Is it Time to Ask Whether Facility Based Birth is Safe for Low Risk Women and Their Babies?

Despite evidence to the contrary, homebirth remains a controversial choice in maternity care, with strong opinions expressed by consumers, health providers and the media [1]. There is rarely any differentiation between the media reporting of adverse outcomes associated with freebirth or homebirth attended by registered health providers [2]. This can cause health services to resist consumer demand for system integrated homebirth [3]. Research shows that homebirth is as safe as hospital birth for women who are low risk and attended by professional midwives who, in turn, are well networked into a responsive health system [4]. It can be less safe for the baby when women with significant risk factors choose homebirth, or when they give birth without regulated health providers in attendance. When systems are overly restrictive and there is significant variation in guidance on homebirth [5], confusion and conflict inevitably arises amongst and between consumers, policy makers and health providers.

Internationally, rates of homebirth attended by registered health professionals (usually a midwife) range from 13% in the Netherlands [6] to 0.3% in Australia [7]. In some countries, homebirth is deemed illegal and midwives are being prosecuted or jailed for supporting women who make this choice [8].

1. The Hutton et al. 2019 Meta-analysis

Hutton and colleagues have published a meta-analysis that includes 14 studies (1990–2018; n = 500,000) examining outcomes for low risk women planning homebirths in well-resourced countries [9]. The study examines the fetal or neonatal loss for low risk women intending to have either a homebirth or a hospital birth. They also examined outcomes by parity and level of integration into the established birth settings. While there was no statistical difference in perinatal or neonatal mortality, they found that homebirths in well-integrated settings appeared to lead to better perinatal outcomes. This meta-analysis has the added advantage of examining fetal or neonatal loss by parity and level of system integration. In the Birth Place in England study (16,840 homebirths) [10], primiparity was identified as associated with an increased risk for babies born at home. Hutton's meta-analysis now provides reassurance about the safety of homebirth for all low risk women, especially when giving birth in well-integrated settings. The large homebirth sample size in this study (> 500,000) makes detection of differences in rare events more likely. We hope the authors will examine maternal outcomes as well in a future study as we did in our 2018 met-analysis [4]. There is now clear evidence that home birth leads to better outcomes for women compared to hospital birth and it is time this was given more attention.

2. Five Unresolved Questions and/or Concerns

• 1.Maternal and perinatal morbidity associated with place of birth needs to be examined across the reproductive life course and into the future when it comes to maternal and child health [11], [12].
• 2.More research needs to be undertaken into which pregnancy risk factors lead to higher adverse outcomes for babies born at home and which have minimal impact on outcomes.
• 3.Financial and environmental sustainability need to be considered in place of birth discussions and in future research [13].
• 4.Human rights should be a central consideration when it comes to birth place choice and availability. Women are increasingly choosing to have homebirths with significant risk factors or with unregulated birth workers due to previous trauma and limited options of care in the mainstream system [14].
• 5.In developing nations, the concerted effort to encourage all women to birth in facilities has met with varying success. A recent Lancet paper found facility birth does not necessarily convey a survival benefit for women or babies [15]. It is time to reconsider facility based birth as being the only option for safe birth in both the developed and developing world.

3. Conclusion

The evidence to support the safety of homebirth for low risk women attended by professionally educated midwives in well-integrated settings is now very convincing. Perhaps we need to ask: is hospital birth safe or sustainable for low risk women in developed and developing nations? To go down this path, we need to change the embedded narrative, to embrace a definition of safety that women instinctively understand and strive for, including physical, psychological, social, cultural and spiritual safety. It is time we recognized the need for all the professional and maternity consumer groups to unite and agree on the central principles needed to ensure women have safe options when they choose their place of birth, whatever that choice may be.