Now more than ever we are seeing women move towards birthing at home. This mass exodus from the conventional ways of birth has been triggered by the current health crisis. Women just don’t want to birth or have their vulnerable newborns in hospitals, seen to be high risk localities.
As a Private Midwife, I attend both home and hospital births. So as much as home birth is the norm for me, I have noticed a marked increase in women wanting to change their plan from birth in hospital to birth at home.
There has been work done by the Maternity Consumer Network and other relevant groups to look at the vast numbers of women moving from hospital to home. Suddenly, women are recognising that there are options, and that those options could be suitable for them.
Home Birth Vs Free Birth
To be clear, this article is discussing ‘home birth’, not ‘free birth’. They are two different things. With the incline in women seeking home birth, we have also seen an increase in women considering free birth.
Also known as unassisted birth, free-birthing is when a woman births her baby at home without the assistance or attendance of a health care practitioner such as a Midwife.
Home birth is when a woman births her baby at home with the attendance of a Midwife (usually two) skilled in supporting births away from the hospital environment. In most cases, the Midwife has cared for that woman throughout her entire pregnancy, and will continue to care for her for 6 weeks post birth.
What is The Evidence on The Safety of Home Birth?
Asking how safe home birth is is like saying ‘how long is a piece of string?’ It’s not something that can be quantified. There is always an element of risk to any birth, no matter the location. To choose whether home birth is a safe option for you individually, the first step is knowing the evidence surrounding home birth to make an informed decision.
Women with low risk pregnancies experience fewer complications and less interventions when they plan to birth at home (Ackerson et al., 2015).
The current Guideline of the National Institute for Health and Care Excellence (NICE) states that women having their second (or more) child with a low-risk pregnancy should be informed that home birth is associated with a lower rate of intervention and the outcome for the baby is no different compared with an Obstetric Unit.
Women having their first child, with a low risk pregnancy should be informed that in home birth there is a small increase in the risk of adverse outcome for the baby.
The Birthplace Study collected data on 64,000 low risk births in the UK, which included 17,000 planned home births. It too found that for low risk pregnancies, planned home birth was associated with significantly fewer rates of intervention, caesarean, instrumental birth (forceps/vacuum) and episiotomy in women having their second or more baby.
In first time mothers, planned home birth does have a small increase in the risk of adverse outcomes for the baby (NICE). For women having their first baby that wish to explore these figures further, homebirth.org.uk have a reference site for ‘having your first baby at home’.
The Royal Australian New Zealand College of Obstetrics and Gynaecology (RANZCOG) support hospitals as the safest place for birth in Australia and New Zealand. The Royal College of Obstetrics and Gynaecology (RCOG) position statement states –
“There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.”
When considering home birth, and the safety of birth at home, women need to consider current evidence, their own individual circumstances, and make an informed decision. It is not a one size fits all approach.
It is also important to recognise that being ‘safe’ in birth isn’t just about physical wellbeing, but also psychological wellbeing, and the safety of the mother-infant dyad in getting off to a good start in motherhood and bonding.
But What if There’s an Emergency?
Emergencies in home birth can and do happen, but as the evidence discussed above shows, they aren’t common with the reduce rates of intervention. So why is that?
Midwives attending home birth (In Australia) follow stringent guidelines surrounding their clinical practice. Keeping home birth safe starts well before the birth.
It involves developing a trusting, professional relationship with the family, getting to know their individual needs, educating the family about normal physiology of birth and complications that can arise, and following appropriate guidelines surrounding complexities of pregnancy and birth and changing the ways in which care is provided and/or the birth location as needed.
Home birth Midwives are skilled in recognising when the normal is becoming abnormal, and adapting care or place of birth before it becomes an issue. ‘Home birth transfer’ can take place before there is an emergency, whether for pain relief or for augmentation or intervention in a hospital setting, and is done so by the woman’s own car.
There is commonly two Midwives present at home births. This is not only a requirement, but a safety measure should an emergency occur. Private Midwives, like all Midwives, are required to complete their annual competencies in neonatal resuscitation, basic life support, and obstetric emergencies.
