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Review
. 2023 Mar 8;3(3):CD000352.
doi: 10.1002/14651858.CD000352.pub3.

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

Ole Olsen  1 , Jette A Clausen  2
Affiliations
Review

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

Ole Olsen et al. Cochrane Database Syst Rev. .

Abstract

Background: Observational studies of increasingly better quality and in different settings suggest that planned hospital birth in many places does not reduce mortality and morbidity but increases the frequency of interventions and complications. Euro-Peristat (part of the European Union's Health Monitoring Programme) has raised concerns about iatrogenic effects of obstetric interventions, and the World Health Organization (WHO) has raised concern that the increasing medicalisation of childbirth tends to undermine women's own capability to give birth and negatively impacts their childbirth experience. This is an update of a Cochrane Review first published in 1998, and previously updated in 2012.

Objectives: To compare the effects of planned hospital birth with planned home birth attended by a midwife or others with midwifery skills and backed up by a modern hospital system in case a transfer to hospital should turn out to be necessary. The primary focus is on women with an uncomplicated pregnancy and low risk of medical intervention during birth. SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register (which includes trials from CENTRAL, MEDLINE, Embase, CINAHL, WHO ICTRP, and conference proceedings), ClinicalTrials.gov (16 July 2021), and reference lists of retrieved studies.

Selection criteria: Randomised controlled trials (RCTs) comparing planned hospital birth with planned home birth in low-risk women as described in the objectives. Cluster-randomised trials, quasi-randomised trials, and trials published only as an abstract were also eligible.

Data collection and analysis: Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked the data for accuracy. We contacted study authors for additional information. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: We included one trial involving 11 participants. This was a small feasibility study to show that well-informed women - contrary to common beliefs - were prepared to be randomised. This update did not identify any additional studies for inclusion, but excluded one study that had been awaiting assessment. The included study was at high risk of bias for three out of seven risk of bias domains. The trial did not report on five of the seven primary outcomes, and reported zero events for one primary outcome (caesarean section), and non-zero events for the remaining primary outcome (baby not breastfed). Maternal mortality, perinatal mortality (non-malformed), Apgar < 7 at 5 minutes, transfer to neonatal intensive care unit, and maternal satisfaction were not reported. The overall certainty of the evidence for the two reported primary outcomes was very low according to our GRADE assessment (downgraded two levels for high overall risk of bias (due to high risk of bias arising from lack of blinding, high risk of selective reporting and lack of ability to check for publication bias) and two levels for very serious imprecision (single study with few events)). AUTHORS' CONCLUSIONS: This review shows that for selected, low-risk pregnant women, the evidence from randomised trials to support that planned hospital birth reduces maternal or perinatal mortality, morbidity, or any other critical outcome is uncertain. As the quality of evidence in favour of home birth from observational studies seems to be steadily increasing, it might be just as important to prepare a regularly updated systematic review including observational studies as described in the Cochrane Handbook for Systematic Reviews of Interventions as to attempt to set up new RCTs. As women and healthcare practitioners may be aware of evidence from observational studies, and as the International Federation of Gynecology and Obstetrics and the International Confederation of Midwives collaboratively conclude that there is strong evidence that out-of-hospital birth supported by a registered midwife is safe, equipoise may no longer exist, and randomised trials may now thus be considered unethical or hardly feasible.

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Conflict of interest statement

Ole Olsen: In the 36 months prior to the RevMan file was made available for us to work on for our updated review and until our draft was accepted for publication I may have published opinions relevant to place of birth in two medical journals (Practicus and Månedsskrift for Almen Praksis).

Jette A Clausen: In the 36 months prior to the RevMan file was made available for us to work on for our updated review and until our draft was accepted for publication I may have published opinions relevant to place of birth in one medical journal (Women Birth).

Figures

1
1
Figure 1. Cascade of interventions and complications
2
2
Applying the Cochrane Pregnancy and Childbirth Trustworthiness Screening Tool
3
3
Study flow and jump diagram.
4
4
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
5
5
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1: Planned hospital birth versus planned home birth, Outcome 1: Caesarean section
1.2
1.2. Analysis
Comparison 1: Planned hospital birth versus planned home birth, Outcome 2: Baby not breastfed
1.3
1.3. Analysis
Comparison 1: Planned hospital birth versus planned home birth, Outcome 3: Other (non‐epidural) medical pain relief
1.4
1.4. Analysis
Comparison 1: Planned hospital birth versus planned home birth, Outcome 4: Assisted vaginal birth
1.5
1.5. Analysis
Comparison 1: Planned hospital birth versus planned home birth, Outcome 5: Perineal sutures
1.6
1.6. Analysis
Comparison 1: Planned hospital birth versus planned home birth, Outcome 6: Mother disappointed about allocation
1.7
1.7. Analysis
Comparison 1: Planned hospital birth versus planned home birth, Outcome 7: Father did not state that he was relieved
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References

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