Review article
Planned home versus planned hospital births in women at low-risk pregnancy: A systematic review with meta-analysis

https://doi.org/10.1016/j.ejogrb.2018.01.016Get rights and content

Abstract

New interest in home birth have recently arisen in women at low risk pregnancy. Maternal and neonatal morbidity of women planning delivery at home has yet to be comprehensively quantified. We aimed to quantify pregnancy outcomes following planned home (PHB) versus planned hospital birth (PHos).

We did a systematic review of maternal and neonatal morbidity following planned home (PHB) versus planned hospital birth (PHos). We included prospective, retrospective, cohort and case-control studies of low risk pregnancy outcomes according to planning place of birth, identified from January 2000 to June 2017. We excluded studies in which high-risk pregnancy and composite morbidity were included. Outcomes of interest were: maternal and neonatal morbidity/mortality, medical interventions, and delivery mode. We pooled estimates of the association between outcomes and planning place of birth using meta-analyses. The study protocol is registered with PROSPERO, protocol number CRD42017058016.

We included 8 studies of the 4294 records identified, consisting in 14,637 (32.6%) in PHB and 30,177 (67.4%) in PHos group. Spontaneous delivery was significantly higher in PHB than PHos group (OR: 2.075; 95%CI:1.654–2.063) group. Women in PHB group were less likely to undergo cesarean section compared with women in PHos (OR:0.607; 95%CI:0.553–0.667) group.

PHB group was less likely to receive medical interventions than PHos group. The risk of fetal dystocia was lower in PHB than PHos group (OR:0.287; 95%CI:0.133–0.618). The risk of post-partum hemorrhage was lower in PHB than PHos group (OR:0.692; 95% CI.0.634–0.755). The two groups were similar with regard to neonatal morbidity and mortality.

Births assisted at hospital are more likely to receive medical interventions, fetal monitoring and prompt delivery in case of obstetrical complications. Further studies are needed in order to clarify whether home births are as safe as hospital births.

Introduction

During the past decades, maternal and neonatal morbidity has markedly reduced thanks to hospitalization of pregnant women in labor, which allows strict monitoring of maternal and fetal wellbeing, reduces the risk of infection, and ensures medical intervention, ranging from amniorrhexis to cesarean delivery. Nonetheless, new interests in home birth have recently arisen in women at low risk pregnancy and the efficacy of medicinal interventions has been questioned. Advantages of home birth consist in fewer vaginal examination, freedom to be mobile during fetal monitoring, expectant management of the third stage of labor, and delayed cord clamping [1]. Medical interventions for low risk pregnancy might be higher than necessary [2]. In contrast, hospital care allows prompt intervention without any delay for transfer and ensures interventions that cannot be provided outside hospitals. Studies, that were conducted in order to analyze perinatal and maternal outcomes according to birth setting, provided conflicting results [[3], [4], [5], [6]]. A Cochrane review showed an increased risk of perinatal mortality [7], whereas a previous Cochrane review did not find significant differences in perinatal death [8]. A meta-analysis also showed that less medical intervention in home births are associated with a higher risk of neonatal mortality [9]. However, the latter did not specify whether the included studies were based on high or low risk pregnancy and whether midwives or obstetricians performed hospital care.

Therefore, we conducted a systematic review and meta-analysis about maternal and perinatal outcomes in home vs. hospital births assisted by midwives.

Section snippets

Methods

Data for this review were identified by searches of PubMed, Scopus Medline, Clinicaltrial.gov, EMBASE, and references from relevant articles using the search terms “home births”, “hospital births”, “neonatal morbidity/mortality”, “maternal morbidity/mortality”, “low risk pregnancy!, ‘midwife care’. Abstract and reports from meetings were included only when they related directly to previously published work. Only articles published in English between January 2000 and June 2017 were included if

Results

We identified 4294 records, and retrieved 937 for a more detailed evaluation after screening titles and abstracts (Fig. 1). We excluded 922, which were aimed to other objectives rather than comparison between planned home and panned hospital births, leaving 15 articles that potentially met the inclusion criteria. Seven articles did not meet at least one inclusion criterion and 8 articles reported usable information included in the review [[1], [4], [10], [11], [12], [13], [14], [15]].

We found

Discussion

This review shows that maternal and neonatal outcomes of women planning to deliver at home are similar to those opting for hospital setting. Post-partum hemorrhage is slightly higher in women delivering at hospital, but this increase does not appear to be clinically meaningful.

Nulliparous women delivering at home are at lower risk of adverse neonatal outcomes compared to those delivered at hospital [16]. We observed lower rates of nulliparous women delivering at home compared to those

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