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What are my options?

Whether you are expecting your first baby, second, third or more, you have the right to choose where you want to give birth. Depending on where you live it may be easier to access some options than others. The main options are:

At Home: where you can have midwifery care from either NHS or Independent midwives. You can hire a birth pool and use whatever methods you want for managing your labour. Midwives usually carry Entonox ("gas and air") and sometimes provide opiate drugs such as Pethidine or Diamorphine if you want them. A prescription for painkillers might also be obtained from a GP. If you decided to have an epidural, however, you would need to transfer to a hospital obstetric unit.

A Birth Centre (sometimes called a Midwife-led unit or MLU) where all care is provided by midwives. They focus on maximising the chances of a straightforward birth, and usually have a homelike setting to encourage relaxation and the flow of hormones that help labour to progress. Most have birth-pools in all or most rooms. Most forms of pain relief are available apart from epidurals and in some centres, opiates are not given. Alternative therapies such as aromatherapy may also be on offer in some units. There are two types of Birth Centre:

A Free-standing Midwife-led Unit (FMU) is on a separate site and is not attached to a hospital with an obstetric unit

An Alongside Midwife-led unit (AMU) is on the same site as a hospital with an obstetric unit, often in the same building, but sometimes a separate one.

An Obstetric Unit (OU) is a maternity unit within a hospital where doctors are available to provide medical care if needed. These are sometimes referred to as 'labour ward' or 'delivery suite'. Doctors will usually only be involved if there are medical complications. Otherwise, if you choose to give birth in an OU you will be cared for by midwives. It's possible to request an epidural though it may not be available exactly when you want it. The availability of birth-pools in OUs varies a lot, and there may be strict local guidelines on who can use them. The environment within an obstetric unit is usually more medical than in a birth centre, and this may inhibit the helpful labour hormones. On the other hand, some people feel safer having doctors closer by.

How safe would it be for my baby?

The best available evidence on safety comes from the Birthplace Study which compared how planning to give birth in different settings affected the outcomes for mothers and babies when there was no reason to expect complications. The comparison was based on where the women planned to give birth even if they eventually gave birth somewhere else. It excluded women having a pre-term labour or a planned Caesarean birth.

The authors concluded that wherever it took place "birth is generally very safe" for babies of "low risk" women. For mothers who had birthed before, there was no difference at all in the outcomes for their babies between the different settings.

First time mothers who planned birth in an obstetric unit or in either kind of birth centre had almost identical outcomes for babies, with only 5 in every 1,000 having any kind of serious complication.

For first-time mothers who planned to give birth at home there was a very small increase in the chance of harm for the baby compared to any of the other settings, though we don't know why this was. The risk remains extremely low even for this group - only 9 in every 1,000. It's hard to be sure what this really means as the figures are a combination of several different things which were too rare to analyse individually, and not all of which had long-term consequences. This means that even in this group where there were serious complications, as in other birth settings, many of the babies were fine in the longer term.

Some of the medical interventions that a mother might experience can also have an impact on her baby. For instance, when a birth is assisted with forceps or ventouse, the baby may experience bruising or small cuts on their face and head. These usually heal quickly but may mean that the baby is more unsettled for the first few days, which can make it harder to establish breastfeeding. Mothers who have had a Caesarean or assisted birth may find it harder to feed and care for their babies in the early days, as well as probably needing longer to recover than those who had a straightforward birth.

How safe would it be for me?

It is fortunately very rare for mothers in this country to die during labour and birth, so in this sense all birthplaces are safe.

However, the Birthplace Study showed that it's significantly more likely that mothers with no complicating factors will experience medical interventions if they plan to give birth in an Obstetric Unit rather than at home or in a Birth Centre. In this sense, these out of hospital settings are safer for the mother. The difference in the likelihood of all the medical interventions as well as the harms such as excessive blood loss, that the Birthplace Study looked at was lower for the women who planned to birth outside hospitals, either in birth centres or at home. For some interventions this difference was quite profound.

For instance, first time mothers were about twice as likely to have an unplanned caesarean if they'd planned to birth in a hospital rather than in a birth centre or at home (16% vs. 7-9%).

For mothers who had given birth before the chances of a planned caesarean were much lower than for first-time mothers, but they were still five times more likely to have one if they planned to birth in hospital compared to other settings (5% vs 1%).

Mothers planning birth in hospital were also more likely to have the birth assisted with forceps or ventouse.

Overall, around 80% of first-time mothers who planned a birth at home or in a Birth Centre had a straightforward birth, compared to only 60% of those that planned a birth in an Obstetric unit.

Women who planned to birth in hospital also appeared to have higher rates of problems like severe tears and blood loss requiring a transfusion, although these were rare in all settings.

The outcomes for those mothers that chose an Alongside Midwife-led Unit were not quite as good as for those choosing home or a Freestanding Midwife-led unit, but still significantly better than for an Obstetric unit.

What if I need to transfer to a hospital Obstetric Unit during labour?

Quite a high proportion of first-time mothers in the Birthplace Study transferred to an OU during labour or just after the birth (around a third of those planning birth in an FMU, slightly more for an AMU and just under half for a homebirth). Transfer rates were much lower for those that had given birth before - around one in ten women.

A follow-up analysis of the Birthplace Study data found that the most common reason for transfer from home or an FMU was that labour was going slowly and the mother wanted it to be speeded up artificially. The other main reason was that a midwife had picked up signs that the baby might not be coping well with labour. Midwives are trained to spot these warning signs early, so the transfer can normally be done in plenty of time and in a calm way.

It was uncommon for mothers to have transferred in order to have an epidural - just under three out of every 100 first time mothers who planned to birth at home and just over two out of every hundred who planned to birth in an FMU. For those who had birthed before the numbers were much lower - four out of every thousand for homebirths, and three out of every thousand for FMUs.

