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By Dr J Kabyemela, MD

Not many people in the UK will know this but as recently as the beginning of the 1960s, over a third of all women had their babies delivered at home.

The home birth rate has steadily fallen to about 1 in 50 today (2%). What may surprise many further is the fact that in neighbouring Holland, the rate today is around 32% (sounds familiar?)  …and yes, the rate of perinatal complications in the two countries is comparable despite this vast difference in practise.

There has always been a significant demand for this option and its availability (or lack of) is a real issue, to varying degrees, in various countries or even various parts of the same country.

Why a Home Birth:

One area where there is almost total consensus is the fact that childbirth is a natural process. There is also an acknowledgement on the part of the medical profession that, in some parts of the western world at least, this process may have been over-medicalised.

Many women realise that the experience of childbirth might be more profound and fulfilling if achieved in their own home environment with the participation, in one way or another of other members of the family, including the older siblings of the newborn.  

Observational studies point to an overwhelmingly positive experience for those who manage to achieve a planned home birth with enhanced satisfaction, self-esteem, sense of control and empowerment.

What is Required:

For those who desire a home birth, it is important to have a grip of all the requirements that need to be in place to ensure a successful outcome. Safety of both mother and baby is the absolute pre-requisite for this strategy. Desiring home birth in itself isn’t sufficient. This may sound obvious but there are a number of people who fail to fully appreciate this. There has got to be a robust organisational framework  allowing this to work without hiccups.

Home Birth requires a multi-disciplinary approach with the midwife who is to assist in the birth at the centre of this. It is an accepted wisdom that home birth is only suited to low-risk pregnancy.  A robust risk-assessment needs to be carried out and this is a continuing process until the onset of labour.  If, for instance, a woman who is planning a home delivery and is assessed to be low-risk goes into labour prematurely, that instantly ceases to be low-risk and the plan should be abandoned.

Why the Difference?

It is rather puzzling to see the stark differences in rates of home births between neighbours like the Netherlands and the UK.  The explanation lies in the cultural difference between the Dutch and the British when it comes to childbirth. The whole approach is therefore different. This is seen in other statistics including the caesarean section rate which has hovered around 10% in the Netherlands for years as compared to the ever-rising rate in the UK, now approaching 25%. Whilst most midwives in the UK are employed by the state via NHS Trusts and therefore are hospital-based, in the Netherlands they are independent practitioners, a situation which is supportive of the home birth option culture. Moreover, in the Netherlands there are maternity assistants, the so-called kraamverzorgsters, who are available for every new delivered mother for up to eight days for up to eight hours every day. The cost of this service is paid for by the state. Community midwives do make postnatal home visits in the UK but this is just to ensure all is well with mother and baby and give any practical advice that might be required.

Is Home Birth suitable for everybody?

Needless to say, home birth would not suit everybody. Moreover, it is important to be realistic about a mother’s expectation. In places like Holland where the practice is established, statistics show that up to a third of all women do eventually have to be transferred to hospital to conclude their delivery there. This is usually for a variety of reasons which include

A slower than expected labour

Unbearable pain requiring strong pain killers

Features suggesting distress of the baby

Unexpectedly difficult delivery

Results of a study published in The April 2008 issue of the British Journal of Obstetrics and Gynaecology  gave  some cause for a little pause. There was evidence that a choice of home-birth increases the risk of losing the baby. While the absolute figures were very small, hence the risk tiny, the difference was clear. This was particularly the case with first time mothers.  It emphasizes the point to make this decision carefully.

Home Birth for first time mothers

In November 2011, the British Medical Journal published the results of The Birthplace in England national prospective cohort study. This was a prospective study which ran over 2 years (April 2008 to April 2010). It involved over 64,000 women with singleton term pregnancies. Results indicated that childbirth in the country was overall safe regardless of the place of birth. Serious problems were encountered at a rate of 3.5 per 1000 births in an obstetric units (in hospitals). However, for first time mothers, the risk rises almost three-fold to 9.5 per 1000 births. This was not the case with mothers who had given vaginal birth before (multiparous). The results add to our knowledge and underscore the importance of making an informed decision regarding the planned place of birth.

In the initial risk assessment, a mother with ambition for a home birth might be advised against it in the presence of such factors as:

Development of gestational diabetes

Increased volumes of amniotic fluid

Fetal  growth restriction

Breech presentation

It is also unlikely that a midwife will be prepared to assist a home birth in cases of:

Multiple pregnancy (twins)

Previous caesarean section

Previous unexplained stillbirth

Midwives are also reluctant to support a quest for a home birth if it is a first pregnancy especially if there is any of the recognised risk factors mentioned above.

What is important is to ensure all bases are covered. The structure has to be in place to ensure continued communication between the assisting midwife and the local hospital. In addition, a smooth transfer to hospital, always via ambulance, has to be available should the need arise.

Home Birth needs to be available for those who desire this option and who are deemed suited to it. It is important that health provision authorities (in the UK, the NHS Trusts), facilitate this.

Last update: August 26th, 2012

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