Outcomes of planned home births with certified professional midwives:
http://www.100md.com
《英国医生杂志》
1 Surveillance and Risk Assessment Division, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, PL 6702A, Ottawa, ON, Canada K1A OK9, 2 Safe Motherhood/Newborn Initiative, International Federation of Gynecology and Obstetrics, Ottawa, Canada
Correspondence to: K C Johnson ken_lcdc_johnson@phac-aspc.gc.ca
Objective To evaluate the safety of home births in North America involving direct entry midwives, in jurisdictions where the practice is not well integrated into the healthcare system.
Design Prospective cohort study.
Setting All home births involving certified professional midwives across the United States (98% of cohort) and Canada, 2000.
Participants All 5418 women expecting to deliver in 2000 supported by midwives with a common certification and who planned to deliver at home when labour began.
Main outcome measures Intrapartum and neonatal mortality, perinatal transfer to hospital care, medical intervention during labour, breast feeding, and maternal satisfaction.
Results 655 (12.1%) women who intended to deliver at home when labour began were transferred to hospital. Medical intervention rates included epidural (4.7%), episiotomy (2.1%), forceps (1.0%), vacuum extraction (0.6%), and caesarean section (3.7%); these rates were substantially lower than for low risk US women having hospital births. The intrapartum and neonatal mortality among women considered at low risk at start of labour, excluding deaths concerning life threatening congenital anomalies, was 1.7 deaths per 1000 planned home births, similar to risks in other studies of low risk home and hospital births in North America. No mothers died. No discrepancies were found for perinatal outcomes independently validated.
Conclusions Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.
Despite a wealth of evidence supporting planned home birth as a safe option for women with low risk pregnancies,1-4 the setting remains controversial in most high resource countries. Views are particularly polarised in the United States, with interventions and costs of hospital births escalating and midwives involved with home births being denied the ability to be lead professionals in hospital, with admitting and discharge privileges.5 Although several Canadian medical societies6 7 and the American Public Health Association8 have adopted policies promoting or acknowledging the viability of home births, the American College of Obstetricians and Gynecologists continues to oppose it.9 Studies on home birth have been criticised if they have been too small to accurately assess perinatal mortality, unable to distinguish planned from unplanned home births accurately, or retrospective with the potential of bias from selective reporting. To tackle these issues we carried out a large prospective study of planned home births. The North American Registry of Midwives provided a rare opportunity to study the practice of a defined population of direct entry midwives involved with home birth across the continent. We compared perinatal outcomes with those of studies of low risk hospital births in the United States.
Methods
The competency based process of the North American Registry of Midwives provides a certified professional midwife credential, primarily for direct entry midwives who attend home births, including those educated through apprenticeship. Our target population was all women who engaged the services of a certified professional midwife in Canada or the United States as their primary caregiver for a birth with an expected date of delivery in 2000. In autumn 1999, the North American Registry of Midwives made participation in the study mandatory for recertification and provided an electronic database of the 534 certified professional midwives whose credentials were current. We contacted 502 of the midwives (94.0%); 32 (6.0%) could not be located through email, telephone, post, or local associations, 82 (15.4%) had stopped independent practice, and 11 (2.1%) had retired. We sent a binder with forms and instructions for the study to the 409 practising midwives who agreed to participate.
Data collection
For each new client, the midwife listed identifying information on the registration log form at the start of care; obtained informed consent, including permission for the client to be contacted for verification of information after care was complete; and filled out a detailed data form on the course of care. Every three months the midwife was required to send a copy of the updated registration log, consent forms for new clients, and completed data forms for women at least six weeks post partum. To confirm that forms had been received for each registered client, we linked the entered data to the registration database. We reviewed the clinical details and circumstances of stillbirths and intrapartum and neonatal deaths and telephoned the midwives for confirmation and clarification. To verify this information we obtained reports from coroners, autopsies, or hospitals on all but four deaths. For these four, we obtained peer reviews.
Validation and satisfaction
We contacted a stratified, random 10% sample, of over 500 mothers, including at least one client for every midwife in the study. The mothers were asked about the date and place of birth, any required hospital care, any problems with care, the health status of themselves and their baby, and 11 questions on level of satisfaction with their midwifery care.
