Place of Birth – should you have a home birth?
By Obstetrician Roger Marwood MSc FRCOG
Once again , the “Place of Birth ” is becoming an important issue, and will doubtless be a political football, which will be kicked around for the next few months by most of the interested parties. This has been prompted by the release , this week , of the draft deliberations of NICE , who are recommending that more women should be delivered in Midwifery led units and, more controversially perhaps, at home.
They are recommending that all low risk women should be encouraged to give birth in midwifery led units, without any medical input during the pregnancy or labour. Hospitals and labour wards should be for women with high risk pregnancies. NICE are concerned that hospital birth may be associated with unnecessary intervention. This document is in draft form and consultation is until June 24th ( But I think we all know what that means!)
The Birthplace study 2011 looked at 65000 births which included 17000 planned home births and 28000 planned midwifery unit births. The evidence found that there were increased risks of a poor outcome for babies delivered at home to first time mothers compared with those delivered in an obstetric unit.
9.3 per thousand compared with 5.3 per thousand
ie. a 75% increase but both levels less than one in a hundred
The study found that there was no increased risk to babies for women in second or subsequent pregnancies. Showing, that, importantly, homebirth, for low risk, second time mothers who had previously delivered vaginally, was just as safe as in hospital.
Transfer rates to obstetric units were high (45%) for first time mothers booked at home, but 12% for subsequent pregnancies.
At the moment, about 2% of women deliver at home. It can be a wonderful experience, and I have seen it myself. It does however require two midwives, and as we have heard from The Royal College of Midwives, they are in desperately short supply. Will increasing home births and midwifery led units improve recruitment? Well, possibly. But numbers of babies being born in England and Wales have risen by 20% in the last 12 years. What’s also true is that women are older, fatter, with more twins and are generally more medically complicated than they were 20 years ago.
We also know that approximately, 15 % of women currently have an unplanned Caesarean Section, and that only 40% will go through pregnancy and delivery without any complications.
Risk assessment is another area of concern. Even if it is done really carefully at the booking visit, problems may arise during pregnancy and labour that may be subtle and not easily spotted. For instance , did you know that, approximately 30% of breech presentations are diagnosed in labour. The classic case of risk changing is the low risk woman who has an unrecognised small baby that does not do well in labour or simply presents a a stillbirth in late pregnancy. Sadly, stillbirth rates in UK are embarrassingly high and give us statistics similar to Belarus ( see last weeks newspapers).
Things have changed radically over the last few years with regards to risk aversion and it is all very well informing the lay person about statistics, but many women many not be prepared to accept any (perceived) extra risk.
Rather cynically , I suspect that finance , as ever , is driving this forward. Home births are almost 40% cheaper than hospital based births.
However, when things go badly wrong, and there is poor outcome wherever the place of birth , and regardless of who was responsible, the cost to the family , society and the health authorities are enormous. If negligence is proven, settlements of several million pounds are now commonplace. We need to do our best for our mothers wherever they are delivered.
What then is the way forward?
- Firstly, a woman should have a real choice of where to deliver, and should not be persuaded to deliver outside a hospital, if that is not their wish.
- Secondly, I think first time mothers should not be encouraged to deliver at home because of higher risks compared with hospital births and significant chance that emergency transfer to hospital may be needed in labour.
- Thirdly, wherever possible , all Midwifery led units should be adjacent to ,or alongside Consultant led units. They are called AMUs and allow easy access to medical advice , pain relief and appropriate intervention if labour becomes complicated.
- Fourthly, and finally, there should be adequate numbers of well trained midwives and Obstetricians. Both the RCOG and the RCM have made impassioned statements in the last few weeks to that effect.
It should be an informed choice for each individual woman. They should be made aware of the fact that aside from the pros of giving birth at home, that there are some cons- there will no be no epidural, no doctor and that 12% are transferred to hospital.
Like all Obstetricians I am aware of all the things that can go wrong such as the shoulders getting stuck or post-partum haemorrhage or even the baby being born in a poor condition, so instinctively I feel more comfortable with a hospital-based delivery.
However , if you are second or third time around , with no extra risks and have a good midwife , then a home birth may just be one the best decisions you’ve ever made . Get all the information and them make the right choice for you and your family .
If you would like to read more about home birth, we have a few wonderful home birth stories here.
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