TYPES OF BIRTH

HOME BIRTH

Why might you choose to have your baby at home?

'Whenever I tell people that I had my second and third babies at home, they say, 'How brave of you!' But the truth is you get a lot more care and attention at home that you would do in hospital!' (Julia, aged 30, Somerset)

Your midwife will stay with you throughout your labour if you give birth at home, whereas in hospital, she is likely to be caring for several women in labour at the same time, and so cannot give you her undivided attention. Other reasons why people choose home birth are:

• because you feel more relaxed in your own home
• you can eat and drink as you please
• you can move around as you please
• and make as much noise as you please!
• you can learn to breastfeed in private
• no queues for the bath or toilet!
• less noise at night
• no visiting times unless you set them!

You can also have whoever you like with you - partner, mum, sister, children - and your baby will be born into a warm and welcoming environment rather than the impersonal atmosphere of a hospital.

You might also choose a home birth because you don't want to have any medical interventions in your labour or pain-relieving drugs.

Caroline Flint, a midwife who runs a Birth Centre in South London, says:

'We find that when women labour at home, they don't need nearly so much pain relief. The pain is more manageable at home.'

The facts on home birth and how they affect you

At the start of the 20th century, 99% of British babies were born at home. By the 1980s, the rate had dropped to less than 1%. Nowadays, the percentage is a little higher - 2.2% at the end of the 1990s. However, women's access to a home-birth service varies greatly between areas and is restricted by the attitudes of health care providers.

Over the past century, the general assumption has been that a hospital birth is always safer for mother and child. However, there has never been any research basis for this contention. After reviewing the evidence, in 1992 the Winterton Committee informed the government that: "The policy of encouraging all women to give birth in hospitals cannot be justified on the grounds of safety."

The safety of home birth

For normal, low-risk women, research shows that home birth is as safe as hospital birth and results in less intervention, and less morbidity (illness) for mothers and babies.

In the past, evidence on the safety of planned home birth has been obscured because outcomes for all out-of-hospital births were amalgamated. Many of these are unplanned home births - premature babies born suddenly, or concealed pregnancies born after no antenatal care, often with no midwife present. Outcomes from such births are often poor and have little in common with a planned home birth, with facilities for transfer to hospital if necessary.

A summary of the issues surrounding place of birth published by the UK's National Perinatal Epidemiology Unit found that: "There is no evidence to support the claim that the safest policy is for all women to give birth within hospital. For some women it is possible, but not proven, that the iatrogenic risks associated with institutional delivery may be greater than any benefit conferred."

The evidence-based maternity care bible, A Guide to Effective Care in Pregnancy and Childbirth, says: "Several methodologically sound observational studies have compared the outcomes of planned home births (irrespective of the eventual place of birth) with planned hospital births for women with similar characteristics. A meta-analysis of these studies showed no maternal mortality and no statistically significant differences in perinatal mortality between the groups. The number of births included in the studies was sufficiently large to rule out any major difference in perinatal mortality risk in either direction."

The British Medical Journal published several large studies on home birth safety in one single issue in 1996. Its editorial concluded that home birth was "safe for normal, low-risk women, with adequate infrastructure and support".
Planned home birth is associated with better outcomes for both mothers and babies. The National Birthday Trust Fund's study of home birth in the UK covered nearly 6,000 planned home births in 1994/5. Each woman was matched for risk level and obstetric history with another who planned a hospital birth.

The study found that:

• The home birth group had roughly half the risk of ending up with a Caesarean section, compared with the hospital group (2.0% versus 4.1%).
• The home birth group had roughly half the risk of ending up with a ventouse or forceps delivery (2.4% versus 5.4%).
• Mothers who planned home births were less likely to suffer a post-partum haemorrhage.
• Babies in the planned home birth group were significantly less likely to be in poor condition at birth, that is, have an APGAR score below 7 (5.2% versus 9.3%) or to need resuscitation.
• Babies in the planned home birth group were less likely to suffer birth injuries.

Do women in the UK have a right to a home birth?

There is not a simple answer to this very simple question! Certainly nobody can make you go into hospital to have your baby - it is not against any law to have your baby at home. But what most women want to know is whether they have a right to maternity services at home - in other words, does the health authority have an obligation to provide a midwife to attend a home birth? The situation is rather confusing because although the health authority cannot be forced by law to provide a home birth service (e.g. if there is a shortage of midwives they can get all the community midwives to work in the hospital) it is legally obliged to provide emergency care. So if a woman insisted on staying at home and called the hospital when in labour, then they would do their utmost to provide a midwife to go to her home to care for her.

