HOME BIRTH Ken Burke, Swindon/Bath GP Registrar DRC 8 Nov 2006

Brief history Hospital births became more popular at the turn of the last century (middle class women turned to doctors for maternity care; more resources for poorer mothers). Doctors felt that the falling rates of maternal mortality due to this shift. In 1980’s <1% UK births were at home

Current data from “Birth Choices” website:

Home Birth Rates For The Southwestern Region Local AuthorityAll Birth (2004) UK %2.06% England %2.18% Bristol %3.6% Devon %5.8% Gloucestershire %2.2%

Home birth rates (as %) Somerset 8652 (all births 2004) 4.2% (2004) 3.7% (2003) Bath and North East Somerset %6.1%

Home birth rates (as %) Wiltshire 7159 (all births 2004) 2.3% (2004) 2.2% (2003) Salisbury % Swindon %0.6%

Why do women choose home birth? Labour tends to progress well at home Mother more relaxed, “in control” Greater privacy One-to-one care with a midwife who she knows Less “interventions” Less failure to progress, foetal distress Less infection risk

Safety of home births BMJ editorial 1996: home birth was “safe for normal, low risk women, with adequate infrastructure and support” Large prospective study in North America pub in BMJ in 2005 concluded that such births were associated with “similar intrapartum and neonatal mortality to that of low risk hospital births”

Outcomes of planned home births with certified professional midwives BMJ 2005;330:1316 Of the population of 5418, 12.1% needed transfer to hospital (main reasons were failure to progress, pain relief, exhaustion and malpresentation)

Intervention rates for home births Intervention% intended home births % >=37/40 USA births in 2000 Induction of labour9.6%21% Episiotomy2.1%33.0% Forceps1.0%2.2% Vacuum0.6%5.2% Caesar3.7%19.0%

Outcomes Intrapartum and neonatal mortality 1.7 per 1000 (=14 deaths in total) - consistent with rates for low risk births in American hospitals Of 80 planned breeches at home, 2 intrapartum deaths

Perinatal death associated with planned home birth in Australia: population based study (BMJ 1998) Included both high and low risk pregnancies Perinatal death rate of 7.1 per % deaths associated with intrapartum asphyxia Main contributors to the excess mortality were underestimation of the risks associated with post-term birth, twin pregnancy and breech presentation, and a lack of response to foetal distress Most midwives relatively inexperienced Transfer distances can be much greater

How many women want to have a home birth? 16% women would consider a home birth (MORI poll) Interest is higher in areas where home birth is seen as a realistic option and where women know others who have given birth at home

A woman’s right to a home birth The NSF for Children, Young People and Maternity Services (2004) states that women should be able “to choose the most appropriate place to give birth from a range of local options including home birth and delivery in midwife-led units”. The NCT supports the Government’s aim.

However…. Midwifery staffing constraints continue to restrict access to home birth as an option for women. A health authority cannot be forced by law to provide a home birth service; however, it is legally obliged to provide emergency care at home.

Many women are not aware that home birth is an option Joint statement between RCGP and RCM (in 1995): “Women wishing to arrange a home birth should be able to do so. GPs who do not wish to provide care for home births should refer women to a local midwife or the local supervisor of midwives (or to a GP who does provide full maternity care).”

There is less need for pain relief TENS, birth pools and massage are popular Woman can choose any position she wants Entonox and pethidine are also used.

Transfer to hospital About 3 in 10 for primips; 1 in 12 for multips Usually for slow progress or long labour Transfers rarely “blue light” 1 in 30 chance of transfer after birth

Cost Home births cost less – less use of hospital facilities, less medical interventions

Quote from BMJ editorial (1996) “Assessing a woman's risk and providing appropriate care is bread and butter to general practitioners. The key to the consistently good results of home births in Dutch primary care settings is meticulous selection of women at low risk of obstetric complications. This results in equal or better obstetric outcome compared with hospital birth”

NICE guidance on antenatal care – women needing additional care In conditions such as hypertension, cardiac or renal disease, endocrine, psychiatric, or haematological disorders, epilepsy, diabetes, autoimmune diseases, cancer, HIV Age >40 or <18 BMI >36 or <18 Previous Caesar Severe pre-eclampsia Previous pre-eclampsia

Continued… >2 miscarriages Previous preterm birth or mid-trimester loss Previous psychiatric illness Previous neonatal death or stillbirth Previous baby with congenital abnormality Previous SGA or large for gestational age baby Family history of genetic disorder

Conclusion Home birth is a safe option for low risk pregnancies However, diversion of resources to hospital care and poor promotion of home birth in most areas is likely to mean most women will continue to ask for hospital births in the near future