Hospital Aspects Of Home Birth

Home births usually occur in the home of the parturient, but include all births outside a hospital or birthing centre. Historically home births were the norm, however in many Western countries there was a sharp decline in the 20th century with a shift towards hospital births. Since the 1970s there has been renewed interest in home births. In 1985, the World Health Organisation issued a statement saying there was no evidence that giving birth in hospital was safer than giving birth at home for an uncomplicated pregnancy. In the UK further impetus was provided by the Winterton report in 1992¹ and the Cumberlege report in 1993². Since then successive health secretaries have pledged to increase patient choice and the availability of home birth.

At present there is great variation in the rate of home births in developed countries ranging from about 0.6% in the USA to more than 30% in the Netherlands.

Across the United Kingdom, there has been a steady increase in the rate of home births in recent years and the current rate is approximately 2%. Most home births in the UK are conducted by midwives, and a minority by General Practitioners. At present home birth provision in the UK is under-resourced. The shortage of midwives often limits the number of women able to deliver at home. Proponents of home birth estimate that the rate in the UK could increase to 10% if adequate resources are provided and patients are given unbiased information³.

Women opt for home birth for many reasons. The most commonly cited are avoidance of medical intervention, fear of hospitals, the desire to give birth in familiar surroundings, the desire to be in control and the fear of hospital acquired infections.

There is a paucity of good quality research comparing outcomes following planned home births with hospital births, however the available evidence suggests that giving birth at home is a safe option for low risk women⁴. The available observational data also suggests that home births have advantages such as lower intervention rates, lower use of pharmacological pain relief, greater patient autonomy and satisfaction rates^5,6. Unscheduled home births on the other hand are associated with significantly greater risks for the mother and baby⁶.

The hospital has an important role in the safe provision of home births. A recent joint statement by the Royal College of Obstetricians & Gynaecologists and the Royal College of Midwives stresses the need for comprehensive involvement of local multidisciplinary teams⁷. Hospital based Obstetricians and midwives need to be involved in drawing up guidelines for antenatal and intra-partum risk identification, clear referral pathways, updating and maintaining the competencies of midwives and other carers, adequate midwifery supervision, record keeping and developing risk management pathways.

It is also important that maternity units strive to make giving birth as natural as possible in a relaxed environment which feels like home, particularly for low risk women. Many women make initial enquiries about home birth because of pre-conceptions about the hospital environment and subsequently change their minds after a tour on a pleasant maternity unit.

A proportion of women who plan to have a home birth will require intra-partum transfer into hospital usually for complications such as malpresentations and malpositions in labour, maternal haemorrhage, inadequate analgesia, slow progress in labour, suspected fetal and neonatal compromise. It is important for hospitals to have clear guidelines to minimise the consequences of any delay due to transfers. These will include good communication between the community based midwives and the hospital, clear referral pathways and ready availability of blood products on the delivery suite.

The Yeovil experience
The Yeovil District Hospital has a catchment area which covers most of East Somerset, part of the rest of Somerset and some parts of Dorset. Each home birth is attended by 2 midwives. The total number of deliveries in 2006 was 1,354 and the planned home birth rate was 5.8%.

Of the planned home births 15.2% required ante-partum hospital transfer for Obstetric indications like post-maturity, prolonged ruptured membranes, breech presentation at term and gestational diabetes. Another 8.9% of the planned home births required intra-partum hospital transfer for slow progress in labour or suspected fetal distress.

A further 7.6% of the planned home births moved out of the area and had their babies in other units.

The actual home birth rate was 4.1%. of which 5.4% required post-partum transfer to hospital for perineal lacerations and post-partum haemorrhage. 3.6% of the home births were unplanned home births in women booked for hospital delivery.

Additional requirements

• Arrange for pre-delivery of a large entonox cylinder to patient’s home.
• Arrange for a doctor to prescribe pethidine in advance if required.
• Patient should make her own arrangements for a birthing pool to be delivered in advance if required.

Management of the high-risk woman who insists on a home birth
Midwives have an obligation to support such women even if they think her decision is unwise. In such situations the midwives will seek the advice of a consultant Obstetrician who will usually arrange a consultation with the patient. If she is adamant about the home birth, the delivery is usually attended by two senior midwives. A planning meeting is also held with a supervisor of midwives in advance of such a delivery.

Challenges faced by midwives
The shortage of midwives across the country makes the provision of home births quite challenging.

Community based midwives who carry out most home deliveries are often on call for the hospital maternity unit as well, if they are called into the hospital they will often have to transfer the planned home birth to the hospital. Midwives who conduct home births also have anxieties about unexpected intra-partum complications and attending home births in unfamiliar and sometimes dangerous neighbourhoods. In spite of these challenges, most midwives who conduct home births find the experience enjoyable and rewarding.

Conclusion
Giving birth at home is popular with many women in the UK. The available evidence suggests that it is a safe option for low risk women.

Home birth is an important component of patient choice in healthcare. Good record keeping and audit are extremely important. There is also a need for further good quality research into outcomes for different places of delivery.

1. House of Commons Health Committee report on maternity services. London: HMSO, 1992.
2. Department of Health Expert Maternity Group report on Changing Childbirth. London: HMSO, 1993.
3. Department of Health. Changing Childbirth: Report of the Expert Maternity Group. HMSO, 2003.
4. Olsen O, Jewell MD. Home versus hospital births. Cochrane Database Systematic Review(3):CD000352.
5. Davies J, Hey E, Reid W, Young G. Prospective regional study of planned home birth. BMJ 1996; 313:1302 -5.
6. The Northern Region’s Perinatal Mortality Survey Coordinating Group. Perinatal loss in planned and unplanned home birth. BMJ 1996; 313:1306-9.
7. Home Births. RCOG and Royal College of Midwives Joint Statement No 2. April 2007.

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