The debate on which is better for birth – hospital or home – is one that often generates strong and emotive responses. On one side are campaigners demanding that babies’ 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 policymakers.
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 event 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 that 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+ ml of blood (half a litre) for a vaginal birth or 1000+ ml (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 Haemorrhage
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. Infant deaths at home cited as proof that home birth is a risky business. More recently though comparative research has shown that homebirth is at least as safe as hospital birth for low-risk women. This is 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. Also, it is a major cause of reduced post-natal health.
The Study
An observational study was conducted recently in the UK. It 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. This is in preparation for a home or hospital birth. Pregnancies resulting in a live or stillbirth between 1988 and 2000, and the rates of subsequent postpartum haemorrhage of 1000+ ml, were compared.
The study targeted births planned as either home or hospital births, including home-to-hospital transfers. It excluded unplanned home births. Exclude 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.
This is by comparing women with similar levels of risk and care in each context. It 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 that 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 hospital births were significantly higher. It is higher than that which occurred after the homebirths studied. In fact, women experiencing postpartum haemorrhages following a hospital birth were around 2.5 times higher than those birthing at home.
More Research on the Risk of Haemorrhage is Needed
It is important to keep in mind that while this figure indicates an association between intended birthplace 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 it does not prove 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 possibility of a higher risk of postpartum haemorrhage in a hospital setting is worth considering. It is worthy of presentation to women and their partners. In addition, those considering homebirth should not be dissuaded based on the 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.
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