Planned home and hospital births in South Australia, 1991-2006: differences in outcomes
Robyn Kennare, Marc Keirse, Graeme Tucker and Annabelle Chan, MJA 192(2), 18 January 2009
You’re going to be hearing a lot from the Australian Medical Association about That Homebirth Study In South Australia, so here are a few actual facts to be getting along with in the meantime. Note that the Medical Journal of Australia is the journal of the AMA, not an independent publication.
What you’ll hear from Dr Pesce and his gang:
[...] while the data showed that planned home births had a perinatal mortality rate similar to that of planned hospital births, they had a sevenfold higher risk of intrapartum death and a 27-fold higher risk of death due to intrapartum asphyxia (lack of oxygen during childbirth). [...]
The study also found that low Apgar scores were more frequent among planned home births, and use of specialised neonatal care, as well as rates of postpartum haemorrhage and severe perineal tears, were lower among planned home births, but these differences were not statistically significant.
What the data actually say when you get past the abstract:
The study was a retrospective population-based review of births in South Australia over a 16-year period. There were 297192 planned hospital births in that time, and 1141 planned home births, 782 of which occurred at home.
There was no difference in Apgar scores or neonatal intensive care unit admissions or postpartum haemorrhage. Everyone agrees on that, though the AMA has worded their press release ambiguously, presumably to try to slip some extra spin past to the keeper.
Intervention rates – Caesarean section, instrumental delivery, episiotomy – were substantially higher in the planned hospital birth group. C section rates were tripled, even when adjusted for maternal age, parity, occupation, smoking, plurality, medical and obstetric complications, gestational age, size for gestational age, congenital anomalies, and rurality. The adjusted instrumental delivery rate was also tripled in the planned hospital birth group.
Episiotomy was seven times as likely with a planned hospital birth , even once risk factors were corrected for. 21.7% of women planning hospital births underwent episiotomy; 3.6% of those planning homebirth underwent episiotomy – and the vast majority of those operations occurred in hospital after transfer, with only 0.4% of women actually birthing at home being cut open. Rates of third and fourth degree perineal tears were the same (higher on paper in the planned hospital birth group, but the difference was not statistically significant); this massive increase in hospital episiotomies prevented no tears.
Perinatal deaths were the same: 2440 (8.2/1000) in planned hospital births, and 9 (7.9/1000) in planned home births. Seven of those nine “homebirth” perinatal deaths were in born in hospital. The details of these nine “homebirth” deaths are as follows:
Actual Home Births:
1. One with lethal congenital anomalies;
2. One stillborn, “fresh” stillbirth, time and cause of fetal death unknown.
Hospital Births (originally planned as home births):
3. Post-term induction of labour, infant died from a lethal anomaly;
4. Second twin born in hospital after a delay in transfer due to maternal dissatisfaction with previous hospital experiences (advised to transfer earlier and declined);
5. infant with congenital anomaly and hydrops fetalis;
6. Growth-restricted infant with suspected abnormal karyotype;
7. Unexplained death with umbilical cord entanglement (no autopsy performed);
8. Early prelabour rupture of membranes with neonatal death from pulmonary hypoplasia; mother declined earlier intervention;
9. A “seriously” post-term birth, mother deferred referral; eventual stillbirth in hospital.
There was no such scrutiny of the 2440 perinatal deaths in the planned hospital birth group, except to say that 87 of them were attributed to intrapartum asphyxia (lack of oxygen supply to the fetus in labour). Of the three deaths attributed to intrapartum asphyxia in the planned home birth group, two occurred in hospital. One at home. One.
So there are your big giant scary homebirth deaths. There is your “sevenfold higher risk of intrapartum death” and your “27-fold higher risk of death due to intrapartum asphyxia”. There are the data being presented in support of the legal restriction of reproductive choice. There is the death Pesce is hanging his hat on as AMA-sponsored proof that midwives are dangerous and need to be controlled by obstetricians. One asphyxia-attributed death in the course of an actual home birth, with cause and timing and preventability unknown. One. In sixteen years.
At least Pesce declares his Competing Interests in his accompanying editorial:
I am President of the Australian Medical Association, which is opposed to home birth in Australia.
Yeah. I think we got that.
Full data tables:
Important Note: If this study had shown a substantial increase in fetal deaths with home birth, this would still not be a reason to place legal restrictions on reproductive choice. It would not be a reason to imprison women in hospital by State force, and it would not be a reason to stop women from making informed decisions about our own bodies. They are our bodies, and until a fetus is born, we get the final say in what happens to us.
Update 20 Jan 2010: More from Melissa Sweet at Crikey: Don’t believe the home-birth horror headlines
And more from Croakey: More critique of the homebirth study and its reporting by the media