The primary aim of this audit is to provide national statistics and an overview of findings from the HSE home birth service in the Republic of Ireland (ROI). This audit aims to collect data on the clinical care and outcomes for all women who registered for a home birth, examining both the maternal and infant outcomes of planned HSE home births, including outcomes whereby the care of the woman is transferred for hospital care in the antepartum, intrapartum or postpartum period. Thus, facilitating maternity services to undertake reviews of its own practices, through monitoring these outcomes with regular audit. This information is essential to ensure that standards of home births in ROI are met.
This document provides an overview of the latest findings and recommendations, for further information, please access the full report in the button below.
For the period from January 1st, 2022 to December 31st 2022, there were 432 women who were registered for a home birth with the Health Service Executive (HSE) home birth service. The number of women who were registered for a home birth steadily increased from 2018 to 2022. This increase is also evidenced in the rate per 1,000 maternities for the Republic of Ireland since 2012
Geographical distribution
The distribution of home births by HSE region is markedly different to the overall distribution of births nationally. For the first time in this report, Dublin Mid Leinster reports the majority of women registering for home birth (n=189). This year, Dublin Mid Leinster includes women who registered with the Coombe maternity hospital (n=17) and the women who registered with the integrated hospital community service (IHCS) available in the National Maternity Hospital (NMH, n=48; Table 1).
IHCS available in UHW (n=4), WGH (n=4) and NMH (n=48) reported a total of 56 women registered for 2022, which represents 13% of the total of women registered for a home birth in the Republic of Ireland in 2022. The remainder of the women in this report chose to have their care provided by self-employed community midwives.
Maternal characteristics
Age
The age range of women who were registered for a home birth in 2022 was 18-43 years, with the average age being 33.5 years. Consistent with data from previous reports, women who registered for a home birth tended to be of an older age demographic when compared to all women who gave birth in Ireland. A higher majority (n = 323 of 432, 74.8%) of women who were registered to give birth at home were aged 30-39 years in 2022 compared to 66.1% of all women who gave birth from 2019 to 2022.
Ethnicity
The majority of women who booked for a home birth were of white Irish ethnicity, which is consistent with the percentage of white Irish in the female population aged 15-49 years surveyed in 2022 (71.3% for 2022 versus 75.4% for female population in 2022). The numbers of Asian/Asian Irish (n=5), Black/Black Irish (n=1), mixed ethnicities (n=2) and Irish Traveller ethnicity (n=1) are small and are under representative of the population for this year as it occurred in previous years.
Body Mass Index (BMI)
Body mass index (BMI) was available for 93.8% (n=405) of women in 2022 (Table 5). As in previous years, the BMI for approximately 57% of women was in the healthy range (18.5-24.9kgm-2), almost one third were classified as overweight (25.0-29.9kgm-2) and approximately one in ten were classified as obese (>30.0kgm-2). The BMI profile of women who were registered for a home birth in the category of BMI less than 25 kgm-2 (58.3%) was higher than that of the general population of women giving birth in Ireland in 2021 (48.2%), based on a comparison with data collated from the country’s four large maternity hospitals in 2021 in Ireland.
Smoking, alcohol and drug consumption
Smoking status and alcohol consumption at the time of booking was recorded for the majority of women (99.5% and 99.1%, respectively). Three women (0.7%) indicated that they were smoking at time of booking, one of whom gave up during pregnancy. Thus, two of the 430 (0.5%, unknown for one woman) women smoked throughout their pregnancy for this report.
The vast majority of women (n=427 of 428, 99.8%) reported they did not consume alcohol at their booking visit. One of them reported to have consumed alcohol monthly or less during her pregnancy. Less than 0.5% had a documented history of drug abuse or attendance at a drug rehabilitation unit prior to this pregnancy (n=1 of 431).
Physical activity
Physical activity was recorded for approximately 50% of the women (n=222). Of them, 90% engaged regularly in physical activity (i.e. more than once a week), 9.9% (n=22) had occasional physical activity (i.e. once every two weeks) at the time of the booking visit.
