care. That was 2004. In 2007, another policy document
came out from the Department of Health on maternity matters
which again stressed this issue about choice access and
continuity about planned place of birth and set out a
national choice guarantee saying that if women wants
to or in discussion with their health professionals
chose different planned places of birth and this would
be provided for them. It would not be long for me to
say that this was on the basis of very little evidence
about the safety of planned place of birth. And I think that although many
government departments talk about evidence-based
policy making, this was one of those instances where
there was policy made without any evidence. So, we have some
information about the safety of planned place of birth
but it was all to do with outcomes from the mother. We have very little information
about how safe or not it was for the baby, partly because
as you might anticipate, the UK like the west–
rest of Western Europe about the safest place to
have a baby in the world. And therefore, anything
going wrong with the baby will be
very, very uncommon. So, studies which we’re able
to look at that were plagued by the fact that they
couldn’t show differences because the numbers
were too small and I’ll come back
to that a bit later. So, we had a huge
lack of evidence about the quantification of
this risk about those outcomes for babies associated
with births planned in different settings. And in this context, I’m going
to talk about in the NHS. And the problem we have
although we have lots of routine data collected in the
NHS, we only have information about actual place of birth,
not planned place of birth. So, we were making
inferences about the safety of different planned
places of birth by only having national
date on actual. So, if I just show
that here, hopelessly, if you’re planning a birth
at home, you are hoping that you have a birth at home. If you’re planning a birth in
hospital, you assume that you that you’re going to have
that birth in the hospital. And if you’re planning birth
in midwifery, you assume or your attention is to
give birth in that midwifery but not surprisingly, there are
transfers and women transfer from home to the hospital and from a midwifery
unit to the hospital. Now, there are very,
very small numbers who transfer different
ways but predominantly, if a problem occurs during
labor or after the birth, then the woman is transferred
to a hospital which is where the baby is delivered. So, you can see that if there’s
a problem with the labor, the baby delivers
in the hospital that is then counted
as a hospital birth. And so, you might anticipate
that babies with problems who– or who have adverse events
or maybe even die will be over represent in the hospitals. So, that’s all the data we have
nationally, where you were born and the outcomes associated
with where you are born, not where you plan
to give birth. So, this was, I think,
recognized finally by policy makers who then
commission some research around trying to
understand the safety of planned place of birth. So, they funded this
large project called “The Birthplace Program”
so the Department of Health and the National Institute for Health Research
jointly funded this program to provide high quality evidence
about processes, outcomes and cost associated with
different settings for birth in the NHS in England and I’m
not going to present all of that but I’m going to
present some of it. The six main components of this
study were– well, first of all, we have to define
terms and definitions because this area is
plagued with different ways of describing the care that
women received in labor. So, often we talk
about midwife-led or consultant-led care
but that’s not a place, that’s just sort of
philosophy of care, that’s who– who’s the primary caregiver. It doesn’t describe that place that one will receive
care during labor. We do a mapping study of England
to find out what was provided because we don’t know. Interesting, the NHS doesn’t
know what services it provides on a national level so good
researchers have to find out by writing to everybody and
finding out what they provide. Predominantly, I’m going to talk about this national perspective
cohorts that a planned place of birth will so alongside that in a large cost
effectiveness analysis. And we did some qualitative
studies and case studies to look at aspects of how
services provide choice around planned place of birth and how they managed
the workforce to be able to provide a choice
which is responsive to women’s wishes and requests. And then, a study of antepartum
related mortality using national data. So, just a little bit, first
of all, the four definitions, the four places of
birth, an obstetric unit which is a hospital, we can sometimes call
the consultant-led unit but for this purpose, this was
a hospital which was equipped with midwives, obstetricians,
neonatologist and anesthetists. Home, fairly clear although
there was lots of debate about what is home and if
a woman plans to deliver in her mother’s home is that