Flow chart for mothers using certified professional midwives, 2000
Data analysis
Our analysis focused on personal details of the clients, reasons for leaving care prenatally, the rates and reasons for transfer to hospital during labour and post partum, medical interventions, health and admission to hospital of the newborn or mother from birth up to six weeks post partum, intrapartum and neonatal mortality, and breast feeding. We compared medical intervention rates for the planned home births with data from birth certificates for all 3 360 868 singleton, vertex births at 37 weeks or more gestation in the United States in 2000, as reported by the National Center for Health Statistics,10 which acted as a proxy for a comparable low risk group. We also compared medical intervention rates with the listening to mothers survey,5 a national survey weighted to be representative of the US birthing population aged 18-44. Intrapartum and neonatal death rates were compared with those in other North American studies of at least 500 births that were either planned out of hospital or comparable studies of low risk hospital births.
Results
A total of 409 certified professional midwives from across the United States and two Canadian provinces registered 7623 women whose expected date of delivery was in 2000. Eighteen of the 409 midwives (4.4%) and their clients were excluded from the study because they failed to actively participate and had decided not to recertify or left practice. Sixty mothers (0.8%) declined participation. The figure provides an overview of why women left care before labour and their intended place of birth at the start of labour.
Characteristics of the mothers
We focused on the 5418 women who intended to deliver at home at the start of labour. Table 1 compares them with all women who gave birth to singleton, vertex babies of at least 37 weeks or more gestation in the United States in 2000 according to 13 personal and behavioural variables associated with perinatal risk. Women who started birth at home were on average older, of a lower socioeconomic status and higher educational achievement, and less likely to be African-American or Hispanic than women having full gestation, vertex, singleton hospital births in the United States in 2000.
Table 1 Characteristics of 5418 women planning home births with certified professional midwives in the United States, 2000, compared with all singleton, vertex births at 37 weeks' gestation in the United States, 2000. Values are percentages unless stated otherwise
Transfers to hospital
Of the 5418 women, 655 (12.1%) were transferred to hospital intrapartum or post partum. Table 2 describes the transfers according to timing, urgency, and reasons for transfer. Five out of every six women transferred (83.4%) were transferred before delivery, half (51.2%) for failure to progress, pain relief, or exhaustion. After delivery, 1.3% of mothers and 0.7% of newborns were transferred to hospital, most commonly for maternal haemorrhage (0.6% of total births), retained placenta (0.5%), or respiratory problems in the newborn (0.6%). The midwife considered the transfer urgent in 3.4% of intended home births. Transfers were four times as common among primiparous women (25.1%) as among multiparous women (6.3%), but urgent transfers were only twice as common among primparous women (5.1%) as among multiparous women (2.6%).
Table 2 Transfers to hospital among 5418 women intending home births with a certified professional midwife in the United States, 2000, according to timing, urgency, and reasons
Medical interventions
Individual rates of medical intervention for home births were consistently less than half those in hospital, whether compared with a relatively low risk group (singleton, vertex, 37 weeks or more gestation) that will have a small percentage of higher risk births or the general population having hospital births (table 3). Compared with the relatively low risk hospital group, intended home births were associated with lower rates of electronic fetal monitoring (9.6% versus 84.3%), episiotomy (2.1% versus 33.0%), caesarean section (3.7% versus 19.0%), and vacuum extraction (0.6% versus 5.5%). The caesarean rate for intended home births was 8.3% among primiparous women and 1.6% among multiparous women.
Table 3 Intervention rates for 5418 planned home births attended by certified professional midwives and hospital births in the United States
Outcomes
No maternal deaths occurred. After we excluded four stillborns who died before labour but whose mothers still chose home birth, and three babies with fatal birth defects, five deaths were intrapartum and six occurred during the neonatal period (see box). This was a rate of 2.0 deaths per 1000 intended home births. The intrapartum and neonatal mortality was 1.7 deaths per 1000 low risk intended home births after planned breeches and twins (not considered low risk) were excluded. The results for intrapartum and neonatal mortality are consistent with most North American studies of intended births out of hospital11-24 and low risk hospital births (table 4).14 21 22 24-30
Table 4 Combined intrapartum and neonatal mortality in studies of planned out of hospital births or low risk hospital births in North America (at least 500 births)
Breech and multiple births at home are controversial among home birth practitioners. Among the 80 planned breeches at home there were two deaths and none among the 13 sets of twins. In the 694 births (12.8%) in which the baby was born under water, there was one intrapartum death (birth at 41 weeks, five days) and one fatal birth defect death.
