Ambiente hogareño para nacer (Cochrane Review)

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Home-like versus conventional institutional settings for birth
(Review)
Hodnett ED, Downe S, Edwards N, Walsh D
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2009, Issue 1
http://www.thecochranelibrary.com
Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
http://www.thecochranelibrary.com
T A B L E O F C O N T E N T S
1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 1 Induction of labour. 17
Analysis 1.2. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 2 Augmentation of labour. 18
Analysis 1.3. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 3 Meconium in labour. 18
Analysis 1.4. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 4 Fetal heart rate
abnormality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Analysis 1.5. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 5 Prolonged 1st stage
labour. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Analysis 1.6. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 6 Prolonged 2nd stage
labour. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Analysis 1.7. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 7 Opioid analgesia. . 20
Analysis 1.8. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 8 Nitrous oxide in labour. 21
Analysis 1.9. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 9 Epidural analgesia. . 22
Analysis 1.10. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 10 No
analgesia/anaesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Analysis 1.11. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 11 Supine/semi-recumbent
birth position. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Analysis 1.12. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 12 Instrumental vaginal
birth (forceps or ventouse). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Analysis 1.13. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 13 Caesarean birth. . 25
Analysis 1.14. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 14 Spontaneous vaginal
birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Analysis 1.15. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 15 Episiotomy. . . 27
Analysis 1.16. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 16 Vaginal/perineal tears. 27
Analysis 1.17. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 17 Intact perineum. 28
Analysis 1.18. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 18 Postpartum
hemorrhage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Analysis 1.19. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 19 1-minute Apgar score <
7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Analysis 1.20. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 20 5-minute Apgar score <
7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Analysis 1.21. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 21 Admission to neonatal
intensive care unit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Analysis 1.22. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 22 Prolonged neonatal
hospital stay. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Analysis 1.23. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 23 Perinatal mortality. 31
Analysis 1.24. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 24 Prolonged postpartum
hospital stay. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
iHome-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.25. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 25 Mother re-admitted to
hospital. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Analysis 1.27. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 27 Breastfeeding initiated. 32
Analysis 1.28. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 28 Breastfeeding at 6-8
weeks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Analysis 1.29. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 29 Involved in decisions
about care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Analysis 1.30. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 30 Prefer same setting the
next time. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Analysis 1.31. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 31 High rating of
intrapartum care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Analysis 2.1. Comparison 2 Home-like versus conventional birth settings - variations in staffing, Outcome 1 Spontaneous
vaginal birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Analysis 2.2. Comparison 2 Home-like versus conventional birth settings - variations in staffing, Outcome 2 Admission to
neonatal intensive care unit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Analysis 2.3. Comparison 2 Home-like versus conventional birth settings - variations in staffing, Outcome 3 Perinatal
mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Analysis 2.4. Comparison 2 Home-like versus conventional birth settings - variations in staffing, Outcome 4 High rating of
intrapartum care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Analysis 3.1. Comparison 3 Home-like versus conventional birth settings - variations in continuity of caregiver, Outcome 1
Spontaneous vaginal birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Analysis 3.2. Comparison 3 Home-like versus conventional birth settings- variations in continuity of caregiver, Outcome 2
Admission to neonatal intensive care unit. . . . . . . . . . . . . . . . . . . . . . . . . 40
Analysis 3.3. Comparison 3 Home-like versus conventional birth settings - variations in continuity of caregiver, Outcome 3
Perinatal mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Analysis 3.4. Comparison 3 Home-like versus conventional birth settings - variations in continuity of caregiver, Outcome 4
High rating of intrapartum care. . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
42FEEDBACK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
43WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
44HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
44CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
44DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
44SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
45INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
iiHome-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]
Home-like versus conventional institutional settings for birth
Ellen D Hodnett1, Soo Downe2 , Nadine Edwards3, Denis Walsh4
1Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada. 2Midwifery Studies Research Unit, University
of Central Lancashire, Preston, UK. 3C/o Cochrane Pregnancy and Childbirth Group, School of Reproductive and Developmental
Medicine, Division of Perinatal and Reproductive Medicine, The University of Liverpool, Liverpool, UK. 4Midwifery, University of
Central Lancashire, Leicester, UK
Contact address: Ellen D Hodnett, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130,
Toronto, Ontario, M5T 1P8 , Canada. ellen.hodnett@utoronto.ca.
Editorial group: Cochrane Pregnancy and Childbirth Group.
Publication status and date: Edited (no change to conclusions), published in Issue 1, 2009.
Review content assessed as up-to-date: 11 November 2004.
Citation: Hodnett ED, Downe S, Edwards N, Walsh D. Home-like versus conventional institutional settings for birth. Cochrane
Database of Systematic Reviews 2005, Issue 1. Art. No.: CD000012. DOI: 10.1002/14651858.CD000012.pub2.
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
Background
Home-like birth settings have been established in or near conventional labour wards for the care of pregnant women who prefer and
require little or no medical intervention during labour and birth.
Objectives
Primary: to assess the effects of care in a home-like birth environment compared to care in a conventional labour ward. Secondary: to
determine if the effects of birth settings are influenced by staffing or organizational models or geographical location of the birth centre.
Search strategy
We searched the Cochrane Pregnancy and Childbirth Group trials register (18 May 2004) and handsearched eight journals and two
published conference proceedings.
Selection criteria
All randomized or quasi-randomized controlled trials that compared the effects of a home-like institutional birth environment to
conventional hospital care.
Data collection and analysis
Standard methods of the Cochrane Collaboration Pregnancy and Childbirth Group were used. Two review authors evaluated method-
ological quality. Double data entry was performed. Results are presented using relative risks and 95% confidence intervals.
Main results
Six trials involving 8677 women were included. No trials of freestanding birth centres were found. Between 29% and 67% of women
allocated to home-like settings were transferred to standard care before or during labour. Allocation to a home-like setting significantly
increased the likelihood of: no intrapartum analgesia/anaesthesia (four trials; n = 6703; relative risk (RR) 1.19, 95% confidence interval
(CI) 1.01 to 1.40), spontaneous vaginal birth (five trials; n = 8529; RR 1.03, 95% CI 1.01 to 1.06), vaginal/perineal tears (four trials;
n = 8415; RR 1.08, 95% CI 1.03 to 1.13), preference for the same setting the next time (one trial; n = 1230; RR 1.81, 95% CI 1.65
to 1.98), satisfaction with intrapartum care (one trial; n = 2844; RR 1.14, 95% CI 1.07 to 1.21), and breastfeeding initiation (two
1Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
mailto:ellen.hodnett@utoronto.ca
trials; n = 1431; RR 1.05, 95% CI 1.02 to 1.09) and continuation to six to eight weeks (two trials; n = 1431; RR 1.06, 95% CI 1.02 to
1.10). Allocation to a home-like setting decreased the likelihood of episiotomy (five trials; n = 8529; RR 0.85, 95% CI 0.74 to 0.99).
There was a trend towards higher perinatal mortality in the home-like setting (five trials; n = 8529; RR 1.83, 95% CI 0.99 to 3.38).
No firm conclusions could be drawn regarding the effects of staffing or organizational models.
Authors’ conclusions
When compared to conventional institutional settings, home-like settings for childbirth are associated with modest benefits, including
reduced medical interventions and increased maternal satisfaction. Caregivers and clients should be vigilant for signs of complications.
P L A I N L A N G U A G E S U M M A R Y
Home-like versus conventional institutional settings for birth
Home-like institutional birth settings reduce the chances of medical interventions and increase maternal satisfaction, but it is important
to watch for signs of complications.
Home-like birth settings are intended for women who prefer to avoid medical intervention during labour and birth, but who either do
not wish or cannot have a home birth. The results of six trials suggest modest benefits, including decreased medical intervention and
higher rates of spontaneous vaginal birth, breastfeeding, and maternal satisfaction. However, there may be an added risk of perinatal
mortality.