home, I think we decided that it was, it was
fairly straightforward. The two types of midwifery
units were more challenging. We came up with a
freestyle midwifery unit. This is a midwifery unit which
is geographically separate from an obstetric unit. So, this could be some
rooms above the shops on the high street or it could
be a unit within a hospital but that hospital does not that
have an obstetric unit in it. So some smaller hospitals where
the obstetric units is closed and the obstetricians
have moved out, that’s become a midwifery unit. So, there are no
obstetricians on sight, there were no obstetric
anesthetists, there were no neonatologists
on sight. By contrast and alongside
midwifery unit is a midwifery unit run entirely by midwives
which is geographically on the same side as
on obstetric unit. That’s the most variable
type, that may be two rooms in the labor ward which
are designated alongside a midwifery unit. Or it maybe a completely
separate structure within the hospital
which is very different, which as has completely
different staffing [inaudible] and so forth. So, those were the four settings that I’m going to
talk about today. So, we did this mapping study
which is very interesting, you’re not supposed to spot
the towns but we looked at those centers that provided
free stand midwifery unit alongside midwifery units
and obstetric units. And you can see there
were parts of the country where there is very
little overlap. So, this was in 2008
and so at that time, this national choice
guarantee couldn’t be delivered because many parts of country
didn’t have a midwifery unit. So, the only real choice was
between home and hospital and that’s based on
the physical location. I mean there are other barriers where we’ve been accessing
planned places of birth but if you didn’t
have a midwifery unit, then you clearly couldn’t plan
to deliver one unless you have to travel a long way
when you went into labor which most women are
not prepared to do. So, coming on to the perspective
study, the cohort study, the primary objective of this
study was to compare intrapartum to during birth and
early neonatal mortality. Early neonatal includes the
first seven days after birth and morbidity whether
the baby has died or whether they were very sick. By planned place of birth at
the start of care and labor, so women can choose
to have a home birth when they first book
for 12 weeks. But clearly, things happen
along the way in pregnancy that may make it not appropriate
for that woman to choose to give birth at home by
the time she gets the stage where she goes into labor. We were interested in the safety
of planning birth and labor at the– the planned
place of birth and labor when you were actually in
that planned place of birth and were receiving some
care from a midwife. Because of that, we felt it
would be the point where you– women would make decisions
about whether planning birth if they knew the
safety of that process. And this was in women
just to be at low risk of complications according
to current national guidance. And very fortunately, notice
the National Institute for Clinical Excellence
produce a guideline on intrapartum care a couple of years before we
started collecting data which had a whole
checklist of conditions which it would be recommended that women don’t consider birth
outside an obstetric unit. So, units were already used
to use to using that checklist which was very helpful, it
gave us a way of deciding who was low and he
was high risk. We knew because we’ve got
very good data on mortality that we could never share
with difference in death. We knew that the risk
of a baby dying at term without any complications
was so very, very low we wouldn’t be able
to share a difference in death. So, we have to think of an
outcome which included death but which included other things,
other outcomes for the baby which were related or could
be related to the quality of care received during labor. And that’s a– that statement
[inaudible] weeks of debates in discussion about how
we came up with this list. But these outcomes, the neonatal
outcomes which are associated with lack of oxygen
during birth or trauma. But clearly, a fractured
clavicle which is the collarbone and I don’t know how many of you
have fractured your clavicle. If you have, you’ll know that
there’s absolutely no treatment, you just have to go take
pain killer and go away and that’s exactly
the same in babies. So, a fractured clavicle is not
quite the same as a stillbirth in labor in terms
of its importance. So, we knew that we were putting
together things which were not of equal importance but
the anticipation was that if there was a problem
with a plan setting for birth or the quality of care in that
setting, those outcomes would go in a similar direction and
I’ll show you later what we actually found. We didn’t know, we have no data
to estimate what the proportion of these outcomes would be when we put this
composite act together. But basically, any baby who
had any of these was count to just having an
adverse outcome for the sake of the study. And we aim to collect
