Health Evidence Bulletins - Wales

Date of Completion: 9.1.98

The contents of this bulletin are likely to be valid for approximately one year, by which time significantly new research evidence may become available

10. Where to be born

(Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation)

This chapter should be read in conjunction with Chapter 15 "Maternal support in labour"

The continuing debate on 'Where to be born', is reviewed by Campbell and Macfarlanei. Reports prior to the 1920s are limited but the change to almost universal institutional delivery was based on a concept of greater safety of hospital confinement. Recent reports on the benefit/risk of different settings share the common problem of choosing outcomes to measure. Mortality is now fortunately small while morbidity and maternal satisfaction are more difficult to define and measure(i). As far back as 1986, Eva Alberman concluded that 'all available evidence suggests that in carefully selected and well-supervised low-risk deliveries the extra risk to the mother and baby attributable only to the absence of hospital facilities must be low, and the satisfaction of a successful delivery high. Against this must be set the chance of needing an emergency transfer"(ii). Any bias in analysis of outcome by place of birth can be avoided in selection, by place of booking not place of delivery, and by inclusion of all women, both high and low risk. Rates of transfer are important and the poorer outcomes noted among women transferred from home or general practitioner units compared with women not transferred may result from selective transfer of women with problems(i,ii).
i. Campbell R, Macfarlane A,. Where to be born? The debate and the evidence. 2nd ed. Oxford: National Perinatal Epidemiology Unit, 1994.
ii. Alberman E., (Epidemiological advisor to the House of Commons Select Committee) in Place of Birth, British Journal of Obstetrics and Gynaecology 1986; 93: 657-658.
The Statements The Evidence
10a. The Scottish study on perinatal mortality shows the strength of using population based data and birthweights and cause of death (i). i. Cole SK, Macfarlane A. Safety and place of birth in Scotland. Journal of Public Health Medicine 1995; 17:17-24.
10b. Confidential enquiry reports and additional analyses reported by Settatree show that, for 1993, births which were planned to take place at home and actually did so experienced a higher rate of intrapartum mortality (9 deaths and 7826 survivors) than all other births (379 deaths and 668578 survivors). This is equivalent to about one extra death per thousand births(i,ii).
(Health gain notation - 3 "trade-off between beneficial and adverse effects")
i. Confidential Enquiry into Stillbirths and Deaths in Infancy 1993 Part II.DOH 1995
(Type IV evidence - well designed non-experimental studies);

ii. Settatree, RJ. Mortality is still important, and hospital is safer. British Medical Journal 1996; 312:756-7
(Type IV evidence - observational studies)

10c. Campbell and Macfarlane conclude that, since women prefer to have a choice, it is probably too late to utilise randomised controlled trials in areas such as home confinement and that while descriptive research, case-control or non-randomised cohort studies are possible there is inherent difficulty in avoiding bias(i,ii,iii). Recommendations from the National Birthday Trust regarding home confinement may be of value to purchasersiii.

A further study is currently underway(iv).

(Health gain notation - 4 "unknown")

i. Campbell R, Macfarlane A. Where to beborn? The debate and the evidence. 2nd ed. Oxford: National Perinatal Epidemiology Unit, 1994.
(Type I evidence - systematic review, mostly observational studies);
ii. MacVicar J, Dobbie G, Owen-Johnstone L, Jagger C, Hopkins M, Kennedy J. Simulated home delivery in hospital: a randomised controlled trial. British Journal of Obstetrics and Gynaecology 1993; 100: 316-323
(Type II evidence - randomised controlled trial);


iii. Chamberlain G, Wraight A, Crowley P (eds.) Home Births. The report of the 1994 confidential enquiry by the National Birthday Trust Fund. New York: Parthenon, 1997. (Type IV evidence - case matched study of midwife-led care);
iv. Davies J, Hey E, Reid W, Young G. Home Birth Study Steering Group. Prospective regional study of planned home births. British Medical Journal. 1996; 313: 1302-1306.
(Type IV evidence - prospective study)

10d. Trials of the efficacy of midwife led care report transfer rates of between 32% and 54%. There is no dispute on the importance of agreed standards for selection and transfer whether from home, community hospital or midwife led care (i). i. Consensus statement on midwife-led care in Wales. Cardiff: Welsh Medical and Nursing Committees. Welsh Office, 1996

(Type V evidence - expert opinion)

10e. Choice for a woman regarding place of birth is inevitably interrelated with choice of carer and continuity of care(i). i. See Chapter 15 ‘Maternal support in labour’;
10f. Continuity of caregivers has been shown to result in less antenatal admissions. Women receiving continuity of care are more likely to be satisfied with that care. It is unclear whether these benefits are due to greater continuity or more midwifery involvement(i,ii,iii).

(Health gain notation - 2 "likely to be beneficial")

The effects of continuity of care are covered in Chapter 15.

i. Hodnett ED. Continuity of caregivers during pregnancy and childbirth. Cochrane database of systematic reviews. Cochrane Library 1997 Issue 4.
(Type I evidence - systematic review of two trials);
ii. Hundley V A, Cruickshank FM, Lang GD et al. Midwife managed delivery unit: a randomised controlled comparison with consultant led care. British Medical Journal. 1994; 309: 1400-1404
(Type II evidence - randomised controlled trial of 2844 women);
iii. Rowley M, Hensley MJ et al. Continuity of care by midwife team versus routine care during pregnancy and birth: a randomised trial. Medical Journal of Australia. 1995; 163: 289-293
(Type II evidence - randomised controlled trial)

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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: