Practice English Speaking&Listening with: Where to give birth, at home or in a hospital? Does it matter? (29 Jan 2013)

Difficulty: 0

>> Good afternoon.

Hello and welcome to this lunch hour lecture.

I'm very pleased to introduce Peter --

Professor Peter Brocklehurst, with his lecture entitled "Where

to give birth: at home or in a hospital?

Does it matter?"

Thank you very much.

>> Thank you.

So, that was a bit loud, wasn't it?

Good afternoon, I'm Peter Brocklehurst, I'm professor

of Women's Health here at UCL.

I'm director of the Institute of Women's Health.

My background is an epidemiologist although I'm not

going to give lots of statistics today.

I'm going to show you some tables but hopefully,

I'll explain them clearly enough.

I'm going to talk safety of planned place of birth.

I'm going to stray from the title a little bit,

not just restricted to home birth but talk

about other birth settings outside the hospital in the UK.

You may be aware that this is still a very controversial

and hotly debated issue.

Most Sunday newspapers have something

about home birth in them most weeks.

And there's very little you can do about home birth

without getting a lot of media attention.

So, I felt I will declare my conflict of interest in this

in a moment but I thought I'd talk about Maternity Care Policy

and I'm talking about England,

I'm talking about the UK initially

but predominantly, about England here.

I'll talk about the big piece of research that we did

which is going to form the bulk of this, about the safety

of planed place of birth.

And I'll talk a little about interpreting the evidence

and what we do with that evidence,

and how we handle evidence in our decision making

around place of birth.

So, first of all, I need to declare a conflict of interest.

I was specifically asked this question when I was presenting

in the Netherlands so I thought I better come absolutely clean

and say that I was born at home but it was by accident

which sort of gets me out of it.

It wasn't a planned home birth, my mother was told she wasn't

in labor so she went back home and promptly have me in the bed.

So, I can sort of feel that I'm on both sides of the fence here

and mutual in terms of the debate

about planned place of birth.

So, a little bit about maternity policy in England set

by the Department of Health.

You may be aware-- some of you may be aware of this,

this was the National Service Framework.

The maternity standard which came out from the Department

of Health of England in 2004 which stated

that every woman should be able

to choose the most appropriate place and professional

to attend her during childbirth based on her wishes

and cultural preferences and any medical and protective needs she

and her baby may have and that options

for midwife-led care will include midwife readiness

in the community or on a hospital side.

And a care was to be provided in a framework which enables easy

and early transfer of women and babies

who unexpectedly require specialist care.

That was 2004.

In 2007, another policy document came out from the Department

of Health on maternity matters which again stressed this issue

about choice access and continuity about planned place

of birth and set out a national choice guarantee saying

that if women wants to or in discussion

with their health professionals chose different planned places

of birth and this would be provided for them.

It would not be long for me to say that this was on the basis

of very little evidence about the safety

of planned place of birth.

And I think that although many government departments talk

about evidence-based policy making, this was one

of those instances where there was policy made

without any evidence.

So, we have some information about the safety

of planned place of birth but it was all to do

with outcomes from the mother.

We have very little information about how safe or not it was

for the baby, partly because as you might anticipate,

the UK like the west-- rest of Western Europe

about the safest place to have a baby in the world.

And therefore, anything going wrong

with the baby will be very, very uncommon.

So, studies which we're able to look at that were plagued

by the fact that they couldn't show differences

because the numbers were too small

and I'll come back to that a bit later.

So, we had a huge lack of evidence

about the quantification of this risk about those outcomes

for babies associated with births planned

in different settings.

And in this context, I'm going to talk about in the NHS.

And the problem we have although we have lots

of routine data collected in the NHS, we only have information

about actual place of birth, not planned place of birth.

So, we were making inferences about the safety

of different planned places of birth

by only having national date on actual.

So, if I just show that here, hopelessly,

if you're planning a birth at home, you are hoping

that you have a birth at home.

If you're planning a birth in hospital, you assume that you

that you're going to have that birth in the hospital.

And if you're planning birth in midwifery, you assume

or your attention is to give birth in that midwifery

but not surprisingly, there are transfers and women transfer

from home to the hospital

and from a midwifery unit to the hospital.

Now, there are very, very small numbers

who transfer different ways but predominantly,

if a problem occurs during labor or after the birth,

then the woman is transferred to a hospital which is

where the baby is delivered.