Apgar scores were reported for 94.5% of babies; 1.3% had Apgar scores below 7 at five minutes. Immediate neonatal complications were reported for 226 newborns (4.2% of intended home births). Half the immediate neonatal complications concerned respiratory problems, and 130 babies (2.4%) were placed in the neonatal intensive care unit.
Health in first six weeks post partum
Health problems in the six weeks post partum were reported for 7% of newborns. Among the 5200 (96%) mothers who returned for the six week postnatal visit, 98.3% of babies and 98.4% of mothers reported good health, with no residual health problems. At six weeks post partum, 95.8% of these women were still breast feeding their babies, 89.7% exclusively.
Outcome validation and client satisfaction
Among the stratified, random 10% sample of women contacted directly by study staff to validate birth outcomes, no new transfers to hospital during or after the birth were reported and no new stillbirths or neonatal deaths were uncovered. Mothers' satisfaction with care was high for all 11 measures, with over 97% reporting that they were extremely or very satisfied. For a subsequent birth, 89.6% said they would choose the same midwife, 9.1% another certified professional midwife, and 1.7% another type of caregiver.
Discussion
Springer NP, Van Weel C. Home birth. BMJ 1996;313: 1276-7.
Olsen O. Meta-analysis of the safety of home birth. Birth 1997;24: 4-13.
Macfarlane A, McCandlish R, Campbell R. Choosing between home and hospital delivery. There is no evidence that hospital is the safest place to give birth. BMJ 2000;320: 798.
Campbell R, Macfarlane A. Where to be born: the debate and the evidence. 2nd ed. Oxford: National Perinatal Epidemiology Unit, 1994.
Declercq ER, Sakala C, Corry MP, Applebaum S, Risher P. Listening to mothers: report of the first national US survey of women's childbearing experiences . New York: Maternity Center Association, 2002. www.maternitywise.org/listeningtomothers/ (accessed 3 Apr 2005).
College of Physicians and Surgeons of Ontario. Reports from council. Home birth policy rescinded. Toronto: CPSO, 2001.
Society of Obstetricians and Gynecologists of Canada. Policy statement No 126. Midwifery. J Obstet Gynecol Can 2003;25: 5.
American Public Health Association. 2001-3: increasing access to out-of-hospital maternity care services through state-regulated and nationally-certified direct-entry midwives. Am J Public Health 2002;92: 453-5.
American College of Obstetricians and Gynecologists. Frequently asked questions about having a baby in the 21st century . Washington; 12 Dec 2001. www.acog.org/from_home/publications/press_releases/nr12-12-01-4.cfm (accessed 3 Apr 2005).
Martin JA, Hamilton BE, Ventura SJ, Mencaker F, Park MM. Births: final data for 2000. National vital statistics reports. Hyattsville, MD: National Center for Health Statistics, 2002;50(5).
Burnett CA III, Jones JA, Rooks J, Chen CH, Tyler CW Jr, Miller CA. Home delivery and neonatal mortality in North Carolina. JAMA 1980;244: 2741-5.
Mehl LE, Peterson GH, Whitt M, Hawes WE. Outcomes of elective home births: a series of 1146 cases. J Reprod Med 1977;19: 281-90.
Schramm WF, Barnes DE, Bakewell JM. Neonatal mortality in Missouri home births, 1978-84. Am J Public Health 1987;77: 930-5.
Janssen PA, Holt VL, Myers SJ. Licensed midwife-attended, out-of-hospital births in Washington state: are they safe? Birth 1994;21: 141-8.
Sullivan DA, Beeman R. Four years' experience with home birth by licensed midwives in Arizona. Am J Public Health 1983;73: 641-5.
Tyson H. Outcomes of 1001 midwife-attended home births in Toronto, 1983-1988. Birth 1991;18: 14-9.
Hinds MW, Bergeisen GH, Allen DT. Neonatal outcome in planned v unplanned out-of-hospital births in Kentucky. JAMA 1985;253: 1578-82.
Durand AM. The safety of home birth: the farm study. Am J Public Health 1992;82: 450-3.
Rooks JP, Weatherby NL, Ernst EK, Stapleton S, Rosen D, Rosenfield A. Outcomes of care in birth centers. The National Birth Center study. N Engl J Med 1989;321: 1804-11.
