Presently 92% of births in England take place in obstetric units even when complex treatment is not required. On the whole, our society has led mothers to believe that hospitals are safer and are where they will receive the best care possible. For many this is true, they have access to blood banks and are just across the corridor from neonatal care units if complications arise. With this in mind, it is natural for anyone to think that a hospital setting for delivery is safer. However, this isn’t always the case. We constantly hear in the news that the NHS is understaffed and overworked if this is true then how can that kind of environment be beneficial for a woman in what can be a scary and vulnerable situation? In many countries, a home birth is standard and believed to be emotionally beneficial to the mother and baby during labour due to being surrounded by family and in a place they know well.
For many years the NHS has encouraged women to give birth in hospitals deeming it better in terms of safety and access to treatment – they have normalised hospitals births. However, recently we have seen in a change in the attitude of NHS. During consultations, women are now offered and encouraged to consider the option of a home birth. This recent phenomenon has given expectant mothers more variety and opportunity to decide on the right place to deliver. Yet for some women having the choice makes it harder – they have been influenced by our culture and are perhaps torn between personal preference and pressure from others.
This essay aims to explore and debunk the myths surrounding the ‘dangers’ of a home birth and ascertain whether a hospital birth is actually safer for mother and baby. This includes looking at the medical conditions that can help dictate where to deliver, the medical impact of each setting on mother and child, the personal reasons why a mother chooses to deliver in one place but not the other and finally the economic implications of each place for the NHS. I believe that allowing women to have access to all the information on the best place to deliver is of the utmost importance. An expectant mother should be fully informed, just as a patient undergoing surgery is, where they are made aware of the risks and side effects. There are websites that discuss the advantages and disadvantages of each option however, these are often biased and vague. In addition to this, there are medical journals and studies showing the benefits and limitations, the issue with these is that they are often inaccessible for ordinary women. My references are made up of published medical journals and websites where women, midwives and doctors have expressed their opinions and beliefs on different birthplaces based on past experiences or scientific evidence. For the purposes of this essay I will only discuss a home and hospital as places to deliver and disregard freestanding midwifery units.
Guidelines that limit the ability to give birth at home:
Ultimately, an expectant mother has patient autonomy as to where she would prefer to give birth. However, there are a set of guidelines followed by midwives and obstetricians on the most suitable place for delivery to achieve the best outcome for both mother and baby. Each case is different and is of course tailored to the woman’s wishes where possible. As advised by the Royal Berkshire NHS Foundation Trust on Planning place of birth guidelines there are a number of medical conditions that recommend admittance to an Obstetric Unit (OU) as opposed to having a home birth. These conditions range from cardiovascular including hypertensive disorders, respiratory such as asthma or cystic fibrosis and conditions like diabetes or epilepsy. There are many other examples but overall any disease that poses a threat to mother or baby during labour and potentially requires obstetric intervention causes the physician to advise on delivering in an OU. If these conditions are genetic and as a result hereditary, this can also impact on the best place for a mother to deliver as the baby may require immediate specialised care once born. The safety of the baby would encourage a mother to give birth in an OU as opposed to at home even if that is not where she necessarily wanted to originally give birth. Naturally, if the obstetric history of a woman suggests the birth will be complicated such as an unexplained neonatal death of a previous child or previous pre-eclampsia then this can also lead to the recommendation of giving birth in a delivery suite where the help of an obstetrician is nearby. In some cases, there are medical conditions that are manageable in a home environment if all other clinical parameters are within normal limits. Their suitability is assessed by a triage/community midwife or GP. These medical conditions are unlikely to have an adverse effect on the mother and baby during or after birth and in most circumstances can be managed by the midwife provided there are no other complications. They include hyperthyroidism, cardiovascular disease with no intrapartum complications, spinal abnormalities depending on anaesthetic assessment and previous neonatal death with a known cause.
In the UK there are no laws that state a woman can be refused a home birth and be forced into hospital to deliver if she is mentally competent. It is useful to note that it not illegal to deny midwife assistance during delivery. However, most women feel more comfortable when they have the assurance of a trained professional to ensure the birth is safe and successful. It is against the law for anyone other than a trained midwife or doctor to attend a woman in a labour, other than in an emergency. Therefore if it can be proved that the ‘birthing partner’ intended to act as a midwife then they are liable to prosecution. The Department of Health expects NHS Trusts to make home birth services available to all expectant mothers in the surrounding area ensuring that midwives have the ability to attend. Under the regulations of The United Kingdom Central Council for Nurses, Midwives and Health Visitors (UKCC) all midwives in the UK have a duty of care to attend a woman who requires assistance in a home setting even if their professional opinion leads them to believe she would be better suited to deliver on an OU or when ‘mutually acceptable arrangements cannot be agreed’ on the planned place of birth. This means a midwife cannot withdraw care and leave the woman unattended as it potentially places mother and baby at risk during birth. The UKCC also states that any practising midwife must be willing to attend a home birth and support them wherever a woman feels most comfortable giving birth. If a Trust refuses to send an attending midwife to a woman in labour and there is a maternal or infant mortality there can be serious legal complications for the hospital and midwives involved.