So, you can see that if there's a problem with the labor,

the baby delivers in the hospital

that is then counted as a hospital birth.

And so, you might anticipate that babies with problems who--

or who have adverse events or maybe even die will be

over represent in the hospitals.

So, that's all the data we have nationally, where you were born

and the outcomes associated with where you are born,

not where you plan to give birth.

So, this was, I think, recognized finally

by policy makers who then commission some research

around trying to understand the safety

of planned place of birth.

So, they funded this large project called

"The Birthplace Program" so the Department of Health

and the National Institute

for Health Research jointly funded this program

to provide high quality evidence about processes, outcomes

and cost associated with different settings for birth

in the NHS in England and I'm not going to present all of that

but I'm going to present some of it.

The six main components of this study were-- well, first of all,

we have to define terms and definitions

because this area is plagued with different ways

of describing the care that women received in labor.

So, often we talk about midwife-led

or consultant-led care but that's not a place,

that's just sort of philosophy of care, that's who--

who's the primary caregiver.

It doesn't describe that place

that one will receive care during labor.

We do a mapping study of England to find out what was provided

because we don't know.

Interesting, the NHS doesn't know what services it provides

on a national level so good researchers have to find

out by writing to everybody and finding out what they provide.

Predominantly, I'm going to talk

about this national perspective cohorts that a planned place

of birth will so alongside

that in a large cost effectiveness analysis.

And we did some qualitative studies and case studies to look

at aspects of how services provide choice

around planned place of birth

and how they managed the workforce to be able

to provide a choice which is responsive

to women's wishes and requests.

And then, a study of antepartum related mortality using

national data.

So, just a little bit, first of all, the four definitions,

the four places of birth, an obstetric unit

which is a hospital,

we can sometimes call the consultant-led unit

but for this purpose, this was a hospital which was equipped

with midwives, obstetricians, neonatologist and anesthetists.

Home, fairly clear although there was lots of debate

about what is home and if a woman plans to deliver

in her mother's home is that home, I think we decided

that it was, it was fairly straightforward.

The two types of midwifery units were more challenging.

We came up with a freestyle midwifery unit.

This is a midwifery unit which is geographically separate

from an obstetric unit.

So, this could be some rooms above the shops

on the high street or it could be a unit within a hospital

but that hospital does not that have an obstetric unit in it.

So some smaller hospitals where the obstetric units is closed

and the obstetricians have moved out,

that's become a midwifery unit.

So, there are no obstetricians on sight,

there were no obstetric anesthetists,

there were no neonatologists on sight.

By contrast and alongside midwifery unit is a midwifery

unit run entirely by midwives which is geographically

on the same side as on obstetric unit.

That's the most variable type, that may be two rooms

in the labor ward which are designated alongside a

midwifery unit.

Or it maybe a completely separate structure

within the hospital which is very different,

which as has completely different staffing [inaudible]

and so forth.

So, those were the four settings

that I'm going to talk about today.

So, we did this mapping study which is very interesting,

you're not supposed to spot the towns but we looked

at those centers that provided free stand midwifery unit

alongside midwifery units and obstetric units.

And you can see there were parts of the country

where there is very little overlap.

So, this was in 2008 and so at that time,

this national choice guarantee couldn't be delivered

because many parts of country didn't have a midwifery unit.

So, the only real choice was between home and hospital

and that's based on the physical location.

I mean there are other barriers

where we've been accessing planned places of birth

but if you didn't have a midwifery unit,

then you clearly couldn't plan to deliver one unless you have

to travel a long way when you went into labor

which most women are not prepared to do.

So, coming on to the perspective study, the cohort study,

the primary objective of this study was to compare intrapartum

to during birth and early neonatal mortality.

Early neonatal includes the first seven days after birth

and morbidity whether the baby has died

or whether they were very sick.

By planned place of birth at the start of care and labor,

so women can choose to have a home birth

when they first book for 12 weeks.

But clearly, things happen along the way in pregnancy

that may make it not appropriate for that woman to choose

to give birth at home by the time she gets the stage

where she goes into labor.

We were interested in the safety of planning birth and labor

at the-- the planned place of birth and labor

when you were actually in that planned place of birth

and were receiving some care from a midwife.

Because of that, we felt it would be the point where you--

women would make decisions about whether planning birth

if they knew the safety of that process.

And this was in women just to be at low risk

of complications according to current national guidance.

