Do the benefits of home births outweigh the risks?

Rachel Mayhew, with husband John and sons Robbie and Ally. Picture: Andrew OBrien

The most pressing concern for Rachel Mayhew and husband John when they decided to have their second baby at home was whether or not their first-floor Edinburgh flat could withstand the weight of a birthing pool. But after a structural engineer said it should be OK, they pressed ahead. Weeks later, their son Ally, now 12, was safely delivered – the cord round his neck untangled by unflappable midwives who rigged up mirrors so they could see underwater – and placed in their arms.

“Being in our own home made the whole thing much less clinical,” says Mayhew, an architect. “I didn’t have to pile into the car in the middle of labour to try to get to hospital and I had two midwives totally devoted to me. I had my own belongings around me, so if I wanted a towel I knew where to get it. It was just so much more relaxed.”

The Mayhews opted for a home birth after having first son, Robbie, now 14, in St John’s Hospital, Livingston. This was, in part, because they were told the popularity of birthing pools meant there was no guarantee one would be available second time round, but also because there was no-one to look after 18-month-old Robbie and they liked the idea of a more natural birth.

“My mum was around and it just felt a lot more of a family event,” Mayhew says. “It was good for John too. Instead of having to sit around for hours doing nothing, he was kept busy fetching more hot water. He was more involved.”

Last week, NICE (the National Institute for Health and Care Excellence) issued new advice for England and Wales suggesting home births, like Mayhew’s, and midwife-led centres (either standalone or alongside consultant-led maternity units) were better than hospitals for some mothers, particularly those who have had at least one straightforward delivery. NICE said midwife-led care had been shown to be safer for women with low-risk pregnancies – 45 per cent of the total – and recommended they should be advised giving birth in a midwife-led unit was “particularly suitable”.

This advice will be looked to by Scottish midwives for guidance. It is proving controversial. It has been welcomed by those who believe childbirth has become hyper-medicalised, leading to unnecessary interventions such as caesareans, episiotomies and the use of forceps or ventouse, and that hospital births carry a greater risk of infection. But it reverses years of NHS orthodoxy and comes in the wake of research which, while not contradicting NICE, introduces important caveats.

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One Oxford University study suggested babies born at home to first-time mothers were three times more likely to die or suffer a complication, while two experts writing for the Journal of Medical Ethics said the risks of a home birth were comparable to not wearing a seatbelt. Some studies have suggested higher risks attached to breech births or where the family home is more than 20 minutes’ drive from an obstetrics department. At the same time, research in Holland – where 20 per cent of babies are born at home – found planned home births were less risky than planned hospital births, particularly for second-time mothers.

During the 20th century the proportion of home births fell from over 80 per cent in the 1920s to 1 per cent in 1999. The move was prompted by a combination of poor living conditions at home and technological advances, and coincided with a reduction in maternal mortality during childbirth from seven deaths per 1,000 in 1900 to 0.077 per 1,000 in 1997.

But, while it contributed to the cut in deaths, this shift also fostered a culture of intervention, with some invasive procedures being carried out unnecessarily. The number of emergency caesareans (which delay recovery and make a natural birth next time round less likely) has reached 25 per cent (the World Health Organisation says it should be no more than 10-15 per cent) while the percentage of women being induced is about 24 per cent. Add the clinical atmosphere of a hospital birth, the structure and procedures, the revolving door of anonymous nurses and auxiliaries as one shift ends and another begins, and it’s little wonder many think the pendulum has swung too far.

With 90 per cent of births in the UK still taking place in a consultant-led maternity unit, just 1.2 per cent of expectant mothers opting for a home birth in Scotland (around 4 per cent down south) and 3 per cent giving birth in free-standing midwife-led units, there is a growing consensus women should be made more aware of the choices available.

“We’re supporting a calm conversation about what is right for each individual in her circumstances,” said Susan Bewley, professor of complex obstetrics at King’s College, London, and chair of the NICE advisory group. “They may choose any birth setting and should be supported in those choices as that’s their right.”

In Scotland, the number of home births may be lower than in the rest of the UK but those determined to have a home birth tend to go ahead regardless of their distance from hospital. In Orkney or Shetland, low-risk pregnancies are delivered at home or in a low-tech unit. If there are complications, the midwives liaise with an obstetrician on the mainland and, if necessary, a caesarean is carried out by a general surgeon. On other islands midwives from the mainland stay over for several days to attend home births, with the air ambulance on standby.