If you decide to transfer from home or an FMU, your midwife will usually accompany you (if it's by ambulance) or follow you to the hospital (if it's by car). If you are transferring from an AMU, you might be able to walk or might prefer to be taken in a wheelchair.

What are my options if I've been told that I'm "high risk"?

Pregnant women and people are often advised to give birth in an Obstetric Unit if there are concerns over their health or that of their baby, or if there are any factors that might make complications in labour more likely. You may be happy with this. If not, you still have the right to choose a homebirth, but may find that your Hospital Trust is reluctant to support this. (You may find our template letter Booking a Homebirth helpful if you are having difficulty with this.)

Birth Centres have criteria for which women they will accept, but they vary from place to place, and it's sometimes possible to negotiate a care plan that enables you to labour there even if you are classed as "high risk". According to Birthrights "Any decision to refuse a woman admission to a birth centre must be backed-up by evidence which supports the decision. For example, if a woman is refused admission because of a particular risk factor in her pregnancy, there must be clear clinical evidence that additional risks may arise during the birth that cannot be safely managed in a birth centre."

Another of the follow-on studies using the Birthplace Study data showed that for women with medical or obstetric risk factors, planning a homebirth actually reduced the chances of the baby being admitted for hospital care in the first few days after the birth, compared to planned birth in an OU. There seemed to be no significant difference in the likelihood of other serious harm to the baby, however the number in this study was too small to be certain about this. For these women planned homebirth was associated with an increased probability of having a straightforward birth compared with planned OU birth.

There hasn't been any analysis of "high risk" women using Birth centres, as the numbers are too small.

What if I'm not being offered the choice I want?

If you have been advised to birth in an OU but want to consider other options; or if you've been told that support for a homebirth or a Birth Centre is not available in your area, the first step would be a discussion with your midwife or consultant. If you are not happy with the outcome of the discussion, you could ask to speak to a Consultant Midwife or the Head of Midwifery. In some Trusts in England there are Professional Midwifery Advocates whose role includes advocating for maternity service users, but not all Trusts provide this. In Scotland, Wales, and Northern Ireland, there is a similar role for "supervisors" (see the AIMS Journal article " What is a Professional Midwifery Advocate (PMA)? ") Contact information for all of these people should be available on your NHS Trust or Board's website or from the maternity ward in your local hospital. You can just phone them up and ask for the information without giving out your name, or the reason why you want their details, if you would prefer not to discuss your situation with anyone else.

It might also be possible to transfer your care to another Hospital Trust or Board that offers the services you want.

If you are keen to have a Homebirth and your Trust/Board is reluctant to support you, another option is to hire an Independent Midwife to provide your care.

Some pregnant women and people choose to birth at home without midwife support (known as freebirthing). This is legal. It is also legal for a relative or friend to support a woman who is labouring without a midwife present, as long as they are not acting in the capacity of a health professional or giving medical or midwifery care.

The AIMS helpline can provide information and support for negotiating the choices that you feel are right for you.

A note on the impact of coronavirus on choice of birthplace

At the start of the coronavirus pandemic many Trusts/Boards suspended support for homebirths although others continued to provide it. Similarly, some closed some or all of their Birth Centres and others kept them open. In some places these service restrictions were lifted during summer 2020 but may or may not have been reimposed since then. The situation continues to change from week to week.

Your Trust or Board should, however, be making information on the current state of their maternity services available to service users in a readily accessible form. Some are proving better at this than others. Another source of information is the But Not Maternity's spreadsheet. This is a Status List of NHS Trusts and Partner Restrictions, which is being maintained by a group of volunteers. It covers all Trusts/Boards in the four nations of the UK but is not guaranteed to have the latest information.

If you want to request support for a homebirth, AIMS has a template letter Homebirth and Coronavirus which you can adapt and send to your Trust/Board.

If you are considering freebirthing, there is information and a list of resources here Freebirth, Unassisted Childbirth and Unassisted Pregnancy.

Further information on the latest guidance about maternity services in the pandemic is available on the AIMS Birth Information page Coronavirus and your maternity care

References

1. National Perinatal Epidemiology Unit "Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study" BMJ 2011;343:d7400
2. Chapter 5 in Hollowell J. et al "The Birthplace in England national prospective cohort study: further analyses to enhance policy and service delivery decision-making for planned place of birth" Health Services and Delivery Research, No. 3.36 2015
​​​​​​ 3. Birthrights factsheet " Choice of place of birth"
4. Study 5 on the NPEU webpage www.npeu.ox.ac.uk/birthplace/birthplace-follow-on-study
5. Birthrights factsheet " Unassisted birth"

Further Reading
Booking a Homebirth | AIMS Freebirth, Unassisted Childbirth and Unassisted Pregnancy | AIMS King's Birthplace Decision Support leaflet
NICE Guideline "Intrapartum care for healthy women and babies" 2017 Section 1.1 "Place of Birth"
www.homebirth.org.uk
Written by: Nadia Higson
Reviewed by: Caroline Mayers
Reviewed on: 04/03/2021
Next review needed: 04/03/2023

AIMS supports all maternity service users to navigate the system as it exists, and campaigns for a system which truly meets the needs of all. AIMS does not give medical advice, but instead we focus on helping women to find the information that they need to make informed decisions about what is right for them, and support them to have their decisions respected by their health care providers. The AIMS Helpline volunteers will be happy to provide further information and support. Please email helpline@aims.org.uk or ring 0300 365 0663.

Published on 14th June 2017

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Whether you are expecting your first baby, second, third or more, you have the right to choose where you want to give birth. Depending on where you live it may be easier to access some options than others. The main options are: At Home: where you can have midwifery care from either NHS or Independent midwives.

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Options and the differences between them

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Options and the differences between them

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Samantha Gadsden, National Virtual Doula, South Wales and the South West.

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A guest blog post by Kath Harbisher

My perspective goes like this.

