Data recording and management

Contribution to clinical audit activities is outlined in the midwifery practice guidelines for the home birth service. (1) After each birth, clinical maternity notes are submitted by the community midwife to the DMO or service manager. The DMO reviews the notes and collates the information using the standardised NPEC home birth data collection form within a secure online audit tool, REDCap (Research Electronic Data Capture). REDCap is a web-based platform hosted at University College Cork, (5,6) designed to support validated data capture. All the data submitted to REDCap is anonymised and subsequently analysed by the NPEC.

For the year 2023, data were collected for all women who registered with the HSE home birth service and gave birth between January 1, 2023 and December 31, 2023. A full list of DMOs who contributed data to the 2023 report is available in Appendix A. This approach to identifying and including all women who registered with the HSE home birth service and gave birth within the calendar year has been consistently applied in previous audit cycles, allowing for year-on-year comparisons.

Data analysis

The clinical audit findings are organised into two main sections (Figure II):

Section 1: All women registered for a home birth

This section presents data on all women who registered with the HSE home birth service in 2023, including trends over time, geographical distribution and maternal characteristics. It also summarises key indicators related to antepartum and intrapartum transfers among all registered women.

Section 2: Women who gave birth at home

This section describes the characteristics and outcomes of women who gave birth at home. It excludes women who were transferred before or during labour and gave birth in a hospital. This section also includes information on infant outcomes, postpartum care and infant feeding, postpartum complications and transfers, and adverse incident reports among women who gave birth at home.

While 2023 data are the primary focus of this report, both sections include trend data from previous years (e.g. 2014 to 2023), where available, to provide a broader and more meaningful overview. In some cases, data from 2021 to 2023 are chosen to ensure consistency and comparability across time following an update to the data collection form for this time period.

Infant outcomes are presented using data from the full 2012-2023 cohort. Due to small number of cases annually, results are summarised across the entire period to provide a more robust analysis of trends and patterns.

Findings are presented using counts and percentages for categorical variables. For numeric variables, mean and standard deviation (SD) are reported where appropriate. Where additional context is needed, median, interquartile range (IQR), and minimum and maximum values are also provided. Rates were calculated using relevant denominators, including HIPE-based national hospital birth data, to allow comparison over time (e.g. registration rates per 1,000 maternities per each year). 

Where possible, maternal and infant characteristics are compared to national statistics using the most up-to-date sources available at the time of analysis. These include the Hospital In-Patient Enquiry (HIPE) dataset (e.g. maternal age and parity) and the national census of the Central Statistics Office’s (CSO), particularly for variables such as ethnicity.

Efforts were made to minimise missing or incomplete data by contacting DMO’s and maternity units directly. However, in some cases, complete information was unavailable, particularly when a woman was transferred to hospital and full records were not available to the community midwife in the early years of the audit. The extent of missing data is reported within the relevant sections of the results.

Definitions and Terminology

• Antepartum Referrals: Referral to hospital due to complications which have arisen during pregnancy, requiring review by an obstetrician.
• Antepartum Transfers: When the care of a woman is transferred from the home birth service to the maternity unit during her pregnancy due to a change in the woman’s eligibility for the service, as per the HSE guidelines (1) or due to maternal choice.
• Booking visit: Booking visit relates to the woman’s first antepartum visit with the community midwife.
• Born Before Arrival (BBA): BBA refers to giving birth at home before the midwife had time to arrive or giving birth before arrival to hospital where this was the intended place of birth. For the purpose of this report, BBAs with home as the intended place of birth will be grouped under the category of having a home birth. Those BBAs whose intended place of birth was the hospital (including antepartum/intrapartum transfers) will be named “BBAs” in this report.
• Community Midwife: Community midwife refers to both self-employed community midwives (SECMs) and integrated hospital community midwives (IHCMs) that provide care to women who chose to register for a home birth.
• Early Neonatal Death: Death of a live born baby occurring before 7 completed days after birth.
• Gravida: The number of times the woman has been pregnant, irrespective of duration; prior to the home birth in this report.
• Home Births: refers to all women registered with the home birth service who ultimately gave birth at home during the reporting period. This includes women who remained within the home birth pathway throughout care, as well as those who returned to home care following a temporary transfer, where the birth subsequently occurred at home. Women registered for home birth who gave birth in hospital are excluded from this cohort. This group represents the final birth outcome population and is used to report outcomes specifically relating to births occurring at home.
• Intrapartum Transfer: Where a transfer of care from the home birth service to the maternity unit during the first, second or third stage of labour is required due to a change in the woman’s eligibility for the service, as per the HSE guidelines (1) or due to maternal choice.
• Maternity Unit: Refers to the 19 public hospitals in the Republic of Ireland providing maternity care services.
• Major Obstetric Haemorrhage (MOH):  For the purpose of this report, major obstetric haemorrhage is defined in accordance with the HSE National Clinical Practice Guideline (Prevention and Management of Primary Postpartum Haemorrhage, 2022). This guideline recommends activation of the MOH / life-threatening haemorrhage (“code red”) protocol at >1500 mL blood loss but defines MOH for reporting purposes as an estimated blood loss ≥2500 mL and/or transfusion of ≥5 units of red cells.
• Parity: The number of completed pregnancies, whether live birth or stillbirth, of at least 24 weeks gestation or with a birthweight ≥500g; prior to the home birth in this report.
• Postpartum Transfer: Where a transfer of care from the home birth service to the maternity unit during the postpartum period (from delivery of the placenta up to 6 weeks). The HSE guidelines for home birth services outline indications for postpartum transfer. (1)
• Registered Home Births: refers to all women who were registered with the home birth service during the reporting period, regardless of their eventual place of birth. This includes women who commenced antenatal care under the service, those accepted onto the home birth caseload, and those who transferred between midwifery-led and hospital-led care at any stage of pregnancy, labour, or the postnatal period. It also includes women who transferred to hospital care either temporarily or permanently. This cohort represents the total service population and is used to describe overall activity and care pathway
• Stillbirth: A baby born without signs of life from 24 weeks’ gestation and/or with a birth weight of ≥500g.
• Use of language: In this home birth clinical audit report, we use the term women to reflect the language commonly used in perinatal care. We acknowledge that not everyone who becomes pregnant or gives birth identifies as a woman, and our findings and recommendations are intended to be inclusive of all people who access the Irish maternity services.
• Women who started labour at home: This group refers to women who commenced labour under the care of the HSE Home Birth Service. It includes women who went on to give birth at home, as well as those who required an intrapartum transfer and gave birth in hospital (including transfers after the third stage of labour and BBAs)’