- Email: [email protected]
Planned home birth in economically developing countries: Are we ready?
International Journal of Gynecology and Obstetrics 119 (2012) 103–104
Contents lists available at SciVerse ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
SPECIAL EDITORIAL
Planned home birth in economically developing countries: Are we ready?
Claudio G. Sosa Pereira Rossell Hospital, University of Uruguay
Dr Claudio G. Sosa is an obstetrician and gynecologist currently working as an Associate Professor in the Department of Obstetrics and Gynecology at the Pereira Rossell Hospital, School of Medicine, University of Uruguay. Dr Sosa received his medical education, residency, and postgraduate training in obstetrics and gynecology in Uruguay. He later obtained a Master's degree in public health with a focus on reproductive and perinatal health from the University of North Carolina at Chapel Hill, USA, and a doctoral degree in epidemiology from the School of Public Health and Tropical Medicine, Tulane University, USA. His special interests are medical education, high-risk pregnancy, pelvic floor dysfunction, evidence-based medicine, clinical epidemiology, and clinical trials. Dr Sosa became an Associate Editor of the IJGO's Contemporary Issues in Women's Health section in 2011. During recent years, many Latin American countries have started to discuss planned home deliveries. Moreover, different nongovernmental organizations and institutions have asked their Ministries of Health for authorization to offer pregnant women the option of delivering at home. However, the controversy surrounding this issue and the need to cover the potential risks to prevent maternal and neonatal morbidity
and mortality are such that planned home deliveries have not been recommended. In most cases, Ministries of Health have discouraged planned home deliveries and emphasized the need for deliveries at the institutional level. Although planned home birth seems to be safe for low-risk mothers, the evidence of the risk to newborns delivered at home is still not clear and even contradictory. In 2010, Wax et al. [1] published a systematic review of observational studies including 12 studies from 7 highresource countries: Australia, Canada, Netherlands, UK, USA, Sweden, and Switzerland. The findings from the pooled analyses showed that planned home births were associated with fewer maternal interventions, less maternal morbidity, similar perinatal mortality rates, but with significantly elevated neonatal mortality. This systematic review raised criticism however, mainly because of the included—and excluded—studies that may have led to the finding of an increase in neonatal mortality for home deliveries [2–4]. Nevertheless, an independent review panel with expertise in maternal fetal medicine, clinical research, and meta-analysis evaluated the study and, after careful review of each step, reached similar results as those presented in the original systematic review [5]. Two additional cohort studies on this topic were published in 2011. A study from the Netherlands [6] tried to improve the comparison between planned home and hospital deliveries by applying a case-mix analysis. The authors found fewer intrapartum and neonatal deaths in planned home births compared with hospital planned births; however, when case-mix adjustment was applied, there was a trend for an increase in this outcome for planned home deliveries. The Birthplace in England Collaborative Group study [7,8] included more than 60 000 low-risk women from different settings in England and considered the planned place of birth at the start of care in labor as the exposure. The results showed that the adverse perinatal outcomes were infrequent in all settings and the interventions during the process of labor were less common for births planned in any of the nonobstetric settings. An interesting finding was that even though the classification of low risk was based on the absence of medical or obstetric risk factors listed in an intrapartum care guideline, there were important differences among pregnant women identified at the start of care in labor in the different planned settings. The study found that for nulliparous women, planned home births had a higher probability of an adverse perinatal outcome. The current epidemiologic evidence suggests that planned home delivery is clearly associated with less intervention during labor and delivery, and rare perinatal adverse outcomes may be present even in some groups of low-risk pregnant women. Nevertheless, the most important limitation of the available evidence is that all of the studies are observational and therefore bias and confounding may be systematically present. Pregnant women who plan to give birth at home probably differ from the majority and are “health conscious-
0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2012.08.003
104
Special editorial
