At the start of the 20th century, 99% of British babies were born at home. However, by the 1980s, the rate dropped to less than 1%. Today, the rate is a little higher at just over 2%.
Hospital birth grew in popularity in the first half of the century. Middle class women became increasingly likely to have their maternity care from doctors rather than from midwives. And, particularly for poorer women, hospital birth provided greater privacy, additional facilities compared with an overcrowded home, and an opportunity to rest after the birth.
As hospital birth became the norm, the perception developed that home birth was less 'advanced ' than birth in more medicalised surroundings. Many doctors believed that home birth was not as safe as birth in hospital and discouraged women from making this choice. Maternal mortality rates had fallen and it was assumed that this was due mainly to care in hospital rather than at home. However, many factors contributed to this important change including smaller family size, better nutrition, improved standard of living, and the development of drugs to combat infection.
There was very limited research to show the effect of hospital birth. However, it is known that in the early 1930s, maternal mortality was lower for women with husbands in manual occupations, who had their care mainly from midwives, than for middle class women who were more likely to be cared for by doctors.
Labour tends to progress well at home, where the mother may feel more relaxed, have greater privacy and is free to move around and do whatever she wishes. She is also more likely to have one-to-one care from a midwife she knows and who has contributed to her antenatal care. These factors seem to help labour develop normally, reducing 'failure to progress ' and fetal distress and the associated medical interventions. There is also less risk of infection for mother and baby.
The British Medical Journal published several large studies on home birth safety in
1996 and concluded that home birth was "safe for normal, low-risk women, with adequate infrastructure and support".
The Nursing and Midwifery Council has issued a statement this year stating that:
"Research over the last couple of decades suggests that home birth is at least as safe as hospital-based birth for healthy women with normal pregnancies"
For healthy women with a straightforward (low-risk) pregnancy there is no evidence to show that a home birth is less safe than a hospital birth provided that the midwife is experienced and has the back up of a modern hospital system, should transfer be needed. Planned home births involve less medical intervention for both mothers and babies.
The National Birthday Trust Fund 's study of home birth in the UK1 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 to 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 - i.e. 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.
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. In Scotland, all births taking place outside a maternity unit are still sometimes grouped together.
A MORI poll in the early 1990s found that 16% of women would consider giving birth at home. However, interest seems 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. Given the opportunity, women from all social classes choose to have a home birth. One midwifery group working in
Peckham, South London, a disadvantaged area with a large proportion of social housing, 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".
Women choose home births for reasons varying from a desire to avoid interventions in childbirth, to avoiding separation from older children. Some have had previous bad experiences in hospital, while others had uneventful hospital births and simply do not see the need to have subsequent children there.
Home birth is a mainstream option that should be a regular choice for pregnant women using the National Health Service, throughout the UK.
In England, the National Service Framework for Children, Young People and
Maternity Services states:
"Women are able to choose the most appropriate place to give birth from a range of local options including home birth and delivery in midwife-led units, with the facility for women delivering in the community to be transferred to hospital rapidly if complications arise."
In Wales, the National Service Framework for Children, Young People and Maternity Services states:
"Birth is a normal physiological process in which medical intervention should only be offered if it can be demonstrated that there is proven benefit for the mother and/ or her child."
NCT research has shown that:
"Women who gave birth in hospital were less likely to have access to helpful facilities compared with women who gave birth at home or in a freestanding midwifery led unit", and that
"Women who had good access to facilities were more likely to have a vaginal birth."
In Scotland, the Maternity Services Clinical Standards report states:
"Women are provided with information in order to make an informed decision about the chosen place of birth for their baby."
choice of home birth to women."
Although a health authority cannot be forced by law to provide a home birth service (e.g. if there is a shortage of midwives, all community midwives could work in the hospital), it is legally obliged to provide emergency care at home. For example, 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.
As there has not yet been a test case in Court brought by women denied a home birth service, there is no legal precedent to show exactly how competing obligations would be weighed up in legal practice. However, one thing is clear; a woman cannot be forced to go into hospital against her will. She has a right to stay at home if she wishes to.
Many women do not realise that they could give birth at home, as often the only choice they are given is between local hospitals.
The Royal College of General Practitioners and Royal College of Midwives 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)"
Home birth rates vary widely across the country. Although differences in local demand will account for some of the discrepancy, it is likely that attitudes of healthcare providers have more influence. Some healthcare professionals fail to present home birth as a real option, while others actively discourage it
During a home birth, women generally find labour easier to manage; they are more likely to feel in control and are much less likely to use drugs for pain relief. Non pharmaceutical methods for coping with pain, such as TENS, birth pools and massage are popular and, because the mother is in her own home, she is free to move around and use any positions she likes. Entonox (sometimes referred to as 'gas and air') is always available, and injected opiates, such as Pethidine, are sometimes used.
The chance of needing to transfer to hospital is quite high for first-time mothers - about three in 10 (although this rate varies widely in different areas). For women who have already had a baby, the chance is much lower - between one in 12. There is also a small chance (about one in 30) of having to be transferred into hospital after the baby has been born, usually because of problems with the delivery of the placenta, or sometimes due to concern about the baby 's breathing. Transfers are rarely 'blue light ' emergencies. The most common reason for transfer is a long labour or slow progress, when either the mother or the baby gets tired and further monitoring or assistance may be needed.
Most women who have a home birth know the midwife who looks after them. Local arrangements vary but usually home births are attended by community midwives who work in teams of up to eight. Women will get the chance to meet all of their midwives during their pregnancy. In some regions women receive most of their antenatal care from one or two midwives who will also attend the birth.
A study of the relative costs of home and hospital births found that home births cost less because there are usually no in-hospital care costs (e.g. use of a bed, catering cleaning, 24 hour staffing) and less use of medical interventions, even after accounting for transfers to hospital.
Women do not need a large home or any special facilities to have a home birth. Emergency access must be considered in case they need to transfer to hospital, but, for instance, living in a flat is unlikely to make much difference to transfer times.
Women who started to have their baby at home and needed to transfer often say that the inconvenience of the transfer, or discomfort during the journey, was worthwhile to spend part of their labour at home and to have the opportunity of a home birth. After all, most women who give birth in hospital have to make a journey to hospital during labour as a matter of routine.
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