The economic impacts of a home or hospital birth for the NHS:
Whilst the wishes of the mother as to where she would like to give birth is of the utmost importance, it is also useful to look at the economic implications of a home birth as opposed to a hospital for the NHS. It is easy to assume that a home birth is more expensive because of the one-to-one care of a midwife that a home birth demands during the delivery and after to make sure both mother and baby are healthy and safe from postpartum complications. However, this in fact false. According to research carried out by the University of Oxford, Warwick and University College London, the cost of a home birth as of April 2012 cost £1,066 compared to on a ward in hospital at ￡1,631. These results are due to a number of factors. A birth in an OU environment tends to be more expensive because there is normally more unnecessary obstetric intervention such as a caesarean section even if it is not necessarily needed. The expense of hospital overheads also adds to the cost of a birth in hospital. The results of this survey stating home births are significantly cheaper might explain why the NHS has suddenly begun to advertise and encourage expectant mothers to give birth at home. For many years the NHS has painted home births in a negative light, enticing mothers into hospitals with offers of ‘epidural analgesia’ and a higher quality of care before, during and after labour. However, since studies as previously mentioned surfaced, the attitude of the NHS towards home births has changed drastically. The NHS website now recommends home births for healthy low-risk women who are multiparous and lists in detail the basic information for women who could potentially be interested in having a home birth. Naturally, one would expect the NHS to promote a cheaper option that can be just as safe as giving birth in a hospital. However, there are some downsides for the NHS in advertising this. Childbirth is an incredibly unpredictable event and even the most low-risk mothers can encounter difficulties resulting in transfer to hospital. As home births grow in popularity (there has been a subtle increase from 1% in 1991 to 2.3% in 2012) this leads to an increase in ambulances required to transfer and therefore put a strain on an already arguably weak sector of our healthcare system. This implies that while a home birth at first glance may be cheaper, this is not always the case. If labour is more complicated than anticipated intrapartum transfer to an OU may be necessary. The ambulance service estimates a transfer to hospital costs around￡254.57. Combining the transfer with the cost of the original planned place of birth at home and the added cost of a bed in the OU can add up to over￡2,900, an expense that no healthcare system can call feasible. So whilst a home birth for the majority of low-risk multiparous woman is economically beneficial to the NHS, there are a lot of cases where a mother is better off on a ward in the first place instead of being at home and then being transferred to hospital. A Birthplace study in 2012 found that 450 out of 1,000 nulliparous women were transferred to an obstetric unit, this high proportion of women needing a transfer shows that encouraging home births isn’t as economically viable as initially thought for the NHS even if the initial price of a home birth is cheaper . The advertisement of a home birth coincides with the National Institute for Health and Care Excellence’s (NICE) revised opinion of a home birth.
Another factor affecting the ability of the NHS to provide effective and safe home births is the number of midwives available to attend a mother planning a home birth. Most, if not all Trusts consider having two midwives present as “good practice”, this is to ensure that if a birth is complicated there are enough health professionals to care for both the mother and baby. However, many Trusts are faced by the problem of understaffing and are not always able to send out two midwives making delivery significantly more hazardous. Imagine a situation where after birth the baby required neonatal resuscitation and the mother suddenly suffered a postpartum haemorrhage and only one midwife was present. This would be an incredibly stressful and difficult situation for two midwives to manage let alone one. Having one midwife present puts both mother and baby at risk and causes one to question the benefits of a home birth if the care they will receive is subpar even if it is a place where the mother feels more comfortable giving birth.
The medical impact of a hospital birth:
Giving birth in a hospital seems like the better option for nearly all expecting mothers. However, there are some ways in which being in a hospital can be detrimental to the smoothness of labour and the health of mother and child.
Being in an obstetric unit can often lead to a labour involving obstetric intervention that isn’t necessarily required. One study concluded that only 22% of women experienced a normal labour and birth.
The effects of these unnecessary interventions can be damaging to a mother’s health and her experience during childbirth. Upon admission, a mother in the early stages of labour is often put on bed rest for many hours. This recumbent position can lead to low-quality contractions, prolonged labour and dystocia. It can also lead to more pain resulting in the need for additional analgesia. The single position of lying down can also lead to an increased rate of caesarean surgeries and instrumental births due to fetal distress or failure to descend.