And very fortunately, notice the National Institute

for Clinical Excellence produce a guideline

on intrapartum care a couple

of years before we started collecting data

which had a whole checklist of conditions

which it would be recommended

that women don't consider birth outside an obstetric unit.

So, units were already used to use to using that checklist

which was very helpful, it gave us a way of deciding

who was low and he was high risk.

We knew because we've got very good data on mortality

that we could never share with difference in death.

We knew that the risk of a baby dying at term

without any complications was so very,

very low we wouldn't be able to share a difference in death.

So, we have to think of an outcome which included death

but which included other things, other outcomes for the baby

which were related or could be related to the quality

of care received during labor.

And that's a-- that statement [inaudible] weeks of debates

in discussion about how we came up with this list.

But these outcomes, the neonatal outcomes which are associated

with lack of oxygen during birth or trauma.

But clearly, a fractured clavicle which is the collarbone

and I don't know how many of you have fractured your clavicle.

If you have, you'll know that there's absolutely no treatment,

you just have to go take pain killer and go away

and that's exactly the same in babies.

So, a fractured clavicle is not quite the same as a stillbirth

in labor in terms of its importance.

So, we knew that we were putting together things which were not

of equal importance but the anticipation was

that if there was a problem with a plan setting for birth

or the quality of care in that setting, those outcomes would go

in a similar direction and I'll show you later what we

actually found.

We didn't know, we have no data to estimate what the proportion

of these outcomes would be

when we put this composite act together.

But basically, any baby who had any of these was count

to just having an adverse outcome

for the sake of the study.

And we aim to collect data from every NHS just

in England providing home birth services;

every free stand midwifery unit, every alongside midwifery unit

and a stratified random sample of 37 obstetric units.

And the stratification fact is one size of the unit and also,

geography, the North and South of England.

I didn't realize there was a line but geography has agreed,

it divides the North and South of England but there is.

So, we took off what stratified sample on either side

of that line and looked to its size.

We knew we needed this study to be big.

We knew we needed to collect data from at least 57,000 women

so that we'd have about 47,

000 who would be classified as low risk.

That doesn't-- that's not the proportion of low risk

to high risk in the entire population of women delivering

in this country because we excluded women having an

elective caesarian section

because they don't have any labor,

those being induced, et cetera.

So, we knew the systems we set-up, we aim to collect

at least 57,000 women and anticipate that about 47,

000 of those women would be in this low risk category.

This meant we had a data collection booklet

which was completed, which had to follow the woman

from when she came in in labor

until she was five days post delivery.

And midwives throughout the country filled in thousands

of thousands of booklets about the data and sent them back

to us because these data are not available routinely.

This is the only slide about analysis and we adjusted

for the main confounders in this co-study.

So, factors such as maternal age, ethnicity, understanding

of English, partner status, body mass index,

area deprivation scores are a proxy

for socio-economic status based on post code.

And para to the number of births you've had and gestation,

so the actual gestational age

for the baby, the number of weeks.

Now, we only need the term babies and that's in 37 weeks.

So, the difference between 37

and 42 weeks could make a difference so we included adjust

for gestation at birth.

Because the large numbers of comparisons we did,

we use 95 percent composite and 99 percent complete

since secondary outcomes and you'll those there on the table

that I'm going to present.

And we also plan to look at the difference

between first time mothers and second

or subsequent time mothers

because first time mothers have a higher risk

of adverse outcomes at birth and on their baby.

And we did this nice technical thing where we collected data

for difference durations from different settings so we have

to wait for the duration of data collection

to take account of that.

We were largely successful, we did manage to collect data

from almost all trusts, 97 percent of trusts

in England participated, and 84 percent of AMUs.

That seems a bit low but that was because during the time

that that study was going on,

people are opening new alongside midwifery units.

And once we'd started data collection,

we didn't get any new alongside midwifery units in.

By the time we'd finish, there were quite of few new ones.

We got almost all free standing midwifery units and we had

to represent samples of 36 obstetric units.

You may remember that the original one was 37,

one was so completely and awfully helpless

that we only got data returned

for four women every six month period.

This is a hospital that had over 5,000 births a year

so a slight understatement we thought so we end up having

to exclude that center.

We wanted to collect data on about 8 --

at least 85 percent of eligible women, as in low risk women

who were in labor in those settings.