Anderson RE, Murphy PA. Outcomes of 11,788 planned home births attended by certified nurse-midwives. A retrospective descriptive study. J Nurse Midwifery 1995;40: 483-92.
Pang JW, Heffelfinger JD, Huang GJ, Benedetti TJ, Weiss NS. Outcomes of planned home births in Washington State: 1989-1996. Obstet Gynecol 2002;100: 253-9.
Schlenzka P. Safety of alternative approaches to childbirth. PhD thesis, California: Stanford University, 1999.
Murphy PA, Fullerton J. Outcomes of intended home births in nurse-midwifery practice: a prospective descriptive study. Obstet Gynecol 1998;92: 461-70.
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: 315-23.
Neutra RR, Fienberg SE, Greenland S, Friedman EA. Effect of fetal monitoring on neonatal death rates. N Engl J Med 1978;299: 324-6.
Amato JC. Fetal monitoring in a community hospital. A statistical analysis. Obstet Gynecol 1977;50: 269-74.
Adams JL. The use of obstetrical procedures in the care of low-risk women. Women Health 1983;8: 25-34.
Rooks JP. Safety of out-of-hospital births in the United States. In: Midwifery and childbirth in America. Philadelphia: Temple University Press, 1997: 345-84.
Leveno KJ, Cunningham FG, Nelson S, Roark M, Williams ML, Guzick D, et al. A prospective comparison of selective and universal electronic fetal monitoring in 34 995 pregnancies. N Engl J Med 1986;315: 615-9.
Eden RD, Seifert LS, Winegar A, Spellacy WN. Perinatal characteristics of uncomplicated postdate pregnancies. Obstet Gynecol 1987;69: 296-9.
Dowswell T, Thornton JG, Hewison J, Lilford RJ, Raisler J, Macfarlane A, et al. Should there be a trial of home versus hospital delivery in the United Kingdom? BMJ 1996;312: 753-7.
Northern Region Perinatal Mortality Survey Coordinating Group. Collaborative survey of perinatal loss in planned and unplanned home births. BMJ 1996;313: 1306-9.
Ackermann-Liebrich U, Voegeli T, Gunter-Witt K, Kunz I, Zullig M, Schindler C, et al. Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. Zurich Study Team. BMJ 1996;313: 1313-8.
Wiegers TA, Keirse MJ, van der ZJ, Berghs GA. Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands. BMJ 1996;313: 1309-13.
Bastian H, Keirse MJ, Lancaster PA. Perinatal death associated with planned home birth in Australia: population based study. BMJ 1998;317: 384-8.
Bastian H, Keirse MJ, Lancaster PA. Authors reply: Perinatal death associated with planned home birth in Australia. BMJ 1999;318: 605.
Johnson KC, Daviss BA. Outcomes of planned home births in Washington State: 1989-1996. Obstet Gynecol 2003;101: 198-200.
Buescher PA, Taylor KP, Davis MH, Bowling JM. The quality of the new birth certificate data: a validation study in North Carolina. Am J Public Health 1993;83: 1163-5.
Piper JM, Mitchel EF Jr, Snowden M, Hall C, Adams M, Taylor P. Validation of 1989 Tennessee birth certificates using maternal and newborn hospital records. Am J Epidemiol 1993;137: 758-68.
Woolbright LA, Harshbarger DS. The revised standard certificate of live birth: analysis of medical risk factor data from birth certificates in Alabama, 1988-92. Public Health Rep 1995;110: 59-63.
Anderson RE, Anderson DA. The cost-effectiveness of home birth. J Nurse Midwifery 1999;44: 30-5.
Perkins BB. The medical delivery business health reform, childbirth and the economic order. New Brunswick, NJ: Rutgers University Press, 2004.(Kenneth C Johnson, senior epidemiologist)
Correspondence to: K C Johnson ken_lcdc_johnson@phac-aspc.gc.ca
Objective To evaluate the safety of home births in North America involving direct entry midwives, in jurisdictions where the practice is not well integrated into the healthcare system.
Design Prospective cohort study.
Setting All home births involving certified professional midwives across the United States (98% of cohort) and Canada, 2000.
Participants All 5418 women expecting to deliver in 2000 supported by midwives with a common certification and who planned to deliver at home when labour began.
Main outcome measures Intrapartum and neonatal mortality, perinatal transfer to hospital care, medical intervention during labour, breast feeding, and maternal satisfaction.