data from every NHS just in England providing
home birth services; every free stand midwifery unit,
every alongside midwifery unit and a stratified random
sample of 37 obstetric units. And the stratification fact is
one size of the unit and also, geography, the North
and South of England. I didn’t realize there was a
line but geography has agreed, it divides the North and
South of England but there is. So, we took off what
stratified sample on either side of that line and
looked to its size. We knew we needed
this study to be big. We knew we needed to collect
data from at least 57,000 women so that we’d have about 47, 000 who would be
classified as low risk. That doesn’t– that’s not
the proportion of low risk to high risk in the entire
population of women delivering in this country because we
excluded women having an elective caesarian section because they don’t
have any labor, those being induced, et cetera. So, we knew the systems we
set-up, we aim to collect at least 57,000 women and
anticipate that about 47, 000 of those women would be
in this low risk category. This meant we had a
data collection booklet which was completed, which
had to follow the woman from when she came in in labor until she was five
days post delivery. And midwives throughout the
country filled in thousands of thousands of booklets about
the data and sent them back to us because these data
are not available routinely. This is the only slide about
analysis and we adjusted for the main confounders
in this co-study. So, factors such as maternal
age, ethnicity, understanding of English, partner
status, body mass index, area deprivation
scores are a proxy for socio-economic
status based on post code. And para to the number of
births you’ve had and gestation, so the actual gestational age for the baby, the
number of weeks. Now, we only need the term
babies and that’s in 37 weeks. So, the difference between 37 and 42 weeks could make a
difference so we included adjust for gestation at birth. Because the large numbers
of comparisons we did, we use 95 percent composite
and 99 percent complete since secondary outcomes and
you’ll those there on the table that I’m going to present. And we also plan to
look at the difference between first time
mothers and second or subsequent time mothers because first time
mothers have a higher risk of adverse outcomes at
birth and on their baby. And we did this nice technical
thing where we collected data for difference durations from
different settings so we have to wait for the duration
of data collection to take account of that. We were largely successful,
we did manage to collect data from almost all trusts,
97 percent of trusts in England participated,
and 84 percent of AMUs. That seems a bit low but that
was because during the time that that study was going on, people are opening new
alongside midwifery units. And once we’d started
data collection, we didn’t get any new
alongside midwifery units in. By the time we’d finish, there
were quite of few new ones. We got almost all free standing
midwifery units and we had to represent samples
of 36 obstetric units. You may remember that
the original one was 37, one was so completely
and awfully helpless that we only got data returned for four women every
six month period. This is a hospital that had
over 5,000 births a year so a slight understatement we
thought so we end up having to exclude that center. We wanted to collect
data on about 8 — at least 85 percent of eligible
women, as in low risk women who were in labor
in those settings. This proved to be phenomenally
difficult because no hospital or free stand midwifery unit
could tell us how many low risk women went into labor. So, we have to set of special
systems to try and monitor this. So, we think we got a very high
proportion but the estimation of the denominator or the
number of high risk women– low risk women going in to labor in the hospital was
extremely difficult to get. We did a huge amount
of data chasing and then ended it was less than
four percent of missing data which the dataset of this
size was quite something. The other thing I’ve
not mentioned is that we could not
risk selection bias. We could not risk parts of the
population agreeing to take part and that has not
because we needed to know what the impact
in the country was. So, these data were
collected without any consent so the women didn’t give consent
and the only way you can do that is if you have
no identifiers. So, we didn’t have name,
address, hospital number, NHS number, we have
none of that. So, data chasing was extremely
challenging as you can imagine because we had to get to
the hospitals and say, “You haven’t filled
this form out properly for woman number 59682.” And they’d have to try and
find back to that woman’s notes to collect the information. So, in the end, we had collected
data from nearly 80, 000 women and ended it with 64,
538 low risk women. That was a lot of boxes of data
sitting around in the office. And ended up with about 20 000
low risk women having a birth in obstetric unit, 17 000
home births, 11 000 death of new births and
