Section IV: International Observational Studies
The next category comprises international cohort and population-based observational studies. This collection of eight studies is of limited use to anyone trying to determine safety of home birth in the United States due to the substantial differences between direct-entry midwifery in the U.S. and the hospital-trained midwives of other countries. I reviewed all of them anyway.
Birthplace in England: The first international study is from England, published in 2011 in the British Medical Journal. It determined that women who had given birth previously had outcomes just as good when giving birth at home as in the hospital; however, women having their first baby at home experienced poorer perinatal outcomes (more deaths and injuries).
Van der Kooy et al: The second study, published in 2011, hailed from the Netherlands and determined that Dutch home births are: “under routine conditions… not associated with a higher intrapartum and early neonatal mortality rate. However, in subgroups, additional risk cannot be excluded.” I quote the study because quite honestly, having read it, I cannot really figure out what it means about the subgroups. Suffice it to say that they haven’t completely ruled out an increase in risk for Dutch home birth, but they did not find an increase in risk.
de Jonge et al: The third study, published in 2009, is also from the Netherlands. De Jonge explains that in the Netherlands about 30% of women plan to give birth at home; the Netherlands also has one of the highest perinatal death rates in Europe. This study found no significant difference in outcomes between planned home and hospital births attended by midwives. (De Jonge did not provide a comparison to hospital births attended by obstetricians. In later reading I discovered that a 2010 study by Evers et al would demonstrate that “low-risk” births attended by Dutch midwives have a higher perinatal death rate than high-risk births attended by Dutch obstetricians, indicating that midwives in the Netherlands have poor statistics regardless of birthplace.)
Kennare et al: The fourth study is from South Australia (2009) and, remarkably, found that although home birth in South Australia carries about the same risk of neonatal death as hospital birth, the risk of intrapartum (during labor) fetal death is seven times that of hospital birth, and the risk of death from intrapartum asphyxia (lack of oxygen) is 27 times higher! Intrapartum asphyxia is a cause of death that ought to be avoidable with proper fetal monitoring. This is included in a list of the best evidence for the safety of home birth?! But this was one rather small study in Australia, so I’ll move on.
Chamberlain et al: The next study listed, Home Births: The Report of the 1994 Confidential Inquiry by the National Birthday Trust Fund, was conducted in Great Britain and was published in the form of a book in 1997. According to the blurb on Amazon.com, the study “shows that planned birth at home is a safe option, that the women who are being selected for home births are appropriate, and that midwives manage home births well and competently.” Due to the outdatedness of the information and the fact that birth with a medically-trained British midwife tells us very little about the safety of home birth with an American direct-entry midwife, I found this study to be irrelevant to my quest to determine the safety of nonhospital birth in the United States.
Ackermann-Liebrich et al: The sixth study is from Switzerland in 1996 and determined that, “The number of participants was too small to detect differences either in maternal or perinatal mortality between the groups.”
Wiegers et al: The seventh study is from the Netherlands, published in 1996, and actually does conclude that home birth in the Netherlands is at least as safe as hospital birth. This is the first study to use the phrase, “at least as good,” which probably inspired the very common phrase “at least as safe” when talking about nonhospital birth. Unfortunately, a 19-year-old study from a country with a completely different midwifery and health care system tells us nothing about current home birth in the U.S.
Northern Region: The last study in this section is from Great Britain and found no significant difference in risk between home and hospital birth from 1981 to 1994. The takeaway from this collection of international studies seemed to be that, in the right circumstances, with highly qualified midwives well-integrated into the medical system, home birth can be as safe as hospital birth. However, with half of these studies dating 1996 or 1997, it seems that there should be more up-to-date information available from these countries with successful and safe home birth programs.