B A C K G R O U N D
In high- and moderate-income countries, hospital labour wards
have become the birth settings for the majority of childbearing
women. Routine medical interventions have also increased steadily
over time, leading to many questions about benefits, safety, and
risk for healthy childbearing women. As a critique of ’technolog-
ical’ approaches to childbirth, there has been a steady increase in
interest in the impact of the environment on the outcomes of
labour and birth. Since the 1970s in many high-income countries,
increased numbers of home-like hospital rooms have been built,
paradoxically during a time of rapid increases in the routine use of
technology during labour and birth. The home-like rooms draw
on notions of domesticity and the naturalness of birth, while hid-
ing the technology behind curtains and wood cabinets (Fannin
2003). According to Fannin (Fannin 2003) these hybrid spaces
send dual messages to birthing women and to the staff working
in them, and home-like birthing rooms exemplify the struggles
over competing conceptualizations of safety, control, and family,
and thus over the very meaning of birth itself (Fannin 2003). In a
parallel trend, home-like locations for birth which are geographi-
cally separate from the hospital labour and delivery unit have been
gaining prominence in high-income countries. These ’freestand-
ing’ birth centres have evolved both out of concerns that routine
hospital policies and practices may have spillover effects on birth
centre care, and as a means of providing an alternative to home
birth. While it may appear that the freestanding units offer more
scope for separation between ’technological’ and ’social’ models of
birth, theevidence is mixed (Annandale 1987; Downe 2004).
Home-like settings vary greatly in location, philosophical orien-
tation, and staffing models. While some home-like settings have
arisen as a re-configuration of previously existing facilities, others
have been purpose built. Some in-hospital birth centres are adja-
cent to conventional labour wards, or on another floor of the same
hospital. Others are freestanding centres that are not physically
part of a hospital but may or may not have administrative linkages
to a hospital.
The organizational models of care delivery in birth centres vary.
The model of care may or may not involve continuity of care
provider, in which the same staff provide antenatal as well as in-
trapartum care. While the core staff of birth centres are usually
midwives or nurse-midwives, they may be a separate staff or they
may be part of the regular labour ward staff. If they are part of
the regular labour ward staff, they provide care for women in the
birthing centre as well as women in the traditional labour ward,
2Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
necessitating a shift in philosophical orientation from one em-
phasizing normality and avoidance of interventions to one em-
phasizing detection/management of risk and use of routine inter-
ventions. Another common, though not universal, feature is that
these units have no routine input by medical practitioners. In these
cases, the core staff are usually midwives or nurse-midwives, some-
times with the addition of trained but non-professional assistants,
and/or doulas.
The focus of this review is on home-like birth settings that are
characterized by a philosophical orientation towards normal birth.
Their philosophies and guidelines value minimal intervention in
labour, and booking is restricted to women deemed at low risk of
obstetric emergency. The physical environment (furniture, light-
ing) is home-like, but in many instances the medical equipment
is readily available, concealed behind cupboards or partitions. Be-
cause of the strict criteria for booking, some women who desire
birth centre care are not accepted for it, and, of those who are
accepted, some will develop problems or needs which necessi-
tate transfer to regular labour ward care. Thus there is the risk
of disappointment for those whose expectations and wishes are
unmet. This Review is complementary to a Cochrane Protocol,
’Midwifery-led versus other models of care delivery for childbear-
ing women’ (Hatem 2004) and a Cochrane Review, ’Home versus
hospital birth’ (Olsen 2004).
O B J E C T I V E S
The primary objective is to evaluate the effects, on labour and
birth outcomes, of care in a home-like birth setting compared to
care in a conventional hospital labour ward.
Secondary objectives were to determine if the effects of care in
home-like birth settings were influenced by:
(a) whether the staff in the home-like setting were also part of the
conventional labour ward staff;
(b) whether care in the home-like setting included more continu-
ity of care provider than women experienced in the conventional
hospital setting; and
(c) whether the home-like setting was in a building that was geo-
graphically separate from the hospital.
M E T H O D S
Criteria for considering studies for this review
Types of studies
All randomized or quasi-randomized controlled trials that com-
pared the effects of a home-like institutional birth environment
to conventional hospital care.
Types of participants
Pregnant women at low risk of obstetric complications.
Types of interventions
Trials were included if the intervention involved care during labour
and birth in a home-like institutional birth setting. Antenatal and
postnatal care may also have occurred in the home-like setting.
Care may have been provided by the same group of caregivers, or by
separate groups of caregivers in the home-like versus conventional
settings. Trials comparing home birth to institutional birth were
excluded; they are the subject of another Cochrane Review (Olsen
2004).
Types of outcome measures
Outcomes of interest included rates of intrapartum medical in-
terventions, intrapartum and postpartum complications, method
of birth, perinatal mortality, mothers’ evaluations of their care,
method of infant feeding and difficulties with feeding, measures
of neonatal health, and adjustment to mothering.
Search methods for identification of studies
Electronic searches
We searched the Cochrane Pregnancy and Childbirth Group trials
register (18 May 2004).
The Cochrane Pregnancy and Childbirth Group’s trials register is
maintained by the Trials Search Co-ordinator and contains trials
identified from:
1. quarterly searches of the Cochrane Central Register of
Controlled Trials (CENTRAL);
2. monthly searches of MEDLINE;
3. handsearches of 30 journals and the proceedings of major
conferences;
4. weekly current awareness search of a further 37 journals.
Details of the search strategies for CENTRAL and MEDLINE,
the list of handsearched journals and conference proceedings, and
the list of journals reviewed via the current awareness service can be
found in the ’Search strategies for identification of studies’ section
within the editorial information about the Cochrane Pregnancy
and Childbirth Group.
Trials identified through the searching activities described above
are given a code (or codes) depending on the topic. The codes are
3Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
linked to review topics. The Trials Search Co-ordinator searches
the register for each review using these codes rather than keywords.
In addition, two review authors (D Walsh, S Downe) handsearched
the following.
(a) Journals:
Journal of Advanced Nursing (1993 to 2004);
Journal of Reproductive & Infant Psychology (1996 to 2004);
Social Science & Medicine (1982 to 2004);
British Journal of Midwifery (1993 to 2004);
Sociology of Health & Illness (1997 to 2004);
Health Care for Women International (1998 to 2004);
Evidence-Based Midwifery (2003 to 2004); and
BMC Pregnancy & Childbirth (2001 to 2004).
(b) Published conference proceedings:
Research in Midwifery & Perinatal Health Conference; and
International Congress of Midwives.
There were no language limitations to the search.
Data collection and analysis
Trials under consideration were evaluated for methodological qual-
ity and appropriateness for inclusion by two review authors (E
Hodnett and S Downe), without consideration of their results.
Included trial data were processed as described in Alderson 2004.
Quality scores for allocation concealment were assigned to each
trial, where A = adequate, B = unclear, C = clearly inadequate,
and D = not used. We resolved differences through discussion.
Wherever necessary, we requested unpublished data from the trial
authors. All eligible trials were included in the initial analysis and
sensitivity analyses carried out to evaluate the effect of trial quality.
This was done by excluding trials given a C or D rating for quality
for allocation concealment.
Double data entry was performed. All data analyses in this review
were based on the principle of intention to treat. To be included in
a given comparison, outcome data had to be available for at least
80% of those who were randomized. Because a systematic review
of the literature on childbirth satisfaction (Hodnett 2002) found
that satisfaction ratings are always negatively skewed (e.g. relatively
few respondents report anything other than the highest levels of
satisfaction), we constructed dichotomous variables in which we
grouped all responses at the highest possible level, such as five out
of a possible five or seven out of a possible seven on Likert scales,compared to a variable that included all other possible responses.
Three a priori subgroup analyses were planned. The first two con-
cerned variations in the models of care, and the third concerned
the organizational relationship of the home-like setting to the hos-
pital. The goals of the subgroup analyses were to compare:
(a) trials in which care in the home-like setting was provided by
staff who were not part of the conventional labour ward staff versus
trials in which the same staff provided care in both settings;
(b) trials in which care in which the home-like birth environment
also included more continuity of care provider, e.g. some antenatal
and/or postnatal care that was provided by birth centre staff, versus
trials in which both groups received the same level (or lack thereof )
of continuity of care provider; and
(c) trials in which the home-like setting was geographically separate
from the hospital versus trials in which the home-like setting was
in the hospital.
The planned subgroup analyses were restricted to the following
outcomes, to reflect the most important concerns of childbearing
women and those who care for them:
(a) spontaneous vaginal birth;
(b) admission to a neonatal intensive care unit;
(c) perinatal mortality; and
(d) high rating of intrapartum care.
We compared categorical data using relative risks and 95% confi-
dence intervals using a fixed effect model. Statistical heterogeneity
between trials was tested using the I² statistic, and where present
(I² greater than 50%), we used a random effects model. When
significant heterogeneity was present within one subgroup analy-
sis in a comparison, the random effects model was used for both
subgroups. Causes of heterogeneity were investigated by the pre-
specified subgroup analyses. Biases in the studies included in the
analyses were investigated by means of funnel plots. Chi squared
tests for differences between subgroups, using the method sug-
gested by Deeks 2001, were used to determine if the subgroup
analyses explained any variation among trials.