17 000 AMU births. Our original sample size
calculation suggested that we leave it to 20,000
daily births, 17,000 home births and we estimated that we might
get as many as 5,000 in each of the types in midwifery
units and we’ve have to put them together to
have any statistical power. But because there was a
fantastic participation, we had enough numbers
to be able to look at the four groups separately. So, that’s what I’m going
to be able to present. So, not surprisingly,
there were differences in maternal characteristics
that women planning birth in different settings
were different. As an epidemiologist,
so it’s useful to see that what you expect
to see is being seen that so you’re getting a good
representative population. But at the same time, it’s
always disappointing sometimes to see your social
prejudices confirmed. So, women planning a place– plan to give birth at
home will much more likely to white middle class, a
bit heavier, a bit older, than women planning
birth in hospitals. So, the big difference that was in women planning their
first births at home, for only 20 percent– 27
percent are women planning birth at home were first time mothers
versus 46 percent in FMUs, 50 percent in AMUs and 54
percent in obstetric units. So, all the analysis that
I’m showing are adjusted for this difference in parity because this is absolutely
crucial. The other thing we found–
this is a complicated table but the message is
on the bottom line. The last time a woman
is seen by a midwife in her antenatal care
before she gets into labor, there’s an assessment
of her risk. If that woman is still
low risk at that time, she’s considered to be low-risk. When the woman is
first seen in labor, another assessment
is done and clearly, new conditions can picked up at
that stage that weren’t there at her last antenatal
clinic appointment. So we call these
complicating conditions at the onset of care and labor. And we found rather
surprisingly a difference. We found more in
the obstetric units than in the other settings. And I think what we now
think, fairly convincing me, that was due to the way
that we selected a cohort because we selected them
at onset of care and labor. Those women who rupture their
membranes at home maybe told to stay at home waiting
for contractions to start. When they get to a certain
duration of membrane rupture without contraction starting,
they’ll be told often over the phones to
come into the hospital so they haven’t had
any face to face care in their planned place of birth. So suddenly, that planned place of birth will become
hospital if that makes sense. So clearly, if we included
women with these risk factors and high blood pressure, and
proteinuria, and bleeding and so on and so forth, are all risk
factors for an adverse outcome. Then if we just included all
women, we prejudice our analysis against obstetric units
because that includes more women with any of these risk factors. So if the analysis
that I’m going to show you show the differences
between the groups for all women and then all women without any
of these complicating conditions at labor onset and so
the truth lies somewhere between the two, probably. I’m just so tired [phonetic]. So, we have 250 primary
outcome events in 64 and a half thousand women. So this is the challenge we have
of doing this sort of research that child birth is
safe in this country, 4.3 adverse events
per thousand births. And if you look at
those broken down, this is the list
of the outcomes. You can see that as we
anticipated, very few, very few babies died so
these are still births after the onset of
care and labor. So the babies were born
and care started in labor but died during the
labor, so there are 14 out of 64 and a half thousand. So in total there was only
about 13 percent of all of those primary outcomes
which were still birth or early neonatal death. But you can also see that most of it was neonatal
encephalopathy. Now, neonatal– and
meconium aspiration syndrome. Neonatal encephalopathy is where you get disordered
brain function. Brain’s function is
depressed because of lack of oxygen during the birth and meconium aspiration is also
largely felt in those babies that are not very post mature
to be because of lack of oxygen, the baby opens their bowels in
the uterus, releases meconium and then gasping in utero
as a consequence of hypoxia, means that the baby inhales
poo into their lungs. Charming I know but often
mild, sometimes very severe. These two outcomes
made up 70 percent of the whole family outcome. So in effect, when you’re
looking at the results, you need to remember that a lot
of this is these two outcomes. Now neonatal encephalopathy
can very mild with no long-term
sequelae to severe. Once you get to severe,
about 50 percent mortality and of the survivors,
about 50 percent will have cerebral palsy. But, the spectrum of mild,
moderate, severe is probably about a third, a third, a third. So even with 114 cases,
the numbers of long– babies with long-term
consequences is probably very small. But of course, without
identifiers, we couldn’t do followup. So, here are some results