Results 655 (12.1%) women who intended to deliver at home when labour began were transferred to hospital. Medical intervention rates included epidural (4.7%), episiotomy (2.1%), forceps (1.0%), vacuum extraction (0.6%), and caesarean section (3.7%); these rates were substantially lower than for low risk US women having hospital births. The intrapartum and neonatal mortality among women considered at low risk at start of labour, excluding deaths concerning life threatening congenital anomalies, was 1.7 deaths per 1000 planned home births, similar to risks in other studies of low risk home and hospital births in North America. No mothers died. No discrepancies were found for perinatal outcomes independently validated.
Conclusions Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.
Despite a wealth of evidence supporting planned home birth as a safe option for women with low risk pregnancies,1-4 the setting remains controversial in most high resource countries. Views are particularly polarised in the United States, with interventions and costs of hospital births escalating and midwives involved with home births being denied the ability to be lead professionals in hospital, with admitting and discharge privileges.5 Although several Canadian medical societies6 7 and the American Public Health Association8 have adopted policies promoting or acknowledging the viability of home births, the American College of Obstetricians and Gynecologists continues to oppose it.9 Studies on home birth have been criticised if they have been too small to accurately assess perinatal mortality, unable to distinguish planned from unplanned home births accurately, or retrospective with the potential of bias from selective reporting. To tackle these issues we carried out a large prospective study of planned home births. The North American Registry of Midwives provided a rare opportunity to study the practice of a defined population of direct entry midwives involved with home birth across the continent. We compared perinatal outcomes with those of studies of low risk hospital births in the United States.
Methods
The competency based process of the North American Registry of Midwives provides a certified professional midwife credential, primarily for direct entry midwives who attend home births, including those educated through apprenticeship. Our target population was all women who engaged the services of a certified professional midwife in Canada or the United States as their primary caregiver for a birth with an expected date of delivery in 2000. In autumn 1999, the North American Registry of Midwives made participation in the study mandatory for recertification and provided an electronic database of the 534 certified professional midwives whose credentials were current. We contacted 502 of the midwives (94.0%); 32 (6.0%) could not be located through email, telephone, post, or local associations, 82 (15.4%) had stopped independent practice, and 11 (2.1%) had retired. We sent a binder with forms and instructions for the study to the 409 practising midwives who agreed to participate.
Data collection
For each new client, the midwife listed identifying information on the registration log form at the start of care; obtained informed consent, including permission for the client to be contacted for verification of information after care was complete; and filled out a detailed data form on the course of care. Every three months the midwife was required to send a copy of the updated registration log, consent forms for new clients, and completed data forms for women at least six weeks post partum. To confirm that forms had been received for each registered client, we linked the entered data to the registration database. We reviewed the clinical details and circumstances of stillbirths and intrapartum and neonatal deaths and telephoned the midwives for confirmation and clarification. To verify this information we obtained reports from coroners, autopsies, or hospitals on all but four deaths. For these four, we obtained peer reviews.
Validation and satisfaction
We contacted a stratified, random 10% sample, of over 500 mothers, including at least one client for every midwife in the study. The mothers were asked about the date and place of birth, any required hospital care, any problems with care, the health status of themselves and their baby, and 11 questions on level of satisfaction with their midwifery care.
Flow chart for mothers using certified professional midwives, 2000
Data analysis
Our analysis focused on personal details of the clients, reasons for leaving care prenatally, the rates and reasons for transfer to hospital during labour and post partum, medical interventions, health and admission to hospital of the newborn or mother from birth up to six weeks post partum, intrapartum and neonatal mortality, and breast feeding. We compared medical intervention rates for the planned home births with data from birth certificates for all 3 360 868 singleton, vertex births at 37 weeks or more gestation in the United States in 2000, as reported by the National Center for Health Statistics,10 which acted as a proxy for a comparable low risk group. We also compared medical intervention rates with the listening to mothers survey,5 a national survey weighted to be representative of the US birthing population aged 18-44. Intrapartum and neonatal death rates were compared with those in other North American studies of at least 500 births that were either planned out of hospital or comparable studies of low risk hospital births.
Results
A total of 409 certified professional midwives from across the United States and two Canadian provinces registered 7623 women whose expected date of delivery was in 2000. Eighteen of the 409 midwives (4.4%) and their clients were excluded from the study because they failed to actively participate and had decided not to recertify or left practice. Sixty mothers (0.8%) declined participation. The figure provides an overview of why women left care before labour and their intended place of birth at the start of labour.