In an emergency at home, Midwives will provide the clinical cares that are necessary for that particular emergency, such as newborn resuscitation or management of heavy blood loss, and should have the equipment to do so (see below).
Whilst stabilising your or your baby’s health, they may also contact an ambulance to transfer you to the closest hospital if required. It is important to understand that in an emergency at home, there is a delay in getting a woman to a theatre should it be required, and there is limited health professionals compared to in a hospital setting.
What Equipment Is Brought To a Home Birth?
Every Midwife will operate differently, yet at the same time very similar. It is best to discuss with your own Midwives what they will be bringing to your birth.
Though often not required, Midwives generally take all equipment and medication that is required for emergencies to a home birth. This includes cannulation equipment (to administer intravenous drugs/fluids for hydration or fainting), catheter equipment (to drain your bladder/assist in managing heavy blood loss), synthetic oxytocics (also used in the management of heavy blood loss, an oxygen cylinder and ‘bag and mask’ (for resuscitation of the baby).
Other equipment utilised in home birth to ensure your and baby’s safety is a doppler to listen to baby’s heart rate often, blood pressure monitoring equipment, and stethoscope, as well as equipment needed for suturing if required.
Narcotics (pain relief) are not brought to a home birth as they increase risk to baby and therefore should not be utilised in the home setting.
Some practical items are also supplied and should be discussed with your Midwife in preparation for birth.
What Other Factors Should I Consider?
Just how safe home birth is, is variable person to person. In deciding whether home birth is the best option for you, there are a few factors that should be considered –
1 – Distance From Hospital
There is no guideline on what is considered a safe or unsafe distance from home to hospital. This is a factor you as an individual need to consider in deciding whether home birth is the right choice for you.
When home birthing, it can be helpful to do a trial run from home to hospital to determine how long it would take in the case of a home birth transfer.
As discussed above, this commonly occurs before there is an emergency and you may take your own car. Whilst doing so, you could take the opportunity to familiarise yourself with where to park the car and how to get to the Birth Suite.
2 – Skills and Qualifications of Your Midwife
When choosing a Midwife to attend your home birth, you should absolutely be comfortable with her skills in managing obstetric or neonatal emergencies.
No Midwife would be offended by these discussions.
3. Individual Complexities of Pregnancy
As the evidence has shown, home birth is considered as safe if not safer than hospital birth for women having their second or more births with a low risk pregnancy.
That’s not to say that women having their first baby can’t birth at home. With regards to safety of home birth in first pregnancies or complex pregnancies, this should be discussed with your health care provider.
4. Referral System
If choosing to birth at home with a Private Midwife, you should consider what their referral system is, should referral be needed.
For instance, if complexities arose in the pregnancy, how do they ensure multidisciplinary collaborative input is received? If you were to require transfer from home to hospital in labour, can they continue to care for you clinically or support you in the hospital setting?
5. Is Home Birth The Best Choice For You?
Ultimately, women will birth best where they feel safest. For some, this is at home. For others, it’s in a hospital.
Additional Information – Safety & Home Birth
Websites: Homebirth Australia is the peak national body for homebirth in Australia. See their literature on homebirth safety here.
Homebirth.org.uk is a homebirth reference site that may help answer questions you didn’t know you should ask.
Books: Gentle Birth, Gentle Mothering by Dr. Sarah Buckley
Films / Documentaries: This comprehensive list of birth documentaries can help you in your decision making surrounding where is the best place for you to birth your baby.
Research / Articles about Home Birth:
Planned home birth: Benefits, risks and opportunities https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4399594/
Intrapartum Care for Healthy Women and Babies (NICE) https://www.nice.org.uk/guidance/cg190/chapter/recommendations
The Birthplace Study (2011) https://www.npeu.ox.ac.uk/birthplace#the-birthplace-cohort-study
Having Your First Baby at Home http://www.homebirth.org.uk/firstbaby.htm