R E S U L T S
Description of studies
See: Characteristics of included studies; Characteristics of excluded
studies.
See table of ’Characteristics of included studies’.
Six trials involving 8677 women were included in this review.
The home-like settings were characterized by a philosophical ori-
entation towards labour and birth as fundamentally normal ex-
periences. All restricted access to women who were experiencing
normal pregnancies. There were differences in the scope of the
interventions. The Stockholm trial (Waldenstrom 1997) enrolled
1860 women in an evaluation of care during pregnancy, child-
birth, and the postpartum period by a team of 10 midwives at
a hospital birth centre, compared to standard care by different
midwives during the antenatal, intrapartum and postnatal peri-
ods, in which intrapartum care was in a conventional labour ward.
The Aberdeen trial (Hundley 1994) enrolled 2844 women in an
evaluation of care in a home-like, midwife-managed delivery unit
compared to care in a consultant-led labour ward; the same mid-
wives also worked in both intrapartum settings. The London (
Chapman 1986) and Montreal (Klein 1984) trials were small (n =
4Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
148 and 114, respectively) trials that compared care in home-like
birth rooms within standard labour wards; the same staff cared
for women in both groups. The Leicester trial (MacVicar 1993)
enrolled 3510 women in an evaluation of intrapartum care in a
home-like, midwife-managed unit compared to care in a standard
labour ward; women allocated to the former group had up to three
antenatal visits (at 26, 36 and 41 weeks) in a clinic run by the
midwives in the birth centre, with the remainder of their ante-
natal care by their general practitioner or community midwife.
The Australian trial (Byrne 2000) enrolled 201 women at 20 to
36 weeks gestation. Birth centre care was provided by midwives
who were ’committed to the normality of the birth process’ and
involved antenatal, intrapartum, and up to 12 hours of postnatal
care.
Thus the trials varied considerably in the scope of the interven-
tion (study groups differed solely in intrapartum care versus study
groups in which there were differences in antenatal and/or postna-
tal care as well as intrapartum care), and the length of time between
randomization and onset of ’treatment’, but all trials shared one
common aspect of the intervention: intrapartum care in a home-
like setting.
No randomized trials were found which compared care in a free-
standing birth centre with hospital-based birth centres or conven-
tional hospital care. All trials in which care in the home-like birth
setting was by separate midwifery staff also involved increased con-
tinuity of caregiver.
Unfortunately response rates to questionnaires seeking informa-
tion about women’s satisfaction with their birth experiences were at
least 80% in only two trials (Hundley 1994; Waldenstrom 1997).
Although 1860 women were enrolled in the Stockholm trial (
Waldenstrom 1997), data on maternal satisfaction outcomes were
sought, and reported, from the first 1230 women who were en-
rolled.
Substantial numbers of women allocated to home-like settings
were transferred to standard care either before or during labour,
because they no longer met eligibility criteria for the home-like
setting. The most common reasons for intrapartum transfer were:
failure to progress in labour, fetal distress, and desire for pharma-
cologic analgesia. In the Australian trial (Byrne 2000) only 23/100
women allocated to birth centre care actually gave birth in the birth
centre. In two UK trials (Hundley 1994; MacVicar 1993), 46%
and 55%, respectively, of women randomized to the birth centres
actually gave birth in them. Thirty-four per cent of women in the
Stockholm trial (Waldenstrom 1997) were transferred to standard
care antenatally or intrapartum for medical reasons, and an addi-
tional 3% withdrew from birth centre care at their own request.
In the Montreal trial (Klein 1984), 63% of nulliparous women
and 19% of multiparous women were transferred intrapartum to
standard care, for an overall transfer rate of 43%. In the London
trial (Chapman 1986), 29% of 76 women were transferred from
birth room to standard care.
Risk of bias in included studies
Generally, the home-like settings were described in some detail,
but little information was provided about care received by the
comparison group, except to note it was ’standard’ or ’routine’.
With the exception of the quasi-random method (strict, centrally-
controlled alternation) used in the smallest trial (Klein 1984), all
trials used sealed, opaque envelopes to randomize participants.
In the Australian trial (Byrne 2000) randomization was centrally
controlled. However, the largest trial (MacVicar 1993) had a poor
method of allocation to study groups. Sealed envelopes contain-
ing randomly-generated group assignments were attached to the
records of 7906 pregnant women at booking. Of these, only 3510
(44%) were considered eligible for the study, and the envelopes
were opened. A further 8% of those randomized to the experi-
mental group refused to participate in the trial. Analyses were by
intent-to-treat of the 3510 women who met eligibility criteria.
Effects of interventions
Main comparisons: Home-like versus conventional
institutional settings for birth
Women who were randomized to receive care in a home-like birth
setting were more likely to:
• have no analgesia or anaesthesia during labour and birth
(four trials; n = 6703; relative risk (RR) 1.19, 95% confidence
interval (CI) 1.01 to 1.40);
• have a spontaneous vaginal birth (five trials; n = 8529; RR
1.03, 95% CI 1.01 to 1.06);
• have vaginal/perineal lacerations(four trials; n = 8415; RR
1.08, 95% CI 1.03 to 1.13);
• prefer to give birth in the same setting the next time (one
trial; n = 1230; RR 1.81, 95% CI 1.65 to 1.98);
• report high ratings of their intrapartum care (one trial; n =
2844; RR 1.14, 95% CI 1.07 to 1.21);
• initiate breastfeeding (two trials; n = 1431; RR 1.05, 95%
CI 1.02 to 1.09); and
• be continuing to breastfeed at six to eight weeks postpartum
(two trials; n = 1431; RR 1.06, 95% CI 1.02 to 1.10).
A consistent pattern of reduced likelihood of medical intervention
was evident in the group randomized to receive care in a home-
like setting, including lower likelihood of:
• detection of a fetal heart rate abnormality (two trials; n =
6354; RR 0.77, 95% CI 0.70 to 0.85);
• epidural analgesia (six trials; n = 8645; RR 0.83, 95% CI
0.75 to 0.92);
• giving birth in a supine or semi-recumbent position (one
trial; n = 1608; RR 0.64, 95% CI 0.56 to 0.72);
5Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
• an episiotomy (five trials; n = 8529; RR 0.85, 95% CI 0.74
to 0.99).
• augmentation during labour (five trials; n = 8529; RR 0.81,
95% CI 0.67 to 1.00);
• opioid analgesia (five trials; n = 8530; RR 0.74, 95% CI
0.55 to 1.00);
• instrumental vaginal birth (five trials; n = 8529; RR 0.88,
95% CI 0.77 to 1.01); and
• caesarean birth (six trials; n = 8677; RR 0.85, 95% CI 0.73
to 1.00).
However, while only three trials reported any perinatal deaths,
there appeared to be an increased risk of perinatal mortality in
those randomized to receive care in home-like settings (five trials;
n = 8529; RR 1.83, 95% CI 0.99 to 3.38).
Subgroup analyses
All four trials, in which the staff of the home-like setting were sep-
arate from the staff of the conventional labour ward, also involved
more continuity of caregiver in the home-like setting. Thus it is
not possible to separate the effects of one staffing model from the
other. We found no trials of freestanding birth centre care com-
pared to conventional institutional settings.
1. Spontaneous vaginal birth
When care in the home-like setting was by staff who were not part
of the conventional labour ward staffing complement and greater
continuity of caregiver was provided (three trials; n = 5571), RR
1.04, 95% CI 1.01 to 1.06. When the same staff provided care in
both settings, with no differences in the amount of continuity of
caregiver (two trials; n = 2958), RR 1.03, 95% CI 0.98 to 1.08.
2. Admission to neonatal intensive care unit (NICU)
NICU admission was reported in only one trial (n = 1860) of
care in the home-like setting by staff who were not part of the
conventional labour ward staffing complement and greater conti-
nuity of caregiver was provided (RR 1.23, 95% CI 0.94 to 1.63).
NICU admission was reported in two trials (n = 2958) in which
the same staff provided care in both settings, with no differences
in the amount of continuity of caregiver (RR 0.76, 95% CI 0.34
to 1.71).
3. Perinatal mortality
When care in the home-like setting was by staff were not part
of the conventional labour ward staffing complement and greater
continuity of caregiver was provided (three trials; n = 5571), RR
2.38, 95% CI 1.05 to 5.41. When the same staff provided care in
both settings, with no differences in the amount of continuity of
caregiver (two trials; n = 2958), RR 1.24, 95% CI 0.48 to 3.19.
4. High rating of intrapartum care
Only one trial contributed data to this outcome, and thus sub-
group analyses could not be performed.