Distance of the woman’s residence to services
Data related to the distance of the woman’s residence to the community midwife and to the nearest maternity hospital is shown in Figure 5. More than 64% of the women were within 30 kilometres of the community midwife (n=242 of 376, 64.4%, excluding n=56 women whose care was provided by ICHMs at the maternity hospital; mean=27.1kms), and more than 70% were within 30 kilometres of the maternity hospital (n=313 of 432, 72.5%, including women whose care was provided by ICHMs; mean=22.8kms). The average distance to the maternity hospital was reduced from a mean of 26.4kms in 2021 compared to 22.8kms in 2022, with statistically significant differences. There was an increase in the distance to the community midwife in 2022 compared to 2021 (27.1kms versus 26.3kms, respectively); however, the difference did not reach statistically significant differences.
Previous pregnancy
Approximately, 29% of women who registered for a home birth did not have a previous pregnancy (n=126 of 432, 29.2%). As indicated in Table 6, almost two-thirds of the women who were registered for a home birth in 2022 had a previous birth (n=276 of 431, 64.0%, number of previous births was missing for one woman), which is similar to that of previous years (69.9%, 65.5% and 64.1% for 2019, 2020 and 2021 respectively).
Antepartum care
Shared Care
All women who were registered for a home birth also registered with a maternity unit (100%). A specific liaison obstetrician or a specific liaison clinic was available in the maternity unit for less than half of the women (n=165, 38.6% and n=42, 9.8%, respectively, unknown for four women) A non-specific obstetrician was available for half of women who registered for a home birth (n=221, 51.6%, unknown for four women)
Approximately 93% of women, who registered for a home birth, were also registered with a general practitioner (GP; n=347 of 372, 93.3%, unknown for 60 women). The GP was unable to provide some aspects of shared care for more than 64% of the women (n=221 of 345, 64.1%, missing for two women) with 34.4% (n=76) of these women not receiving any shared care from their GP. Where a GP was not able to provide antenatal care, they were also unlikely to be able to complete the examination of the newborn on day 3 (n=123, 55.7%).
Midwifery-led hospital services (n=85, 38.5%) and care from the community midwife only (n=68, 30.8%) were the most common alternatives to providing shared care when a GP was unable to do so. Of the women who received shared care from their maternity hospital’s obstetric led service, 30% had a specific liaison obstetrician or clinic available (n=21 of 71, 29.6%, unknown for one woman).
Estimated date of delivery and antepartum ultrasound scans
Estimated date of delivery (EDD) was calculated using ultrasound scan alone in the majority of cases (n=176 of 431, 40.8%) in 2022. For the remainder of the women, EDD was calculated using last menstrual period (LMP) only for 36% of women (n=157, 36.4%), and both ultrasound scan and LMP for 23% of women (n=98 of 431, 22.7%), missing information for one women.
Approximately 72% of women who registered for a home birth had a booking scan before 14 weeks of gestation (n=305 of 425, 71.8%, missing for seven women). Both, women who were not reported to have had a booking scan performed and those who data was missing for, could possibly be attributed to the women registering with the home birth service after they have had their initial scan.
Of the 432 women registered for a home birth in 2022, 99.3% (n=427of 430, missing information for two cases) had an anomaly scan. Anomaly scans were commonly performed between 18 and 21 weeks of gestation (n=272 of 423, 64.3%) or after 21 weeks of gestation (n=149 of 423, 35.2%), and rarely performed at less than 18 weeks (n=2, 0.5%; unknown for four women).
Risk factors requiring review when planning place of birth
In 2022, 23.4% (n=101 of 432) of women who registered for a home birth had a reported risk factor that required review by an obstetrician to determine eligibility for the service. Of them, 82.2% (n=83) had only one risk factor, 15.8% (n=16) had two risk factors and the remaining two women had three or more risk factors. In total, 122 risk factors were identified in 2022. Consistently with previous years, maternal age over 40 at the booking visit (33.7%) was the most common risk factor identified in 2022. It was followed by endocrine disorders (14.9%), infection (13.9%) and mental health history (10.9%). Other risk factors include those such as in vitro fertilization (IVF, n=4) and anaemia (n=4), among others.
