1. Outcomes of Five Years of Planned Home Birth Attended by Regulated Midwives vs. Planned Hospital Birth in British Columbia P Janssen, PhD, 1,2,4,5, MC Klein, MD,CCFP 2,5 L Saxell, RM, MA 3 R Liston, MD, FRCSC, FRCOG. 4,5 SK Lee, MBBS, PHD, FRCPC, 6 Department of Health Care and Epidemiology 1, Family Practice 2, Midwifery 3 and Obstetrics and Gynecology, 4 Faculty of Medicine, University of British Columbia, Child & Family Research Institute 5, Vancouver, B.C., ICARE Research Centre, Edmonton, Alberta. 6

2. Controversy exists…. ACOG Choosing to deliver a baby at home is to place the process of giving birth over the goal of having a healthy baby. (2008) SOGC Endorses evidence- based practice and encourages ongoing research into the safe environment of all birth settings. (2003)

3. Is the decision to plan birth at home with a regulated midwife in attendance compared to the decision to plan birth in hospital attended by a) a physician or b) a regulated midwife associated with adverse perinatal or maternal outcomes? Primary outcome: perinatal mortality Study Question

4. Limitations of studies to date

5. Large Cohort Studies of Planned Home vs Hospital Incomplete Ascertainment

6. Midwifery in Canada BC Regulated and funded, 4 year baccalaureate program Alberta – similar as of last month week Saskatchewan –Regulated and funded Manitoba – Regulated and funded Ontario – Regulated and funded, 4 year baccalaureate program Quebec – Regulated and funded for birth centres, baccalaureate program New Brunswick – Regulated and funded Nova Scotia,, PEI, Nfld, Nunavit, Yukon – not regulated Northwest Territories – in process

7. Eligibility Requirements for Home Birth in BC Inclusion Informed signed consent Exclusions Gestational age > 41 or < 37 weeks Multiple birth Breech or other abnormal presentations Cardiac disease Hypertensive chronic renal disease PIH with proteinuria >30 mg/dl Insulin-dependent diabetes Antepartum hemorrhage after 20 weeks Active genital herpes More than 1 previous C/S

8. Transfer Rates from Home Nullips 38.1% Multips 12.8% Overall: 23.6%

9. Methods

10. Comparison of Birth Outcomes Study Group n = 2899 All births planned (at the onset of labour) to be at home and attended by a regulated midwife eg Complete Ascertainment Comparison Groups 1. Physician-attended births in hospital n = 5331 2. Midwife-attended births planned (at the onset of labour) to be in hospital n = 4752 (same midwives)

11. Home Birth Study Group Inclusion: College of Midwives of BC records indicated birth was planned at home Birth took place at home or in hospital and midwife listed as caregiver

12. Physician Hospital Comparison Group Inclusion: Delivered by a physician in hospital in which midwives were practicing Midwife not listed as any kind of caregiver in hospital record Met eligibility requirements for home births Matching (2:1) Year of Birth: 2000-2004 Parity (nulliparous vs. multiparous) Hospital where midwife caring for study subject has privileges Lone parent (yes, no) Age (< 15 yrs, 15-19, 20-24, 25-29, 30-34, 35+)

13. Midwife Hospital Comparison Group Inclusion (all midwife-attended planned hospital births) Gave birth in 2000-2004 Met eligibility requirements for home birth Midwife listed as any type of caregiver in hospital record College of Midwife records indicate birth was planned in hospital

18. Results

19. Socio-Demographic Characteristics - Age

20. Socio-Demographic Characteristics – Median Family Income Quintile per Postal Walk

21. Socio-Demographic and Pregnancy Characteristics

22. Use of Substances

23. Other Pregnancy Characteristics

24. Interventions in Labour by Intention to Treat

25. Method of Delivery

26. Indication for Cesarean Section

27. Maternal Outcomes 1 1 1

28. Maternal Outcomes

29. 2 9 6 2 1 1 2

30. Maternal Outcomes

31. * Adjusted for parity Statistically Significant

32. Stillbirth or Neonatal Death/1000 Births

33. Neonatal Outcomes In newborns without major congenital anomalies

34. Neonatal Resuscitation

35. Birth Trauma

36. Neonatal Outcomes

37. Statistically Significant

38. Comment, Conclusions

39. Not a Randomized Controlled Trial Strength or Limitation?

40. Conclusions physician Compared to women who planned birth in hospital with a physician, women who planned birth at home with a regulated midwife were: Less likely to have interventions during labour Less likely to have adverse maternal outcomes: –3 rd /4 th degree tear –Postpartum hemorrhage –Infection or pyrexia Less likely to have newborns with: –Apgar scores less than 7 at one minute –Birth trauma –Resuscitation at birth –Birthweight < 2500 g at term –Requirement for oxygen therapy more than 24 hours

41. Conclusions Compared to women who planned birth in hospital with a regulated midwife, women who planned birth at home with a regulated midwife were: Less likely to have interventions during labour Less likely to have adverse maternal outcomes: –3 rd /4 th degree tear –Postpartum hemorrhage –Pyrexia Less likely to have newborns with: –Apgar scores less than 7 at one minute –Meconium aspiration –Birth trauma –Resuscitation at birth –Requirement for oxygen therapy more than 24 hours More likely to have a newborn: –Admitted to hospital

42.  Home birth is neither safe or unsafe  Hospital birth is neither safe or unsafe  Either can be safe or unsafe  DEPENDS!!  In BC home birth by regulated supported midwives appears to be safe

43. END

44. Caregiver by Study Group Home BirthPhysicianMW-Hosp MW 2814 (97.1%)04537 (95.5%) FP 15 (0.5%)2714 (50.9%)87 (1.8%) OB 70 (2.4%)2615 (49.1%)127 (2.7%)