If the government’s pledge, laid down in Maternity Matters, that all women in England should have the choice of a home birth by the end of 2009 is to be met, every maternity service should be discussing home birth with every woman.
In 1900, over 99 per cent of babies were born at home. But this changed, as the management of midwives was moved into acute services and the information provided to women emphasised that modern high tech was good and home birth was outdated and dangerous.
In 1970 the Peel report recommended “100 per cent hospital confinement” and by the beginning of the 1990s the home birth rate dropped to less than 1 per cent. Since then a parliamentary inquiry has placed the evidence of parents and midwives, as well as doctors, into the equation, and choice of place of birth has become a government policy. In 2007, 2.7 per cent of UK births took place at home.
Women choose home births for varying reasons: they may want to be in their own space - getting comfort from their own familiar surroundings, to have certain access to a water birth or to avoid medical intervention. Some may have had a bad experience in hospital, and others may feel more confident when it is not their first child.
Keeping labour and birth uncomplicated keeps costs down and services targeted at those who need them most
Labour tends to progress well at home, where the mother may feel more relaxed, have greater privacy and be free to move around. She is also more likely to have one-to-one care from a midwife she knows and trusts. These factors seem to help labour develop normally, reducing “failure to progress” and foetal distress and the associated medical interventions. There is also less risk of infection for mother and baby.
For a healthy woman with a straightforward, low-risk pregnancy, there is no evidence that a home birth is less safe than a hospital birth, provided the midwife is experienced and has the back-up of a modern hospital system, should transfer be needed. Recently, the largest ever study on the safety of home birth, involving more than half a million women in the Netherlands, showed home birth is a safe option for women at low risk of complications. Previous studies have been much smaller and included women who developed complications during pregnancy, and premature and unplanned home births.
Keeping labour and birth uncomplicated keeps costs down and services targeted at those who need them most. This is reflected in the payment by results tariffs. Home births do not involve staff and other costs associated with hospital birth, including accommodation, meals and domestic and ancillary services.
A woman planning a home birth is less likely to have a caesarean section. By increasing the number of low risk women having a home birth you can effectively reduce the intervention rate in this group without any detrimental effects on maternal or infant health. Thus, providing a full home birth service allows maternity services to target their more specialised and costly resources at those women more likely to need them.
Users of home birth services also have high satisfaction levels, an increased sense of control, empowerment and self esteem, and better emotional outcomes as a result.
Very few babies born to healthy mothers die through birth-related causes; the rate is around 1/1,000 for both planned home and for hospital births, so there is no need to limit access to choice on grounds of safety.
In England and Wales, seven local authorities have a home birth rate of over 10 per cent. In Wales, ministers set a 10 per cent target for home births, which increased the growth in home birth faster. Areas with the highest home birth rate routinely discuss home birth as a birth option but do not require a woman to make a choice about where she will have her baby until she is ready. Many do not make the decision until they are in labour.
Too many women around the UK find it difficult to access a home birth on the NHS. This undermines the principles of women-centred maternity care. Low midwifery staffing levels also mean that too often the option of a home birth is either not being offered or services end up being withdrawn at short notice.
NHS maternity services need to re-examine their approach. Not all hospital midwifery managers are aware of policies to support home birth and of the strength of the data supporting home birth as a valid and safe choice. As a result not all pregnant women are aware of their options.
As well as benefits for patients, home births offer midwives the flexibility of working within a community setting. If we allow midwives to practise their skills in enabling women to have a straightforward and safe birth, midwives enjoy greater levels job satisfaction and tend to stay in the profession for longer.
The pressure is on to deliver the government’s choice guarantee in Maternity Matters by the end of 2009. We need to see greater numbers of maternity services offering pregnant women a choice they can believe in and take up. Steps now need to be taken to look at how the commitment is turned to reality in your local trust or PCT. What are your current home birth rates? What information are women offered on choice of place of birth? Working with local maternity services liaison committee representatives, trusts can work towards a system of offering a service that will be used if promoted well to women who feel that it is a real option and they know they’ll be safe in choosing it.
So if the health service is to be evidence based and meet the needs of parents, home birth will need to become a fully accepted and routinely offered option. Over the next decade it is likely that the home birth rate will rise to 30 per cent. Is your service ready?