This proved to be phenomenally difficult because no hospital

or free stand midwifery unit could tell us how many low risk

women went into labor.

So, we have to set of special systems to try and monitor this.

So, we think we got a very high proportion but the estimation

of the denominator or the number of high risk women--

low risk women going in to labor

in the hospital was extremely difficult to get.

We did a huge amount of data chasing

and then ended it was less than four percent of missing data

which the dataset of this size was quite something.

The other thing I've not mentioned is

that we could not risk selection bias.

We could not risk parts of the population agreeing to take part

and that has not because we needed

to know what the impact in the country was.

So, these data were collected without any consent

so the women didn't give consent and the only way you can do

that is if you have no identifiers.

So, we didn't have name, address, hospital number,

NHS number, we have none of that.

So, data chasing was extremely challenging as you can imagine

because we had to get to the hospitals and say,

"You haven't filled this form out properly

for woman number 59682."

And they'd have to try and find back to that woman's notes

to collect the information.

So, in the end, we had collected data from nearly 80, 000 women

and ended it with 64, 538 low risk women.

That was a lot of boxes of data sitting around in the office.

And ended up with about 20 000 low risk women having a birth

in obstetric unit, 17 000 home births, 11 000 death

of new births and 17 000 AMU births.

Our original sample size calculation suggested

that we leave it to 20,000 daily births, 17,000 home births

and we estimated that we might get as many as 5,000 in each

of the types in midwifery units and we've have

to put them together to have any statistical power.

But because there was a fantastic participation,

we had enough numbers to be able to look

at the four groups separately.

So, that's what I'm going to be able to present.

So, not surprisingly, there were differences

in maternal characteristics that women planning birth

in different settings were different.

As an epidemiologist, so it's useful to see

that what you expect to see is being seen

that so you're getting a good representative population.

But at the same time, it's always disappointing sometimes

to see your social prejudices confirmed.

So, women planning a place--

plan to give birth at home will much more likely

to white middle class, a bit heavier, a bit older,

than women planning birth in hospitals.

So, the big difference that was

in women planning their first births at home,

for only 20 percent-- 27 percent are women planning birth

at home were first time mothers versus 46 percent in FMUs,

50 percent in AMUs and 54 percent in obstetric units.

So, all the analysis that I'm showing are adjusted

for this difference in parity

because this is absolutely crucial.

The other thing we found-- this is a complicated table

but the message is on the bottom line.

The last time a woman is seen by a midwife

in her antenatal care before she gets into labor,

there's an assessment of her risk.

If that woman is still low risk at that time,

she's considered to be low-risk.

When the woman is first seen in labor,

another assessment is done and clearly,

new conditions can picked up at that stage that weren't there

at her last antenatal clinic appointment.

So we call these complicating conditions

at the onset of care and labor.

And we found rather surprisingly a difference.

We found more in the obstetric units

than in the other settings.

And I think what we now think, fairly convincing me,

that was due to the way that we selected a cohort

because we selected them at onset of care and labor.

Those women who rupture their membranes at home maybe told

to stay at home waiting for contractions to start.

When they get to a certain duration of membrane rupture

without contraction starting, they'll be told often

over the phones to come into the hospital

so they haven't had any face to face care

in their planned place of birth.

So suddenly, that planned place

of birth will become hospital if that makes sense.

So clearly, if we included women with these risk factors

and high blood pressure, and proteinuria, and bleeding and so

on and so forth, are all risk factors for an adverse outcome.

Then if we just included all women, we prejudice our analysis

against obstetric units because that includes more women

with any of these risk factors.

So if the analysis that I'm going

to show you show the differences between the groups for all women

and then all women without any of these complicating conditions

at labor onset and so the truth lies somewhere

between the two, probably.

I'm just so tired [phonetic].

So, we have 250 primary outcome events in 64

and a half thousand women.

So this is the challenge we have of doing this sort of research

that child birth is safe in this country,

4.3 adverse events per thousand births.

And if you look at those broken down,

this is the list of the outcomes.

You can see that as we anticipated, very few,

very few babies died so these are still births

after the onset of care and labor.

So the babies were born and care started in labor

but died during the labor, so there are 14

out of 64 and a half thousand.

So in total there was only about 13 percent of all

of those primary outcomes which were still birth

or early neonatal death.

But you can also see that most

of it was neonatal encephalopathy.

Now, neonatal-- and meconium aspiration syndrome.

