World Health Matters (The Netherlands): Hospitals safer than home births in poor areas

by Gary Finnegan: Home births lead to higher infant mortality than hospital births, at least for mothers living in poorer areas, according to a new Dutch study which is likely to spark debate on a topic of considerable controversy.

However, outcomes for low-risk deliveries by mothers in the richer half of the country were equal to those in hospitals. Home birth is preferred by some as a less medicalised option and other studies have suggested faster recovery times and fewer “unnecessary” interventions.

The safety of home births for low-risk women is a hotly debated topic in the Western world. The Netherlands stands out as one of the few developed countries with a healthcare system geared toward home births, with more than half of all low-risk deliveries taking place at home. This makes it one of the best settings to study the safety of home births.

The research conducted by scientists at the University of Southern Denmark and IZA, VU University Amsterdam and the University of Mainz examines 356,412 low-risk Dutch women who delivered between 2000 and 2008 and who were allowed to choose between a home and a hospital birth. Their findings were published in the American Economic Journal: Applied Economics.

The study shows that home births lead to higher infant mortality among the poorer half of Dutch women. The researchers suggest that the infant mortality rate may be lower in hospitals because of the availability of advanced medical treatments (such as neonatal intensive care units).

In the richer half of the Dutch population, on the other hand, home births are as safe for the child as hospital births. The researchers suspect that low-income women benefit from hospital births because it is more difficult to assess whether they are low-risk or high-risk, for example due to difficulties communicating with their midwife.

One of the major challenges when investigating the effect of home births is that even among low-risk women, those who give birth at home or in a hospital may have different risk factors, with riskier deliveries usually taking place in the hospital. Therefore, babies born in a hospital often have more health problems than babies born at home and simple comparisons of these two groups are misleading.

In the present study, the researchers came up with an innovative solution to circumvent this problem. They noticed that some women gave birth at home or in a hospital depending on how far they lived from the nearest obstetric ward. The researchers then compared two groups of low-risk women who were identical, except that the women in one group had a higher probability of delivering in a hospital only because they lived closer to a hospital.

This study demonstrates that home births can lead to higher infant mortality for certain women, even in a country where the health care system is geared toward home births. In the context of the Netherlands, these women are those who live in the poorer half of the country and whose decision to deliver in a hospital or at home is affected by how far they live from the nearest hospital.