and I don’t have a pointer. So, in the top half
of the table, you’ll see all low-risk women. Now that’s all 64
and a half thousand. So you can see the four planned
places of birth down the side. We’ve used obstetric units
as the reference group because it was the
largest group not because that’s considered
the standard but it’s the largest say,
physically more powerful. And we present the numbers
per thousand of the events. Those are weighted
numbers per thousand with their confidence interval and then we presented
the odds ratio. So we’ve compared home in
that top half of the table with obstetric units and
got an alteration of 1.16 with 95 percent of confidence
interval, 1.76 to 1.77. So no statistically significant
excess of the primary outcome in women planning
birth at home compared as women planning birth
in an obstetric unit. Yeah. And then FMU
compared with obstetric unit and AMU compared
with obstetric unit. So you can see on that right
side ’cause those confidence intervals include one, there
is no statistically significant increased risk of adverse
primary outcome associated with different planned
places of birth. In the bottom half of the
table, we have repeated that analysis excluding women with complicating
conditions at labor onset. And here, you can begin to see that there is a statistically
significant difference which suggests that there
is an increased risk of the adverse outcome,
primary outcome, associated with women planning
birth at home, this one here, where the confidence
interval is 1.01 to 2.52. It’s only just statistically
significant. But for FMU and AMU
compared with OUs, there was no apparent
increase in risk. That’s all women. If we separate these
women by parity so nulliparous women are
women having their first baby and multiparous having their
second or subsequent baby. You can see something
beginning to emerge. So here, the association with
an adverse primary outcome if you’re planning
birth at home compared than those obstetric units,
now had an odds ratio of 1.75 and the confidence
interval was 1.0 or 72.86. So again, a suggestion
in first time mothers that there was an
increased risk associated with planning birth at home. But there could be
numbers per thousand, I’m going to note these
odds ratios are adjusted for the factors but the
event rate is still 5.3, 9.3 per thousand. The event rate is still low but
there is a significant access. For women having their
second or subsequent baby, there was no difference, no statistically
significant difference in where you plan to get birth. But of course, the event
rates as you might anticipate, the number of adverse events
for multiparous women are lower. If you repeat that and
take out all the women without complicating
conditions at labor onset, that’s association
with planning– first time mothers planning
birth at home becomes stronger. So there, the odds ratio
is 2.8 and the lower limit for the confidence interval
is now well away from 1, it’s 1.59 so a stronger
association. And the absolute event
rates, 3.5 versus 9.5. For multiparous women,
again, no difference and women planning
birth in FMUs and AMUs, no statistically significant
excess of risk associated to planning birth
in those settings. So for multiparous women,
women having their second or subsequent baby, and
remember, this is low-risk women so to be a low-risk woman
having your second baby, you have to have a normal
birth the first time around. So perhaps not surprisingly, that’s pretty good indication
you can have a normal straightforward birth
the second time around. So for multiparous low-risk
women, there were no differences in adverse perinatal outcomes in
treatment settings but the risk of an adverse perinatal
outcome appears to be higher for first time women, mothers
who plan to give birth at home. Now, we did look at a variety of
other outcomes, I’m just going to present a couple of them, particularly interventions
during labor and birth. So this is cesarean
section during labor. And as you can see, these
aren’t numbers per thousand, these are percents now. So those are much higher risk
of having a cesarean section if you plan to give birth in
an obstetric unit compared with all other settings, very, very highly statistically
significant difference for both nulliparous women
and multiparous women. In terms of forceps
delivery, exactly the same, much higher risk of having a
forceps delivery if you plan to give birth in an
obstetric unit compared with settings outside. And there is this definition of normal birth, I
almost forget this. Normal birth is without
induction, without epidural, without general anesthetics,
without forceps or ventouse, without the cesarean section
and without an episiotomy. So if you classify women
according to normal birth, you can see for both
the first time mothers and second time mothers planning
a birth outside hospital increased your chance of
having a normal birth. The other important information that we didn’t know beforehand
was how many women transferred during labor. In here, 45 percent of women
transferred from home during or shortly after the birth, about 80 percent