A consultant led unit (CLU) is the place for high tech, high intervention, medic-led obstetric care. They are in place for women with obstetric complications that are high risk and this care saves lives. We're grateful to have them.

But, what research and the Birth Place study, in particular, shows, is that low risk women on a CLU end up with a lot of unnecessary interventions. Interventions affect birth outcomes.

Some women prefer to give birth on a CLU and our society has certainly bought into the myth that all women need medical help when giving birth. If a woman feels psychologically safer birthing on a CLU then I respect that, and believe she should have that option because psychological well-being is as important as physical well-being.

Midwife led units (MLUs) and home births are not high tech, so the overall level of intervention is much lower and those interventions are low tech. The point is to facilitate normal physiological birth with skilled midwives.

In the UK we have seen a rising trend of Post Natal Depression (PND) and birth related post traumatic stress disorder (PTSD) that correlates with the rising trend in intervention and caesarean birth. It's extremely complex and this is just one facet of that complexity, but one has to consider whether women are suffering psychological damage when births are happening in high tech environments.

One of the reasons linked to this seems to be that in high tech environments, particularly when the NHS is driven by litigation and defensive practice, how women are treated seems to deteriorate and the focus in only on keeping mother and child alive and undamaged physically with no thought to the impact on the dyad (mother and baby as a unit).

In fact, most maternity care related complaints are about or will include issues of poor communication, being treated unkindly, without compassion, without explanation, being treated disrespectfully and having legal rights ignored.

Click HERE for more information on National and Local Birth Pool and Tens hire.

Then comes scaremongering and coercion followed by assault. While a focus on keeping mother and child alive is absolutely necessary for the true emergency, many women on CLUs these days are not in dire emergency; they're there just in case an emergency might happen. Yet they may be subject to many unnecessary interventions, and for some, all the poor treatment things I've mentioned. This kind of treatment is far less likely to happen on an MLU or at a homebirth. I think, in part, because there is far less pressure on staff to be seen to be doing something or to 'fix' birth even when it doesn't need fixing.

The whole atmosphere of an MLU and home birth is invariably far more relaxed and accommodating.

Vaginal birth after a caesarean (VBAC) has a scar rupture risk of 0.2% which actually makes it low risk. This risk is comparable to other obstetric risks which do not exclude women from MLUs and home births. But women planning a VBAC in the UK are, generally, routinely excluded from MLUs and advised against home birth, where they feel they will get a more positive birth experience, and from the option of low intervention physiological birth which is better for mother and child where possible.

Women seeking to birth on an MLU or at home are looking for skilled help in a calm and relaxed environment which also facilitates physiological birth. It's because that's recognised that we have MLUs at all

So, wanting to be on an MLU or to birth at home, is all about the benefits of physiological birth and protecting oneself from psychological damage which is very reasonable.

For vaginal birth after caesarean, this can be explored in more detail in this articles

Uterine Rupture By Intended Mode Of Delivery In The UK.

If you have found my blog and support helpful and would like to support my work - you can donate to my paypal https://paypal.me/SamanthaGadsdenDoula

Feel free to join the South Wales Birth Circle, Home Birth Support Group UK or the South Wales Home Birth Group.

The Royal Berkshire Hospital now has midwife led care as the standard path way for women who want a vaginal birth after a previous caesarean. Although I am not a fan of routine sweeps and vaginal examinations - I think this is a massive step forward for VBAC. The Royal Berkshire Policy can be read HERE. This link also contains all the latest policy and research.

Samantha Gadsden walks with women on their life's journeys. She is an experienced Doula, based close to Cardiff in South Wales, mother to 4 children and wife to Eddie, more information can be found on her facebook page, Samantha Gadsden Doula and her website, Caerphilly Doula. SOS Doula, Telephone and online support is always available.

If you are interested in writing a guest blog or sharing a life or birth story please feel free to contact her HERE.

"Your Journey, Your Body, Your Baby, Your Birth"

NomNom Organic Products - Neals Yard Organics -MoonCup Affiliate

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What Is The Difference Between A Consultant Led Unit And Midwife Led Birth(CLU/MLU/Homebirth) - Samantha Gadsden, National Virtual Doula, South Wales and the South West.

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A guest blog post by Kath Harbisher My perspective goes like this. A consultant led unit (CLU) is the place for high tech, high intervention, medic-led obstetric care. They are in place for women with obstetric complications that are high risk and this care saves lives. We're grateful to have them.

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Lancet study - Impact of birth place on outcomes.

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Lancet study - Impact of birth place on outcomes.

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Is home birth safe?

According to the most recent and up-to-date research evidence, yes. On this page, I'll share some of that with you. I also link to a number of articles and blog posts that I've written about this.

In 2019, a large systematic review and meta-analysis was published in The Lancet. It looked at 14 studies including data from around 500,000 intended home births. The authors found that, "The risk of perinatal or neonatal mortality was not different when birth was intended at home or in hospital." (Hutton et al 2019).

This is just one of many studies that show the same thing. The Hutton et al (2019) study was remarkable because of its size. But, as the studies on this page show, it's not a unique finding.

More on safety

If you're the kind of person that likes the detail, here are the results of the Hutton et al (2019) study:

"Among nulliparous women intending a home birth in settings where midwives attending home birth are well-integrated in health services, the odds ratio (OR) of perinatal or neonatal mortality compared to those intending hospital birth was 1.07 (95% Confidence Interval [CI], 0.70 to 1.65); and in less integrated settings 3.17 (95% CI, 0.73 to 13.76). Among multiparous women intending a home birth in well-integrated settings, the estimated OR compared to those intending a hospital birth was 1.08 (95% CI, 0.84 to 1.38); and in less integrated settings was 1.58 (95% CI, 0.50 to 5.03)." (Hutton et al 2019).

Hutton et al (2019). Perinatal or neonatal mortality among women who intend at the onset of labour to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analyses. doi.org/10.1016/j.eclinm.2019.07.005

This paper has also been discussed by Henci Goer and you can read her analysis here.