A sensitivity analysis, conducted by excluding the one quasi-ran-
domized trial, did not substantially change any results. Chi squared
analyses of the differences between subgroups were all non-signif-
icant, indicating the subgroup analyses did not explain variations
among trials.
D I S C U S S I O N
Although almost 9000 women have participated in randomized
trials of home-like birth settings, the low number of women allo-
cated to home-like settings who actually gave birth in their allo-
cated setting serves to dilute both the potential benefits and risks
of home-like settings. Thus it is impossible to draw firm conclu-
sions about some of the most important questions. Other impor-
tant factors that complicate interpretation of the results are the
variations in organizational models of care in the trials. The ef-
fects of a home-like environment may be overpowered by routine
institutional policies and practices (Fannin 2003).
At present the benefits are consistent but modest in magnitude.
The lower rates of epidural analgesia may be a result of two factors:
increased support during labour (Hodnett 2004) and the lack of
availability of epidural analgesia in many birth centres (and thus
women had to agree to transfer to the standard labour ward to
receive it). Detection bias (due to the use of electronic fetal heart
rate monitoring in the conventional settings and auscultation in
the home-like settings) may account for the difference in rates of
fetal heart rate abnormalities. Regardless of the causal mechanisms,
the slightly increased likelihood of spontaneous vaginal birth may
be a function of increased mobility because of less use of restrictive
technology (Gupta 2004), lower likelihood of epidural analgesia
(Howell 2004), and/or lower likelihood of continuous electronic
fetal heart rate monitoring (Thacker 2004).
The trend towards higher rates of perinatal mortality in the home-
like settings raises important questions. A focus on normality may
have a negative impact on the ability of caregivers and childbearing
women to detect, act upon, and/or receive assistance with compli-
cations. Other possible causes include poor communication be-
tween the staff in the two settings, inter-unit rivalries, and/or de-
lays in detection and intervention. However, when Deeks’ method
was used (Deeks 2001) none of the subgroup analyses explained
the variation among trials, suggesting that the apparent differences
may be due to wide variations in trial size as well as the play of
chance.
There were only two trials in which losses to follow up on ques-
tionnaires were low enough to permit inclusion of the data in this
review (Hundley 1994; Waldenstrom 1997), but similar results
6Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
are reported in the other trials that measured satisfaction with
care. Different measures were used in the trials. In Hundley 1994,
women were asked to rate the extent of their involvement in deci-
sions about their care and to provide an overall satisfaction rating.
In Waldenstrom 1997 women were asked if they would choose
the same birth setting the next time. In all instances women’s rat-
ings favoured the group allocated to the home-like setting. Given
the high rates of transfer from birth centre to conventional ward
for intrapartum care, which presumably would create disappoint-
ment, these results strongly suggest higher levels of satisfaction in
those allocated to home-like birth settings.
The results of this review suggest a possible increase in risk of peri-
natal mortality, a small increase in likelihood of spontaneous vagi-
nal birth, small decreases in intrapartum medical interventions,
and increased maternal satisfaction. But no conclusions can be
drawn about optimum staffing or organizational models of home-
like settings.
A U T H O R S ’ C O N C L U S I O N S
Implications for practice
The results of this review illustrate the difficulties faced by women
and their caregivers, within the societal context of competing
conceptualizations of safety, technology, and normality (Fannin
2003). Policies and practices must address the dual challenge of
supporting an orientation towards normality concurrently with
vigilance in detectingand prompt intervention in the presence
of abnormality. And the high rates of transfer out of birth centre
care lead to questions about the usefulness of both booking and
transfer criteria.
It was not possible to examine the separate influences of continuity
of caregiver and whether the staff provided care in both the home-
like and conventional settings, and there were no trials of free-
standing birth centres. Thus those who wish to develop a home-
like birth setting, and those who wish to use them, have little to
go on when making decisions about staffing models, organization
of care, and autonomy of the setting.
This review focused on evaluations of home-like birth settings that
are characterized by a philosophical orientation towards normal
birth. Therefore it would be inappropriate to expect the same
benefits when simply redecorating the physical environment, with
no alterations to the philosophy of care and the behaviours of care
providers.
Implications for research
Future trials of alternative birth settings should seek participants’
consent prior to randomization and use bias-free methods of ran-
dom allocation. Plans for such trials should also address the poten-
tial confounding effects of differences in the extent of continuity
of caregiver in the home-like versus conventional birth settings. It
would be helpful to have full descriptions of both the home-like
and usual care interventions.
Given the growing awareness of the importance of the birth en-
vironment, the escalating caesarean delivery rates in many high-
income countries, and the results of large observational studies
of freestanding birth centres (e.g. Rooks 1989), randomized tri-
als of freestanding birth centres are warranted. Future trials of all
home-like settings should include evidence-based approaches to
encourage high response rates to postal questionnaires, and cost-
effectiveness analyses.
Questions have arisen about: the impact of competing philo-
sophical, political, and administrative pressures on the operation
of home-like settings (Annandale 1987); these questions require
qualitative investigation. Qualitative studies, examining what hap-
pens when women are transferred from home-like to conven-
tional birth settings, would shed light on the impact of transfer
on women, care providers, and decision-making processes regard-
ing the need for intervention. Questions which can be answered
quantitatively include: the effects of home-like settings on birth
outcomes, women’s preferences for traditional labour ward care
compared to birth centre care, the pros and cons of freestanding
versus hospital-based birth centres, and the optimum organiza-
tional models of birth centre care. Evidence from both qualitative
and quantitative sources is needed, to provide a complete picture
of the nature, benefits, and risks of birth centre care.
A C K N O W L E D G E M E N T S
As part of the pre-publication editorial process, this review has been
commented on by two peers (an editor and referee who are external
to the editorial team), one or more members of the Pregnancy
and Childbirth Group’s international panel of consumers and the
Group’s Statistical Adviser.
7Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
R E F E R E N C E S
References to studies included in this review
Byrne 2000 {published data only}
Byrne JP, Crowther CA, Moss JR. A randomised controlled trial
comparing birthing centre care with delivery suite care in Adelaide,
Australia. Australian and New Zealand Journal of Obstetrics and
Gynaecology 2000;40(3):268–74.
Chapman 1986 {published data only}
Chapman MG, Jones M, Spring JE, De Swiet M, Chamberlain
GVP. The use of a birthroom: a randomized controlled trial
comparing delivery with that in the labour ward. British Journal of
Obstetrics and Gynaecology 1986;93:182–7.
Hundley 1994 {published data only}
Hundley VA, Cruickshank FM, Lang GD, Glazener CMA, Milne
JM, Turner M, et al.Midwife managed delivery unit: a randomised
controlled comparison with consultant led care. BMJ 1994;309:
1400–4.
Hundley VA, Cruickshank FM, Milne JM, Glazener CM, Lang
GD, Turner M, et al.Satisfaction and continuity of care: staff views
of care in a midwife-managed delivery unit. Midwifery 1995;11(4):
163–73. [MEDLINE: 96161080]
Hundley VA, Donaldson C, Lang GD, Cruickshank FM, Glazener
CMA, Milne JM, et al.Costs of intrapartum care in a midwife-
managed delivery unit and a consultant-led labour ward. Midwifery
1995;11:103–9.
Hundley VA, Milne JM, Glazener CM, Mollison J. Satisfaction and
the three C’s: continuity, choice, and control. Women’s views from
a randomised controlled trial of midwife-led care. British Journal of
Obstetrics and Gynaecology 1997;104:1273–80.
Klein 1984 {published data only}
Klein M, Papageorgiou A, Westreich R, Spector-Dunsky L, Elkins
V, Kramer M, et al.Care in a birth room versus a conventional
setting: a controlled trial. Canadian Medical Association Journal
1984;131:1461–6.
MacVicar 1993 {published data only}
MacVicar J, Dobbie G, Owen-Johnstone L, Jagger C, Hopkins M,
Kennedy J. Simulated home delivery in hospital: a randomised
controlled trial. British Journal of Obstetrics and Gynaecology 1993;
100:316–23.
Waldenstrom 1997 {published data only}
Gottvall K, Waldenstrom U. Does birth center care during a
woman’s first pregnancy have any impact on her future
reproduction?. Birth 2002;29(3):177–81.
Waldenstrom U. Effects of birth centre care on fathers’ satisfaction
with care, experience of the birth, and adaptation to fatherhood.
Journal of Reproductive and Infant Psychology 1999;17(4):357–68.