Neonatal encephalopathy is

where you get disordered brain function.

Brain's function is depressed because of lack

of oxygen during the birth

and meconium aspiration is also largely felt in those babies

that are not very post mature to be because of lack of oxygen,

the baby opens their bowels in the uterus, releases meconium

and then gasping in utero as a consequence of hypoxia,

means that the baby inhales poo into their lungs.

Charming I know but often mild, sometimes very severe.

These two outcomes made up 70 percent

of the whole family outcome.

So in effect, when you're looking at the results,

you need to remember that a lot of this is these two outcomes.

Now neonatal encephalopathy can very mild

with no long-term sequelae to severe.

Once you get to severe, about 50 percent mortality

and of the survivors, about 50 percent will have

cerebral palsy.

But, the spectrum of mild, moderate, severe is probably

about a third, a third, a third.

So even with 114 cases, the numbers of long--

babies with long-term consequences is probably

very small.

But of course, without identifiers,

we couldn't do followup.

So, here are some results and I don't have a pointer.

So, in the top half of the table,

you'll see all low-risk women.

Now that's all 64 and a half thousand.

So you can see the four planned places of birth down the side.

We've used obstetric units as the reference group

because it was the largest group not

because that's considered the standard

but it's the largest say, physically more powerful.

And we present the numbers per thousand of the events.

Those are weighted numbers per thousand

with their confidence interval

and then we presented the odds ratio.

So we've compared home in that top half of the table

with obstetric units and got an alteration of 1.16

with 95 percent of confidence interval, 1.76 to 1.77.

So no statistically significant excess of the primary outcome

in women planning birth at home compared

as women planning birth in an obstetric unit.

Yeah. And then FMU compared with obstetric unit

and AMU compared with obstetric unit.

So you can see on that right side 'cause those confidence

intervals include one, there is no statistically significant

increased risk of adverse primary outcome associated

with different planned places of birth.

In the bottom half of the table, we have repeated

that analysis excluding women

with complicating conditions at labor onset.

And here, you can begin to see

that there is a statistically significant difference

which suggests that there is an increased risk

of the adverse outcome, primary outcome,

associated with women planning birth at home, this one here,

where the confidence interval is 1.01 to 2.52.

It's only just statistically significant.

But for FMU and AMU compared with OUs,

there was no apparent increase in risk.

That's all women.

If we separate these women by parity

so nulliparous women are women having their first baby

and multiparous having their second or subsequent baby.

You can see something beginning to emerge.

So here, the association with an adverse primary outcome

if you're planning birth at home compared

than those obstetric units, now had an odds ratio of 1.75

and the confidence interval was 1.0 or 72.86.

So again, a suggestion in first time mothers

that there was an increased risk associated

with planning birth at home.

But there could be numbers per thousand,

I'm going to note these odds ratios are adjusted

for the factors but the event rate is still 5.3,

9.3 per thousand.

The event rate is still low but there is a significant access.

For women having their second or subsequent baby,

there was no difference,

no statistically significant difference

in where you plan to get birth.

But of course, the event rates as you might anticipate,

the number of adverse events for multiparous women are lower.

If you repeat that and take out all the women

without complicating conditions at labor onset,

that's association with planning--

first time mothers planning birth at home becomes stronger.

So there, the odds ratio is 2.8 and the lower limit

for the confidence interval is now well away from 1,

it's 1.59 so a stronger association.

And the absolute event rates, 3.5 versus 9.5.

For multiparous women, again, no difference

and women planning birth in FMUs and AMUs,

no statistically significant excess of risk associated

to planning birth in those settings.

So for multiparous women, women having their second

or subsequent baby, and remember, this is low-risk women

so to be a low-risk woman having your second baby,

you have to have a normal birth the first time around.

So perhaps not surprisingly,

that's pretty good indication you can have a normal

straightforward birth the second time around.

So for multiparous low-risk women, there were no differences

in adverse perinatal outcomes in treatment settings but the risk

of an adverse perinatal outcome appears to be higher

for first time women, mothers who plan to give birth at home.

Now, we did look at a variety of other outcomes, I'm just going

to present a couple of them,

particularly interventions during labor and birth.

So this is cesarean section during labor.

And as you can see, these aren't numbers per thousand,

these are percents now.

So those are much higher risk of having a cesarean section

if you plan to give birth in an obstetric unit compared

with all other settings, very,

very highly statistically significant difference

for both nulliparous women and multiparous women.

