A first baby and a later baby are different decisions
In the English data, planning a home birth carried a higher rate of serious problems for a first baby and a slightly lower one for a later baby. And only 12% of those problems were deaths.
This is the single most important thing in this stage. If you take away one idea, take this one.
The Birthplace in England study followed 64,538 healthy women with low-risk pregnancies who booked a birth in one of four settings, and counted a combined measure of serious problems for the baby. Here are the whole-group results, per 1,000 births, with the counts.
| Planned place of birth | All women | First baby | Later baby |
|---|---|---|---|
| Hospital labor unit | 4.4 (81/19,551) | 5.3 (52/10,541) | 3.3 (29/8,980) |
| Home | 4.2 (70/16,553) | 9.3 (39/4,488) | 2.3 (31/12,050) |
| Freestanding midwifery unit | 3.5 (41/11,199) | 4.5 (24/5,158) | 2.7 (17/6,025) |
| Midwifery unit at a hospital | 3.6 (58/16,524) | 4.7 (38/8,256) | 2.4 (20/8,234) |
One note about the arithmetic, before you check it. Birthplace sampled hospital labor units at random rather than counting all of them, and it publishes rates weighted for that design rather than simple proportions. So the rate in each cell is not the two numbers beside it divided out: 39 out of 4,488 is printed as 9.3 per 1,000, not 8.7. Both the counts and the rates are as published, and this is true of every Birthplace figure in this stage.
Read the middle column and the right-hand column separately, because they point in opposite directions.
For a first baby, planning a home birth carried 9.3 serious problems per 1,000 against 5.3 in a hospital labor unit, an adjusted odds ratio of 1.75 (95% confidence interval 1.07 to 2.86). Among first-time women with no complicating conditions at all when labor care started, it was 9.5 against 3.5 per 1,000, an adjusted odds ratio of 2.80 (1.59 to 4.92). NICE puts the difference in its own words: planning birth at home is associated with an overall small increase in the risk of a baby having a serious medical problem (about 4 more per 1,000 births) compared with planning birth in other settings.
For a later baby, planning a home birth carried 2.3 per 1,000 against 3.3 in a hospital labor unit, with an adjusted odds ratio of 0.72 (0.41 to 1.27). That runs the other way, and it did not reach statistical significance in either direction. NICE's own advice reflects this split exactly, and it is worth quoting because it is a national guideline recommending home birth for one group and warning about it for another: Advise low-risk multiparous women that planning to give birth at home or in a midwifery-led unit (freestanding or alongside) is associated with a lower rate of interventions and the outcome for the baby is no different compared with an obstetric unit.
And for first babies: Explain that if they plan birth at home, there is a small increase in the risk of an adverse outcome for the baby.
Now the second half of this topic, which is the part most often left out.
The phrase "serious medical problem" in that study does not mean death. NICE published the breakdown of what the 255 events actually were.
| What happened | Babies affected | Share of all the problems counted |
|---|---|---|
| Neonatal encephalopathy | 102 / 63,955 (1.6 per 1,000) | 40% |
| Meconium aspiration syndrome | 86 / 63,955 (1.3 per 1,000) | 34% |
| Brachial plexus injury | 24 / 63,955 (0.38 per 1,000) | 9% |
| Death in the first week | 18 / 64,292 (0.28 per 1,000) | 7% |
| Stillbirth after labor care started | 14 / 64,535 (0.22 per 1,000) | 5% |
| Broken collarbone or arm bone | 11 / 63,955 (0.17 per 1,000) | 4% |
"When you say the risk of a serious problem, do you mean death, or do you mean something broader? What is in that count?"
"What are the numbers per 1,000 for a woman like me, having the baby I am having?"