Home births have dominated the UK media today, following the publication of guidance by the National Institute for Health and Care Excellence (NICE) on the care of healthy women and their babies during childbirth. The main talking point was the recommendation that women thought to have a low risk of pregnancy complications would be better served by giving birth at home or at a midwife-led unit, rather than at hospital.
NICE has reviewed the evidence for the vast majority of pregnant women in England and Wales who have healthy, uncomplicated pregnancies. The rate of interventions, such as the use of forceps or a caesarean section, in these low-risk women are generally slightly lower in the home or midwife-led units, compared with hospital-based maternity wards.
For women having their second or subsequent baby, a birth in either the home or a midwife-led unit are equally safe options. However, for low-risk first-time mothers, the midwife-led unit may be the best choice.
No woman will be “forced” to give birth at home or a midwife-led unit. NICE advises that all low-risk women should be free to choose their birth setting, and be supported in this choice.
This new guidance focuses on the care of healthy women with uncomplicated pregnancies and low risk of complications. This represents the majority of pregnant women and childbirth in this country.
According to NICE, about 700,000 women give birth in England and Wales each year, around 40% of whom are having their first baby. The majority of these women will have a straightforward pregnancy and birth – around 90% giving birth at full term (over 37 weeks of pregnancy) to a single baby who is presenting head first. Around two-thirds of women will also go into labour spontaneously (without needing to be induced).
Media reaction to the guidelines has been mixed. Some news organisations, such as The Guardian, have been broadly supportive, emphasising the benefits of home or midwife-led unit births, such as a lower risk of interventions, which include caesarean sections. Others, such as the Daily Mirror, have taken a more negative tone, implying that the guidelines have been influenced by concerns that some hospitals are under-resourced or are unsafe to handle cases of labour.
Claims by the Mail Online that “new rules” have been introduced are also misleading. As mentioned, all women will have the choice of where they want to give birth.
NICE has compared the outcomes for “low-risk” women giving birth in four different settings: the standard hospital maternity (obstetric) unit, alongside midwifery units (separate midwife-led units alongside an obstetric unit), a freestanding midwifery unit and birth at home.
When looking at rates per 1,000 women, they found that most outcomes were generally similar or slightly better in the home, compared to the hospital setting. Results included the following:
When looking at outcomes for the baby, there was no difference in rates of complications between birth settings for babies born to multiparous women:
For babies born to first-time mothers, there were four extra babies born with serious medical problems:
Therefore, birth in a hospital obstetric unit is generally associated with slightly higher rates of interventions and lower rates of spontaneous vaginal birth, compared to the other settings. While a number of possible reasons for the slightly higher rate of interventions in hospital have been discussed (such as women finding the hospital setting more stressful), none have been proven. Further research is therefore required.
For multiparous women, either at home or a in midwife-led unit are equally safe. However, for low-risk first-time mothers, the finding that four extra babies per 1,000 are born with serious medical problems with home births compared to other settings suggests that the midwife-led unit may be the best option for them.
A summary of the main guideline recommendations in terms of patient care, on place of birth, are as follows:
NICE concludes that for low-risk women, whether having their first or subsequent baby, birth is generally very safe for both mother and baby, and they should be free to choose any of the four birth settings and be supported in their choice.
As their findings suggest, it is important that the woman is able to make a fully informed decision, by being given all the relevant information about birth in the different settings – including, as Professor Mark Baker of NICE states: “Where and how a woman gives birth to her baby can be hugely important to her. Although women with complicated pregnancies will still need a doctor, there is no reason why women at low risk of complications during labour should not have their baby in an environment in which they feel most comfortable.” He suggests that the new guidance “will encourage greater choice in these decisions and ensure the best outcomes for both mother and baby”.
As Susan Bewley, Professor of Complex Obstetrics at King’s College London, importantly highlights, women should not feel pressured into giving birth outside of a hospital if this is not their preference: “If a woman would prefer to have her baby in a hospital because it makes her feel ‘safer’, that is also her right. Giving birth is a highly personal experience and there is no ‘one size fits all’ model that suits all women.
“What’s important is that women and their families are given the most up-to-date information based on the best available evidence, so that they can make an informed decision about where the mother gives birth to her child.”