This is not the way that most women would like their care in labour to be organised! If you are living in an area where you cannot, during your pregnancy, get the maternity services to support your choice to have a baby at home, get in contact with one of the supervisors of midwives from the hospital, or the community midwifery manager. In most areas, midwives are supportive of a woman's choice to have her baby at home and will try hard to provide a home birth service.

Are women aware that home birth is an option?

Despite the Patient's Charter, many women do not realise that they could give birth at home, as the only choice they are offered is between local hospitals. GPs are still the gatekeepers to maternity care and some will attempt to dissuade women from booking home births. Their opposition may be based upon a misunderstanding of the GP's role - they may believe that they have to attend the birth personally, or that they would be legally liable for adverse outcomes. Neither is the case. The Royal College of General Practitioners and the RCM issued a joint statement in 1995: "Women wishing to arrange a home birth should be able to do so. General practitioners who do not wish to provide care for home births should refer women to a local midwife or the local supervisor of midwives (or to a general practitioner who does provide full maternity care)."

How many women really want home births? Who are they?

The MORI poll commissioned by the Expert Maternity Group found that 16% of women would consider giving birth at home. However, interest is likely to be higher in areas where home birth is seen as a realistic option and where women know others who have given birth at home. One midwifery group working on an under-privileged estate in south London has a 43% home birth rate. A local midwife commented that "the biggest element of 'persuasion' comes, not from the midwives, but from other women".

The home birth rate varies greatly between trusts - from over 20% of births in some areas, to less than 1% in others. Although differences in local demand will account for some of the discrepancy, it is likely that attitudes of health care providers have more influence. Some simply fail to present home birth as a real option, while others actively discourage it.

Women choose home births for reasons varying from a desire to avoid interventions in childbirth, to avoiding separation from older children. Some have had bad experiences in hospital, while others had uneventful hospital births and simply do not see the need to have subsequent children there. In areas where home birth is well supported, it is certainly not restricted to the well-off, as the South-East London Midwifery Group has shown.

NCT policy

The NCT campaigns for women to have ready access to birth at home or in a community unit, and for all those who are interested to have the information and support they need. Contact your local branch for details of the nearest home birth support group.

References

Beland, P. (2001) Individual trusts are impeding home births, not the UKCC. British Journal of Midwifery; 9: 1, 46.
Campbell, R., McFarlane, A. (1994) Where to be Born? The Debate and The Evidence. Oxford: Dodds. R., Newburn, M. (1995) The Availability of Home Birth. London: National Childbirth Trust.
Enkin, M., Keirse, M.J. et al (2000) A Guide to Effective Care in Pregnancy and Childbirth. Third Edition. Oxford: Oxford University Press.
The Independent. UKCC Registrar's letter Supporting women who wish to have a home birth, para 7 and 16. 30 June, 2000.
Office for National Statistics (1999) Births: By Place of Delivery: 1961 to 1997. Social Trends Dataset. London: Office for National Statistics.
Office for National Statistics (1999) South-East Thames Perinatal Monitoring Unit - Maternity Hospitals' Provisional Statistics, History of Home Birth. London: Office for National Statistics.
Lord Hunt of King's Heath (2000) Hansard. 20 December. Column 734.
National Childbirth Trust. Home Birth in the United Kingdom (2001) London: NCT.
National Perinatal Epidemiology Unit.
National Birthday Trust Fund (1997) History of Home Births. Home Births - The Report of the 1994 Confidential Enquiry. London: The Parthenon Publishing Group.
Peel, J. (1970) Domiciliary Midwifery and Availability of Hospital Beds. London: HMSO.
House of Commons Health Committee (1992) Winterton Report. Maternity Services. London: HMSO.
Royal College of Midwives and Royal College of General Practitioners (1995) Responsibilities in Intrapartum Care: Working Together. London: RCM and RCGP. The NCT would like to thank the RCM and RCGP for their permission to publish this statement.
Sandall, J., Davies, J., Warwick, C. (2001) Evaluation of the Albany Midwifery Practice. Final Report. London: King's College.
Springer, N., Weel, C. (1996) British Medical Journal; 313: 1276-1277.