The debate on which is better for birth – hospital or home – is one which often generates strong and emotive responses. On one side are campaigners demanding that baby’s lives are being put at risk due to ‘ill-informed notions’ that home is safer, or just plain selfishness on the part of mothers. On the other side we have campaigners demanding the right to choose their place of birth, contesting the methodology of research which ‘proves’ that homebirth is unsafe, and in some cases eluding to a conspiracy between hospitals, medicos and policy makers.
The fact that this debate is so emotion charged should not come as a surprise. Birth could be considered the single most important event of an individual’s life, since without it life cannot begin. For this reason it is important to consider carefully the place in which this most meaningful and important of events should occur. Cutting through the fear mongering though can be hard. Comparative research however can often hold the key to the truth behind risks. One such comparative research study recently sought to explore a risk factor which has the potential to strike fear into the hearts of many expectant mothers – postpartum haemorrhage.
Postpartum haemorrhage refers to the loss of sufficient blood after birth to threaten a woman’s recovery and ultimately her life. Generally speaking this amount is quantified as being around 500+ mls of blood (half a litre) for a vaginal birth or 1000+ mls (1 litre) for a caesarean. This is a rather meaningless figure until you consider that an adult human body contains only around 5 litres of blood, with blood volume increasing by about 50% (to about 7.5 litres) by week 30 of pregnancy.
The risk of postpartum haemorrhage has long been held up as a significant risk in homebirth. However the homebirth safety debate has to date mostly centred on the risk of homebirths for babies, with infant deaths at home cited as proof that homebirth is risky business. More recently though comparative research has shown that homebirth is at least as safe as hospital birth for low risk women in terms of outcomes for babies. That accepted, the safety of homebirth for mothers must also be considered. When it comes to negative outcomes for women, the effects of postpartum haemorrhage are significant. In fact while only occurring in around one per cent of births, significant blood loss after birth is the most common cause of maternal death in the developed world, and is also a major cause of reduced post-natal health.
An observational study conducted recently in the UK sought to define whether the risk of postpartum haemorrhage differed depending on whether a home or a hospital birth was planned. Specifically the study looked at women receiving maternity care in one of 15 English hospitals in preparation for a home or hospital birth. Pregnancies resulting in a live or still birth between 1988 and 2000, and the rates of subsequent postpartum haemorrhage of 1000+ mls, were compared.
The study targeted births planned as either home or hospital births, including home to hospital transfers. It excluded unplanned home births and those during which an attendant midwife was not present (whether by design or due to a rapid birth). In addition, pregnancies designated ‘high risk’ as well as pre-term births, elective caesareans and medical inductions were also excluded for the purpose of the primary results.
Simply put the researchers sought to compare apples with apples (as opposed to apples with oranges) by comparing woman with similar levels of risk and care in each context. This is important because it is relatively easy for either side of a debate to cite contraindications as the reason for what they deem ‘skewed’ results. Similarly including types of treatment which can only occur in one context, like an elective caesarean or a medical induction, has the ability to inflate results. Only by comparing like with like can we get a truer picture of quantifiable risk.
Within the targeted group there were 273,872 pregnancies and subsequently 2,808 cases of postpartum haemorrhage. This equates to approximately one per cent, a figure on par with current statistics on postpartum haemorrhage in the developed world. However the rate at which postpartum haemorrhages occurred after the hospital births was significantly higher than that which occurred after the homebirths studied. In fact women experiencing postpartum haemorrhages following a hospital birth was around 2.5 times higher than those birthing at home.
It is important to keep in mind that while this figure indicates an association between intended birth place and the risk of postpartum haemorrhage, it doesn’t tell us why. It also does not prove that hospital birth leads to postpartum haemorrhage or that homebirth ensures the absence of it (known as a causal relationship). What it does suggest however is that in making a decision about where to birth, the possibly of a higher risk of postpartum haemorrhage in a hospital setting is worth considering and worthy of presentation to women and their partners. In addition, those considering homebirth should not be dissuaded based on purported risks of postpartum haemorrhage alone.
Further research is required to attempt to uncover why postpartum haemorrhage appears more prevalent in a hospital setting. Augmentation of labour, episiotomy and emergency caesareans are all known to increase risks of postpartum haemorrhage. The part that overuse of these procedures plays in elevating rates of postpartum haemorrhage in hospital births also needs to be considered. In the meantime this research adds gravity to the case for acknowledging homebirth as being at least as safe as hospital birth for low risk women.