More evidence

The findings of Hutton et al (2019) also confirmed those of the meta-analysis conducted by Scarf et al (2018). And both of these reviews are simply the latest in a long series of studies confirming home birth safety.

Here's how I summarised the Scarf et al (2018) review:

"A systematic review and meta-analysis has further confirmed the safety of home birth for healthy women, even if they are having their first baby. After comparing data from births planned at home birth, in birth centres and in hospital, researchers found that high-quality studies found no statistically significant difference in infant mortality between the different settings, although women giving birth at home or in birth centres were more likely to have a normal vaginal birth. In fact, women planning home births were nearly three times more likely to have a normal (that is, non-instrumental) vaginal birth than women planning a hospital birth."

The Scarf et al (2018) review was an important one because, as the authors explain in the background to their paper, there have been many debates on this area and there exist methodological challenges which have to be taken into account. Some of the so-called evidence that is cited on this topic is not of good quality. The review authors include some world experts on this topic, and in order to produce high-quality research they "reviewed original research from high-income countries (World Bank, 2016) using a birthplace-specific quality appraisal instrument (Vedam et al 2017a), and undertook meta-analysis of outcome data where possible." (Scarf et al 2018).

In their summary of the findings and conclusions, the researchers noted that, "Meta-analysis indicated that women planning hospital births had statistically significantly lower odds of normal vaginal birth than in other planned settings. Women experienced severe perineal trauma or haemorrhage at a lower rate in planned home births than in obstetric units. There were no statistically significant differences in infant mortality by planned place of birth, although most studies had limited statistical power to detect differences for rare outcomes. Differences in location, context, quality and design of identified studies render results subject to variation. High-quality evidence about low-risk pregnancies indicates that place of birth had no statistically significant impact on infant mortality. The lower odds of maternal morbidity and obstetric intervention support the expansion of birth centre and home birth options for women with low-risk pregnancies." (Scarf et al 2018).

Turning it around: the harms of hospital

"A 2023 summary of the best available research published in the internationally recognized Cochrane Library shows that planned hospital births can do more harm than good. This applies if the pregnant woman is healthy, expects an uncomplicated birth, and the birth takes place in a well-organized health care system." ( Olsen and Clausen 2023).

The summary was written by senior researcher Ole Olsen, Research Unit for General Practice, in collaboration with midwife and PhD Jette Aaroe Clausen.

It highlights that, while there is a lack of evidence from randomised controlled trials, "Evidence from observational studies suggests that planned hospital birth does not reduce mortality but may lead to more interventions, more complications, and more neonatal problems." ( Olsen & Clausen 2023).

The World Health Organization (WHO) has raised concern that the increasing medicalisation of childbirth tends to undermine women's own capability to give birth and negatively impacts their childbirth experience. (Olsen & Clausen 2023).

Olsen O & Clausen JA (2023). Planned hospital birth compared with planned home birth for pregnant women at low risk of complications. doi.org/10.1002/14651858.CD000352.pub3

Read the researchers' summary at https://publichealth.ku.dk/news/hospital-births-can-do-more-harm-than-good/

Read the Cochrane review which highlights the lack of RCT evidence and the need for a different approach at https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000352.pub3/full

Other benefits of homebirth

Studies also confirm other benefits of homebirth. For example, a study which looked at the experiences of more than 28,000 women in the UK and Ireland showed a significant association between home birth and breastfeeding (Quigley et al 2016).

And, when researchers asked fathers about their experiences of homebirth, they described it as magical.

A study in Ireland which collated the experiences of 141 participants who birthed both in hospital and at home between 2011 and 2021 found that, "Participants' overall experience scores were significantly higher for homebirth (9.7/10) than hospital birth (5.5/10)." "Homebirth was perceived far more positively than hospital birth experiences across all aspects of care surveyed." The authors concluded that, "This study provides evidence regarding the need for genuine choices for maternity care and reveals the importance of care which is respectful and responsive to divergent ideologies about birth." ( Gregory et al 2023).

Home birth and risk

Home birth isn't just for those who manage to stay in the 'low risk' box either!

Research shows that home birth is also safer for women who are labelled as 'high risk'. (Let's acknowledge that this labelling is often inaccurate, unhelpful and offensive though.)

Here's more evidence from The Netherlands and Australia.

We also have papers from the US. and New Zealand.

The research keeps coming

Many individual studies from around the world have evidenced the safety of homebirth, as well as the reviews. Here are a few of the most recent:

Finland

In Finland, researchers were concerned that, "compared to in-hospital births, the long-term outcome of children born out-of-hospital, planned or unplanned, is poorly studied."

Researchers often use hospital birth as the standard by which the safety of home birth is measured. This is curious, because hospital birth is a relatively new intervention and it was introduced without evidence of safety compared to home birth. But that's another post.

So they looked at the outcomes of 790,136 children born in Finland between 1996 and 2013. These included planned and unplanned out-of-hospital births. Usually, it's better to separate the two as there can be quite a difference in outcomes.

The fact that planned AND unplanned out-of-hospital births were included make the results even more interesting.

They actually found that, although on the whole there is no difference in children's health at the age of seven, "morbidity (illness) related to asthma or allergic diseases and infections by seven years of age appeared to be lower in children born out-of-hospital."

The paper is by Ovaskainen et al (2021) and it is freely available online.