Of the 306 women who had a previous pregnancy and were registered for a home birth, 73 (24.0%, unknown for two women) were reported to have had a previous obstetric condition or risk factor for review which included a history of Group B streptococcus (12.3%), three or more miscarriages (12.3%), preterm labour or mid-trimester loss (9.6%), extensive vaginal, cervical, or third- or fourth- degree perineal trauma (8.2%) and previous baby weighing >4.5kg (8.2%; Table 9). There was a 3.18% increase in the reporting of previous pregnancy problems compared to the previous year 2022. Which might reinforce the hypothesis that the increase found in the previous report may possibly be attributed to an update in the data collection tool, following a recommendation from the triennial report. Other risk factors include those such as previous induction of labour for an infant measuring small-for-dates or post maturity (n=5, respectively) and anaemia (n=4), among others.
Current pregnancy
Of the 432 women who were registered for a home birth in 2022, 176 women (40.7%) were reported to have a medical or obstetric condition develop during the current pregnancy (Table 10). The most common conditions reported in 2022 were indication of maternal infection (16.5%; four of which were Covid related cases), post-dates pregnancy (14.8%), malpresentation of the fetus (10.2%) and prolonged rupture of membranes (8.5%).
Of the 176 women who had a problem arise during this pregnancy while under the care of the home birth service, 95.5% (n=168) were reviewed by an obstetrician in the maternity unit. The care was transferred antenatally to a maternity unit for 80.9% (n=136) of them.
Following the obstetric review, there was a small cohort of women (n=32) who required extra monitoring during their pregnancy but that did not require transfer of care to the maternity unit, demonstrating effective collaboration between services. Reasons included:anaemia, indication of maternal infection, low-lying placenta that required re-scanning and was later deemed safe, malpresentation, diagnoses of oligo/polyhydramnios, post-dates, fetal growth monitoring requiring extra growth scans and reduced fetal movements. Twelve of these women (37.5%) went on to have an intrapartum transfer, nine gave birth in hospital, two at home and one gave birth before arrival to the hospital. The remaining 20 women did not require transfer and gave birth at home.
Antepartum transfers
A total of 136 women were transferred in the antepartum period due to a problem arising during the pregnancy. Nineteen further women transferred their care to the maternity unit by choice. Therefore, in 2022, a total of 155 (35.9%) women were transferred to a maternity hospital during their pregnancy. This is in line with previous findings, where approximately one-third of women’s care was transferred antenatally to a maternity hospital (Table 11). No woman was transferred back to the home birth service later in the pregnancy in 2022. Of the women who were transferred in the antepartum period, three women gave birth before arrival at the hospital (BBAs), six women gave birth outside of the HSE service, and the remaining 146 women gave birth in hospital. Similar to previous years, nulliparous women were more likely to transfer in the antepartum period compared to multiparous women (47% versus 29%).
The most common reasons for antepartum transfers in 2022 were post-dates pregnancy (n=22, 14.2%), prolonged rupture of membranes with no signs of labour (n=15, 9.0%) and malpresentation (n=14, 9.0%, Table 12).
Following transfer of care, 33.3% nulliparous women (n=20) and 87.5% multiparous women (n=63) had a spontaneous vaginal birth in 2022. Nulliparous women were more likely to have a caesarean section than multiparous women in 2022 in line with previous findings (56.7% versus 9.7%; Table 13). The mode of birth was unknown for 14% of women (n=22 of 154, 14.3%, parity was unknown for one woman who had an antepartum transfer).