Waldenstrom U, Nilsson CA. A randomized controlled study of
birth center care versus standard maternity care: effects on women’s
health. Birth 1997;24:17–26.
Waldenstrom U, Nilsson CA. Experience of childbirth in birth
center care: a randomized controlled study. Acta Obstetricia et
Gynecologica Scandinavica 1994;73:547–54.
Waldenstrom U, Nilsson CA. No effect of birth centre care on
either duration or experience of breast feeding, but more
complications: findings from a randomised controlled trial.
Midwifery 1994;10:8–17.
Waldenstrom U, Nilsson CA. Women’s satisfaction with birth
center care: a randomized, controlled study. Birth 1993;20:3–13.
Waldenstrom U, Nilsson CA, Winbladh B. The Stockholm birth
centre trial: maternal and infant outcome. British Journal of
Obstetrics and Gynaecology 1997;104:410–8.
Wilhelmson B. First results from a randomized study: ABC for
alternative childbirth [Forsta resultat fran randomiserad studie:
ABC for alternativ forlossning]. Lakartidningen 1993;90:180–2.
References to studies excluded from this review
Westreich 1991 {published data only}
Westreich R, Spector-Dunsky L, Klein M, Papageorgiou A, Kramer
M, Gelfand M. The influence of birth setting on the father’s
behavior toward his partner and infant. Birth 1991;18:198–202.
References to studies awaiting assessment
Abdullahi 1990 {published data only}
Abdullahi L, Kongsgaard E, Mogensen K, Sass L, Bock JE. The
significance of the environment for delivery at a special department
[Miljoets betydning for fodsler pa specialafdeling]. Ugeskrift for
Laeger 1990;152:732–4.
Additional references
Alderson 2004
Alderson P, Green S, Higgins JPT, editors. Cochrane Reviewers’
Handbook 4.2.2 [updated March 2004]. In: The Cochrane
Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.
Annandale 1987
Annandale EC. Dimensions of patient control in a freestanding
birth center. Social Science and Medicine 1987;25(11):1235–48.
Deeks 2001
Deeks JJ, Altman DG, Bradburn MJ. Statistical methods for
examining heterogeneity and combining results from several studies
in meta-analysis. In: Egger M, Davey Smith G, Altman DG editor
(s). Systematic reviews of health care: meta-analysis in context.
London: BMJBooks, 2001.
Downe 2004
Downe S, Walsh D. Bridging the divide: a meta-synthesis of the
culture of, and phenomenon within, freestanding midwife led birth
centres. Submitted for publication 2004.
Fannin 2003
Fannin M. Domesticating birth in the hospital: “Family-centered”
birth and the emergence of “homelike” birthing rooms. Antipode
2003;35(3):513–35.
Gupta 2004
Gupta JK, Hofmeyr GJ. Position for women during second stage of
labour. The Cochrane Database of Systematic Reviews 2003, Issue
3. Art. No.: CD002006.pub2. DOI: 10.1002/
14651858.CD002006.pub2.
8Home-like versus conventional institutional settings for birth (Review)
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Hatem 2004
Hatem M, Hodnett ED, Devane D, Fraser WD, Sandall J, Soltani
H. Midwifery-led versus other models of care delivery for
childbearing women. The Cochrane Database of Systematic
Reviews 2004, Issue 1. Art. No.: CD004667. DOI: 10.1002/
14651858.CD004667.
Hodnett 2002
Hodnett ED. Pain and women’s satisfaction with the experience of
childbirth: a systematic review. American Journal of Obstetrics and
Gynecology 2002;186(5):S160–72.
Hodnett 2004
Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support
for women during childbirth. The Cochrane Database of
Systematic Reviews 2003, Issue 3. Art. No.: CD003766. DOI:
10.1002/14651858.CD003766.
Howell 2004
Howell CJ. Epidural versus non-epidural analgesia for pain relief in
labour. The Cochrane Database of Systematic Reviews 1999, Issue
3. Art. No.: CD000331. DOI: 10.1002/14651858.CD000331.
Olsen 2004
Olsen O, Jewell MD. Home versus hospital birth. The Cochrane
Database of Systematic Reviews 1998, Issue 3. Art. No.:
CD000352. DOI: 10.1002/14651858.CD000352.
Rooks 1989
Rooks JP, Weatherby NL, Ernst EKM, Stapleton S, Rosen D,
Rosenfield A. Outcomes of care in birth centers. The National
Birth Center Study. New England Journal of Medicine 1989;321:
1804–11.
Thacker 2004
Thacker SB, Stroup D, Chang M. Continuous electronic heart rate
monitoring for fetal assessment during labor. The Cochrane
Database of Systematic Reviews 2001, Issue 2. Art. No.:
CD000063. DOI: 10.1002/14651858.CD000063.
∗ Indicates the major publication for the study
9Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
C H A R A C T E R I S T I C S O F S T U D I E S
Characteristics of included studies [ordered by study ID]
Byrne 2000
Methods Randomized controlled trial; randomization centrally controlled, using sealed, opaque envelopes. Women
who consented were randomized between 20-36 weeks gestation.
Participants 201 nulliparous and multiparous women booked for delivery at a hospital in Adelaide, Australia. All were
experiencing normal, uncomplicated pregnancies.
Interventions Those allocated to birth centre care had antenatal, intrapartum, and up to 12 hours of intrapartum care
from midwives who were “committed to the normality of the birth process”. Intrapartum care may have
been by midwives who were not known to the women. The women were also encouraged to attend 2 classes
about the birthing centre. The birthing centre consisted of 2 homelike rooms adjacent to the delivery
suite, staffed by midwives. The control group received usual care antenatal care and their intrapartum care
was in the conventional delivery suite; they were under the care of both a midwife and doctor.
Outcomes Maternal satisfaction, intervention rates, method of infant feeding at 6 weeks postpartum, and costs.
Notes Experimental group: 13 allocated to birth centre care did not receive it because of staffing problems, and
64 were transferred to delivery suite care for medical reasons. Control: 1 woman was lost to follow-up,
and 1 transferred to birthing centre at her request.
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Yes A - Adequate
Chapman 1986
Methods Randomized controlled trial via ’random envelope selection’ at or before 30 weeks’ gestation. No other
details provided.
Participants 150 multiparous women booked for delivery at London, UK hospital. All were multiparous, had had
normal previous pregnancies and deliveries, and had asked for early discharge and lived within 5 miles of
the hospital.
Interventions All participants had routine antenatal care, and the same group of community midwives cared for both
the experimental and control groups during labour. During labour and birth the experimental group was
cared for in a home-like birth room close to the labour ward. The control group was admitted to the
labour ward.
Outcomes Reason for withdrawal, intrapartum analgesia, perineal trauma, meconium staining, forceps delivery, cae-
sarean delivery, breastfeeding, effect on relationship with baby, preferred birth setting for future pregnan-
cies.
10Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Chapman 1986 (Continued)
Notes 22 in the experimental group were withdrawn, 11 before labour. 10 in the standard care group were
withdrawn in the antenatal period. However, data were provided about all of those randomized, thereby
permitting intent-to-treat analyses.
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Hundley 1994
Methods Randomized controlled trial, randomization by ’consecutive, sealed opaque envelopes’ at booking. 2:1
randomization scheme.
Participants 2844 nulliparous and multiparous women (1900 in experimental group and 944 in control group) who
were low-risk at booking at a hospital in Aberdeen, Scotland. Exclusion criteria were: age > 35, height
< 150 cm, pre-existing maternal disease, history of infertility or prior obstetric complications, multiple
pregnancy.
Interventions Experimental: antenatal care and delivery in a midwife-managed, home-like unit 20 yards from the
hospital’s delivery suite. The midwives’ unit was staffed by hospital midwives who also worked in the
delivery suite. Strict protocols were in place for booking, admission, and transfer of women. Labour was
managed with minimal intervention and fetal monitoring by intermittent auscultation. Control: care in
the consultant-led delivery suite.
Outcomes Number transferred from care in the midwives’ unit and reason for transfer, type of fetal heart rate
monitoring, fetal distress, meconium staining in labour, shoulder dystocia, undiagnosed malpresentation,
induction of labour, augmentation of labour, delay in 1st and 2nd stage labour, intrapartum analgesia,
mobility in labour, perineal trauma, mode of delivery, neonatal resuscitation, neonatal intensive care unit
admission, stillbirths and neonatal deaths, satisfaction with care, costs.
Notes 54% of those allocated to the experimental group were not delivered in the midwives’ unit. 4% were lost
to follow-up. Analyses were by intent-to-treat.
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Yes A - Adequate
11Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Klein 1984
Methods A quasi-random method of allocation was used - ’strict alternation’. Only one birth room was available.
