It’s confusing.
The UK, with an elaborate system for studying maternity care, publishes reams of statistics about stillbirths, perinatal mortality, infant mortality and maternal mortality through MBRRACE-UK, Mothers And Babies: Reducing Risk through Audits and Confidential Enquiries. Here’s the latest publication UK Perinatal Deaths for Births from January to December 2017.
In 266 pages, with dozens of tables and charts, they slice and dice the mortality statistics in a thousand different ways: by ethnicity, by socio-economic status, by hospital system, by post code. Yet there’s one critical statistic that is missing: death rates at home birth. In fact, I’ve been writing about homebirth in the UK since 2006, but to my knowledge the UK has hidden their homebirth death rates the entire time.
Why? It might have something to do with the fact that the government began promoting homebirth aggressively BEFORE they could show that homebirth was safe. The key study of UK homebirth, the Birthplace Study, began years AFTER the government promotion efforts.
Indeed, a cynical person might wonder if perhaps the statistics from UK homebirths that were occurring before the Birthplace Study showed that homebirth has an increased risk of perinatal death and the government was desperately searching for some way to make homebirth appears as safe as hospital birth.
It might have something to do with the fact that back in 2006, NICE (the National Institute for Clinical Excellence) reviewed the existing homebirth literature and concluded that homebirth increases the risk of perinatal death.
The report was quoted in The Telegraph, June 2006 before it was officially published:
Birth outside a [physician] led unit is consistently associated with an increase in normal vaginal births, an increase in women with an intact perineum and an increase in maternal satisfaction…
The only other feature of the studies comparing planned births outside [physician] units is a small difference in perinatal mortality … Our best broad estimate of the risk is an excess of between 1 death in a 1000 and 1 death in 5000 births. We would not have expected to see this, given that in some of the studies the planned hospital groups were a higher risk population.
But the government wanted to promote homebirth and exerted pressure on NICE to change the report.
From The Telegraph, July 2, 2006:
Nice’s draft guidance, which included a recommendation for all pregnant women to be told of a “trend towards a reduction in perinatal mortality” in hospitals, was submitted to the Department of Health nearly a fortnight ago.
Several days later – and ahead of its publication on June 23 – it was altered by Andrew Dillon, chief executive of Nice, after concerns were raised by the Department of Health. To the fury of his own experts, who felt that their message was being diluted, the wording was changed to: “There may be a risk of lower perinatal mortality” in hospital.
Think about that: in an effort to promote homebirth, the government suppressed the opinion of its experts that homebirth increases the risk of perinatal death.
The Birthplace Study itself was hardly the unalloyed success they were hoping for. The authors found that homebirth increases the risk of death, brain damage and serious neonatal injury.
They evaluated the results by creating a composite index of poor outcomes: intrapartum stillbirths, early neonatal deaths, neonatal encephalopathy [brain damage] meconium aspiration syndrome, brachial plexus injury, and fractured humerus or clavicle. Using this measurement:
… [T]here was a significant excess of the primary outcome in births planned at home compared with those planned in obstetric units in the restricted group of women without complicating conditions at the start of care in labour. In the subgroup analysis stratified by parity, there was an increased incidence of the primary outcome for nulliparous women in the planned home birth group (weighted incidence 9.3 per 1000 births, 95% confidence interval 6.5 to 13.1) compared with the obstetric unit group (weighted incidence 5.3, 3.9 to 7.3).
In other words, the risk of death and serious injury was nearly double in the homebirth group and that increase was seen mainly among first time mothers. Moreover, the criteria for inclusion in the study were far stricter than the actual UK criteria for homebirth. Only the lowest risk women were included in the study despite the fact that higher risk women are eligible for homebirth.
The Birthplace Study fails to answer the most important question that women have about homebirth: does homebirth AS PRACTICED in the UK increase the risk of perinatal death. That information is undoubtedly available. A government that tracks perinatal death rates by ethnicity, socio-economic status, health system and post code can track perinatal death rates by whether or not a birth was a planned homebirth.
So why is the UK hiding their homebirth death rate? I suspect that it’s because the government fears (or knows) that homebirth in the UK increases the risk of perinatal death substantially, even more than what the Birthplace Study shows.