Being in an OU limits the freedom a woman can have during labour to move around and change positions that normally utilise gravity to help the fetus to descend properly, she also unable to have a shower or bath that can aid in easing the pain of contractions. These limitations are often due to the use of continuous Electronic Fetal Monitoring (EFM). This form of monitoring is thought by many to only be necessary in high risk cases. The use of EFM can also lead to higher caesarean and vacuum extractions. Due to EFM being an internal form of monitoring it poses the risk of infection in both mother and baby. Frequent vaginal exams are common practice for nurses and physicians in enabling health professionals to determine cervical changes in labour. These examinations also put the mother at risk of infections and chorioamnionitis that can have an impact on future fertility. The same study also found that if a woman had 7 or more vaginal exams during labour her newborn was 4.5 times more likely to contract neonatal sepsis and require antibiotic therapy. One of the most common interventions during labour is cesarean surgery. Currently, the rates of caesarean surgery are at 31% which is higher than recommended by the World Health Organisation (WHO) at 13-15%. The reason for the increase is thought to be either as “a matter of convenience to the physician” or at a patient’s request. There are many risks involved during surgeries like a caesarean including bladder injury, placenta previa and uterine problems. There is also a 69% higher incidence of neonatal deaths compared to vaginal births. Another widely used intervention is the administration of anaesthesia via an epidural or spinal injection. Whilst it reduces the pain it can prolong the first and second stage of labour which is very tiring and stressful. It can also lead to the need for catheterization, a further form of intervention. There is no doubt that of course in some cases any of the above mentioned interventions may be life-saving for both the mother and baby, however they have almost become routine practice within hospitals that can have drastic effects on mothers if they aren’t required. Each of these interventions carries risks as I have discussed and carrying them out should not be something that is taken lightly. As I will go on to talk about, many women find the thought of these nonessential procedures daunting and dangerous, thus causing them to feel they would prefer to give birth in another location.
Overall studies show that for women who were deemed low-risk at the beginning of labour has a three times greater risk of experiencing an adverse outcome at home compared to in an obstetric unit. This is of course expected. A midwife attending a home birth does not have access to pain relief and cannot perform surgery. If a mother required a procedure beyond the ability of the midwife, then a transfer to hospital would be necessary. The risk is higher because the mother is not in close proximity to specialized care or a trained obstetrician and if labour becomes complicated the time taken to get to the hospital could ultimately have an effect on how successful the intervention once in the OU is.
Why mothers choose to give birth in a hospital or at home:
Choosing where to give birth is a fundamental part of any woman’s pregnancy. Their decision can hugely affect how comfortable they feel and potentially how difficult the actual birth is. Expectant mothers have a wide range of personal reasons when choosing where to give birth, but as seen in many surveys there are a number of factors taken into account. In the UK most women who give birth at home are multiparous, low-risk women, however, they also tend to be older, white and with a higher socioeconomic status. This is perhaps because they are more experienced when giving birth due to previous pregnancies meaning the idea of childbirth is familiar and therefore don’t desire the security an obstetric ward can provide. In addition to this, coming from a wealthier background implies the environment they want to deliver in is more suited to a home birth due to having lots of space and more facilities compared to others. They may also have the means to purchase items that can aid in delivery such as a birthing pool. Many women who choose to deliver at home do so based on previous experiences from other pregnancies. A study found that many chose a home birth for their second child due to a negative experience in a hospital environment previously. Firstly, some felt that giving birth in an obstetric unit led to unnecessary obstetric intervention. They believed childbirth was a natural process and shouldn’t be treated like disease, that it was a more positive experience without intervention that could possibly have an adverse effect on the delivery. Many mothers also disliked the interruptions they experienced in a hospital setting, where unfamiliar people constantly walked in. They felt this led to a “loss of concentration” but also had a detrimental effect on their emotional wellbeing whilst in labour. Leading on from this, another reason why people choose to have a home birth was because they felt the care they received in hospital was unsatisfactory and felt they lost their right to patient autonomy. This was especially evident when procedures such as the administration of pharmacological pain relief without much explanation or a desire to respect the patient’s wishes. This ultimately led to many mothers feeling a loss of control, only adding to the trauma of what can be a stressful and daunting experience. They reported feeling pressured by the medical staff to undergo a procedure even if it was not what they wanted. A study by Lindgren and Erlandsson showed that 75% of 722 women rarely mentioned the theme of pain when planning to deliver at home. Lots of women don’t desire an epidural or other pain relief and often felt safe in the knowledge that a home birth would prevent narcotic intervention from being administered. They instead found other ways to manage the pain of childbirth which made them feel more in control. Empowerment is also another huge factor for woman choosing to give birth at home. Being in an environment without the threat of interventions, interruptions and knowing their wishes would be respected is an incredibly important element of childbirth. Having a homebirth encouraged mothers to be more informed about the process and they found the experience less daunting. Finally, women choose to have a home birth because it is an environment where they feel safe and at peace. They can choose who is present during the birth and have more control throughout the labour. Again some women felt that a home birth provided a higher quality of care due to having two midwives attending who were only focused on them and removed the distractions of being in a hospital
