Birth is an event of great importance in family life Although
pregnancy and delivery are, under healthy conditions, normal social and
physiological processes, childbirth has become hospital centred in most
industrialised countries. The assumption is that hospital based
deliveries are safer for mother and child. Yet the Cumberlege report
sees home birth as a real option,(1) and the wishes of women to have
home births must be viewed in that light. A randomised controlled trial
would help to resolve the controversy over the relative safety of home
and hospital birth,(2) but conditions for a "fair" trial are difficult
to achieve. Such a study would require large numbers because of the low
frequency of adverse events, and the necessary environment of
experienced home deliveries has virtually disappeared. In the absence of
a randomised trial, observational studies are welcome, and this week's
BMJ carries four papers reporting on the safety, professional support,
and patient satisfaction of home births.(3)(6)
The first of these, from the Northern region's perinatal mortality
survey, reports 134 perinatal losses in 3466 births outside the
hospital,(3) about four times the number of losses in hospital births.
At first sight this seems to endorse the view that hospital is the
safest place to deliver. But 97% (131) of these perinatal deaths at home
were recorded in women who were actually booked for a hospital delivery
or had no prearranged plan for delivery. The perinatal outcome in
planned home births was better than for all women giving birth in the
region - a result in line with Swiss and Dutch findings also reported in
this week's BMJ.(4)(5) This supports the safety of home birth provided
it is offered to women at low risk of obstetric complications. Most
perinatal deaths occur in women with health or obstetric problems that
existed before or developed during pregnancy, and these women can be
identified and referred before the onset of labour.
Assessing a woman's risk and providing appropriate care is bread and
butter to general practitioners. The key to the consistently good
results of home births in Dutch primary care settings(5)(7) is
meticulous selection of women at low risk of obstetric complications.
This results in equal or better obstetric outcome compared with hospital
birth, and fewer interventions, for a large number of women in the
community.(7) Risk assessment is based on a protocol for referral(8)
(the Kloostermanlist, named after its designer), which is used routinely
in the community(7) and serves as the national reference of good
practice.
Promotion of home birth is not restricted to Europe: there have also
been initiatives in the United States and Australia.(9)(10) In our view
such initiatives should be integrated in comprehensive primary care, as
the roles of general practitioner and midwife are not limited to the
place of birth they cover the whole of pregnancy, delivery, and neonatal
care.(7) However, some primary care practitioners may need to be
persuaded to provide the option to their patients: the survey from
Britain's Northern region found that general practitioners, and to a
lesser extent midwives, often had reservations about the safety of home
birth and tended to discourage it.
General practitioners and midwives have responsibility for creating
the right circumstances for safe and satisfying home births. This means,
firstly, selecting women who are not at high risk of complications;
secondly, establishing an infrastructure for safe obstetric
interventions - such as providing elevated beds and ensuring adequate
hygiene; thirdly, providing support during labour and in the days after
delivery, for which maternity home care assistants are important; and,
finally, allowing access to hospital facilities - this is vital, as
serious complications during labour can never be excluded. Transfer
during labour can be safe,(6)(7) but safety must not be assumed, and the
availability of obstetric care must be established beforehand.
Coordinated planning between primary care practitioners and
obstetricians is crucial, and much will depend on local conditions:
hospital facilities are usually available within 15 minutes in densely
populated Holland, but transfer will take much longer in remote areas of
North America and Australia. Such variation underlines the importance of
comprehensive care for pregnant women. This should focus on patients'
individual needs, based on a proper assessment of risk and local
circumstances, rather than simply accommodating patients' demands.
NACHIEL P SPRINGER
Professor
Department of General Practice,
Leiden University,
PO Box
2088,
230 CB, Leiden,
Netherlands
CHRIS VAN WEEL
Professor
Department of General Practice and Social Medicine,
University of
Nijmegen,
P0 Box 9101,
6500 HB Nijmegen,
Netherlands
References
1 Department of Health Expert Maternity Group. Changing
childbirth. 1. The Cumberlege report. London: HMSO, 1993.
2 Education and debate. Should there be a trial of home versus
hospital delivery in the United Kingdom. BMJ
1996;312:753-7.
3 The Northern
Region's Perinatal Mortality Survey Coordinating Group. Perinatal loss
in planned and unplanned home birth. BMJ
1996;313:1306-9.
4 Ackermann-Liebrich U, Voegli T, Guenther-Witt K, Kunz I, Zullig M,
Schindler C, et al. Home versus hospital
deliveries: a prospective study on matched pairs. BMJ
1996;313:1313-8.
5 Wiegers T A, Keirse M J N C, van der Zee J, Berghs G A H. Outcome of planned home
and planned hospital births in low risk pregnancies in the Netherlands.
BMJ 1996;313:1309-13.
6 Davies J, Hey E, Reid W, Young G. Prospective regional study
of planned home birth. BMJ 1996;313:1302-5.
7 Springer M E Quality of obstetric performance of general
practitioners [Kwaliteit van het verloskundig handelen van huisartsen]
[thesis]. Leiden: Leiden University, 1991. (English summary.)
8 Ziekenfondsraad. Verloskundige indicatielijst 1987: final report
of the working party to adjust the Klootermanlist (WBK). Amstelveen:
Ziekenfondstaad, 1987.
9 Acheson L S, Harris S E, Zyzanski S J. Patient selection and
outcomes for out-of-hospital births in one family practice. J Fam
Pract 1990;31:128-36.
10 Cunningham D J. Experiences of Australian mothers who gave birth
either at home, or in hospital labour wards. Soc Sci Med
1993;36:473-83.