References for “The Myth of A Safer Hospital Birth for Low Risk Pregnancies” –> literature search

by faithgibson on August 11, 2013


Studies #1 thru # 12 are methodologically defined by this author as the “best of the best”.

These high quality studies, all published since 1995, are from Canada, Switzerland, Sweden, Holland, US, UK, New Zealand and Israel, show planned attended homebirth to have either lower or similar rates of perinatal mortality, while also documents a very significantly lower rates of maternal morbidity, such as cesareans, hemorrhage, and third and fourth degree tears compared to matched groups of low risk women who plan to deliver in hospital.

1. Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee SK. Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ 2009;181:377–83.

2. Hutton EK, Reitsma AH, Kaufman K. Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003–2006: a retrospective cohort study. Birth 2009;36:180–9.

3. Janssen, P.A., et al. 2002. Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. CMAJ 166: 315-23.

4. Ackermann-Liebrich U, Voegeli T, Gunter-Witt K, Kunz I,Zullig M, Schindler C, et al. Home versus hospital deliveries Zurich: follow up study of matched pairs for procedures and outcome. BMJ 1996;313:1313–8.

5. Lindgren HE, Radestad IJ, Christensson K, Hildingsson IM. Outcome of planned home births compared to hospital births in Sweden between 1992 and 2004. A population-based register study. Acta Obstet Gynecol Scand 2008;87:751–9.

6. Shiftan, A., et al. 2009. Planned home deliveries in Israel between the years 2003-2007. Harefuah 148(6): 362-6, 413. Hebrew.

7. Johnson KC, Davis BA. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ 2005;330:1416.

8. Wiegers TA, Keirse MJ, van der Zee J, Berghs GA. Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in The Netherlands. BMJ 1996;313:1309–13.

9. Anderson RE, Murphy PA. Outcomes of 11,788 planned home births attended by certified nurse-midwives. A retrospective descriptive study. J Nurse Midwifery 1995;40:483–92.

10. Chamberlain G, Wraight A, Crowley P. Birth at home. Pract Midwife 1999;2:35–9.

11. Gulbransen G, Hilton J, McKay L, Cox A. Home birth in New Zealand 1973–93: incidence and mortality. N Z Med J 1997;110:87–9.

12. Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ. 2011;343:d7400.

Studies #13 through #17 all conclude that OOH birth as less safe than planned hospital birth but unfortunately, all 5 of these papers are methodologically flawed.

All claim homebirth to have a higher perinatal mortality rate compared to hospital birth, but they all include high risk births in the planned homebirth group.  Instead of excluding the high risk births from both groups, they include the homebirth outcomes of:

  • premature births at 34-37 weeks gestation (13-17)
  • breech and twins (13,14)
  • lethal anomalies incompatible with life(13,14)
  • unattended homebirths (15,16)
  • unplanned homebirths(15,16) or
  • women who became risked out of homebirth by becoming high risk at the end of pregnancy, had hospital births, but are included in the homebirth group. (17)

What these 5 papers actually found is that low risk births are safer at home but premature births have better outcomes in hospital.  Possible explanations for the false conclusion of these studies could be paternalistic power games over women or hospital birth being not only the most common but also the most profitable reason for hospitalization.  Remove the high risk births from those studies and they also confirm that homebirth is safer for low risk women than hospital birth.

#13 Bastian H, Keirse MJ, Lancaster PA. Perinatal death associated with planned home birth in Australia: population based study. BMJ 1998;317:384–8.

#14 Kennare RM, Keirse MJ, Tucker GR, Chan AC. Planned home and hospital births in South Australia, 1991–2006:differences in outcomes. Med J Aust 2010;192:76–80.

#15 Pang JW, Heffelfinger JD, Huang GJ, Benedetti TJ, Weiss NS.Outcomes of planned home births in Washington State:1989–1996. Obstet Gynecol 2002;100:253–9.

#16 Wax JR, Lucas FL, Lamont M, Pinette MG, Cartin A, Blackstone J. Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol 2010;203:243.e1– 8.

#17 Evers AC, Brouwers HA, Hukkelhoven CW, Nikkels PG,Boon J, van Egmond-Linden A, et al. Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study. BMJ 2010;341:c5639.

Studies #18, 19 & 20

Margaret Tew, a statistician, pointed out as early as 1977 (18) that hospital birth was never researched for safety before it was instituted.  She analyzed whatever data she could find from the years in which birth transitioned to hospital 1920-1950, searching for evidence of improved outcomes of hospital birth, but did not find any.  She found great resistance to publishing her findings in peer reviewed journals, with only the one scholarly reference in a journal(18) and the rest of her findings published in a chapter of a book and her own book. (19,20)

#18. Tew M. 1977. Obstetric hospitals and general practitioner units: the statistical record. Journal of the Royal College of General Practitioners. 27:689-94.

#19. Tew M. 1978, The case against hospital deliveries: the statistical evidence. In: Kitzinger S, Davis J. eds. The place of birth: A study of the environment in which birth takes place with special reference to home confinements. Oxford: Oxford University Press: 55-65.

