Review of Cochrane report: Planned hospital birth compared with planned home birth for pregnant women at low risk of complications

AIMS Journal, 2023, Vol 35, No 3

By Catharine Hart

Cochrane report: Planned hospital birth compared with planned home birth for pregnant women at low risk of complications

What is it: An updated review of randomised controlled trials that compare birth in hospital with planned home birth in low‐risk women. This is an update of a Cochrane Review first published in 1998, previously updated in 2012.

Who published it: The Cochrane Library

Publication date: 08 March 2023

Key points:

This review tries to discern the benefits and harms of hospital birth compared with planned home birth for low-risk women. This is in the context of a well-organised home birth service, backed up by medical support in case of transfer to hospital, as in the UK.

The authors searched databases for new studies to include. However, after applying exclusion criteria, only one new study with 11 participants was found to be included in this update. Clearly, such a low number of participants does not allow any conclusions to be drawn that could be generalised more widely. The authors also felt that the study was at risk of bias. They conclude that at present it is uncertain whether planned hospital birth reduces mortality or other important outcomes and further research is needed.

Extremely large trials are required for good quality evidence relating to mortality rates; the authors acknowledge that this will hardly ever be achievable. Randomised controlled trials studying the “effect” of place of birth remove any agency or choice about place of birth from the birthing woman. It is therefore good to see the authors of this review taking parents’ views into account that these kinds of trials are “no longer appropriate”. The authors recommend including evidence from observational studies instead (where data is looked at after the birth has happened, rather than randomising into two groups beforehand) in future Cochrane reviews. AIMS would welcome this development, given some of the limitations of randomised controlled trials, as outlined in our webpage understanding quantitative research evidence.

The authors of this report remind us that many interventions in obstetrics have not been supported by evidence. Archie Cochrane^[1] awarded a ‘wooden spoon’ prize to obstetrics in 1979 because of the lack of evidence to support the blanket policy encouraging all UK women to give birth in hospital at the time. Hospital birth is considered by the authors to be an ‘intervention’ in and of itself in this context, backed by concerns that the European Union's Health Monitoring Programme and World Health Organization have raised about the medicalisation of childbirth.

The report includes an interesting discussion about how interventions in a hospital may lead to disruption of physiological birth and also to further interventions - the ‘cascade of intervention’, with potential impacts not only on the current pregnancy, mother and child, but even into the following generation. There is a detailed analysis of how hospital birth could lead to this - although it was a little surprising to read that “sitting in a car with contractions” and “finding a car park” are listed as some of the first aspects of hospital birth, with an assumption that all birthing women and people drive to hospital!

The authors also note that information-giving about choice of place of birth is often not evidence-based or patient centred, but is subject to “organisational pressures and professional norms”; this is reflected in the feedback from women calling the AIMS helpline. AIMS campaigns for all pregnant women and people to be supported in their choice of place of birth, as in our Position Paper on Choice of Birthplace. Although this review may support this choice, the rhetoric often isn’t transformed into reality when significant numbers of birthing women and people still do not currently have a full choice of birthplace options in the UK. For this reason we continue to campaign for a maternity system that offers a genuine choice of birthplace for all pregnant women and people and better support for truly personalised care and for all those navigating the maternity system as it currently exists.

Author Bio: Catharine Hart studied biology at the University of York and later trained as a midwife at the University of East Anglia; she is an AIMS volunteer and a member of the Campaigns Team.