ness,” which may act as a strong confounder and is very difficult to control for even when case-mix analysis is used [9]. There is only 1 currently known feasibility trial in which 11 pregnant women were allocated either to deliver in hospital or at home; however, the small sample size precludes any conclusions [10]. Certainly, there is a very low probability that a randomized controlled trial could be designed because a large sample size would be required and pregnant women would need to consent to randomization to deliver at home or hospital. A potential alternative may be a community randomized trial in which one intervention arm would provide standard prenatal care but with more emphasis on promoting birth at home as a delivery option. An important issue is the external validity of the current evidence for application to different settings around the world. As noted, all of the observational studies that have approached this topic have been conducted in high-resource countries [1]. This is relevant because extrapolation to economically developing countries may not be accurate. Existing guidelines that support home delivery highlight the need for easy access to maternity units and hospitals and to avoid any delay during the transfer. The latter may have serious consequences even in low-risk pregnant women. Without a doubt, home birth services should integrate and incorporate into their structure emergency ambulances to transfer women with complicated labor to an obstetric unit. Although a proportion of the population may be able to access health institutions easily and some services could respond quickly to assist emergency complications, we cannot assume that this will be applicable for all pregnant women in most scenarios. This is another factor that must be considered in economically developing countries where health systems and services may have different characteristics, and home birth service structures—including transfer to obstetric units—may not provide the optimal support. Advocates for home delivery support it because the process of birth is physiological and may be enhanced if the pregnant woman is in a quiet and familiar setting. In addition, a woman in labor who enters a hospital or maternity ward may experience fear and uncertainty, making her vulnerable as a consequence of the strange environment. This is a key issue that caregivers in delivery settings need to keep in mind in order to develop welcoming environments at the time of receiving a pregnant woman and her companion. Most will be low-risk pregnant women who do not require invasive obstetric interventions, high technology, or costly maternity care. Moreover, some medical interventions are usually unnecessary, do not add benefit, and dehumanize the process of labor. Therefore, hospitals and maternity units should provide evidence-based services where health providers support pregnant women and their families from
the beginning of the assistance, giving comfort and providing appropriate care for each individual and their own distinct needs. Health systems in economically developing countries should emphasize these practices in their services rather than incorporating technology and interventions from high-resource countries that have not been properly evaluated or do not have clear external validity for application in different regions. Women have the right to choose where to give birth, but must be clearly informed and know of the potential risks, such as transfer time to hospital in case of an unexpected complication, and the potential of rare but severe perinatal complications that can emerge even in low-risk pregnancies. Knowledge of how the home delivery system would respond is vital if the time to intervene becomes crucial.
References [1] Wax JR, Lucas FL, Lamont M, Pinette MG, Cartin A, Blackstone J. Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol 2010;203(3):243.e1-8. [2] Zohar N, De Vries R. Study validity questioned. Am J Obstet Gynecol 2011;204(4): e14. [3] Davey MA, Flood MM. Perinatal mortality and planned home birth. Am J Obstet Gynecol 2011;204(4):e18. [4] Gyte GM, Dodwell MJ, Macfarlane AJ. Home birth metaanalysis: does it meet AJOG's reporting requirements? Am J Obstet Gynecol 2011;204(4):e15. [5] [No authors]Editors’ comments. Am J Obstet Gynecol 2011;204(4):e20. [6] van der Kooy J, Poeran J, de Graaf JP, Birnie E, Denktass S, Steegers EA, et al. Planned home compared with planned hospital births in the Netherlands: intrapartum and early neonatal death in low-risk pregnancies. Obstet Gynecol 2011;118(5):1037-46. [7] Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011;343:d7400. [8] Schroeder E, Petrou S, Patel N, Hollowell J, Puddicombe D, Redshaw M, et al. Cost effectiveness of alternative planned places of birth in woman at low risk of complications: evidence from the Birthplace in England national prospective cohort study. BMJ 2012;344:e2292. [9] Pascoe JM, French J. Development of positive feelings in primiparous mothers toward their normal newborns. A descriptive study. Clin Pediatr (Phila) 1989;28(10):452-6. [10] 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(7033):753-7.
