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The place of birth

The debate about the choice of place of delivery continues unabated as can be seen in four articles in this issue (pp. 659,675,684 and 690). Sadly the protagonists have tended to take up fixed positions, and the initially stimulating and useful discussion is in danger of degenerating into a sterile argument. It is perhaps a good time to look again at the questions which have been raised to see whether we cannot advance further. To start, a reading of the literature suggests that there is often confusion between three separate issues. First, is home delivery more or less safe than institutional delivery, all other factors being equal? Second, is it inevitable that the rate of obstetric intervention must rise with the proportion of deliveries in consultant units? Third, what are the effects on mothers and babies of such a rise? Moreover there is a fourth issue, which is less well documented but also important, and that is the cost, in financial and manpower resources, of altering again the proportions of deliveries at home, in general practitioner and in consultant units. It is now almost impossible to answer the first question about the relative safety of home and hospital confinements, and the reasons for this are well set out in the article by Campbell & Macfarlane (p. 675). However, all the available evidence suggests that in carefully selected and well-supervised low-risk deliveries the extra risk to mother and baby attributable only to the absence of hospital facilities must be low, and the satisfaction of a successful delivery high. Against this must be set the chance of needing an emergency transfer during, or after, the delivery, and although data on such events are limited, extrapolation from the experience of general practitioner units suggests it may be of the order of lo%, similar to the figures quoted by Scherjon (p. 684). Such emergency transfers are both distressing and costly if flying squad aid is needed, but it should not be forgotten that they may also occur in split-site hospitals where the maternity unit is removed from other specialist facilities. The tendency for intervention rates to rise with the proportion of institutional deliveries is shown again in the paper by Scherjon (p. 684). A change in policy in Denmark between 1960 and 1980 led to a rise in institutional deliveries from 50% to 99%. During the same period this proportion in The Netherlands rose from about 28% to 67%. The caesarean section rate in both countries was about 2% at the beginning of the period, but rose to 11% in Denmark and only to 4% in the Netherlands. However, the wide variations found in intervention rates between institutions and countries suggests that this trend could be contained or reversed. Apart from the threat of litigation, we know very little about the factors which predispose to unduly high intervention rates, and this would be an interesting area of research. It would also be important to know, where there is a real choice between domiciliary and institutional delivery, how a woman’s choice is influenced by her knowledge of the risk of possibly unnecessary intervention. For instance it is a pity that the paper by Treffers & Laan (p. 690), which shows remarkable differences in the proportion of domiciliary births between large cities in the Netherlands, did not also give us some indication of the variation in the rates of caesarean section, or other instrumental deliveries in the institutions in these cities. The question of the benefits and hazards of these interventions in low-risk pregnancies is still largely unanswered. Campbell & Macfarlane (p. 675) show how even the ingenuity of Tew (p. 659) in manipulating published data on place of delivery and perinatal mortality cannot overcome the shortcomings of the data set. The same is true of Treffers & Laan’s attempt to relate regional variations in the proportion of institutional births to the perinatal mortality