More births at home: Prudence required

Some parties have recently been championing home births. Where the mother is young, the pregnancy uneventful and if ambulance transfer to hospital can be made quickly in an emergency, a home birth might be an option.

But not many buy the idea. Out of 39,874 live births in Singapore last year, only 104 were home births. Still, that was the highest number of home births in the last 10 years, which saw between 60 and 80 annually.

The same is true in the United States, always a bellwether of social change: US home births rose by 41 per cent between 2004 and 2010. But in absolute terms, home births were only 0.79 per cent of all US births in 2010 compared to 0.56 per cent in 2004.

A study of 16,924 planned home births published last month in the Journal of Midwifery & Women's Health found that "planned, midwife-led home births for low-risk women" are very safe.

The study uses data from the 2004 to 2009 Midwives Alliance of North America (Mana) Statistics Project. Home deliveries of healthy babies were uneventful, there was no rise in complication rates and there was little need for transfer to hospital.

The study involved low-risk pregnancies, meaning mainly young healthy mothers with no complications such as hypertension or diabetes during preganncy. In contrast, women in Singapore tend to have their first baby at an older age, as the median age at first marriage for women in 2012 here was 28.

Conventionally, there are two measures of infant death rates. The first is the "neonatal mortality rate", which is defined as deaths from birth to four weeks of life for every 1,000 live births. This is used the world over.

This study, however, covered infant deaths from birth up to six weeks of life, instead of four. No one else uses such a statistic. And the study showed that the death rate of babies from birth to six weeks was 1.61 for every 1,000 low-risk, live births at home.

By contrast, the death rate of babies from birth up to four weeks of life, for all live births in the US - both in hospital and at home - was around four for every 1,000 live births.

Why did the study resort to such an unusual measure of infant mortality? Perhaps statistical manipulation turned up the best rates for midwives if the period covered was stretched from birth to six rather than four weeks.

After all, hospital deliveries always include babies who are more likely to have serious conditions that could be fatal. It might have been that including such babies who die in the fifth and sixth weeks of life as well made the hospital numbers look worse than home births which are almost entirely low-risk pregnancies.

If so, and if infant deaths in the fifth and sixth weeks of life were removed, the study may well have shown that home births were no safer than - or even not as safe as - hospital births. Unless the authors explain this odd statistic, their study is to be viewed sceptically. Unfortunately, they do not justify its use.

An unusual statistic was also used in a 2009 midwifery study "proving" that low-risk pregnancy home births in Canada were twice as safe as hospital deliveries of low-risk pregnancies.

Which brings us to the other conventional measure of infant death rates, the perinatal mortality rate. Used the world over, this is defined as death from 28 weeks of pregnancy to 28 days of life.

Yet this second study devised its own unique measure of infant deaths: from 20 weeks of pregnancy to seven days of life. But no one else uses such a range. This is because when babies die in the womb up to 28 weeks of pregnancy, the quality of obstetric care is not usually the cause. Genetics are more likely the reason for stillbirths.

Perhaps including the additional stillbirths from 20 to 28 weeks of pregnancy made the hospital birth group look worse than the home birth group.

Statistical shenanigans aside, it is useful to compare the US and Canada. The infant mortality rates for hospital deliveries in both advanced health-care systems are much the same. However, the infant mortality rate for home births in the US is triple that of Canada.

The reason is likely because midwifery is highly regulated in Canada compared to the US.

In both countries, home births are managed by midwives, not doctors. However, in Canada, midwives receive more education and training to ensure they can recognise complications during labour and initiate their treatment even as they transfer a case to hospital.

In Canada, anyone who wants to become a midwife must first possess a university degree in a health science. Then comes four years of midwifery training in university, followed by a residency, during which the midwife-to-be must attend births both at home and in hospital.

As such, Canadian midwives know what can be done by doctors in hospital that cannot be achieved in the home environment. And they also have to remain affiliated to a hospital.

By contrast, the US midwife does not have such regulated educational and stringent licensing requirements to meet. American midwives are also not affiliated to hospitals. In recent times, a high school diploma has become the entry requirement but many practising midwives did not have to meet even that educational requirement.

A second difference is that in Canada, not every woman may have a home birth just because she wants one. There are strict eligibility requirements in place for home births. So anything other than a very low-risk case is considered too dangerous for home birth in Canada.

Even after getting the go-ahead for a home birth, the mother is pre-registered at a nearby hospital to which the midwife is affiliated and can be sent to hospital speedily if there are problems when the baby arrives.

None of these applies in Singapore, where midwifery is a 32-week, full-time advanced diploma course taught at Nanyang Polytechnic for trained nurses registered with the Singapore Nursing Board.

The course involves both classroom instruction and clinical training. Singapore midwives generally work in hospitals together with doctors during a mother's pregnancy and labour, and help in the care of the newborn, as well as when the mother is breastfeeding.

That is, they offer pregnancy and birth support but do not generally deliver babies.

Unless Singapore adopts the Canadian model for midwife training while also imposing strict eligibility requirements for home births, it seems prudent to stick with hospital deliveries.

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