Intrapartum transfers
Of the 277 women who began labouring at home in 2022, 23.5% (n=65) were transferred to a hospital. Of these women, 64.6% were transferred by ambulance (n=42), one woman who started labouring near the hospital went on foot, and the remainder by private car (n=22). It took between five and 77 minutes to transfer women from their homes to the hospital. The average time it took to transfer a woman was 28.1 minutes.
More than half of women who had an intrapartum transfer, were transferred to a maternity unit in less than 30 minutes in 2022 (n=30 of 58, 51.7%, missing information for seven women). Another 43% took between 30 and 60 minutes to be transferred (n=25, 43.1%). International studies show average times for intrapartum transfers between 15 and 30 minutes, which is similar to our results. Approximately 5% of transfers took longer than 61 minutes
Of the 65 women who were transferred in the intrapartum period, 87.7% (n=57) women gave birth in the hospital, six women gave birth at home but were transferred in before the 3rd stage of labour was completed, and two women gave birth before arrival at the hospital (BBAs).
Nulliparous women were three times more likely to transfer during labour than multiparous women in 2022 and in line with previous findings (43.9% versus 14.9%). Approximately seventy-nine percent of intrapartum transfers occurred during the first stage of labour (n=51, 78.5%).
Almost 31% of intrapartum transfers to the maternity unit were associated with confirmed delay in 1st or 2nd stage of labour (n=20, 30.8%), another 30% with maternal request for medical analgesia (n=18, 27.7%), and approximately 12% with meconium-stained liquor (n=8, 12.3%). Maternal request for medical analgesia was more common among nulliparous women than for multiparous women in 2022 (38.9% versus 13.8%), similarly to previous years (37.9% versus 20.4%).
The difference between nulliparous and multiparous women who were transferred during labour because of confirmed delay in the 1st or 2nd stage of labour was less evident in 2022 (36.1% versus 24.1%, respectively), but is still in line with the findings in the aggregate data from previous years.
More than 60% of women who transferred to the maternity unit during the intrapartum period had a spontaneous vaginal birth (n=37 of 60, 61.7%), and 16.7% (n=10) had a caesarean section. Spontaneous vaginal birth was two times more common among multiparous women, and caesarean section was more common among nulliparous women.
Home births
Of the women who registered for a home birth in 2022 (n=432), 218 women gave birth at home (50.5%) including 49 nulliparous women and 169 multiparous women. The distribution of actual births at home by HSE region was similar to the distribution of registered home births. The care of the women who registered for a home birth was predominately provided by SECMs (n=376 of 432, 87%), while 13% of women had their care provided by ICHMs in 2022 (n=56, 13%).
Present at birth
As indicated in Table 23, the woman’s primary community midwife was present at the vast majority of home births in 2022 (n=210 of 218, 96.3%). Approximately 76% of women had both a primary and second midwife present at birth (n=169, 77.5%). A second midwife was called but only present at delivery of placenta in almost 12% of births (n=26, 11.9%) and a second midwife was called but only present postpartum for a small number of women (n=9, 4.1%). The woman’s partner was also present in the majority of cases (n=216, 99.1%). Other people noted to have been present at the birth include a doula (n=16, 7.3%) and family members or friends (n=31, 14.2%). Student midwives and ambulance crew were among the other type of people who were present at the birth in 2022 (n=19, 8.7%).
For women who were not attended by their primary community midwife for the birth (n=8), a community midwife arrived shortly after the birth for four women to continue to provide care to the woman and her baby. For the remaining four women, one of the women had a doula present at the birth, one had another family member, ambulance staff was present at birth for one woman and for the fourth woman, the midwife was phoned after the baby was born. The partner was present in all of the eight births. Multiparous women accounted for all but one of these women (n=7 of 8, 87.5%). It was reported that none of these women or their babies required transfer to hospital following the birth, and all the babies were alive and well and continued receiving their routine care under the home birth service.
