But what if there's an emergency? An analysis of home birth transfer rates

Home birth is a little chosen birth place option, often considered a risky choice. Societal beliefs that birth is inherently risky (spoiler alert! it's not!) had led to hospital being the most chosen place to give birth, with the safety net of doctors, midwives and drugs "just in case". Yet we know that opting to birth in hospital ironically increases the likelihood of you needing medical intervention due to culture, environment and policy. Studies have shown that choosing to give birth at home reduces your risk of a laundry list of medical interventions (see my previous post here). Home birth means 70% less likely to request an epidural; 40% less likely to end up with an unplanned caesarean; 50% less likely to have an instrumental birth (forceps or vacuum); 55% less likely to have an episiotomy; 40% less likely to have a 3rd or 4th degree tear; 60% less likely to require synthetic oxytocin to augment labour and induce contractions; a reduced chance of postpartum haemorrhage; and 75% less likely to get an infection. But despite these statistics, the niggling "what if" still prevails and many opt for hospital despite the evidence showing birth is safe, as is home. Midwives expressing concern over availability of ambulances, and staffing shortages add to the pressure to opt for hospital. So what IS the likelihood you may need to transfer from home if you choose to birth there?


A systematic review done in 2014 looked at home births and the number of transfers to hospital as well as the reasons. When looking at transfer rates, it's important to break these stats down, as this is often given as a reason first time parents shouldn't birth at home (the transfer rate is higher for first time birthers but we'll dig in to the reasons in a moment). This study looked at 215,257 women and found that overall, the transfer rate from home to hospital was between 9.9% and 31.9%. Of these transfers, only a small percentage were true emergencies:

  • Stalled/slow labour - 5.1% to 9.8%

  • foetal distress - 1% to 3.6%

  • postpartum haemorrhage 0% to 0.2%

  • infant respiratory problems 0.3% to 1.4%

  • emergency transfers 0% to 5.4%

The majority of transfers took place during labour and before birth of baby (between 8.4% to 24.1%). Between 1.7% and 7.3% of transfers took place after the birth, but classification of transfers after birth varied between 2 hours and 5 days, which skews these figures massively and again could be argued that the true transfer rate to be smaller when considering safety of home birth. The 0-5.4% of "emergency transfers" (and these are the ones that people tend to worry about as they are believed to need an ambulance) included reasons arguably not a true blue light emergency such as failure to progress and meconium. In one of the studies, transfer by ambulance classed the transfer as an emergency, but simply being transferred by ambulance does not necessarily mean it was an emergency, purely that someone called an ambulance. For these reasons, potentially the emergency transfer figure may be in reality much smaller.


The risk of transfer for first time birthers was higher (between 23.4% and 45.4%) in comparison to subsequent births (between 5.8% and 12%). Across both these groups, slow labour was the most common reason.


They found transfer rates much higher when birth was attended by a midwife from an integrated setting, versus home births attended by independent midwives. This may be explained by the stricter rules in place by NHS and hospital midwives who are obliged to recommend transfer compared to independent midwives who can watch and wait. In my personal opinion this implies that some transfers (particularly the high number of transfers for slow labour) are due to a failure to wait and give the birthing person and baby the time they need to progress. We know that hospital guidelines state a specified rate of progression of labour, and if this is not demonstrated, intervention is recommended (sometimes unnecessarily). A specific UK study compared births supported by NHS midwives versus independent midwives and found that only 0.4% of NHS midwife supported births were home births compared to 66% of births assisted by independent midwives. It's very apparent that the NICE guidelines and policies NHS midwives have to follow influence the choices a pregnant person makes.


When choosing a birth place, or arguably any decision regarding your birth, it's important to have access to research, information and statistics to help inform that decision. Quite often my clients do not get this information from their midwife or consultant, or they are given outdated studies, or studies specifically selected to back up the recommendation being made. Having access to an unbiased and knowledgable birth worker who can signpost you to reliable sources of information to inform your decisions is invaluable, and that's just one of the many benefits of choosing to do a course with me. If you'd like support with your bath prep, get in touch.


References:

Blix, E., Kumle, M., Kjærgaard, H. et al. Transfer to hospital in planned home births: a systematic review. BMC Pregnancy Childbirth 14, 179 (2014). https://doi.org/10.1186/1471-2393-14-179

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