The research co-ordinator was the only person aware of which setting was to be used next, and she made
the assignment when notified by telephone that a study participant had arrived in the delivery unit.
Participants 114 nulliparous and multiparous women (56 allocated to the birth room and 58 to conventional care),
at low-risk for obstetric complications.
Interventions Intrapartum care in a home-like birth room was compared to standard care in an adjacent labour ward in
a tertiary care hospital in Montreal, Canada. The same medical and nursing staff provided care in both
settings.Outcomes Oxytocin augmentation of labour, epidural analgesia, forceps delivery, episiotomy, perineal trauma, cae-
sarean delivery, 1-minute Apgar score < 7, admission to special care nursery.
Notes In the experimental group, transfer from the birth room for labour or delivery occurred in 39 of 62 (63%)
primiparas and 11 of 59 (19%) multiparas. Analyses were by intent-to-treat.
Risk of bias
Item Authors’ judgement Description
Allocation concealment? No C - Inadequate
MacVicar 1993
Methods Randomized controlled trial. Randomization by Zelen method (i.e. women were randomized prior to
seeking consent to participate, and consent was sought only from the experimental group). 2:1 random-
ization scheme favouring the experimental group. Consecutively numbered, sealed, opaque envelopes
containing random assignment were attached to the records of 7906 pregnant women at booking. Of
these, 3510 (44%) were considered eligible for the study, and the envelopes were opened. A further 8%
of those randomized to the experimental group refused to participate in the trial.
Participants 3510 nulliparous and multiparous women (2304 in experimental group and 1206 in control group)
booked for delivery at a hospital in Leicester, UK. Exclusion criteria: previous caesarean delivery, maternal
illness such as diabetes, epilepsy, and renal disease, previous stillbirth or neonatal death, previous small for
gestational age baby, multiple pregnancy, Rhesus antibodies, and elevated serum alpha-feto protein level
on 2 occasions.
Interventions Experimental: antenatal care that included routine care by the general practitioner or community midwife
except for 3 scheduled visits to the clinic staffed by hospital midwives, and intrapartum care in a 3-room,
home-like unit adjacent to the delivery suite, staffed by 10 staff midwives who were not normally involved
with the care of women in the delivery suite. Control: routine antenatal care and care in the delivery
suite. The majority had antenatal care shared between a consultant and general practitioner or community
midwife; a small number had antenatal care from the general practitioner and community midwife.
Outcomes Induction of labour, augmentation of labour, intrapartum bleeding, meconium staining, electronic fetal
monitoring, fetal heart rate abnormality, delay in 1st or 2nd stage labour, intrapartum analgesia, mode of
delivery, perineal trauma, postpartum haemorrhage, neonatal resuscitation, prolonged neonatal hospital
12Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
MacVicar 1993 (Continued)
stay, stillbirths, neonatal deaths, numbers of, and reasons for, transfers from the experimental form of care,
woman’s satisfaction.
Notes Analyses were by intent-to-treat of the 3510 women who met eligibility criteria. 45% of the experimental
group were transferred to specialist care (23% during the antenatal period, 18% during first stage labour,
and 4% in the second or third stage or after delivery).
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Yes A - Adequate
Waldenstrom 1997
Methods Randomized controlled trial. The woman herself chose a sealed, opaque envelope from a box containing
at least 50 envelopes.
Participants 1860 nulliparous and multiparous women (928 in the experimental group and 932 controls) who were:
residents of Greater Stockholm, Sweden, and did not have any disease that might complicate the birth
or jeopardize the baby’s health, including diabetes, multiple pregnancy, pre-eclampsia, drug abuse, or
smoking during the current pregnancy.
Interventions Experimental: antenatal, intrapartum, and postnatal care in a home-like birth centre located one floor
below the ordinary labour ward at a Stockholm hospital, with 1:1 midwife-woman ratio during labour,
and discharge within 24 hours of the birth. Control: antenatal care at neighbourhood antenatal clinics,
intrapartum care in the hospital labour delivery suite (usually each midwife caring for more than 1 woman),
and postnatal care for 3-4 days in the hospital postnatal ward.
Outcomes Transfers to and reasons for standard care, intrapartum medical interventions, operative delivery, postpar-
tum hemorrhage, 5 minute Apgar score < 7, transfer to NICU, perinatal mortality, at least one postnatal
home visit, breastfeeding, stopped breastfeeding within 2 months, sore nipples, engorgement, milk stasis,
mastitis, satisfaction with care.
Notes 34% of birth centre group were transferred to standard care either antenatally or intrapartally, and an
additional 2% were transferred in the postpartum period. Analyses were by intent-to-treat. Women were
enrolled between October 1989 and June 1993. The 1230 women who gave birth between October 1989
and January 1992 comprised the sample to assess birth satisfaction and breastfeeding.
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
NICU: neonatal intensive care unit
13Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Characteristics of excluded studies [ordered by study ID]
Westreich 1991 A secondary report of the Klein trial, focussing on fathers’ behaviours during labour. Data were available for only 70
of the original 114. Using a time sampling method, observers coded fathers’ behaviours. The only data provided,
in which two study groups were compared, were mean numbers of times the fathers touched, kissed, and hugged
their labouring partners, but no standard deviations are reported.
14Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
D A T A A N D A N A L Y S E S
Comparison 1. Home-like versus conventional birth settings - all trials
Outcome or subgroup title
No. of
studies
No. of
participants Statistical method Effect size
1 Induction of labour 4 8415 Risk Ratio (M-H, Random, 95% CI) 0.89 [0.72, 1.09]
2 Augmentation of labour 5 8529 Risk Ratio (M-H, Random, 95% CI) 0.81 [0.67, 1.00]
3 Meconium in labour 2 6354 Risk Ratio (M-H, Fixed, 95% CI) 0.99 [0.87, 1.13]
4 Fetal heart rate abnormality 2 6354 Risk Ratio (M-H, Fixed, 95% CI) 0.77 [0.70, 0.85]
5 Prolonged 1st stage labour 2 6354 Risk Ratio (M-H, Fixed, 95% CI) 1.11 [0.92, 1.33]
6 Prolonged 2nd stage labour 2 6354 Risk Ratio (M-H, Fixed, 95% CI) 0.95 [0.79, 1.16]
7 Opioid analgesia 5 8530 Risk Ratio (M-H, Random, 95% CI) 0.74 [0.55, 1.00]
8 Nitrous oxide in labour 5 8530 Risk Ratio (M-H, Random, 95% CI) 0.79 [0.48, 1.29]
9 Epidural analgesia 6 8645 Risk Ratio (M-H, Fixed, 95% CI) 0.83 [0.75, 0.92]
10 No analgesia/anaesthesia 4 6703 Risk Ratio (M-H, Random, 95% CI) 1.19 [1.01, 1.40]
11 Supine/semi-recumbent birth
position
1 1608 Risk Ratio (M-H, Fixed, 95% CI) 0.64 [0.56, 0.72]
12 Instrumental vaginal birth
(forceps or ventouse)
5 8529 Risk Ratio (M-H, Fixed, 95% CI) 0.88 [0.77, 1.01]
13 Caesarean birth 6 8677 Risk Ratio (M-H, Fixed, 95% CI) 0.85 [0.73, 1.00]
14 Spontaneous vaginal birth 5 8529 Risk Ratio (M-H, Fixed, 95% CI) 1.03 [1.01, 1.06]
15 Episiotomy 5 8529 Risk Ratio (M-H, Random, 95% CI) 0.85 [0.74, 0.99]
16 Vaginal/perineal tears 4 8415 Risk Ratio (M-H, Fixed, 95% CI) 1.08 [1.03, 1.13]
17 Intact perineum 4 6669 Risk Ratio (M-H, Random, 95% CI) 1.10 [0.91, 1.33]
18 Postpartum hemorrhage 2 4704 Risk Ratio (M-H, Fixed, 95% CI) 0.97 [0.80, 1.18]