Spain

In 2021, researchers published a descriptive study of planned homebirth in Catalonia (Spain).
"In Spain, official records show that 0.63% of births take place at home, but these records do not state the proportion of planned and unplanned home births. For this reason, official records do not enable the analysis of maternal and neonatal outcomes according to the place of birth; thus, the rate of adverse advents with respect to planned place of birth remains to be determined." "Catalonia is the region with the largest number of home births, and thanks to the data collected by CAHBM midwives, we know that most home births in Catalonia were planned." "The rates of maternal and neonatal morbidity show a high degree of safety during birthing and reflect the work of independent midwives in Catalonia. The variety of positions during the birth and the low percentages of high-grade perineal tears and episiotomies, as well as the high percentage of women who used water during birth and of babies who started feeding within an hour of birth, demonstrate that the care provided by the midwives in these planned home births in Catalonia is based on the scientific evidence and on a respect for physiology."
The full study can be read at https://www.sciencedirect.com/science/article/pii/S0266613821000565

Norway

In 2020, a Norwegian study by Skrondal et al (2020) which is freely available here provided more evidence of homebirth safety.

"Planned home birth may be experienced as a very positive occurrence for nulliparous women, and the care those women in this study received contained several elements that can help to promote normal labour and birth at a time in which reducing interventions in maternity care is of importance. Their positive birth experiences gave the women confidence both in their transition to motherhood as well as in other aspects of life." (Skrondal et al 2020).

The Netherlands

One older but important study is de Jonge et al's (2013) study, Severe adverse maternal outcomes among low risk women with planned home versus hospital births in the Netherlands: nationwide cohort study.

The authors of this research looked at the experiences of 146,752 low-risk women, of whom 92,333 (62.9%) had a planned home birth and 54,419 (37.1%) had a planned hospital birth. Upon analysing the outcomes, they discovered that, although the absolute risks were small in both groups, low risk women who planned home birth had lower rates of severe acute maternal morbidity, postpartum haemorrhage, and manual removal of placenta than those with planned hospital birth. These differences were statistically significant for women who had had given birth before.

The take-home message, although worded in the negative as is often the case with such studies, is that: There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system (de Jonge et al 2013).

Australia

Another useful study is Publicly funded homebirth in Australia: a review of maternal and neonatal outcomes over 6 years.

This comprises the first national evaluation of 97% of the women who chose publicly funded homebirth between 2005 and 2010. While 97% is a significant proportion of the available sample, however, the rarity of poor outcomes means that the sample size isn't big enough to be conclusive about safety. What the evaluation shows is that 84% of the women who planned to give birth at home actually did so, and 90% of the women (which will include a few of those who transferred to hospital) had a normal vaginal birth.

Other positive outcomes included that intervention rates among these women were low. Women choosing homebirth had low rates of postpartum haemorrhage (which is particularly significant given that around three quarters of the women had physiological placental births) and third degree perineal tears and stillbirth and early neonatal death rates were also low. In other good news, 69% of the women were breastfeeding at 6 weeks postpartum. Transfer rates were high though and, although this is consistent with some other studies, it warrants further exploration.

In a related editorial, Professor Marc Kierse addresses those who may question the need for publicly funded homebirth programs, especially as only around half a per cent of Australian women currently choose homebirth, noting that, " It is a woman's prerogative and her fundamental human right to determine her reproductive behaviour, and this includes how and where to give birth. " (Kierse 2013: 575).

Women's experiences of planning home birth

I have had the privilege of working with Nadine Edwards for many years now, and Nadine's PhD research turned into a book: Birthing Autonomy: Women's Experiences of Planning Home Births: Women's Experiences of Home Births.

Nadine undertook research in which she talked to thirty Scottish women about their experiences of planning a home birth and her book explores the themes that arose within these woman's stories alongside some of the key issues, debates and tensions that exist in relation to modern maternity care.

I am especially fond of citing her work on how the women she talked to perceived notions such as risk and safety, which explores these concepts into a very different light from the way they are viewed by many birth attendants in the modern culture of the maternity services.

In fact, I wish that everybody involved in maternity care was made to read this book before they were allowed to practice, because in its entirety it provides one of the most compelling arguments for listening to women and ensuring that their care is woman-centred that I have ever read.

*****

In 2023, a systematic review of women's experiences of planning home birth in consultation with maternity care providers in middle to high-income countries (Gillen et al 2023) also highlighted a number of key issues in this area, including that:

All women need accessible evidence-based information about planned home birth;

Women need to feel supported in their plans for home birth;

Women value the care of midwives when planning home birth;

Fully resourced home birth services should be a prioritised service. (Gillen et al 2023)

This is an important topic. We know that there is a significant discrepancy between what women want/are asking for, and the services they are told they can access.

This is particularly the case when it comes to midwifery care, out-of-hospital settings, and interventions that are low-tech, physiology-focused, and requested by the women themselves, such as water immersion.

We know that some women's desire to birth at home is rooted in previous poor experiences, and these researchers also found that, "Women's prior traumatic experience of hospital birth and a preference for physiological birth motivated their assertive decision to have a planned home birth despite criticisms and stigmatisation from their social circle and some maternity care providers."

The study also showed that, "Midwives' competence and support enhanced women's confidence and positive experiences of planning a home birth."

What about freebirth?

Several studies also look at how, when home birth isn't made available by the maternity services, some women will decide to freebirth instead. This highlights how important it is that homebirth is offered. It's important to know that the studies cited on this page showing that homebirth is safe are looking at planned home births attended by midwives.

But I know that people are also interested in freebirth, so here are some recent papers.

An Australian study is beautifully described by its title. Birthing outside the system: the motivation behind the choice to freebirth or have a homebirth with risk factors in Australia (Jackson et al 2020, also freely available).

"The core category was 'wanting the best and safest,' which describes what motivated the women to birth outside the system. The basic social process, which explains the journey women took as they pursued the best and safest, was 'finding a better way'. Women who gave birth outside the system in Australia had the countercultural belief that their knowledge about what was best and safest had greater authority than the socially accepted experts in maternity care. The women did not believe the rhetoric about the safety of hospitals and considered a biomedical approach towards birth to be the riskier birth option compared to giving birth outside the system. Previous birth experiences taught the women that hospital care was emotionally unsafe and that there was a possibility of further trauma if they returned to hospital. Giving birth outside the system presented the women with what they believed to be the opportunity to experience the best and safest circumstances for themselves and their babies." (Jackson et al 2020)

Another Australian survey of why women choose homebirth showed that, "if a midwife was not available, half of the respondents indicated they would give birth without a registered midwife (freebirth) or find an unregistered birthworker." (Sassine et al 2020). Unfortunately, this paper isn't freely available, but you can see the abstract here.

