Why is the UK hiding their homebirth death rate?

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It’s confusing.

The UK, with an elaborate system for studying maternity care, publishes reams of statistics about stillbirths, perinatal mortality, infant mortality and maternal mortality through MBRRACE-UK, Mothers And Babies: Reducing Risk through Audits and Confidential Enquiries. Here’s the latest publication UK Perinatal Deaths for Births from January to December 2017.

In 266 pages, with dozens of tables and charts, they slice and dice the mortality statistics in a thousand different ways: by ethnicity, by socio-economic status, by hospital system, by post code. Yet there’s one critical statistic that is missing: death rates at home birth. In fact, I’ve been writing about homebirth in the UK since 2006, but to my knowledge the UK has hidden their homebirth death rates the entire time.

Why? It might have something to do with the fact that the government began promoting homebirth aggressively BEFORE they could show that homebirth was safe. The key study of UK homebirth, the Birthplace Study, began years AFTER the government promotion efforts.

Indeed, a cynical person might wonder if perhaps the statistics from UK homebirths that were occurring before the Birthplace Study showed that homebirth has an increased risk of perinatal death and the government was desperately searching for some way to make homebirth appears as safe as hospital birth.

It might have something to do with the fact that back in 2006, NICE (the National Institute for Clinical Excellence) reviewed the existing homebirth literature and concluded that homebirth increases the risk of perinatal death.

The report was quoted in The Telegraph, June 2006 before it was officially published:

Birth outside a [physician] led unit is consistently associated with an increase in normal vaginal births, an increase in women with an intact perineum and an increase in maternal satisfaction…

The only other feature of the studies comparing planned births outside [physician] units is a small difference in perinatal mortality … Our best broad estimate of the risk is an excess of between 1 death in a 1000 and 1 death in 5000 births. We would not have expected to see this, given that in some of the studies the planned hospital groups were a higher risk population.

But the government wanted to promote homebirth and exerted pressure on NICE to change the report.

From The Telegraph, July 2, 2006:

Nice’s draft guidance, which included a recommendation for all pregnant women to be told of a “trend towards a reduction in perinatal mortality” in hospitals, was submitted to the Department of Health nearly a fortnight ago.

Several days later – and ahead of its publication on June 23 – it was altered by Andrew Dillon, chief executive of Nice, after concerns were raised by the Department of Health. To the fury of his own experts, who felt that their message was being diluted, the wording was changed to: “There may be a risk of lower perinatal mortality” in hospital.

Think about that: in an effort to promote homebirth, the government suppressed the opinion of its experts that homebirth increases the risk of perinatal death.

The Birthplace Study itself was hardly the unalloyed success they were hoping for. The authors found that homebirth increases the risk of death, brain damage and serious neonatal injury.

They evaluated the results by creating a composite index of poor outcomes: intrapartum stillbirths, early neonatal deaths, neonatal encephalopathy [brain damage] meconium aspiration syndrome, brachial plexus injury, and fractured humerus or clavicle. Using this measurement:

… [T]here was a significant excess of the primary outcome in births planned at home compared with those planned in obstetric units in the restricted group of women without complicating conditions at the start of care in labour. In the subgroup analysis stratified by parity, there was an increased incidence of the primary outcome for nulliparous women in the planned home birth group (weighted incidence 9.3 per 1000 births, 95% confidence interval 6.5 to 13.1) compared with the obstetric unit group (weighted incidence 5.3, 3.9 to 7.3).

In other words, the risk of death and serious injury was nearly double in the homebirth group and that increase was seen mainly among first time mothers. Moreover, the criteria for inclusion in the study were far stricter than the actual UK criteria for homebirth. Only the lowest risk women were included in the study despite the fact that higher risk women are eligible for homebirth.

The Birthplace Study fails to answer the most important question that women have about homebirth: does homebirth AS PRACTICED in the UK increase the risk of perinatal death. That information is undoubtedly available. A government that tracks perinatal death rates by ethnicity, socio-economic status, health system and post code can track perinatal death rates by whether or not a birth was a planned homebirth.

So why is the UK hiding their homebirth death rate? I suspect that it’s because the government fears (or knows) that homebirth in the UK increases the risk of perinatal death substantially, even more than what the Birthplace Study shows.

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  • https://medicalxpress.com/news/2020-02-component-human-breast-cognitive-babies.html

    Just another piece of ammunition for the lactivists. I’m pretty sure they’ll spin this into something it isn’t.

  • mabelcruet

    I’m speaking from a position of pure ignorance here, but I wonder what proportion of homebirths are supervised by NHS midwives, and what proportion by independent midwives? We don’t have a lot of independent midwives because they have difficulty getting insurance I think. NHS midwives do look after homebirths, but they are integrated with standard NHS obstetrics as well and can transfer women into hospital based care if the need arises. I don’t know if independent midwives can do that, other than as an emergency same for any other emergency. Independent midwives are properly qualified degree level midwives (we don’t have anything like the CPM level midwives in the UK). For hospital and midwife led unit deaths, there is an awful lot of paperwork to be completed for MBRRACE, and all deaths are treated as a significant adverse incident and investigated, but I don’t know if independent midwives have to do that as well, especially as they are outside the normal NHS infrastructure. So maybe the figures aren’t properly being recorded?

    • Anna

      Doesn’t it have to be a neonatal death for there to be an investigation? in Aus its at the discretion of the coroner. There were a few well known cases 10ish years ago where the coroner decided to investigate even though it was not clear whether the baby was born live or not but my understanding is that if the baby is stillborn there usually isn’t an investigation. I do think its likely perinatal death rates would differ between independent and NHS midwives so it would be useful to break down homebirth deaths further – and include data such as whether the woman was low risk or not. The big meta analysis that came out last year excluded a number of reasonable studies because they didn’t meet the strict “low risk” criteria. Yet still that study is used to trumpet that homebirth is as safe as hospital. Drives me nuts, so many homebirthers are VBACers trying to “get it right”.

      • mabelcruet

        At the moment, Northern Ireland is the only region of the UK where the coroner can investigate stillbirths (on the grounds that a stillbirth could be considered a form of ‘child destruction’, under the terms of the 1929 children’s act, in that any fetus greater than 24 weeks gestation is capable of sustaining extra uterine life and the death may have been caused by someone doing something or not doing something). In England and Wales, the coronial legislation doesn’t cover stillbirths yet, although there is an ongoing consultation programme going on about whether the law should be changed. They are legally only permitted to investigate deaths of live born babies, or cases where it is not known if the baby was live born or stillborn (which occasionally happens with concealed pregnancies where the woman didn’t attend for medical care, or if she wasn’t aware she was pregnant). So a homebirth midwife delivering a live born baby who subsequently dies might be subject to a coronial investigation, but if the baby was stillborn, the coroner has no power. There could still be civil proceedings if the parents sue the midwife, and independent midwives still have to be properly registered and accredited by RCM, so if they were found to be clinically negligent they could be struck off, but it wouldn’t be a criminal investigation.