Characteristics of the mothers
We focused on the 5418 women who intended to deliver at home at the start of labour. Table 1 compares them with all women who gave birth to singleton, vertex babies of at least 37 weeks or more gestation in the United States in 2000 according to 13 personal and behavioural variables associated with perinatal risk. Women who started birth at home were on average older, of a lower socioeconomic status and higher educational achievement, and less likely to be African-American or Hispanic than women having full gestation, vertex, singleton hospital births in the United States in 2000.
Table 1 Characteristics of 5418 women planning home births with certified professional midwives in the United States, 2000, compared with all singleton, vertex births at 37 weeks' gestation in the United States, 2000. Values are percentages unless stated otherwise
Transfers to hospital
Of the 5418 women, 655 (12.1%) were transferred to hospital intrapartum or post partum. Table 2 describes the transfers according to timing, urgency, and reasons for transfer. Five out of every six women transferred (83.4%) were transferred before delivery, half (51.2%) for failure to progress, pain relief, or exhaustion. After delivery, 1.3% of mothers and 0.7% of newborns were transferred to hospital, most commonly for maternal haemorrhage (0.6% of total births), retained placenta (0.5%), or respiratory problems in the newborn (0.6%). The midwife considered the transfer urgent in 3.4% of intended home births. Transfers were four times as common among primiparous women (25.1%) as among multiparous women (6.3%), but urgent transfers were only twice as common among primparous women (5.1%) as among multiparous women (2.6%).
Table 2 Transfers to hospital among 5418 women intending home births with a certified professional midwife in the United States, 2000, according to timing, urgency, and reasons
Medical interventions
Individual rates of medical intervention for home births were consistently less than half those in hospital, whether compared with a relatively low risk group (singleton, vertex, 37 weeks or more gestation) that will have a small percentage of higher risk births or the general population having hospital births (table 3). Compared with the relatively low risk hospital group, intended home births were associated with lower rates of electronic fetal monitoring (9.6% versus 84.3%), episiotomy (2.1% versus 33.0%), caesarean section (3.7% versus 19.0%), and vacuum extraction (0.6% versus 5.5%). The caesarean rate for intended home births was 8.3% among primiparous women and 1.6% among multiparous women.
Table 3 Intervention rates for 5418 planned home births attended by certified professional midwives and hospital births in the United States
Outcomes
No maternal deaths occurred. After we excluded four stillborns who died before labour but whose mothers still chose home birth, and three babies with fatal birth defects, five deaths were intrapartum and six occurred during the neonatal period (see box). This was a rate of 2.0 deaths per 1000 intended home births. The intrapartum and neonatal mortality was 1.7 deaths per 1000 low risk intended home births after planned breeches and twins (not considered low risk) were excluded. The results for intrapartum and neonatal mortality are consistent with most North American studies of intended births out of hospital11-24 and low risk hospital births (table 4).14 21 22 24-30
Table 4 Combined intrapartum and neonatal mortality in studies of planned out of hospital births or low risk hospital births in North America (at least 500 births)
Breech and multiple births at home are controversial among home birth practitioners. Among the 80 planned breeches at home there were two deaths and none among the 13 sets of twins. In the 694 births (12.8%) in which the baby was born under water, there was one intrapartum death (birth at 41 weeks, five days) and one fatal birth defect death.
Apgar scores were reported for 94.5% of babies; 1.3% had Apgar scores below 7 at five minutes. Immediate neonatal complications were reported for 226 newborns (4.2% of intended home births). Half the immediate neonatal complications concerned respiratory problems, and 130 babies (2.4%) were placed in the neonatal intensive care unit.
Health in first six weeks post partum
Health problems in the six weeks post partum were reported for 7% of newborns. Among the 5200 (96%) mothers who returned for the six week postnatal visit, 98.3% of babies and 98.4% of mothers reported good health, with no residual health problems. At six weeks post partum, 95.8% of these women were still breast feeding their babies, 89.7% exclusively.
Outcome validation and client satisfaction
Among the stratified, random 10% sample of women contacted directly by study staff to validate birth outcomes, no new transfers to hospital during or after the birth were reported and no new stillbirths or neonatal deaths were uncovered. Mothers' satisfaction with care was high for all 11 measures, with over 97% reporting that they were extremely or very satisfied. For a subsequent birth, 89.6% said they would choose the same midwife, 9.1% another certified professional midwife, and 1.7% another type of caregiver.
Discussion
Springer NP, Van Weel C. Home birth. BMJ 1996;313: 1276-7.
Olsen O. Meta-analysis of the safety of home birth. Birth 1997;24: 4-13.
Macfarlane A, McCandlish R, Campbell R. Choosing between home and hospital delivery. There is no evidence that hospital is the safest place to give birth. BMJ 2000;320: 798.
Campbell R, Macfarlane A. Where to be born: the debate and the evidence. 2nd ed. Oxford: National Perinatal Epidemiology Unit, 1994.
Declercq ER, Sakala C, Corry MP, Applebaum S, Risher P. Listening to mothers: report of the first national US survey of women's childbearing experiences . New York: Maternity Center Association, 2002. www.maternitywise.org/listeningtomothers/ (accessed 3 Apr 2005).
College of Physicians and Surgeons of Ontario. Reports from council. Home birth policy rescinded. Toronto: CPSO, 2001.
Society of Obstetricians and Gynecologists of Canada. Policy statement No 126. Midwifery. J Obstet Gynecol Can 2003;25: 5.
American Public Health Association. 2001-3: increasing access to out-of-hospital maternity care services through state-regulated and nationally-certified direct-entry midwives. Am J Public Health 2002;92: 453-5.
American College of Obstetricians and Gynecologists. Frequently asked questions about having a baby in the 21st century . Washington; 12 Dec 2001. www.acog.org/from_home/publications/press_releases/nr12-12-01-4.cfm (accessed 3 Apr 2005).
Martin JA, Hamilton BE, Ventura SJ, Mencaker F, Park MM. Births: final data for 2000. National vital statistics reports. Hyattsville, MD: National Center for Health Statistics, 2002;50(5).
Burnett CA III, Jones JA, Rooks J, Chen CH, Tyler CW Jr, Miller CA. Home delivery and neonatal mortality in North Carolina. JAMA 1980;244: 2741-5.
Mehl LE, Peterson GH, Whitt M, Hawes WE. Outcomes of elective home births: a series of 1146 cases. J Reprod Med 1977;19: 281-90.
Schramm WF, Barnes DE, Bakewell JM. Neonatal mortality in Missouri home births, 1978-84. Am J Public Health 1987;77: 930-5.
Janssen PA, Holt VL, Myers SJ. Licensed midwife-attended, out-of-hospital births in Washington state: are they safe? Birth 1994;21: 141-8.
Sullivan DA, Beeman R. Four years' experience with home birth by licensed midwives in Arizona. Am J Public Health 1983;73: 641-5.
Tyson H. Outcomes of 1001 midwife-attended home births in Toronto, 1983-1988. Birth 1991;18: 14-9.
Hinds MW, Bergeisen GH, Allen DT. Neonatal outcome in planned v unplanned out-of-hospital births in Kentucky. JAMA 1985;253: 1578-82.
Durand AM. The safety of home birth: the farm study. Am J Public Health 1992;82: 450-3.
Rooks JP, Weatherby NL, Ernst EK, Stapleton S, Rosen D, Rosenfield A. Outcomes of care in birth centers. The National Birth Center study. N Engl J Med 1989;321: 1804-11.
Anderson RE, Murphy PA. Outcomes of 11,788 planned home births attended by certified nurse-midwives. A retrospective descriptive study. J Nurse Midwifery 1995;40: 483-92.
Pang JW, Heffelfinger JD, Huang GJ, Benedetti TJ, Weiss NS. Outcomes of planned home births in Washington State: 1989-1996. Obstet Gynecol 2002;100: 253-9.
Schlenzka P. Safety of alternative approaches to childbirth. PhD thesis, California: Stanford University, 1999.
Murphy PA, Fullerton J. Outcomes of intended home births in nurse-midwifery practice: a prospective descriptive study. Obstet Gynecol 1998;92: 461-70.
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: 315-23.
Neutra RR, Fienberg SE, Greenland S, Friedman EA. Effect of fetal monitoring on neonatal death rates. N Engl J Med 1978;299: 324-6.
Amato JC. Fetal monitoring in a community hospital. A statistical analysis. Obstet Gynecol 1977;50: 269-74.
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