Home birth and distance from hospital

Anna M.

Home birth and distance from hospital

I have been trying to find information about studies that would show how the safety of homebirth relates to the distance to the hospital. In other words, what is, or is there a safe distance from hospital for a homebirth. I have come across many places that say that about 30 mins is a safe distance and many midwives refuse to attend homebirths if the distance is longer, but I haven't been able to find what basis this decision is usually made on. I also found that for example in England, in a place called cornwall local midwives favour homebirths although the closest hospitals are 45-60 mins away because they say the long journey is an unnecessary risk to the birthing mothers.

The reason I am asking this is because I live about 50-60 mins away from the closest birthing hospital, and am still considering a home birth. Where I live there really are no options, no birth centers, etc. The hospital (as well as the others furher away) are places where you cannot even chose who your care provider is going to be. It is midwife led, but there are countless "standard  procedures" (=interventions) that are unneccessary and I would like to avoid. I also have no way of chosing who the midwife who would be in charge of me would be as it just depends on who's in turn when the birth takes place (care during pregnancy is done by community nurses who are not involved in birth). I had a very negative experience with the birth of my second child in a local hospital, which amounted to birth trauma and ppd. I don't want this to happen again, but I also don't want to be stupid and take a risk if I simply live too far from a hospital to have a safe home birth. The distance is an issue to local home birth midwives. Ironically the ones closer refused to assist a birth here, but I have found one who lives 2hrs away who is willing to travel here for my birth (my previous two have been very slow births).

So if you are aware of any studies or facts that would help me research and understand this issue and make a truly informed choice I would be very thankful for your help.

Henci Goer

RE: Home birth and distance from hospital
(in response to Anna M.)

I am not aware of any research on this point. I think, though, that the 30 minute limit is based on a rule of thumb that a hospital ought to be able to perform an urgent cesarean within 30 minutes of making the decision, a.k.a. "30 minutes decision-to-incision." By extension, women laboring outside of the hospital should live no further than 30 minutes away so that by calling ahead, the hospital could be prepared to operate within that time frame.

I am not aware of any evidence basis for this rule--in fact, just the opposite. As Amy Romano, my co-author, wrote in the birth center chapter of Optimal Care in Childbirth, because the 30 minute rule is invoked by plaintiffs in malpractice cases, obstetricians have been motivated to establish that they should not be held to it. We have studies, therefore, showing that outcomes correlate poorly with decision-to-incision times, that even in well-equipped and staffed hospitals many urgent cesareans begin beyond that 30-minute limit, and that no interval between decision and cesarean, however brief, guarantees a healthy baby. (See below.)

Is it possible that something could go so seriously wrong in this next labor that inability to get to the hospital within 30 minutes could make a difference? Yes, but it isn't likely, especially if you have no medical risk factors and considering that this is your third baby. That being said, if something went that wrong, that fast, it is also possible that living closer or even being in the hospital, especially if it is a community hospital and not equipped and staffed for urgent cesareans 24/7, wouldn't make a difference. If you could obtain optimal care in your local hospital, a case could be made that you might be better off there, but as you relate, your local hospital is far from providing care that best promotes safe, healthy birth.    

~ Henci

Bloom SL, Leveno KJ, Spong CY, et al. Decision-to-incision times and maternal and infant outcomes. Obstet Gynecol 2006;108(1):6-11. 

Hillemanns P, Strauss A, Hasbargen U, et al. Crash emergency cesarean section: decision-to-delivery interval under 30 min and its effect on Apgar and umbilical artery pH. Arch Gynecol Obstet 2005;273(3):161-5.

Leung TY, Chung PW, Rogers MS, et al. Urgent cesarean delivery for fetal bradycardia. Obstet Gynecol 2009;114(5):1023-8.

MacKenzie IZ, Cooke I. Prospective 12 month study of 30 minute decision to delivery intervals for "emergency" caesarean section. BMJ 2001;322(7298):1334-5.

Nasrallah FK, Harirah HM, Vadhera R, et al. The 30-minute decision-to-incision interval for emergency cesarean delivery: fact or fiction? Am J Perinatol 2004;21(2):63-8. 

Tuffnell DJ, Wilkinson K, Beresford N. Interval between decision and delivery by caesarean section--are current standards achievable? Observatiional case series. BMJ 2001;322(7298):1330-3.


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