On the other hand, the majority of births take place in an obstetric unit or some kind of hospital setting, for example in 2012 97.7% of births didn’t take place in a home environment. This is because as a society we have encouraged women to believe it the best place to deliver. It is a widely accepted concept that giving birth in a hospital is safer for both mother and baby as opposed to anywhere else. They have access to specialised units such as a neonatal ward if the baby requires further treatment and also for themselves if they experienced complications. Many women also choose to give birth in a hospital because they feel they could not cope with labour out of a hospital environment. The majority of women in one study concluded that giving birth in a hospital was the best option “just in case” there was an adverse outcome. Naturally, the majority of high-risk mothers are strongly advised to deliver in a hospital due to the higher potential for a difficult birth. However, the decision as to where to give birth for low-risk mothers can be harder as they do not want to wish to pick a birthplace that could potentially put their baby’s life or their own in danger. When making the decision, many women refer and compare their own birth to that of a relative or friend who may have had a more difficult experience. Even after they have consulted with midwives who conclude they are low-risk based on medical history and constant check-ups, some still feel the need to have the security of an obstetric unit. In contrast with women in other studies, some reported feeling more comfortable in a hospital environment where they knew more specialised help was nearby in case of an emergency, again showing that the place of birth chosen is different for every woman and every pregnancy. In addition to this, many women choose to give birth in an OU because they view childbirth as a traumatic and embarrassing experience that they wish to keep separate from their home environment and personal lives. They expressed that having to walk into the same room after birth would make them feel uncomfortable and remind them of the experience. Linked to this, women with older children raised concerns at them being present in the house whilst in labour and felt that being on a ward kept the realities of birth hidden from them.
Conclusion:
For many women giving birth is an incredibly empowering and intimate experience where they can take charge of their own body but for others the idea of it is daunting and can cause much distress. Every woman has an idea of where she would ultimately feel most comfortable giving birth, whether this is in her own bed or in a hospital. For some women, being surrounded by loved ones in a known environment is better than others, who prefer to know that if there are complications every treatment is available. Before researching this I was of the opinion that most if not all women felt safer in a hospital due to having access to the latest technology or experienced obstetricians in close proximity and that women who choose home births were similar to the likes of ‘mad maternity evangelists’. However, I have come to realise that these assumptions are incorrect.
There are regulations and recommendations in place when planning where to deliver, midwives and health care practitioners use them to help advise expectant mothers. If a woman is multiparous and deemed low risk, then a home birth is advisable if the mother wishes so. If the mother is a primigravida but low risk then home delivery is also a viable option. However, if the mother is a primigravida and high risk then a hospital birth is advised to allow for the potential of an adverse outcome. This is also the case for high risk mothers who have complications from other pregnancies and births or previous medical conditions.
From the perspective of the NHS, there are some cases where a home birth is more economic than a hospital birth due to the overall cost being cheaper. This is due to hospital births normally resulting in some kind of obstetric intervention requiring a longer stay combined with high hospital overheads. This perhaps explains to some extent why the NHS has begun to encourage home births for certain women. Be that as it may, there are cases where a birth begins at home but then requires being transferred to hospital by ambulance and delivering in a labour suite. This is incredibly expensive for the NHS and is much more than just planning to deliver in hospital due to the cost of sending midwives to attend, the ambulance transfer and then the cost of staying in hospital.
When looking at personal reasons for choosing one place of birth over another there are a number of factors women take into account. One continuous theme was the negative previous experiences in hospitals where there had been unnecessary intervention and women felt helpless. Another reason was that women felt home births gave them the opportunity to be in control of the process and feel empowered.
I have come to realise that for many women being in hospital can be detrimental to the birth. They typically receive more obstetric intervention that can be unnecessary. In addition to this, the protocol followed by hospitals can have a negative impact as well. This includes fetal monitoring and frequent internal examinations that can cause infection. Whilst this is an important issue for hospitals to address and develop, it is vital not to assume that a home birth would be better. For high-risk and primigravida these protocols and interventions are necessary to ensure a birth is a safe as possible.
Overall, there is no right answer for the best place for women to deliver. Every case is different, with an intricate background and present history that must be taken into account when deciding. Despite this, patient autonomy is ultimately the most important factor that comes into play. Expectant mothers have different desires and needs and these have to be respected regardless of risk factors and the beliefs of a physician.