Homebirth and cost

There are lots of reasons to opt for a home birth. We know from research studies that home birth is both safe and satisfying, that it leads to fewer interventions, a higher chance of breastfeeding success, and helps to make confident parents.

A 2021 study from the USA also showed that it is also far more cost effective than hospital birth.

Anderson and Gilkison (2021) set out to estimate the cost of home birth in the USA and found that: "On the basis of a nationwide study, we estimate that the average cost of a home birth in the United States is USD 4650, which is significantly below existing cost estimates for an uncomplicated birth center or hospital birth." "Further, we find that each shift of one percent of births from hospitals to homes would represent an annual cost savings to society of at least USD 321 million."

No, it's not just about money.

But it makes you think.

Anderson, D.A.; Gilkison, G.M. The Cost of Home Birth in the United States. Int. J. Environ. Res. Public Health 2021, 18, 10361. https://doi.org/10.3390/ijerph181910361 The paper is freely available at https://www.mdpi.com/1660-4601/18/19/10361

How to find out more

I helped a colleague with putting the evidence on safety together for a book. Homebirth: Safe & Sacred.

It was written by American homebirth midwife Kim Osterholzer. The book's aim is to get information out to those who have questions in an affordable, readable format. It is written for a US audience, so some of the information about midwifery care is US-specific. But the stories and the evidence transcend national borders. You can find out more about the book here.

Articles

This site also contains other articles that might interest you if you're looking for information on home birth.

Home birth after caesarean

Home births - where are we heading?

Unexpected home birth: let's keep our shoelaces on...

Homebirth: Safe & Sacred

Further confirmation of home birth safety

How midwives make a difference when there's an emergency at home...

Home birth also safer for 'higher risk' women

If you'd like to know more about your options, or explore tools for decision making, I can help!

My book What's Right For Me? has been written to help women and families make the decisions that are right for them.

What's Right For Me?

Books to help you become informed and make the decisions that are right for you...

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Our home birth information hub - the latest research on the safety of home birth and links to Dr Sara Wickham's articles on this.

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Findings of the Birthplace Study and the NICE guidelines.

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NCT leaflet

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How to create a birth environment that will maximise your chances of having a straightforward birth.

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What makes for the perfect birth environment?

The perfect environment for giving birth is:

These five elements will help you to feel relaxed and secure. Your body can then release the hormone you need for labour to progress (oxytocin), and the hormones that will help you through labour (endorphins). If you feel safe and undisturbed, you will be able to focus on giving birth to your baby.

So whether you're planning to give birth at home, in a birth centre, or in hospital, take some time to think about how you will create these five elements.

How do I create my own perfect birth environment?

Plan what you will need with your birth partner. It will be his job to create that environment, and to protect it, once your labour has started. He'll be the guardian of your birth space, and your midwife can help him to adapt the birth room to meet your needs.

Create a nesting area
This may involve moving furniture around or softening the room with cushions and blankets. At home you can use the furniture as props. You could hold on to the kitchen surface and rock your way through a contraction. Or you may prefer to lean over the sofa and doze in between contractions. In hospital, you may choose to ask for any unnecessary technical equipment to be moved out of sight.

Make sure that the bed is pushed to the side of the room to reduce the chance of you lying flat on your back on it. Use mats, beanbags, cushions, blankets and a birth ball to make yourself comfortable. Remember that upright positions will help your labour to progress.

Adjust the heating and lighting
At home use candles, tea lights, dimmer switches and fairy lights to make soft, calm, ambient lighting. Whatever the season, you want to be comfortably warm, so keep out draughts, turn up the thermostat if you need to, or put the fire on.

However, it's always hot in hospitals! Use dimmer switches, if there are any, to adjust the lighting. You could take along battery-operated lights which you can buy from hardware or camping shops or garden centres. Some hospital units are better designed than others, but there will always be an anglepoise lamp. If all else fails, turn the lamp towards the wall and turn off overhead lighting to create a soft glow.

Shut the doors and draw the curtains

Don't be afraid to close doors or draw the curtains. Privacy is not just about being watched, it's also about being heard. You need to feel able to move around, make noise, and wear what's comfortable. Playing music may help you to feel more confident about making noise as well as filtering out other people's noise.

Have someone with you who you trust
Continuous support from someone you trust right from the start of labour will help your labour to progress. It will help you feel safe and protected. Your supporter could be your partner, a close friend or relative, or a doula. You could have two supporters lined up so that one can take over from the other as your labour progresses.

Keep chat to a minimum and turn off your mobile
Distractions can be useful, and laughter is good for you, particularly early on. However, as labour becomes more established, it will take more of your energy and concentration. During contractions you will need to focus on your breathing.

A ringing phone or constant text messages can intrude on your privacy, and even produce adrenaline. This can interfere with the hormone oxytocin which you need to give birth. If the room is dark, people will be quieter. People automatically drop their voice in a darker room. Likewise, playing soft music or ambient noise prevents people from getting nervous and talking to fill the silence.

Surround yourself with familiar smells
You can use essential oils to help your labour. Or you might prefer familiar, homely smells. Nuzzling into your partner's neck, or a pillow or throw from home, may work for you.

Cover any visible clocks
It can be useful to check in with the contractions every so often, but you don't want to count or time every one. If you measure labour in terms of the number of minutes or contractions, this is how it will pass.

You don't know how long labour will be, and time doesn't mean anything until afterwards. Try to focus on being in the moment. Endorphins will help with this, as they can alter your perception of time, which is perfect for labour!