Claudio G. Sosa Pereira Rossell Hospital, University of Uruguay E-mail address: [email protected].
Contents lists available at SciVerse ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
SPECIAL EDITORIAL
Planned home birth in economically developing countries: Are we ready?
Claudio G. Sosa Pereira Rossell Hospital, University of Uruguay
Dr Claudio G. Sosa is an obstetrician and gynecologist currently working as an Associate Professor in the Department of Obstetrics and Gynecology at the Pereira Rossell Hospital, School of Medicine, University of Uruguay. Dr Sosa received his medical education, residency, and postgraduate training in obstetrics and gynecology in Uruguay. He later obtained a Master's degree in public health with a focus on reproductive and perinatal health from the University of North Carolina at Chapel Hill, USA, and a doctoral degree in epidemiology from the School of Public Health and Tropical Medicine, Tulane University, USA. His special interests are medical education, high-risk pregnancy, pelvic floor dysfunction, evidence-based medicine, clinical epidemiology, and clinical trials. Dr Sosa became an Associate Editor of the IJGO's Contemporary Issues in Women's Health section in 2011. During recent years, many Latin American countries have started to discuss planned home deliveries. Moreover, different nongovernmental organizations and institutions have asked their Ministries of Health for authorization to offer pregnant women the option of delivering at home. However, the controversy surrounding this issue and the need to cover the potential risks to prevent maternal and neonatal morbidity
and mortality are such that planned home deliveries have not been recommended. In most cases, Ministries of Health have discouraged planned home deliveries and emphasized the need for deliveries at the institutional level. Although planned home birth seems to be safe for low-risk mothers, the evidence of the risk to newborns delivered at home is still not clear and even contradictory. In 2010, Wax et al. [1] published a systematic review of observational studies including 12 studies from 7 highresource countries: Australia, Canada, Netherlands, UK, USA, Sweden, and Switzerland. The findings from the pooled analyses showed that planned home births were associated with fewer maternal interventions, less maternal morbidity, similar perinatal mortality rates, but with significantly elevated neonatal mortality. This systematic review raised criticism however, mainly because of the included—and excluded—studies that may have led to the finding of an increase in neonatal mortality for home deliveries [2–4]. Nevertheless, an independent review panel with expertise in maternal fetal medicine, clinical research, and meta-analysis evaluated the study and, after careful review of each step, reached similar results as those presented in the original systematic review [5]. Two additional cohort studies on this topic were published in 2011. A study from the Netherlands [6] tried to improve the comparison between planned home and hospital deliveries by applying a case-mix analysis. The authors found fewer intrapartum and neonatal deaths in planned home births compared with hospital planned births; however, when case-mix adjustment was applied, there was a trend for an increase in this outcome for planned home deliveries. The Birthplace in England Collaborative Group study [7,8] included more than 60 000 low-risk women from different settings in England and considered the planned place of birth at the start of care in labor as the exposure. The results showed that the adverse perinatal outcomes were infrequent in all settings and the interventions during the process of labor were less common for births planned in any of the nonobstetric settings. An interesting finding was that even though the classification of low risk was based on the absence of medical or obstetric risk factors listed in an intrapartum care guideline, there were important differences among pregnant women identified at the start of care in labor in the different planned settings. The study found that for nulliparous women, planned home births had a higher probability of an adverse perinatal outcome. The current epidemiologic evidence suggests that planned home delivery is clearly associated with less intervention during labor and delivery, and rare perinatal adverse outcomes may be present even in some groups of low-risk pregnant women. Nevertheless, the most important limitation of the available evidence is that all of the studies are observational and therefore bias and confounding may be systematically present. Pregnant women who plan to give birth at home probably differ from the majority and are “health conscious-
0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2012.08.003
104
Special editorial
