Janssen and colleagues1 present data on a variety of adverse events and outcomes associated with childbirth. Although they compare home births attended by midwives, hospital births attended by midwives and hospital births attended by physicians, their primary focus is on the outcomes in births assisted by midwives. Those delivering at home would be expected to be at lower risk of medical interventions than those delivering in hospital. However, it might have helped to understand the results had they used a composite score of outcomes. The outcomes, taken from their data, are in my view important (see Table 1).
Table 1
Comparing home delivery to hospital delivery attended by midwives (thus evaluating site of delivery and possibly selection criteria) eliminates the issue of different caregivers. A composite outcome variable of the need for obstetrical shock, neonatal ventilation and perinatal deaths shows a significant difference (1.16% vs. 0.18%, the Fisher exact 1-tailed p value = 0.03) between home and hospital deliveries. I recognize that this analysis selects outcomes post factum; nonetheless, these are important outcomes.
Hospital deliveries and births are safer, and this is why there is a selection process for assigning patients to home birth. The issue is how small the risk is to women delivering at home. Relevant risks of home birth and the risks of being transferred in labour (16.5%) need to be discussed and understood. Extensive information is available that shows lower rates of analgesia, monitoring and cesarean section at home, but this is to be expected of home deliveries.
Janssen and colleagues showed that the risks of home birth are quite low but possibly significant. An analogy may be that keeping patients in hospital for the full 9 months of pregnancy would be the safest thing to do. However, neither patients nor caregivers would consider the risks worthy of such a drastic measure. The still unanswered question is if home delivery carries a similar low risk in selected patients.
Dan Farine Professor of Obstetrics and Gynecology University of Toronto Toronto, Ont.
Reference
- 1.Janssen PA, Lee SK, Ryan EM, Etches DJ, Farquharson DF, Peacock D, et al. Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. CMAJ 2002;166(3):315-23 [PMC free article] [PubMed]