Try to create the same sort of atmosphere as you would for a romantic night in. After all, oxytocin is the hormone of love and lactation, as well as labour. It helped you to fall in love with your partner and conceive your baby, and it will help you to bond with and breastfeed your baby after the birth, too.

Oxytocin and labour work best under the same conditions as when you make love. This is when you feel safe, secure, warm and undisturbed.

See our video on how to help your baby be born, or discover how other women stayed calm in labour.

References

Buckley SJ. 2002. Ecstatic birth. Mothering 111 mothering.com [Accessed April 2012]

Buckley SJ. 2004. Undisturbed birth - nature's hormonal blueprint for safety, ease and ecstasy. MIDIRS Midwifery Digest 14(2):203-9

Hodnett ED, Downe S, Walsh D, et al. 2010. Alternative versus conventional institutional settings for birth. Cochrane Database of Systematic Reviews (9): CD000012. onlinelibrary.wiley.com [pdf file, accessed April 2012]

Hodnett ED, Gates S, Hofmeyr GJ, et al. 2011. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews (2): CD003766. onlinelibrary.wiley.com [pdf file, accessed April 2012]

Kitzinger S. 2003 The new pregnancy and childbirth: Choices and challenges. 4th edition. London: Dorling Kindersley

Lothian JA. 2004. Do not disturb: the importance of privacy in labor. J Perinatal Ed 13(3):4-6

NCCWCH. 2007. Intrapartum care: care of healthy women and their babies during childbirth. National Collaborating Centre for Women's and Children's Health, Clinical guideline. London: RCOG Press. www.nice.org.uk [pdf file, accessed April 2012]

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Creating the perfect environment for giving birth

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The perfect environment for giving birth is: These five elements will help you to feel relaxed and secure. Your body can then release the hormone you need for labour to progress (oxytocin), and the hormones that will help you through labour (endorphins).

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A tool for finding out about and comparing the different types of birth venue.

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Find your local maternity units by searching for your postcode on the NHS maternity service .

How does the tool work

The interactive Where to give birth tool is designed to encourage women to think about where would be most suitable for them to give birth - be that at home, in a birth centre or in a hospital labour ward.

The recommendations of the tool are based on guidelines on place of birth from the National Institute for Health and Care Excellence (NICE), the results of the Birthplace Study from the British Medical Journal (2011) as well as considerations for women's personal preferences.

Results are only an indication of a birth setting that is suitable based on the details you submit to the tool. It does not constitute medical advice nor guarantee availability of your option. It's your responsibility to discuss your choice with healthcare professionals to find the right place for you to give birth.

Coronavirus and birthing options

The RCOG says, 'Maternity units everywhere are working around the clock right now to manage additional pressures and facilitate women's choices.'

Although, like all areas of the NHS, maternity services are being affected by the pandemic, it says maternity units are working to ensure services are provided in a way that is safe, with the necessary staffing levels and the ability to provide emergency care where necessary.

In some areas of the UK, Trusts and Boards had to pause their home birth service or close their midwife-led unit but most of these cases have now been reinstated. You will be told if this is not the case.

Pregnant women with suspected or confirmed coronavirus are being advised to give birth in a hospital obstetric unit for the safety of both mum and baby, even if they had been planning delivery at home or in a midwife-led centre.

This is so that the baby can be monitored using continuous electronic foetal monitoring, and your oxygen levels, temperature and respiratory rate can be monitored, too.

This kind of monitoring can only take place in an obstetric unit where doctors and midwives are both present.

It is also reported that women with symptomatic COVID-19 have an increased risk of caesarean birth, making it even more important that they give birth in an obstetric unit where prompt access to emergency care is available.

The RCOG says that women's birth plans should be followed as closely as possible and advises checking with your local maternity team as to what birthing options are available.

If you have chosen private antenatal care and to give birth in a private facility, contact them directly to see how coronavirus will impact you.

Page last updated 09/03/21. Please check out Royal College of Obstetricians and Gynaecologists for any more recent updates.

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Find your local maternity units by searching for your postcode on the NHS maternity service . The interactive Where to give birth tool is designed to encourage women to think about where would be most suitable for them to give birth - be that at home, in a birth centre or in a hospital labour ward.

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Practical changes you can make to adapt a clinical hospital room to make it into a better birth environment.

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Information from the NHS on making the decision about where to birth your baby.

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Choosing your birth location

You can give birth at home, in a unit run by midwives (a midwifery unit or birth centre) or in hospital.

Your options about where to have your baby will depend on your needs, risks and, to some extent, on where you live.

If you're healthy and have no complications ("low risk") you could consider any of these birth locations. For women with some medical conditions, it's safest to give birth in hospital, where specialists are available. This is in case you need treatment during labour.

Women who give birth at home or in a unit run by midwives are less likely to need assistance such as forceps or ventouse (sometimes called instrumental delivery).

Wherever you choose, the place should feel right for you. You can change your mind at any point in your pregnancy.

Find out what's in your area

Your midwife will discuss the options available in your area but, if you're willing to travel, you're free to choose any maternity services.

As well as from your midwife, you can get information from:

You may also want to get advice from your friends and family.

Talk to your midwife about going to have a look around the local maternity services, and ask questions if you don't understand something or think you need to know more.

Home birth

If you have a straightforward pregnancy, and both you and the baby are well, you might choose to give birth at home. In England and Wales, just over 1 in 50 pregnant women give birth at home.

Giving birth is generally safe wherever you choose to have your baby.

But for women having their first baby, home birth slightly increases the risk of serious problems for the baby - including death or issues that might affect the baby's quality of life - from 5 in 1,000 for a hospital birth to 9 in 1,000 for a home birth.

For women having their second or subsequent baby, a planned home birth is as safe as having your baby in hospital or a midwife-led unit.