transferred before the birth. Now that– you know,
that– when people see that, they think that’s a blue
flashing light and [inaudible] down the road for 75
percent of those 85 percent who transfer before
birth, it was for epidural, failure of the labor to
progress quickly enough. So, it was a slow labor but there’s no concern
about the baby. That still left about 20 percent
where there were concerns about the baby but
this is not inevitable. And of course, well they
basically will be transferred by ambulance. And if you can’t give birth on
an obstetric unit versus home, there is 100 percent
transfer rate in labor. You got to get to the hospital. And so, higher than we
anticipated certainly, in terms of transfer. So, our conclusions of this
study were that there was lots of [inaudible] policy of
offering healthy women with lowest pregnancy a
choice of birth setting. And I’ll come back to that later because that’s been the most
controversial thing we’ve said. And women planning
birth in midwifery units and multiparous women
planning birth at home experience
fewer interventions than those planning birth in an
obstetric unit with no impact on perinatal outcomes. And for first time mothers, planned home births also
have fewer interventions but have poorer perinatal
outcomes. So, that’s the sort of dryness
of their study but I just wanted to talk about what
happened subsequently. So, with those couple of BMJ
papers, the first one which was on November 2011 on the left which was presenting the
clinical data I’ve presented to you and the one on the right
was the cost effectiveness which also caused a [inaudible]
publicity around the safety, nothing has to do with the cost
effectiveness but has all to do with the safety planned
home birth again. There was lots of press. We managed. We had a very active process
of managing the press release around it and most of the
press were fairly sensible in their reporting and
were fairly accurate. We did this to the Science
Media Centre which all of you know is based on
Wellcome Trust, very experienced at communicating scientific
results to an invited audience of science correspondence
and not surprising, there were a couple of
exceptions to the measured and accurate reporting
of the data. I was called several times
on the day before that. Newspapers came out
wanting me to confirm that these headlines
were accurate and I repeatedly said no, you
know, they’re not accurate. They’re completely fictitious. And they said well, we’re
going to go with them anyway. And so, we felt this was an
important research question. I just want to touch
on a couple of things. We’d love to have done a
randomized control trial. Randomized control
trials are the best way to evaluate the effects
of an intervention where you randomize
participants to receive one hour of the intervention
versus the other. There’s no way we could have
done a randomized control trial of planned place of birth
at onset of care and labor. You saw the contracting,
we’ll just randomize you. We have the stay at home,
we come into the hospital or get to an FMU unit. Somebody once tried to do
a randomized control trial of home birth versus hospital
birth, and over a course of two years of had
managed to recruit 11 women which I think was
a sterling effort. So, we knew that we couldn’t
do their goal standard to evaluate this
intervention which meant we have to very careful about
the design of the study to do everything we possibly
could to try and get that, the answer that we
hope was there. But no observation
[inaudible] are perfect. I’ve been quite careful
about talking about the– you know, these results
appear to suggest because there may be
other explanations for way we’re finding
these, the findings we did. And it’s been interesting. It’s been a bit of a, the
most controversial piece of research I’ve ever done. It is still being widely
criticized by people who don’t like the results. We knew there’d be
some criticism. Interestingly, some
consumer groups, some women’s groups are very
critical that the results of this will force women
to give birth at home when they don’t want to. It’s probably worth reminding
those of you who don’t know that planning birth
at home is still a bit of a minority activity
in this country. Only about 3 percent of women
in the UK plan to give birth at home and probably about
5 percent overall plan to give birth at the hospital. So, the idea that suddenly
we’d be forcing four 40 percent of women to give
birth at home I think, would be stretching
our services a little and also our credibility. There has been quite a lot of
lobbying of the NHS about this and professional bodies,
I’ll show you in a minute, and an international response. But it has led us to think
how to implement this finding into practice which I’ll
also just come back to. I suppose one of the
most disappointing things that the Royal College
of Obstetricians and Gynecologists,
their president. Sorry, my president, I am
a fellow of the College of Obstetricians
and Gynecologists who was a gyne-oncologist,
