Home delivery in low risk women reduces the number of caesarean sections without affecting perinatal outcome

OBJECTIVE: Worldwide, there is a strong increase in the number of Caesarean sections. This increase is worrisome, as it is generating morbidity withoutanimprovementinperinatal outcome.One reason for the increased C section rate might be the immediate presence of gynaecologists in hospital, who are used to intervene irrespective of the a priori risk. STUDY DESIGN: We performed a retrospective nationwide cohort study among 488,568 low risk women delivering under primary midwife-led care in The Netherlands over aperiod of 7 years (2000-2006). In The Netherlands, low risk women deliver under primary responsibility of a midwife, who has the possibility to refer to a gynaecologist for fetal distress, non-progressive labour or the need for pain relief. These low risk women have the choice between a planned home delivery and a planned hospital delivery, both under supervision of an independent working midwife. Caesarean section was the primary outcome. Analysis was according to intention-to-treat: the planned place of birth at home or in hospital. RESULTS: The Caesarean section rate was 5,973 among 321,307 women (1.9%) in the home delivery group versus 4,348 among 163,261 women (2.7%) starting in hospital (RR .70, 95% confidence interval .67 to .73). Similarly, the vaginal assisted delivery rates were 7.1% (22,698/321,307) in the home delivery group and 8.4% (13,707/ 163,261) in the hospital group (RR .84, 95% confidence interval .82 to .86). There was no difference in perinatal outcome in the two groups. CONCLUSION: In low risk women a barrier for immediate intervention by a gynaecologist reduces the operative delivery rate without compromising perinatal outcome.