Using birth statistics

The Birthplace study: Safety, transfers and interventions compared

7 min read

Where you plan to give birth can affect the experience you have – from how likely it is that you’ll have an unplanned caesarean to your chances of being transferred during labour. Here we outline the findings of the BMJ Birthplace study.

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About the study

The Birthplace study by the British Medical Journal (BMJ) in 2011 looked at what happened to more than 64,000 mothers giving birth in England. This large study compared how safe it was for women with no medical complications who were having straightforward, healthy pregnancies to give birth at home, in a labour ward or in a birth centre.

The study looked at whether the planned place of birth affected the outcome for the baby; whether there were any benefits for women to choose one place of birth over another; and how the chosen place of birth affected how likely a woman is to be transferred to an obstetric unit.

Our handy Birth Choice tool takes the findings of this study into account, so if you’re ready to find the right place for you to give birth, use the tool to compare your local options and find your best fit.

Main findings

  • For first-time mothers planning a home birth, there was a small increase in the risk to their baby over planning birth in a labour ward, but babies of women having a second or subsequent baby did not have this increased risk.
  • Planning to give birth in a birth centre was found to be as safe for the baby as planning birth in a labour ward for all mothers at low risk of complications.
  • First-time mothers planning a home birth or birth in a birth centre were more likely to transfer to the labour ward in labour or immediately after the birth than women having a second or subsequent baby.
  • Women planning to give birth at home or in a birth centre were less likely to have major interventions (such as an unplanned caesarean) during labour than women planning vaginal birth in a labour ward.

How were outcomes for the baby measured?

In general, a birth was counted as unsafe if the baby suffered any birth injury, didn’t get enough oxygen during the birth or died during the labour or shortly afterwards. These were termed ‘serious adverse outcomes’. The definition used included some complications that don’t necessarily lead to long-term problems for the baby, but that are serious at birth.

How were outcomes for the mother measured?

The research looked at whether the mother had interventions like a caesarean or assisted birth, or if she needed a blood transfusion. It also looked at positive measures, such as whether she breastfed her baby after the birth, or if she had a ‘normal birth’ without medical intervention.

Which women were included in the study?

The Birthplace study was based on the women’s plans for where they were going to give birth, based on their care at the start of labour – so it was not based on where they actually gave birth. The study included:

  • 17,000 women planning a home birth
  • 28,000 women planning birth in a birth centre (midwife-led unit)
  • 20,000 women planning birth in a hospital labour ward (obstetric unit).

The main study looked only at women who were at low risk of complications, so women who were healthy and who didn’t have complications in their current or a previous pregnancy or birth. The study didn’t include women who were having twins or a planned caesarean.

Was this a good quality study?

Yes, this study was well-conducted with expert researchers and investigators. Enough women took part in the study to be able to see if there were real differences in safety and other outcomes between the different birth settings. It also took into account factors which could have affected the results, such as the women’s age, ethnicity and whether it was their first pregnancy.

Outcomes for the baby

Overall, for women at low risk of complications, the results showed that wherever a woman has her baby, birth is very safe. Only about 4.3 in 1,000 births were found to have a serious adverse outcome for the baby.

First-time mothers

For women having their first baby, there was no difference in safety for the baby between women planning to give birth in a hospital labour ward and those planning to give birth in a birth centre, whether that unit was some distance away from the hospital (‘freestanding’) or on the same site (‘alongside’).

For women planning a home birth for a first baby, the number of babies having a serious adverse outcome was 9.3 per 1,000 births compared to 5.3 per 1,000 in an obstetric unit.

Table 1: Outcomes for the baby for each planned place of birth: low-risk women having their first baby (per 1,000 births).


Second or subsequent births

For women at low risk of complications who had already given birth at least once before, there was no difference in safety for the baby between births planned to be in a hospital labour ward, a birth centre or at home.

Table 2: Outcomes for the baby for each planned place of birth: low-risk women who have had a baby before (per 1,000 births).


Transfer rates

Women who were having their first baby were around three times more likely to transfer from their home or birth centre to an obstetric unit than women who’d had a baby before. The difference was most pronounced when looking at transfers taking place before the baby was born, rather than after.

First-time mothers

35% of first-time mothers planning a home birth transferred to the hospital before their baby was born, and 9% afterwards. About 55% of women planning to have their first baby at home were able to successfully complete their home births without going to hospital.

The transfer rates for first-time mothers from birth centres were around 36-40%, with slightly higher transfer rates from an alongside birth centre compared to freestanding birth centres.

Table 3:  Transfers during labour or immediately after birth among healthy first-time mothers with low-risk pregnancies by their planned place of birth at start of care in labour.


Second or subsequent births

About 10% of second or subsequent birth mothers planning out-of-hospital births were transferred to hospital either in labour or after the baby was born. The rate of transfer was lower from freestanding birth centres (9%) compared to home birth and alongside birth centres (12%).

Table 4:  Transfers during labour or immediately after birth among healthy second or subsequent time mothers with low-risk pregnancies by their planned place of birth at start of care in labour.


Interventions in labour

Low-risk women planning births at home or in midwifery units had significantly fewer interventions than women planning to give birth in obstetric units. 

First-time mothers

Low-risk women planning a first birth in a hospital labour ward were nearly twice as likely to have an unplanned caesarean or ventouse birth than those planning a home birth, and were also more likely to have a forceps delivery.

Table 5: Outcomes for low-risk first-time mothers planning birth in different birth environments

*’Normal birth’: without induction, epidural or spinal, general anaesthetic, caesarean, forceps, ventouse or episiotomy.


Second or subsequent births

The difference in birth interventions between low-risk women planning to give birth in a labour ward compared to at home or in a birth centre were even bigger in women having a second or subsequent baby.

They were four to eight times more likely to have an unplanned caesarean in a labour ward compared with other settings. Women planning birth in a labour ward were also substantially more likely to have an epidural, episiotomy or augmentation of labour.

Table 6: Outcomes for low-risk women planning birth in different birth environments for second or subsequent time mothers.

*’Normal birth’: without induction, epidural or spinal, general anaesthetic, caesarean, forceps, ventouse or episiotomy.


Conclusions

The results of the Birthplace study support the principle that women should have a choice in where they give birth, as all birth settings were found to be safe for women at low risk of complications.

While there were some variations in the rate of interventions and safety for the baby depending on planned place of birth and if the women had given birth before, the BMJ concluded that the differences were not so great that they should restrict women’s birth choices.

We took the findings of the Birthplace study into account when creating our Birth Choice tool. When you use the tool, we’ll ask you if you have any risk factors and whether you’ve given birth before, as well as how willing you are to plan for the possibility of having to transfer in labour, before we make suggestions of the best place for you to give birth.

References

These are the sources of information used in this article:

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 (2011)

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 – Appendices, Data supplement to BMJ 2011;343:d7400 (2011)

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