ness,” which may act as a strong confounder and is very difficult to control for even when case-mix analysis is used [9]. There is only 1 currently known feasibility trial in which 11 pregnant women were allocated either to deliver in hospital or at home; however, the small sample size precludes any conclusions [10]. Certainly, there is a very low probability that a randomized controlled trial could be designed because a large sample size would be required and pregnant women would need to consent to randomization to deliver at home or hospital. A potential alternative may be a community randomized trial in which one intervention arm would provide standard prenatal care but with more emphasis on promoting birth at home as a delivery option. An important issue is the external validity of the current evidence for application to different settings around the world. As noted, all of the observational studies that have approached this topic have been conducted in high-resource countries [1]. This is relevant because extrapolation to economically developing countries may not be accurate. Existing guidelines that support home delivery highlight the need for easy access to maternity units and hospitals and to avoid any delay during the transfer. The latter may have serious consequences even in low-risk pregnant women. Without a doubt, home birth services should integrate and incorporate into their structure emergency ambulances to transfer women with complicated labor to an obstetric unit. Although a proportion of the population may be able to access health institutions easily and some services could respond quickly to assist emergency complications, we cannot assume that this will be applicable for all pregnant women in most scenarios. This is another factor that must be considered in economically developing countries where health systems and services may have different characteristics, and home birth service structures—including transfer to obstetric units—may not provide the optimal support. Advocates for home delivery support it because the process of birth is physiological and may be enhanced if the pregnant woman is in a quiet and familiar setting. In addition, a woman in labor who enters a hospital or maternity ward may experience fear and uncertainty, making her vulnerable as a consequence of the strange environment. This is a key issue that caregivers in delivery settings need to keep in mind in order to develop welcoming environments at the time of receiving a pregnant woman and her companion. Most will be low-risk pregnant women who do not require invasive obstetric interventions, high technology, or costly maternity care. Moreover, some medical interventions are usually unnecessary, do not add benefit, and dehumanize the process of labor. Therefore, hospitals and maternity units should provide evidence-based services where health providers support pregnant women and their families from
the beginning of the assistance, giving comfort and providing appropriate care for each individual and their own distinct needs. Health systems in economically developing countries should emphasize these practices in their services rather than incorporating technology and interventions from high-resource countries that have not been properly evaluated or do not have clear external validity for application in different regions. Women have the right to choose where to give birth, but must be clearly informed and know of the potential risks, such as transfer time to hospital in case of an unexpected complication, and the potential of rare but severe perinatal complications that can emerge even in low-risk pregnancies. Knowledge of how the home delivery system would respond is vital if the time to intervene becomes crucial.
References [1] Wax JR, Lucas FL, Lamont M, Pinette MG, Cartin A, Blackstone J. Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol 2010;203(3):243.e1-8. [2] Zohar N, De Vries R. Study validity questioned. Am J Obstet Gynecol 2011;204(4): e14. [3] Davey MA, Flood MM. Perinatal mortality and planned home birth. Am J Obstet Gynecol 2011;204(4):e18. [4] Gyte GM, Dodwell MJ, Macfarlane AJ. Home birth metaanalysis: does it meet AJOG's reporting requirements? Am J Obstet Gynecol 2011;204(4):e15. [5] [No authors]Editors’ comments. Am J Obstet Gynecol 2011;204(4):e20. [6] van der Kooy J, Poeran J, de Graaf JP, Birnie E, Denktass S, Steegers EA, et al. Planned home compared with planned hospital births in the Netherlands: intrapartum and early neonatal death in low-risk pregnancies. Obstet Gynecol 2011;118(5):1037-46. [7] Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011;343:d7400. [8] Schroeder E, Petrou S, Patel N, Hollowell J, Puddicombe D, Redshaw M, et al. Cost effectiveness of alternative planned places of birth in woman at low risk of complications: evidence from the Birthplace in England national prospective cohort study. BMJ 2012;344:e2292. [9] Pascoe JM, French J. Development of positive feelings in primiparous mothers toward their normal newborns. A descriptive study. Clin Pediatr (Phila) 1989;28(10):452-6. [10] 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(7033):753-7.
Claudio G. Sosa Pereira Rossell Hospital, University of Uruguay E-mail address: [email protected].