Thursday, July 1, 2010

BMJ Letter published: Homebirth versus elective caesarean risks

My letter, published in the British Medical Journal on 4th July 2010, was in response to the publication: 'Study shows higher rates of neonatal mortality with planned home births', by Susan Mayor.

It says:

The findings in this study, that planned home birth increases a baby's (albeit very small) risk of dying compared with a hospital birth plan, has received a great deal of media attention, and numerous medical professionals and birth groups have spoken out to defend home birth legitimacy and advocacy in the UK.

Surely then, particularly in light of studies such as this one published in Canada last year, 'Caesarean section on maternal request: risks and benefits in healthy nulliparous women and their infants' by LS Dahlgren et al, which found that an elective pre-labour caesarean delivery in a nulliparous woman at full term "decreased the risk of life- threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery", it is time to review current attitudes towards caesarean delivery on maternal request.

This Canadian study included almost 40,000 births, and even though the comparison used breech presentation as a healthy elective caesarean surrogate (which is arguably a more complicated delivery than a cephalic- presenting fetus) to compare with the healthy onset spontaneous labour group, the caesarean group's babies still had better outcomes.

Similarly an American study, also based on intent to deliver and not just actual delivery, 'Maternal Outcomes Associated with Planned Vaginal Versus Planned Primary Cesarean Delivery’ by EJ Geller et al, found that planned caesarean delivery had less chorioamnionitis (2.2% versus 17.2%), postpartum hemorrhage (1.1% versus 6.0%), uterine atony (0.6% versus 6.4%), and prolonged rupture of membranes (2.2% versus 17.5%) for the mother but a longer hospital stay (3.2 versus 2.6 days). There were no differences in transfusion rates.

If a healthy woman's maternal request to give birth at home is acceptable, then given the (two examples of) improved outcomes cited above, her request for a prophylactic caesarean delivery at 39+ weeks should be acceptable too."

News reports on the study that week included:

*01 July Home births are good for mothers but riskier for babies, says study, The Guardian
Breathing problems and failed resuscitation blamed for increased risk, with experts recommending two midwives for deliveries

*01 July Home birth risks under scrutiny, BBC News

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