Duration of labour
Information about the duration of labour was available for 99.1% of women who gave birth at home (n=216 of 218). The mean duration of labour for those that gave birth at home was 2.52 hours in 2022 (SD=2.48 hours, range=0 to 19 hours). As in previous years, multiparous women laboured faster than nulliparous women (mean time 2.08 hours, 95%CI=1.78-2.37 for multiparous women versus 4.02 hours 95%CI=3.04-5.00 for nulliparous; Figure 7), with mean change of 1.94 hours and statistically significant differences (95%CI=1.19-2.96; p-value < 0.010). Similarly, women whose midwives arrived shortly after the birth (i.e. unattended home births) had a lower duration of labour compared to home births where the midwives were present at birth (mean time 0.86 hours, 95%CI=0.03-1.69 for unattended home births versus 2.57 hours, 95%CI=2.23-2.91 for home births where a midwife was present at the birth), with mean change of 1.71, but this did not reach statistically significant differences.
As documented in Table 24, the two most common maternal positions for birth were all fours position (n=81 of 214, 37.9%, unknown for four women) and kneeling position (n=58, 27.1%). Other birth positions included use of a birth stool and a running start position.
Pain relief
Type of pain relief used was recorded for all 218 women who gave birth at home (Figure 7). Over one third of women used no pain relief (n=75, 34.4%) with multiparous women being more likely to not use any pain relief (37.9% versus 22.4%). Nulliparous women were more likely to use water for pain relief than multiparous women (51.0% versus 30.8%). Approximately 6% of women gave birth in water, using water immersion for pain relief (n=13 of 218, 6.0%). At the time of the births, the HSE had a pause on giving birth in water.
Management of third stage of labour
The vast majority of women who gave birth at home had a physiological third stage of labour (n=159 of 218, 72.9%). The physiological management of the third stage comprises of the following components: no routine use of uterotonic drugs, no clamping of the cord until pulsation has stopped, delivery of the placenta by maternal effort.
Of the 59 women who had active management of the third stage of labour in the home, intramuscular syntocinon was administered in 39 cases, syntometrine in 23 cases, one woman required ergometrine, and one woman required a syntocinon infusion (figures are not mutually exclusive). Almost twenty nine percent of nulliparous women had active management at home (n=14 of 49, 28.6%; Figure 8) and almost twenty seven percent of multiparous women had active management in the home (n=45 of 169, 26.6%).
Infant outcomes
Of the 218 infants born at home, 102 were female (46.8%) and 116 were male (53.2%). The mean birth weight for infants born at home was 3708.5 grams, ranging from 2,550 to 5,020 grams, unknown for one infant. Nulliparous women were more likely to have infants with lower weight than multiparous women (mean=3,553 SD=416 grams versus mean=3753, SD=402 grams respectively)
Apgar scores
Data on Apgar scores at one minute and five minutes were available for 211 and 216 infants born at home (n=218) respectively. Only one infant had an Apgar score of less than six at one minute after birth. At five minutes, the majority of infants had an Apgar score of either nine (n=59, 27.3%) or ten (n=155, 71.8%).
Resuscitation and other infant outcomes
Seven of the 218 infants born at home (3.2%) needed some form of resuscitation. One infant was resuscitated with suction only, four infants received oxygen and two infants were resuscitated by intermittent positive pressure ventilation. Of the seven babies that required resuscitation, four were transferred to the maternity unit for review (one of them as an intrapartum transfer in the 3rd stage of labour). Two of the infants did not require additional support, however, were transferred to hospital to accompany their mother who required transfer. The other two babies required additional support and were admitted to the SCBU. Cardiac massage was not required by any baby born at home as a mode of resuscitation in 2022.
Of the women who required transfer to the hospital in labour, six infants required some form of resuscitation after their birth in the hospital (n=6 of 59, 10.2%, missing information for three infants). In 2022, all infants who required resuscitation at birth following intrapartum transfer were transferred to the hospital in the first stage of labour.
One woman who gave birth at birth at home experienced a shoulder dystocia (n=1 of 218, 0.5%), resolved with position change. The infant had Apgars of 9 at 1 minute and 9 at 5 minutes and did not require any resuscitation or additional care.