#20. Tew M 1990. Safer Childbirth: a critical history of maternity care: London: Chapman and Hall.

Commentary on Study #21:

#21. Shearer JML. Five year prospective survey of risk of booking for a home birth in Essex. BMJ 1985;219:1478-80.

Dr Shearer 1985: “When I started in general practice in 1954 about a third of all babies were born at home, and only women with problems and a few primiparas were able to book a bed in the local hospital, St John’s Chelmsford.  By the early 1970s this had changed greatly, and it was possible to book all mothers who wished for or needed a bed in the consultant unit. Although my partners and I continued to look after home deliveries, we were often asked about the risk of a home birth, and in the past decade the usual reason given by low risk mothers for a request for a hospital delivery was”because it is safer.’ There appears to be no firm evidence for this view.” (21)

Commentary on Studies #22, 23, & 24:

#22. MacDorman MF, Declercq E, Menacker F, Malloy MH. Infant and neonatal mortality for primary cesarean and vaginal births to women with “no indicated risk,” United States, 1998-2001 birth cohorts. Birth. 2006 Sep;33(3):175-82.

#23. Anderson RE, Murphy PA. Outcomes of 11,788 planned home births attended by certified nurse-midwives: a retrospective descriptive study. J Nurse-Midwifery. 1995;40:483_92.

#24. Worth J. District midwifery in the 1950s. MIDIRS Midwifery Digest 2002. 12:2:174-6.

Published perinatal mortality rates of low risk women at planned attended homebirth and hospital birth average 0.6/1000 for vaginal births and 1.8/1000 for cesareans (22,23).   Perinatal mortality rates for hospital births of low risk women are similar to outcomes of planned homebirth in general, but the maternal morbidity at planned hospital births is much higher.  The most optimal perinatal mortality and maternal outcomes are reported by excellently trained, motivated homebirth midwives:

0/1000 Poplar, East London District, UK 1950: Jennifer Worth reports having delivered well over 100 babies before qualification and several thousand after in the post WWII tenements, where there was no running water and a family of 10 lived in one room, and a family of 10 was common.  “I do not recall any instance of an emergency occurring, still less a disaster during delivery. Young people today simply do not believe me when I say this but I can only say ask any midwife of my generation who has had a good deal of district experience and she will confirm this.

One reason, I think, why we did not have many problems is because we gave very good prenatal care, with careful screening for abnormalities such as rickets. Any woman with rickets was referred to hospital for cesarean delivery. Undiagnosed breech and twins did occur though. Disasters just did not seem to occur. Perhaps this had something to do with the attitude of the mother and the midwife.” (24)

#25. Lindgren HE, Radestad IJ, Christensson K, Hildengsson IM. Outcomes of planned home births compared to hospital births in Sweden between 1992 and 2004: a population-based register study. Acta Obstet Gynecol 2008;87:751-9.

#26. Doumouchtsis SK, Arulkumaran S. Head trauma after instrumental births. Clin Perinatol. 2008;35(1):69-83, viii.

#27. Richardson J. Supervisory issues: lessons to learn from a home birth. 2009. BJM 17:11:710-12.

#28. Kahana B, Sheiner E, Levy A, Lazer S, Mazor M. Umbilical cord prolapse and perinatal outcomes. Int J Gynaecol Obstet. 2004;84(2):127-32.

#29. Landon MB. Predicting uterine rupture in women undergoing trial of labor after prior cesarean delivery. Semin Perinatol. 2010 Aug;34(4):267-71.

#30. Knight M., D. Tuffnell, P. Brocklehurst, et al. 2010. UK Obstetric Surveillance System. “Incidence and risk factors for amniotic-fluid embolism.” Obstet Gynecol 115 (5): 910–7.

#31. McCormack R, Doherty D, Magann E, Hutchinson M, Newnham J. Antepartum bleeding of unknown origin in the second half of pregnancy and pregnancy outcomes. BJOG 2008;115:1451–1457.

#32. Laughon SK, Zhang J, Grewal J, Sundaram R, Beaver J, Reddy UM. Induction of labor in a contemporary obstetric cohort. Am J Obstet Gynecol. 2012;206(6):486.e1-9.

#33. Pariente G, Wiznitzer A, Sergienko R, Mazor M, Holcberg G, Sheiner E. Placental abruption: critical analysis of risk factors and perinatal outcomes. J Matern Fetal Neonatal Med. 2011;24(5):698-702.

#34. Landon MB. Predicting uterine rupture in women undergoing trial of labor after prior cesarean delivery. Semin Perinatol. 2010 Aug;34(4):267-71. (redundant reference)

================================== About the Author ======================

Judy Slome Cohain is a masters degree certified nurse midwife in the US who has been living and working in Israel since 1983 as an unlicensed midwife. This twist of fate enables her to practice evidence-based midwifery, instead of less-than-optimal protocols to protect a license. Judy welcomes feedback or questions which can be sent to