In terms of forceps delivery, exactly the same,

much higher risk of having a forceps delivery if you plan

to give birth in an obstetric unit compared

with settings outside.

And there is this definition

of normal birth, I almost forget this.

Normal birth is without induction, without epidural,

without general anesthetics, without forceps or ventouse,

without the cesarean section and without an episiotomy.

So if you classify women according to normal birth,

you can see for both the first time mothers

and second time mothers planning a birth outside hospital

increased your chance of having a normal birth.

The other important information

that we didn't know beforehand was how many women transferred

during labor.

In here, 45 percent of women transferred from home during

or shortly after the birth,

about 80 percent transferred before the birth.

Now that-- you know, that-- when people see that,

they think that's a blue flashing light and [inaudible]

down the road for 75 percent of those 85 percent

who transfer before birth, it was for epidural,

failure of the labor to progress quickly enough.

So, it was a slow labor

but there's no concern about the baby.

That still left about 20 percent where there were concerns

about the baby but this is not inevitable.

And of course, well they basically will be transferred

by ambulance.

And if you can't give birth on an obstetric unit versus home,

there is 100 percent transfer rate in labor.

You got to get to the hospital.

And so, higher than we anticipated certainly,

in terms of transfer.

So, our conclusions of this study were that there was lots

of [inaudible] policy of offering healthy women

with lowest pregnancy a choice of birth setting.

And I'll come back to that later

because that's been the most controversial thing we've said.

And women planning birth in midwifery units

and multiparous women planning birth

at home experience fewer interventions

than those planning birth in an obstetric unit with no impact

on perinatal outcomes.

And for first time mothers,

planned home births also have fewer interventions

but have poorer perinatal outcomes.

So, that's the sort of dryness of their study but I just wanted

to talk about what happened subsequently.

So, with those couple of BMJ papers, the first one which was

on November 2011 on the left

which was presenting the clinical data I've presented

to you and the one on the right was the cost effectiveness

which also caused a [inaudible] publicity around the safety,

nothing has to do with the cost effectiveness but has all to do

with the safety planned home birth again.

There was lots of press.

We managed.

We had a very active process of managing the press release

around it and most of the press were fairly sensible

in their reporting and were fairly accurate.

We did this to the Science Media Centre which all

of you know is based on Wellcome Trust, very experienced

at communicating scientific results to an invited audience

of science correspondence and not surprising,

there were a couple of exceptions to the measured

and accurate reporting of the data.

I was called several times on the day before that.

Newspapers came out wanting me to confirm

that these headlines were accurate

and I repeatedly said no, you know, they're not accurate.

They're completely fictitious.

And they said well, we're going to go with them anyway.

And so, we felt this was an important research question.

I just want to touch on a couple of things.

We'd love to have done a randomized control trial.

Randomized control trials are the best way

to evaluate the effects of an intervention

where you randomize participants to receive one hour

of the intervention versus the other.

There's no way we could have done a randomized control trial

of planned place of birth at onset of care and labor.

You saw the contracting, we'll just randomize you.

We have the stay at home, we come into the hospital

or get to an FMU unit.

Somebody once tried to do a randomized control trial

of home birth versus hospital birth, and over a course

of two years of had managed to recruit 11 women

which I think was a sterling effort.

So, we knew that we couldn't do their goal standard

to evaluate this intervention which meant we have

to very careful about the design of the study

to do everything we possibly could to try and get that,

the answer that we hope was there.

But no observation [inaudible] are perfect.

I've been quite careful about talking about the--

you know, these results appear to suggest

because there may be other explanations

for way we're finding these, the findings we did.

And it's been interesting.

It's been a bit of a, the most controversial piece

of research I've ever done.

It is still being widely criticized by people

who don't like the results.

We knew there'd be some criticism.

Interestingly, some consumer groups,

some women's groups are very critical that the results

of this will force women to give birth at home

when they don't want to.

It's probably worth reminding those of you who don't know

that planning birth at home is still a bit

of a minority activity in this country.

Only about 3 percent of women in the UK plan to give birth

at home and probably about 5 percent overall plan

to give birth at the hospital.

So, the idea that suddenly we'd be forcing four 40 percent

of women to give birth at home I think,

would be stretching our services a little

and also our credibility.

There has been quite a lot of lobbying of the NHS about this

and professional bodies, I'll show you in a minute,

and an international response.