Adverse incidents
There were 42 adverse incidents identified among women who registered for a home birth in 2022 (n=432), 31 of them occurred among women who gave birth at home (n=218). A HSE National Incident Report Form (NIRF) was completed in all the cases, except for one (Table 33). In 2022, 80% of incidents were classified as Category 3 (n=24) and 16.7% were Category 2 (n=5), missing for one case. There was one Category 1 incident reported for 2022.
Sadly, there was one maternal death of a woman who gave birth at home in 2022. A review into the case is ongoing with a report due to be published from the HSE.
Infant transfers
Thirteen of the infants born at home were transferred to hospital for reasons specified in Table 29. Ten infants were transferred by ambulance and 3 infants transferred by private car. The most common reason for infant transfer was to accompany their mother who required transfer to the maternity unit (n=7 of 13, 53.8%). Seven infants required additional care, six of which were admitted into the Special Care Baby Unit (SCBU) with the length of stay ranging from half a day to seven days, and one was cared for on the ward following transfer. All of the 13 infants were well at discharge.
Postpartum care and infant feeding
Women who gave birth at home were discharged from the care of the home birth service, on average, 12 days after the birth of their babies. In some circumstances the community midwives may provide care beyond this agreed timeframe, this is provided on an individual basis. For 2022, 11.5% women who gave birth at home received postpartum care beyond 14 days (n=25 of 217, missing for one woman). The average number of postpartum visits by the community midwife among the 217 women who gave birth at home was 5.2 visits (missing for one woman). It ranged between three and 11 visits, with 90.3% of women having between 4 and 6 total number of postpartum visits in 2022 (n=196 of 218, missing for one woman).
Method of feeding was recorded on both day one and on day of discharge from the care of the community midwives. As outlined in Table 31, the vast majority of women who gave birth at home were exclusively breastfeeding on both day one (n=209 of 218, 95.9%) and on day of discharge (n=204 of 218, 93.6%). Women who birthed at home were twice as likely to breastfeed exclusively on the day of discharge than the total population of women who gave birth in Ireland in 2021 (93.6% versus 46.3%).
Postpartum transfers
There were 17 reported postpartum complications among the 217 women who gave birth at home in 2022 (Table 32, unknown for one woman). Seven of these women required transfer to the hospital in the postpartum period (which is considered from birth to 6 weeks). The remaining women had a complication that did not require transfer of care and was managed in the community setting. Six women were transferred by ambulance, and one by private car. Indications for transfer are outlined in Table 32. Six of the women were transferred shortly after the birth, and a further woman was transferred on day 2 due to complications arising in the days after the birth.
Recommendations made from this report
It is recommended that the home birth service identifies a communication pathway to continue to capture data points when a woman’s care is transferred to the maternity unit.
Access to the birth details/maternity clinical records of women who were transferred to the maternity hospital in the antepartum period was higher in 2022 compared to 2021 (i.e. full access was 37% in 2022 and 22% in 2021); however, the level of missing information in this audit still high among women and their infants who need a transfer of care. To more accurately capture the outcomes of both the woman and infant in these circumstances, it is recommended that communication pathways is further supported between the services. With the ongoing integration of HSE home births into the acute services governance, gaining access to maternity clinical records for the home birth services may facilitate this further.
Continue to encourage presence of a second midwife at the home birth.
Approximately 76% of women had both a primary and second midwife present at birth in 2022 which shows a small increase from last year (74% in 2021). The presence of two midwives at the home birth has been a mandatory part of the service since 2014. This should continue to be encouraged as an important safety measure when providing community care.
Help us disseminate our findings
Citation for this report:
San Lázaro Campillo I & Keane J, Corcoran P, McKernan J, Escanuela Sanchez T and Greene RA on behalf of the Registered Home Births Audit Governance Group. Registered Home Births National Audit Report 2022; HSE National Home Birth Service. Cork: Health Service Executive, 2024.