which means he deals with women’s cancer,
on his blog stated that the RCOG favors birth and
collocated [inaudible] units, well often standalone
units since these women– means women have better
access to consultant care. And what I didn’t show is
this sentence was preceded by as the birthplace study shows
which, of course, you know, assuming results in the
birthplace study did not show that fees [inaudible] units
were to increase risk. And very recently, January, this
month, in the American College of Obstetricians and
Gynecologists, a very, very influential
obstetrician and ethicist, Frank Chervenak produced this
paper called planned home birth, the professional
responsibility response. Obstetricians and other
concerned physicians should understand, identify and
correct the root causes of the recrudescence of home
birth, respond to expressions of interesting planned
home birth by women with evidence-based
recommendations against it, refused to participate
in planned home birth. Obstetrician should not
participate in or refer to randomized controlled
trials of planned birth home versus planned hospital birth. This was based on a lecture he
gave in Paris towards the end of 2012 where interestingly,
I came into some very, very personal criticism for
even daring to do the study, to even question where the
planned home birth could be considered safe. So, the idea that one
should even do a study like this was considered
anathema to this obstetrician
ethicist in the US. And fortunately,
we’re not in the US and I realized I obviously must
have been doing something right to cause this degree of upset. And so, where to give birth,
at home or in hospital? Does it matter? I can’t tell you
where to give birth. All this has done is
provide some more evidence. The issue about where you
plan to give birth and safety. Safety isn’t a yes or no answer. Safety depends on what
your views and belief are. What you’re prepared to accept. Some of you will go skiing. Some of you will do even
more dangerous sports which put your life and your
family’s happiness at risk. But we make those choices. Women make those choices when they’re pregnant
about what to do. What screening to accept. What to eat. What to drink. Whether to smoke. They make all sorts of
choices about themselves because this is about
themselves. They make choices about where
they plan to give birth. I can’t tell you where you
should plan to give birth. What I can now do is give you
some evidence and some data which allows you to make
a more informed decision than where we were a
couple of years ago when we didn’t have
this information. But ultimately, it is up to
women to decide where they want to give birth based on the
information they’ve got and the ability of the
servicers to provide care for them in their settings. Does it matter? Of course, it matters. There isn’t a dinner
party I didn’t go to where I don’t
hear birth story. The most recent was
from a 95-year-old woman who told me the story of
her first birth in detail. Not graphic detail but, you
know, this is a major event for women and their
families, having a baby and people can remember this. These choices matter not just
in terms the physical outcome of that event, whether you
have a caesarian section, whether the baby has a fractured
clavicle but the emotional and psychological
consequences that play from that are really important. So, yes, it does matter but I can’t tell you
whether it’s safe or not. What I can tell you is you
have to make that decision about whether you feel for
you, with your set of values of beliefs, these different
settings are safe for you. So, finally, very finally, how
are the results being used? I wish I could tell you. Are lots of women planning
to give birth at home, I’ve no idea ’cause we
didn’t collect the data, still don’t collect the data
in the UK although, to be fair, this week, I have now
started formal discussions with the Department of Health about how they can
collect the data so that we can hopefully
do this study again. This study, we estimated
in total cost over 12 million pounds to do. And the idea that we
could never do it again, even though the results are
likely to change practice, seemed almost a negligent waste
of resources because we need to be able to monitor
what’s happening. If more women choose to
give birth outside hospital, are we going to get
the same results? We need to know. We need routine data
so we can look at that impact on mortality. There were 760,000
births a year in the UK. Two or three years, if we
can classify low-risk women and planned place of
birth at labor onset, we’ll know where the
planning based at home leads to a higher risk of babies dying
as a consequence of that choice. They’ll still be very, very,
very, very small numbers but at least, we’ll be able
to look for differences. So, we may, it’s the
first time I’ve been able to say this while
talking about birthplace. We may be able to
do this routinely in the future on
a rolling basis. So, first of all, we
must thank everybody. And thank you very much. [ Applause ]

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