19 1-minute Apgar score < 7 1 114 Risk Ratio (M-H, Fixed, 95% CI) 0.35 [0.04, 3.22]
20 5-minute Apgar score < 7 2 2060 Risk Ratio (M-H, Fixed, 95% CI) 1.19 [0.53, 2.64]
21 Admission to neonatal intensive
care unit
3 4818 Risk Ratio (M-H, Random, 95% CI) 1.00 [0.70, 1.43]
22 Prolonged neonatal hospital
stay
1 3510 Risk Ratio (M-H, Fixed, 95% CI) 0.81 [0.46, 1.42]
23 Perinatal mortality 5 8529 Risk Ratio(M-H, Fixed, 95% CI) 1.83 [0.99, 3.38]
24 Prolonged postpartum hospital
stay
1 1860 Risk Ratio (M-H, Fixed, 95% CI) 1.00 [0.51, 2.00]
25 Mother re-admitted to hospital 1 1860 Risk Ratio (M-H, Fixed, 95% CI) 1.87 [0.75, 4.65]
26 Baby re-admitted to hospital 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
27 Breastfeeding initiated 2 1431 Risk Ratio (M-H, Fixed, 95% CI) 1.05 [1.02, 1.09]
28 Breastfeeding at 6-8 weeks 2 1431 Risk Ratio (M-H, Fixed, 95% CI) 1.06 [1.02, 1.10]
29 Involved in decisions about care 1 2844 Risk Ratio (M-H, Fixed, 95% CI) 1.04 [1.00, 1.08]
30 Prefer same setting the next
time
1 1230 Risk Ratio (M-H, Fixed, 95% CI) 1.81 [1.65, 1.98]
31 High rating of intrapartum care 1 2844 Risk Ratio (M-H, Fixed, 95% CI) 1.14 [1.07, 1.21]
15Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Comparison 2. Home-like versus conventional birth settings - variations in staffing
Outcome or subgroup title
No. of
studies
No. of
participants Statistical method Effect size
1 Spontaneous vaginal birth 5 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
1.1 Separate staff in birth
centre
3 5571 Risk Ratio (M-H, Fixed, 95% CI) 1.04 [1.01, 1.06]
1.2 Same staff in both settings 2 2958 Risk Ratio (M-H, Fixed, 95% CI) 1.03 [0.98, 1.08]
2 Admission to neonatal intensive
care unit
3 Risk Ratio (M-H, Random, 95% CI) Subtotals only
2.1 Separate staff in birth
centre
1 1860 Risk Ratio (M-H, Random, 95% CI) 1.23 [0.94, 1.63]
2.2 Same staff in both settings 2 2958 Risk Ratio (M-H, Random, 95% CI) 0.76 [0.34, 1.71]
3 Perinatal mortality 5 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3.1 Separate staff in birth
centre
3 5571 Risk Ratio (M-H, Fixed, 95% CI) 2.38 [1.05, 5.41]
3.2 Same staff in both settings 2 2958 Risk Ratio (M-H, Fixed, 95% CI) 1.24 [0.48, 3.19]
4 High rating of intrapartum care 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
4.1 Separate staff in birth
centre
0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
4.2 Same staff in both settings 1 2844 Risk Ratio (M-H, Fixed, 95% CI) 1.14 [1.07, 1.21]
Comparison 3. Home-like versus conventional birth settings - variations in continuity of caregiver
Outcome or subgroup title
No. of
studies
No. of
participants Statistical method Effect size
1 Spontaneous vaginal birth 5 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
1.1 Greater continuity of
caregiver in birth centre
3 5571 Risk Ratio (M-H, Fixed, 95% CI) 1.04 [1.01, 1.06]
1.2 No difference in extent of
continuity of caregiver
2 2958 Risk Ratio (M-H, Fixed, 95% CI) 1.03 [0.98, 1.08]
2 Admission to neonatal intensive
care unit
3 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
2.1 Greater continuity of
caregiver in birth centre
1 1860 Risk Ratio (M-H, Fixed, 95% CI) 1.23 [0.94, 1.63]
2.2 No difference in extent of
continuity of caregiver
2 2958 Risk Ratio (M-H, Fixed, 95% CI) 0.97 [0.75, 1.26]
3 Perinatal mortality 5 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3.1 Greater continuity of
caregiver in birth centre
3 5571 Risk Ratio (M-H, Fixed, 95% CI) 2.38 [1.05, 5.41]
3.2 No difference in extent of
continuity of caregiver
2 2958 Risk Ratio (M-H, Fixed, 95% CI) 1.24 [0.48, 3.19]
4 High rating of intrapartum care 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
4.1 Greater continuity of
caregiver in birth centre
0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
16Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
4.2 No difference in extent of
continuity of caregiver
1 2844 Risk Ratio (M-H, Fixed, 95% CI) 1.14 [1.07, 1.21]
Comparison 4. Home-like versus conventional birth settings - freestanding versus in-hospital
Outcome or subgroup title
No. of
studies
No. of
participants Statistical method Effect size
1 Spontaneous vaginal birth 0 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
1.1 Freestanding 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
1.2 In-hospital 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
2 Admission to neonatal intensive
care unit
0 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
2.1 Freestanding 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
2.2 In-hospital 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
3 Perinatal mortality 0 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3.1 Freestanding 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
3.2 In-hospital 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
4 High rating of intrapartum care 0 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
4.1 Freestanding 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
4.2 In-hospital 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
Analysis 1.1. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 1 Induction of
labour.
Review: Home-like versus conventional institutional settings for birth
Comparison: 1 Home-like versus conventional birth settings - all trials
Outcome: 1 Induction of labour
Study or subgroup Home-like Conventional Risk Ratio Weight Risk Ratio
n/N n/N M-H,Random,95% CI M-H,Random,95% CI
Byrne 2000 20/100 25/101 12.1 % 0.81 [ 0.48, 1.36 ]
Hundley 1994 385/1900 181/944 40.1 % 1.06 [ 0.90, 1.24 ]
MacVicar 1993 218/2304 131/1206 34.5 % 0.87 [ 0.71, 1.07 ]
Waldenstrom 1997 25/928 42/932 13.3 % 0.60 [ 0.37, 0.97 ]
Total (95% CI) 5232 3183 100.0 % 0.89 [ 0.72, 1.09 ]
Total events: 648 (Home-like), 379 (Conventional)
Heterogeneity: Tau2 = 0.02; Chi2 = 6.29, df = 3 (P = 0.10); I2 =52%
Test for overall effect: Z = 1.14 (P = 0.25)
0.1 0.2 0.5 1 2 5 10
Favours home-like Favours conventional
17Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.2. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 2
Augmentation of labour.
Review: Home-like versus conventional institutional settings for birth
Comparison: 1 Home-like versus conventional birth settings - all trials
Outcome: 2 Augmentation of labour
Study or subgroup Home-like Conventional Risk Ratio Weight Risk Ratio
n/N n/N M-H,Random,95% CI M-H,Random,95% CI
Byrne 2000 40/100 47/101 17.5 % 0.86 [ 0.63, 1.18 ]
Hundley 1994 274/1900 135/944 24.2 % 1.01 [ 0.83, 1.22 ]
Klein 1984 17/56 16/58 8.8 % 1.10 [ 0.62, 1.96 ]
MacVicar 1993 270/2304 192/1206 25.3 % 0.74 [ 0.62, 0.87 ]
Waldenstrom 1997 140/928 223/932 24.2 % 0.63 [ 0.52, 0.76 ]
Total (95% CI) 5288 3241 100.0 % 0.81 [ 0.67, 1.00 ]
Total events: 741 (Home-like), 613 (Conventional)
Heterogeneity: Tau2 = 0.03; Chi2 = 13.86, df = 4 (P = 0.01); I2 =71%
Test for overall effect: Z = 1.99 (P = 0.047)
0.1 0.2 0.5 1 2 5 10
Favours home-like Favours conventional
Analysis 1.3. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 3 Meconium
in labour.
Review: Home-like versus conventional institutional settings for birth
Comparison: 1 Home-like versus conventional birth settings - all trials
Outcome: 3 Meconium in labour
Study or subgroup Home-like Conventional Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Hundley 1994 251/1900 129/944 44.2 % 0.97 [ 0.79, 1.18 ]
MacVicar 1993 322/2304 166/1206 55.8 % 1.02 [ 0.85, 1.21 ]
Total (95% CI) 4204 2150 100.0 % 0.99 [ 0.87, 1.13 ]
Total events: 573 (Home-like), 295 (Conventional)
Heterogeneity: Chi2 = 0.13, df = 1 (P = 0.71); I2 =0.0%
Test for overall effect: Z = 0.09 (P = 0.93)
0.1 0.2 0.5 1 2 5 10
Favours home-like Favours conventional
18Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.4. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 4 Fetal heart
rate abnormality.
