Women used to give birth at home: in 1900s over 99 per cent of babies were born at home. However, as GPs and obstetricians persuaded women that giving birth in hospital was safer than at home the rate dropped to 1 per cent in the 1980s. Today the home birth rate is increasing again, but it is still only 2.7 per cent.
Several studies have indicated that home birth is a safe option. The latest one from the Netherlands (published 15 April) where one in three women have a home birth, confirms that home birth is a safe option for those at low risk of complications.
So what does this mean for NHS maternity services: do they need a shift in mind set when it comes to offering pregnant women the choice of a home birth?
In the past, studies have not been large enough and evidence on the safety of planned home birth has been obscured because research has included women who developed complications during pregnancy, or premature and unplanned home births.
This Dutch study however, which included half a million women, is free from these factors. The result is a powerful indicator that home birth and hospital birth can no longer be separated on safety grounds for low risk women.
Home birth is slowing becoming a popular option. In 2007, across the UK 20,548 (2.7 per cent) of all births (765,317) took place at home, compared with 18,953 (2.5 per cent) in 2006. This is an encouraging rise of (1,595) 8.4 per cent but still only represents 2.7 per cent of all UK births.
A MORI poll commissioned by the Expert Maternity Group in the 1990s found that 16 per cent of women would consider giving birth at home. However, interest is higher in areas where home birth is more common, it’s seen as a realistic option and women know others who have given birth at home.
It is possible that the UK could have a similar home birth rate to Holland. About 60 per cent of women, if given good midwifery care, are likely to have a straightforward birth without medical intervention.
How would NHS maternity services look in the UK if we followed the Dutch example?
Many maternity services are already adjusting their home birth rates. In England and Wales, seven local authorities have a home birth rate of over 10 per cent. 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.
In fact, many women in these areas do not make the decision on where to have their baby until they are in labour. Best practice is for the woman to call her midwife when she thinks she is in labour, and for the midwife to visit her to assess needs and wishes.
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 access to water birth which is often more accessible at home or to avoid medical intervention. Some may have had a previous bad experience in hospital, and others may feel confident that after having one baby in hospital, they can have another at home.
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 trusts, and who has contributed to her antenatal care.
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 to show 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.
Taking into account those who need to transfer for additional help, planned home births involve less medical intervention and good outcomes for both mothers and babies
However, many women around the UK still find it difficult to access a home birth on the NHS. This is unacceptable as it undermines the principles of women-centred maternity care. There is a lack of balanced information available to women to enable them to make a choice about where to have their baby.
The NCT provides excellent home birth information sheets and booklets that are available for midwifery managers to order.
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 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.
Home births are cost effective – with low technology and low cost. They provide positive satisfaction levels for women; fewer women suffer negative medical consequences and they 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 of job satisfaction and tend to stay in the profession for longer.
If the government’s choice guarantee for England - which says women should be able to give birth at home - is to be implemented by the end of 2009, every maternity service should be discussing home birth with every woman.
Similarly, all women in other parts of the UK should be able to access home births if they wish.
In Wales, ministers set a 10 per cent target for home births which increased the growth in home birth faster than in other UK countries and this exemplary work needs to continue. And Scotland’s Keeping Childbirth Natural and Dynamic (KCND) programme has plans to increase home birth rates also.
The NCT hears from hundreds of women each year who want to have a home birth. Now we know that home birth is a safe and sound choice, how are maternity services preparing for the change in gear?