Today is the day, you have reached 8 weeks of pregnancy and its time to book in with your midwifery care provider.
The midwife greets you then the questions commence. After stating your name, address, medical history and your last period date, she then drops the big question; “Where would you like to give birth?” You look up blankly, “I have no idea, what do you think?” Your partner then stops his '40 winks' and pops his head up and gets involved "Well, in a hospital surely, this is our first baby after all?" After you tut, roll your eyes and a give him a sharp digging in the ribs, you await the proper professional advice... Yes, you have choices, have you actually thought about where you would like to give birth and why? You have a few months to decide but there are a few things you should know…
As a midwife, I provide care to women throughout the child birthing process and beyond; providing evidenced-based information to a couple in order to assist them in their decision-making processes.
I fully believe that good birth preparation is key however birth, of course, has its own agenda and does not always happen the way we had envisaged it. With this in mind some women feel that maybe they should not ‘plan’ towards their birth experience as birth itself cannot be ‘planned’, but having knowledge of your choices, your body, the process of normal birth, and the interventions that may be offered if needed; will only but enhance your experience further.
Achieving a normal birth for the majority of women and ‘normalising’ the process of birth for all regardless of the type of labour and birth they experience, is paramount. The birth environment and the care providers during this intimate and somewhat challenging time can vastly effect this natural physiological process and impact greatly on the outcomes of birthing.
So to the question, where should I give birth and why?
Most women would prefer to give birth physiologically and for most this is the safest way, ensuring optimal outcomes for all women and their babies. Attention must be paid to providing a supportive and comfortable environment to all women in labour. Relaxation and security are key to this.
Normal birth is defined as without induction, cesarean section, instrumental delivery or episiotomy but includes epidurals and other anesthetics. The voluntary organisation Birth Choice UK shows current National statistics for achieving ‘Normal Birth’ as being 45%.
In 2010-2011 Normal birth rates for 1st-time mums were 34%. Almost 2/3rd's of women having 1st babies had medical interventions of some kind. For 2nd babies, the normal birth rate was 49%. In total around 60% of Low-Risk women achieve a normal birth.
The Birth Place Study, 2011 was a research programme designed to compare outcomes for birth in different settings for healthy women with a straightforward pregnancy. The results were analysed according to where the birth was planned at the start of labour care. It concluded that birth is generally very safe for healthy women with low-risk pregnancies and those adverse outcomes for babies are rare regardless of where a mother gives birth (4-5 in1000 needing assistance/serious or potentially serious, but are rare).
It was also clearly revealed that when planning a home birth women were significantly less likely to have an episiotomy, Forceps, Ventose or a Cesarean Section and thus significantly more likely to achieve a normal birth. Statistics highlighted showed that 88% of planned home births are normal births whereas only 60% of planned hospital births (In an Obstetric Unit) are normal births.
For a 1st baby where mum is planning a home birth, the risks for their baby is increased slightly in that 9.3 in1000 will have an adverse outcome compared to 5.3 in 1000 born in a hospital.
The rate of transfer to a hospital in 1st-time mothers also rises when planning a home birth although transfers are one reason why planned home birth is deemed as safe as they are, as transfers are easily arranged and achieved in a timely manner.
Overall The Birth Place Study supports women with healthy pregnancies (Low Risk) to have free choice of place of birth depending on where they feel more comfortable.
Continuity of carer is also an important issue to be explored and has been at the centre of maternity policy since 1993 with the publication of Changing Childbirth, 1993 (ref below). It is deemed as the ‘Gold Standard’ that each woman has a named midwife who is responsible for offering individualised one to one care throughout the child birthing process. Indeed a substantial body of evidence now exists showing that care provided by midwives in a one to one model (Continuity of Care Models) contribute to high-quality safe care, and significant benefits for both mother and her baby (Sandal et al, 2013).
As you may recall the offer of one to one care throughout labour experience was a big part of the Labour candidates promises during the General Election campaign “Women to be guaranteed one to one care during birth…” “Call The Midwife shouldn’t just be a part of a TV Program from the past but part of our NHS future too…” (April 2015, Labour Party Campaign Statement). However evidence suggests that a large number of women, 1 in 4, have reported being left alone and worried during labour or birth and that currently 1 in 5 maternity units do not provide one to one care. Why?
Well providing such quality of care would mean recruiting many more midwives. The Royal College of Midwives (RCM, 2015) suggest around 3000 more midwives are needed. This would obviously be very costly to local Trusts (Hospitals) but on the flip side might there be less intervention; fewer cases of perceived negligence; and ultimately much less trauma experienced by women, their partners, their babies and even by the staff?
NICE (National Institution for Clinical Excellence) also state that one to one care could result in the higher take-up of breastfeeding and a reduction in Postnatal Depression. All incentive enough, surely? NICE goes on to therefore recommend one to one care as a model for care for ALL women and that women in established labour should receive such care to ensure safe care for all (NICE, 2015). This has all been a Hot Topic in recent years following the Francis Enquiry and the Berwick Report which highlighted the serious consequences of care falling short of expectations. Both raised issues with staffing levels: “The care women receive from her first visit to her midwife through to the final postnatal visit will have a lasting impact on a woman’s well being and the health of her baby” (NICE, 2015).
In conclusion, ALL first time mums who are deemed as healthy and low risk should be advised that they are particularly suited to planning a home birth as the rate of intervention is lower, the outcome for the baby is no different than in hospital, and that one to one care can then be provided which is deemed as optimal for best outcomes. But we must explain that if they plan to birth at home there is a small increase in the risk of adverse outcomes for their baby.
So, my strong advice is to explore your options, look at the evidence, ask questions, have confidence in your decisions and ultimately birth where you feel most confident. For some of you, a hospital will be the right place for you to birth, for others, the comfort and safety of your own home are what you most desire. Be empowered in your decision, this is your body, your birth and your baby.
You will undoubtedly still have many questions after further research and discussion, feel free to get in touch with your care provider to talk through your options.
Ps. If you would like to look a little further at the research and statements I have included above, please click on these links where underlined. No link available for Changing Childbirth, reference as follows;
Department of Health (1993). Changing childbirth. Part 1: report of the Expert Maternity Group. London: HMSO.