Review: Home-like versus conventional institutional settings for birthComparison: 1 Home-like versus conventional birth settings - all trials
Outcome: 4 Fetal heart rate abnormality
Study or subgroup Home-like Conventional Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Hundley 1994 336/1900 205/944 38.3 % 0.81 [ 0.70, 0.95 ]
MacVicar 1993 480/2304 336/1206 61.7 % 0.75 [ 0.66, 0.84 ]
Total (95% CI) 4204 2150 100.0 % 0.77 [ 0.70, 0.85 ]
Total events: 816 (Home-like), 541 (Conventional)
Heterogeneity: Chi2 = 0.72, df = 1 (P = 0.40); I2 =0.0%
Test for overall effect: Z = 5.29 (P < 0.00001)
0.1 0.2 0.5 1 2 5 10
Favours home-like Favours conventional
Analysis 1.5. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 5 Prolonged
1st stage labour.
Review: Home-like versus conventional institutional settings for birth
Comparison: 1 Home-like versus conventional birth settings - all trials
Outcome: 5 Prolonged 1st stage labour
Study or subgroup Home-like Conventional Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Hundley 1994 57/1900 20/944 13.4 % 1.42 [ 0.86, 2.34 ]
MacVicar 1993 267/2304 132/1206 86.6 % 1.06 [ 0.87, 1.29 ]
Total (95% CI) 4204 2150 100.0 % 1.11 [ 0.92, 1.33 ]
Total events: 324 (Home-like), 152 (Conventional)
Heterogeneity: Chi2 = 1.12, df = 1 (P = 0.29); I2 =10%
Test for overall effect: Z = 1.08 (P = 0.28)
0.1 0.2 0.5 1 2 5 10
Favours home-like Favours conventional
19Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.6. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 6 Prolonged
2nd stage labour.
Review: Home-like versus conventional institutional settings for birth
Comparison: 1 Home-like versus conventional birth settings - all trials
Outcome: 6 Prolonged 2nd stage labour
Study or subgroup Home-like Conventional Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Hundley 1994 94/1900 47/944 32.6 % 0.99 [ 0.71, 1.40 ]
MacVicar 1993 177/2304 99/1206 67.4 % 0.94 [ 0.74, 1.18 ]
Total (95% CI) 4204 2150 100.0 % 0.95 [ 0.79, 1.16 ]
Total events: 271 (Home-like), 146 (Conventional)
Heterogeneity: Chi2 = 0.08, df = 1 (P = 0.78); I2 =0.0%
Test for overall effect: Z = 0.47 (P = 0.64)
0.1 0.2 0.5 1 2 5 10
Favours home-like Favours conventional
Analysis 1.7. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 7 Opioid
analgesia.
Review: Home-like versus conventional institutional settings for birth
Comparison: 1 Home-like versus conventional birth settings - all trials
Outcome: 7 Opioid analgesia
Study or subgroup Home-like Conventional Risk Ratio Weight Risk Ratio
n/N n/N M-H,Random,95% CI M-H,Random,95% CI
Waldenstrom 1997 33/912 120/916 19.8 % 0.28 [ 0.19, 0.40 ]
Byrne 2000 33/100 29/100 18.5 % 1.14 [ 0.75, 1.72 ]
Chapman 1986 4/76 9/72 5.6 % 0.42 [ 0.14, 1.31 ]
Hundley 1994 1063/1900 498/944 28.2 % 1.06 [ 0.99, 1.14 ]
MacVicar 1993 812/2304 477/1206 27.9 % 0.89 [ 0.82, 0.97 ]
Total (95% CI) 5292 3238 100.0 % 0.74 [ 0.55, 1.00 ]
Total events: 1945 (Home-like), 1133 (Conventional)
Heterogeneity: Tau2 = 0.08; Chi2 = 57.88, df = 4 (P<0.00001); I2 =93%
Test for overall effect: Z = 1.93 (P = 0.053)
0.1 0.2 0.5 1 2 5 10
Favours home-like Favours conventional
20Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.8. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 8 Nitrous
oxide in labour.
Review: Home-like versus conventional institutional settings for birth
Comparison: 1 Home-like versus conventional birth settings - all trials
Outcome: 8 Nitrous oxide in labour
Study or subgroup Home-like Conventional Risk Ratio Weight Risk Ratio
n/N n/N M-H,Random,95% CI M-H,Random,95% CI
Waldenstrom 1997 128/912 417/916 20.6 % 0.31 [ 0.26, 0.37 ]
Byrne 2000 51/100 55/100 20.0 % 0.93 [ 0.71, 1.20 ]
Chapman 1986 19/76 27/72 17.5 % 0.67 [ 0.41, 1.09 ]
Hundley 1994 1408/1900 657/944 21.1 % 1.06 [ 1.01, 1.12 ]
MacVicar 1993 654/2304 240/1206 20.8 % 1.43 [ 1.25, 1.63 ]
Total (95% CI) 5292 3238 100.0 % 0.79 [ 0.48, 1.29 ]
Total events: 2260 (Home-like), 1396 (Conventional)
Heterogeneity: Tau2 = 0.30; Chi2 = 221.61, df = 4 (P<0.00001); I2 =98%
Test for overall effect: Z = 0.95 (P = 0.34)
0.1 0.2 0.5 1 2 5 10
Favours home-like Favours conventional
21Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.9. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 9 Epidural
analgesia.
Review: Home-like versus conventional institutional settings for birth
Comparison: 1 Home-like versus conventional birth settings - all trials
Outcome: 9 Epidural analgesia
Study or subgroup Home-like Conventional Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Byrne 2000 37/100 48/101 7.2 % 0.78 [ 0.56, 1.08 ]
Chapman 1986 3/76 6/72 0.9 % 0.47 [ 0.12, 1.82 ]
Hundley 1994 246/1900 140/944 28.2 % 0.87 [ 0.72, 1.06 ]
Klein 1984 14/56 15/58 2.2 % 0.97 [ 0.52, 1.81 ]
MacVicar 1993 326/2304 208/1206 41.2 % 0.82 [ 0.70, 0.96 ]
Waldenstrom 1997 108/912 135/916 20.3 % 0.80 [ 0.63, 1.02 ]
Total (95% CI) 5348 3297 100.0 % 0.83 [ 0.75, 0.92 ]
Total events: 734 (Home-like), 552 (Conventional)
Heterogeneity: Chi2 = 1.39, df = 5 (P = 0.92); I2 =0.0%
Test for overall effect: Z = 3.61 (P = 0.00031)
0.1 0.2 0.5 1 2 5 10
Favours home-like Favours conventional
22Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.10. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 10 No
analgesia/anaesthesia.
Review: Home-like versus conventional institutional settings for birth
Comparison: 1 Home-like versus conventional birth settings - all trials
Outcome: 10 No analgesia/anaesthesia
Study or subgroup Home-like Conventional Risk Ratio Weight Risk Ratio
n/N n/N M-H,Random,95% CI M-H,Random,95% CI
Byrne 2000 32/100 26/101 14.1 % 1.24 [ 0.80, 1.93 ]
Chapman 1986 31/76 17/72 11.0 % 1.73 [ 1.05, 2.84 ]
Hundley 1994 32/1900 14/944 6.9 % 1.14 [ 0.61, 2.12 ]
MacVicar 1993 270/2304 127/1206 68.0 % 1.11 [ 0.91, 1.36 ]
Total (95% CI) 4380 2323 100.0 % 1.19 [ 1.01, 1.40 ]
Total events: 365 (Home-like), 184 (Conventional)
Heterogeneity: Tau2 = 0.0; Chi2 = 2.68, df = 3 (P = 0.44); I2 =0.0%
Test for overall effect: Z = 2.05 (P = 0.040)
0.1 0.2 0.5 1 2 5 10
Favours conventional Favours home-like
Analysis 1.11. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 11
Supine/semi-recumbent birth position.
Review: Home-like versus conventional institutional settings for birth
Comparison: 1 Home-like versus conventional birth settings - all trials
Outcome: 11 Supine/semi-recumbent birth position
Study or subgroup Home-like Conventional Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Waldenstrom 1997 268/829 396/779 100.0 % 0.64 [ 0.56, 0.72 ]
Total (95% CI) 829 779 100.0 % 0.64 [ 0.56, 0.72 ]
Total events: 268 (Home-like), 396 (Conventional)
Heterogeneity: not applicable
Test for overall effect: Z = 7.38 (P < 0.00001)
0.1 0.2 0.5 1 2 5 10
Favours home-like Favours conventional
23Home-like versus conventional institutional settings for birth (Review)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.12. Comparison 1 Home-like versus conventional birth settings - all trials, Outcome 12
Instrumental vaginal birth (forceps or ventouse).
Review: Home-like versus conventional institutional settings for birth
Comparison: 1 Home-like versus conventional birth settings - all trials
Outcome: 12 Instrumental vaginal birth (forceps or ventouse)