As hospital confinement has become the norm, many health professionals feel that homebirth puts the lives of mothers and babies at unnecessary risk. The medical model of pregnancy and birth that has prevailed for nearly thirty years starts from the premise that childbearing can only be deemed normal in retrospect. Since one cannot know what will happen, hospitals - with their emergency support systems and personnel - are seen as the safe place for birth.
However increasing numbers of women are no longer prepared to go along with this view and are requesting home births. It is often assumed that they choose home birth for the “birth experience”, but for many, it can be an informed choice to protect the health of both mother and baby. It is now well established that planned home birth does not increase infant or maternal mortality rates for healthy women with normal pregnancies. There is also ample evidence that planning a home birth improves overall outcomes for mothers and babies.
Risks and realities
Many myths and legends surround home birth, especially in relation to safety. And there is no shortage of anecdotal evidence. In reality planned home birth is associated with good outcomes for both mothers and babies. A study of home birth by the National Birthday Trust Fund covered nearly 6000 planned home births in the UK in 1994/5, matched against women planning hospital birth. The study found that women in the planned home birth group had approximately half the risk of an instrumental delivery or caesarean section, and were less likely to have a post-partum haemorrhage. Babies in the planned home birth group were significantly less likely to have low Apgar scores and suffered less birth injuries
Making the decision
Ideally homebirth is for fit, healthy women with uncomplicated pregnancies. But there are also women who want a homebirth who other health professionals may consider unsuitable. In such situations, you need to work with the woman on an individual basis, providing information relating to her personal risk factors. You should then draw upon the available evidence and your own clinical judgment to provide advice on the risks and benefits associated with each place of birth.
There is no evidence to support the commonly held belief that home birth is unsafe for fit, healthy women with uncomplicated pregnancies. Evidence indicates that the health outcomes of planned home birth are as good as those for hospital birth. There is sufficient evidence available to suggest that criteria often used at the booking visit to determine place of birth are not evidence based and are skewed towards abnormality. The whole concept of risk in relation to normal pregnancy and birth and place of birth is therefore open to further debate.
Tips and tricks
Learn from colleagues experienced in homebirth - if you want to attend women at home, your must develop the experience and skills required to facilitate a non-interventionist approach to normal labour and birth. These include expert clinical skills in relation to the diagnosis of the onset of labour and monitoring the progress of labour, as well as training and competency in maternal and neonatal resuscitation. Shadowing a midwife experienced in homebirth is very valuable.
Be aware of policies relating to the management of homebirth - there should be clear guidelines and support systems in place. Supervisors and managers should ensure professional and personal support is readily available to help you deal with any anxiety or stress you may experience.
Practise your skills for any relevant emergency procedures - Set aside a regular time to practice emergency procedures with peers there should be adequate emergency backup systems in place, including direct referral to a consultant obstetrician in the event of an emergency. You must also carry the necessary equipment including appropriate equipment for resuscitation of the newborn.
Campbell R (1999) Review and assessment of selection criteria used when booking pregnant women at different places of birth. British Journal of Obstetrics and Gynaecology
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Maternal and Childbirth Research Consortium (1998) Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI): 5th Annual Report. Focus group place of delivery. Chapter 6 paragraph 6.1- 6.5. Maternal and Child Health Research Consortium: London.
Olsen O and Jewell MD (2002) Home versus hospital birth.
(Cochrane Review). In: The Cochrane Library, Issue 1, 2002. Update Software: Oxford.
Royal College of Midwives (2003) Home Birth Handbook Volume 2: Practising Home Birth
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Tew M (1998) Safer Childbirth? A Critical History of Maternity Care.
Free Association Books Limited, London third edition.