But it has led us to think how to implement this finding

into practice which I'll also just come back to.

I suppose one of the most disappointing things

that the Royal College of Obstetricians

and Gynecologists, their president.

Sorry, my president, I am a fellow of the College

of Obstetricians and Gynecologists

who was a gyne-oncologist, which means he deals

with women's cancer, on his blog stated

that the RCOG favors birth and collocated [inaudible] units,

well often standalone units since these women--

means women have better access to consultant care.

And what I didn't show is this sentence was preceded

by as the birthplace study shows which, of course, you know,

assuming results in the birthplace study did not show

that fees [inaudible] units were to increase risk.

And very recently, January, this month, in the American College

of Obstetricians and Gynecologists, a very,

very influential obstetrician and ethicist,

Frank Chervenak produced this paper called planned home birth,

the professional responsibility response.

Obstetricians and other concerned physicians should

understand, identify and correct the root causes

of the recrudescence of home birth, respond to expressions

of interesting planned home birth by women

with evidence-based recommendations against it,

refused to participate in planned home birth.

Obstetrician should not participate in or refer

to randomized controlled trials of planned birth home

versus planned hospital birth.

This was based on a lecture he gave in Paris towards the end

of 2012 where interestingly, I came into some very,

very personal criticism for even daring to do the study,

to even question where the planned home birth could be

considered safe.

So, the idea that one should even do a study

like this was considered anathema

to this obstetrician ethicist in the US.

And fortunately, we're not in the US

and I realized I obviously must have been doing something right

to cause this degree of upset.

And so, where to give birth, at home or in hospital?

Does it matter?

I can't tell you where to give birth.

All this has done is provide some more evidence.

The issue about where you plan to give birth and safety.

Safety isn't a yes or no answer.

Safety depends on what your views and belief are.

What you're prepared to accept.

Some of you will go skiing.

Some of you will do even more dangerous sports

which put your life and your family's happiness at risk.

But we make those choices.

Women make those choices

when they're pregnant about what to do.

What screening to accept.

What to eat.

What to drink.

Whether to smoke.

They make all sorts of choices about themselves

because this is about themselves.

They make choices about where they plan to give birth.

I can't tell you where you should plan to give birth.

What I can now do is give you some evidence and some data

which allows you to make a more informed decision

than where we were a couple of years ago

when we didn't have this information.

But ultimately, it is up to women to decide where they want

to give birth based on the information they've got

and the ability of the servicers to provide care

for them in their settings.

Does it matter?

Of course, it matters.

There isn't a dinner party I didn't go

to where I don't hear birth story.

The most recent was from a 95-year-old woman

who told me the story of her first birth in detail.

Not graphic detail but, you know, this is a major event

for women and their families, having a baby

and people can remember this.

These choices matter not just in terms the physical outcome

of that event, whether you have a caesarian section,

whether the baby has a fractured clavicle but the emotional

and psychological consequences that play

from that are really important.

So, yes, it does matter

but I can't tell you whether it's safe or not.

What I can tell you is you have to make that decision

about whether you feel for you, with your set of values

of beliefs, these different settings are safe for you.

So, finally, very finally, how are the results being used?

I wish I could tell you.

Are lots of women planning to give birth at home,

I've no idea 'cause we didn't collect the data,

still don't collect the data in the UK although, to be fair,

this week, I have now started formal discussions

with the Department of Health

about how they can collect the data

so that we can hopefully do this study again.

This study, we estimated in total cost

over 12 million pounds to do.

And the idea that we could never do it again,

even though the results are likely to change practice,

seemed almost a negligent waste of resources because we need

to be able to monitor what's happening.

If more women choose to give birth outside hospital,

are we going to get the same results?

We need to know.

We need routine data so we can look

at that impact on mortality.

There were 760,000 births a year in the UK.

Two or three years, if we can classify low-risk women

and planned place of birth at labor onset,

we'll know where the planning based at home leads

to a higher risk of babies dying as a consequence of that choice.

They'll still be very, very, very, very small numbers

but at least, we'll be able to look for differences.

So, we may, it's the first time I've been able

to say this while talking about birthplace.

We may be able to do this routinely

in the future on a rolling basis.

So, first of all, we must thank everybody.

And thank you very much.

[ Applause ]

The Description of Where to give birth, at home or in a hospital? Does it matter? (29 Jan 2013)