Scotland also has more than 20 midwife-led units. The free-standing unit in Montrose for example has 12 midwives dedicated to natural labour and birth. In 2005, it won the Royal College of Midwives “promotion of normality” award.

Though, ideally, they require the attendance of two midwives, home births are the cheapest option for the NHS followed by births in midwife-led centres, with birth in a consultant-led unit the most expensive. Yet, despite this, a recent study commissioned by the Scottish Government found only 25 per cent of women had been offered the option of a home birth and only 23 per cent the chance of going to a midwife-led unit.

Gillian Smith, director of the Royal College of Midwives in Scotland, welcomes the new NICE guidance, but says the key to good maternity care is making sure the suitability of women for births at home or in midwife-led units is correctly assessed. “They should be low-risk; we know there is a slightly higher risk for first-time mothers because they haven’t tested their pelvis before,” she says.

Nevertheless, when Leanne O’Donnell, 36, was expecting her first baby more than six years ago, she decided she wanted a home birth with a pool and as little intervention as possible. At the time she was living in Australia and had to hire an independent midwife. It was a typically long first labour and it took a worrying four hours for the placenta to be delivered but she believes staying in her own home gave her more control. “It felt like labour was something I was doing as opposed to something that was being done to me,” she says.

Returning to Scotland, O’Donnell was determined her next two babies would also be born at home and met no opposition from NHS midwives in Fife. This time, her older son Innes, now six, was also part of the process. “I went into labour during the night, but Innes woke up and seemed quite interested. I was in the pool, I remember, in the middle of a contraction, and he smiled at me and that contraction just melted away. It was lovely,” says O’Donnell, who helps run a home birth support group in Fife.

“When it came to my third child, Eilidh, my second son Archie woke up just as she was born; she was a few minutes old. Archie was two and a half by then and was saying ‘there’s a baby in the swimming pool, there’s a baby in the swimming pool’. He was just so excited and happy. And then Innes came downstairs a few hours later and said ‘hello baby, I’m your big brother’. I was just really glad they were there and involved.”

Not everyone who opts for a home birth is so lucky; in Australia, independent midwife Akal Khalsa was ordered to pay A$6.6 million (£3.5m) in damages last year after a botched home delivery left a baby with severe disabilities. Although such negligence is rare, you don’t have to look far to find cases where complications have led to a last-minute transfer to hospital, with the life of the mother or baby in the balance.

“The most important thing for mothers giving birth in their own homes or midwife-led units is to have the right protocols in place for transfer so there is no procrastination. You must have a trigger that tells you: ‘This is the time to transfer’,” says Smith.

Given the conflicting reports on the risks of home births and, the paternalistic attitude of some obstetricians, women seem reluctant to embrace the concept.

Whether the new NICE guidance will do much to turn this around remains to be seen. South of the Border, a shortage of midwives means even if women are convinced by the benefits, health authorities might not be able to cope with the demand.

In Scotland, however, it is still possible to provide two midwives for every home birth. And although some midwife-led units have closed due to lack of demand, others are set to open in Inverurie, Peterhead and Aberdeen.

Whether or not more women can be persuaded to forsake maternity hospitals, the trend seems to be for lower-tech births, with even consultant-led units trying to tackle the so-called cascade of intervention. In Scotland, for example, it is no longer standard practice to put cardiotachography (CTG) monitors on every woman who arrives in the labour ward. In the past, it was not uncommon for these monitors to stay on throughout delivery, causing the women to fret (if, for example, the readings began to fluctuate).

Smith, a midwife for 37 years, says she has witnessed maternity services’ obsession with technology. “When I started out we put intrauterine catheters in all women who were being induced,” she says. “I worked in acute labour wards and my blood pumped when something came through the door that was an emergency. But I would shift my thinking now and say: ‘Let’s make normality the default’.

“In trying to strike a balance, we shouldn’t forget that the reason maternal mortality rates are so low is that we have access to caesarean sections, to anaesthetists, to obstetricians.

“But equally, we shouldn’t be making every woman who opts to give birth in a consultant-led unit high-risk, simply on the basis of her choice; we should be changing that philosophy.”

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