Home birth in the UK: a safe choice?

Abstract

The safety of home as a place of birth in developed countries, and the extent to which pregnant women should have the right to choose a home birth, are highly contentious and emotive subjects which have been hotly debated for many years. Since 1993, Government policy in England and Wales has been that pregnant women should have a free and informed choice about whether to give birth at home or in a hospital or birthing centre. However, fewer than 3% of maternities take place at home, indicating either that this option is not routinely available or that most women do not want to have a home birth. Previous research indicates that there is an element of both, and that most women believe that hospital birth is safer than home birth. Although research has demonstrated that, for low-risk pregnancies in most developed countries, perinatal death is no more common for planned home birth than for hospital birth, and that maternal outcomes tend to be better if there is a planned home birth, this research has been done at the population level. At the level of the individual women, there remain lingering doubts over whether home birth can be as safe as hospital birth if there are serious complications in labour. Using data from four UK datasets, this thesis contains detailed analysis of the characteristics of women who plan a home birth in the UK, and how these have varied over time and according to where the woman lives. Recognising that decisions about place of birth are subject to change over the course of a pregnancy, the analysis presented here identifies key factors which robustly predict whether women will express an intention to give birth at home, whether their intentions will change during the pregnancy, and whether those who intend a home birth will actually have a planned home birth. Understanding these predictors helps to understand the factors that may influence women’s choices at different stages of pregnancy. There is evidence from this analysis to suggest that women do not all have equal access to choice about where to give birth. Understanding of the factors that predict women’s choices also enables a fair comparison of the relative safety of planned home birth and planned hospital birth, while controlling for the fact that women who plan a home birth are not a random sub-set of the population of childbearing women. From the perspective of the mother, planning a home birth (whether or not she goes on to give birth at home) is associated with a much lower risk of the potentially life-threatening postpartum haemorrhage (defined as the loss of more than 1,000ml of blood) and several other distressing labour complications such as retained placenta. From the perspective of the baby, the risk of perinatal death is slightly, but not significantly higher, if a home birth is planned than if a hospital birth is planned, even if high-risk pregnancies are included in the analysis. However, there is weak evidence to suggest that, if pregnancy/labour is complicated by malpresentation, umbilical cord prolapse or the need for infant resuscitation via positive pressure/cardiac massage, the risk of perinatal death is higher if a home birth is planned than if a hospital birth is planned. Other pregnancy and labour complications are associated with a higher risk of negative outcomes, but this is true whether a home birth or a hospital birth is planned – hospital birth has not been shown to be safer in these situations. Malpresentation occurs in roughly 1 in 20 pregnancies and is detectable before labour commences, so this research provides some support for the current advice that women with a malpresented foetus should be advised to plan a hospital birth unless and until midwives attending home births can be fully confident in their ability to deliver a malpresented foetus vaginally. Cord prolapse and the need for positive pressure/cardiac massage, on the other hand, are both extremely rare and not predictable before labour. Given their rarity and the lack of strong evidence that home birth is less safe when they occur, rather than being encouraged to plan a hospital birth ‘just in case’, women should be provided with the available information and allowed to come to an informed decision without being put under pressure to choose any particular birth setting. Additionally, midwives attending home births should have a thorough grounding in dealing effectively with these situations when they occur in the home setting

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Identifiers

ORCID for Ann Berrington: orcid.org/0000-0002-1683-6668

ORCID for Zoe Matthews: orcid.org/0000-0003-1533-6618

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