It's rare but, if something goes seriously wrong during your labour at home, it could be worse for you or your baby than if you were in hospital with access to specialised care.

If you give birth at home, you'll be supported by a midwife who will be with you while you're in labour. If you need any help or your labour is not progressing as well as it should, your midwife will make arrangements for you to go to hospital.

Advantages of home birth

The advantages of giving birth at home include:

being in familiar surroundings, where you may feel more relaxed and better able to cope

not having to interrupt your labour to go into hospital

not needing to leave your other children, if you have any

not having to be separated from your partner after the birth

increased likelihood of being looked after by a midwife you have got to know during your pregnancy

lower likelihood of having an intervention, such as forceps or ventouse, than women giving birth in hospital

Considerations

There are some things you should think about if you're considering a home birth.

You may need to transfer to a hospital if there are complications. The Birthplace study found that 45 out of 100 women having their first baby were transferred to hospital, compared with only 12 out of 100 women having their second or subsequent baby.

Epidurals are not available at home, but you can use gas and air, a warm bath, a birth pool, TENS and any relaxation techniques you've learned. Find out about pain relief in labour.

Your doctor or midwife may recommend you give birth in hospital - for example, if you're expecting twins or if your baby is lying feet first (breech). Your midwife or doctor will explain why they think a hospital birth is safer for you and your baby.

If you choose to give birth at home or in a unit run by midwives, you should be given information by your midwife or GP about what would happen if you had to be transferred to hospital during labour and how long this would take.

Planning a home birth

Ask your midwife whether a home birth is suitable for you and your baby.

If it is, your midwife will arrange for members of the midwifery team to help and support you. Here are some questions you might want to ask:

how long would it take if I needed to be transferred to hospital?

which hospital would I be transferred to?

would a midwife be with me all the time?

how do I obtain a birthing pool?

Midwifery units or birth centres

Midwifery units or birth centres are more comfortable and homely than a maternity unit in a hospital. They can be:

part of a hospital maternity unit, where pregnancy (obstetric), newborn (neonatal) and anaesthetic care is available

separate from a hospital, and without immediate obstetric, neonatal or anaesthetic care

Advantages of a midwifery unit or birth centre

The advantages of giving birth at a midwifery unit include:

being in surroundings where you may feel more relaxed and better able to cope with labour

being more likely to be looked after by a midwife you have got to know during your pregnancy

the unit potentially being much nearer your home, making it easier for people to visit

lower likelihood of having an intervention such as forceps or ventouse than women giving birth in hospital

Considerations

There are some things to think about if you're considering giving birth in a midwifery unit or birth centre.

You may need to be transferred to a hospital if there are any complications. The Birthplace study found that approximately 4 in 10 women having their first baby in a midwifery unit or birth centre were transferred to hospital, compared with approximately 1 in 10 women having their second or subsequent baby.

In a unit that's completely separate from a hospital, you won't be able to have certain kinds of pain relief, such as an epidural. Ask your midwife whether the unit or centre is part of a hospital or completely separate.

Your doctor or midwife may feel it's safer for you to give birth in hospital

Planning a birth in a midwifery unit or birth centre

Ask your midwife if there are any midwifery units or birth centres in your area. There may be others you can use if you're prepared to travel.

Read some useful questions to ask.

Hospital birth

Most women give birth in an NHS hospital maternity unit. If you choose to give birth in hospital, you'll be looked after by midwives, but doctors will be available if you need their help.

You'll still have choices about the kind of care you want. Your midwives and doctors will provide information about what your hospital can offer.

Advantages of hospital birth

The advantages of giving birth in hospital include:

direct access to obstetricians if your labour becomes complicated

direct access to anaesthetists, who give epidurals and general anaesthetics

there will be specialists in newborn care (neonatologists) and a special care baby unit if there are any problems with your baby

Considerations

There are some things you should think about if you're considering a hospital birth:

you may go home directly from the labour ward or you may be moved to a postnatal ward

in hospital, you may be looked after by a different midwife from the one who looked after you during your pregnancy

women giving birth in hospital are more likely to have an epidural, episiotomy, or a forceps or ventouse delivery

Planning a hospital birth

Your midwife can help you decide which hospital feels right for you. If there's more than one hospital in your area, you can choose which one to go to. Find out more about the care provided in each so you can decide which will suit you best.

Birth questions to ask

Here are some questions you might want to ask if you're considering having your baby in a midwifery unit or birth centre, or in hospital:

Are tours of the maternity facilities available before the birth?

When can I discuss my birth plan?

Are TENS machines available for pain relief or do I need to hire one?

What equipment is available - for example mats, a birthing chair or bean bags?

Are there birthing pools?

Are fathers, close relatives or friends welcome in the delivery room?

Are they ever asked to leave the room - if so, why?

Can I move around in labour and find my own position for the birth?

What is the policy on induction, pain relief and routine monitoring?

Are epidurals available?

How soon can I go home after the birth?

What services are provided for premature or sick babies?

Who will help me to breastfeed my baby?

Who will help me if I choose to formula feed?

Are babies with their mothers all the time or is there a separate nursery?

Are there any special rules about visiting?

How long would it take if I needed to be transferred to hospital from a birth centre?

Which hospital would I be transferred to?

Would a midwife be with me all the time?

Wherever you decide to give birth, you can change your mind at any stage of pregnancy. Talk to your midwife if there's anything you're not sure or want to know more about.

Further information

Which? Birth Choice can help you think about the right birth place for you.

Healthtalk.org has women's experiences of thinking about where and how to give birth.

Your choice - where to have your baby

Two NHS guides - one for people having their first baby and one for people who have had a baby before - are available to explain what birth choices you have and the research that may help you make a decision:

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You can give birth at home, in a unit run by midwives (a midwifery unit or birth centre) or in hospital. Your options about where to have your baby will depend on your needs, risks and, to some extent, on where you live.