“Wow, you’re brave”, she winced at me. Nine pounds? Really? Just gas and air? I didn’t tell her that the majority of my 11 hour labour didn’t even feature entonox – I blew through two canisters in two hours and the final twenty minutes were pure agony – unsullied by analgesic euphoria and only augmented by the most primal, elephantine trumpeting.
I’m not going to lie. Physiological birth – with just warm water and short-acting entonox- is a full body workout. Coping with contractions involves an iron will, steel core backbone and an unshakeable faith in the countless birthing ancestors we have descended from. After all, you and I – and everyone we know – have all come from a long line of women who successfully birthed their children. Even if, sadly, they didn’t survive the process themselves.
Giving birth at home was something I’d wanted since after my first was born in 2016 and I had a tough birth. Sadly, my second child was breech and I was taken to hospital gravely ill from a pulmonary embolism that kept me in the high dependency unit for about 10 days at 35 weeks’ pregnant. Now I’ve had my third child in a pool, at home, I realise that it would have been far tougher were I struggling to breathe, too. So I don’t regret the caesarean that I had with my middle child.
Home birth was common, expected and usual when my parents were born in the 1950s. My father was born at home, as were all three of his siblings. However, birth became increasingly medicalised between 1965 and 1975 when home births fell below 5%, a rate that has remained stable ever since, according to historyandpolicy.org, having dropped from around a third of all births being at home from the late-1940s to the mid-1960s.
The blame for the reduction in home birth rates is controversial – some point towards a view that hospital birth is safer, whilst others indicate that higher birth rates and the growing number of “high risk” pregnancies is the reason for a greater need for hospital deliveries.
The National Health Service was introduced in 1948 and its inception meant a huge turning point in maternity services. Whilst infant mortality rates had reduced from 170 deaths per 1,000 live births in 1900, to less than 35 deaths per 10,000 births by 1948, maternal mortality rates rose between the same period to 40 deaths per 10,000.
In 1956, the Guillebaud inquiry suggested a full review of maternity services was required. The Earl of Cranbrook was appointed by Anthony Eden to investigate what was called “a state of confusion” in maternity services and his appointment resulted in the Cranbrook report. The report suggested a target of 70% of births occurring in a hospital setting was desirable, with the remaining 30% to take place at home. However, due to improvements in obstetric knowledge and new methods to pick up potential birth difficulties, the medical establishment debate raged on – and continues to, to this day.
The Maternity and Midwifery Advisory Committee met in 1967 and those proceedings heralded the publication of the Peel report, which recommended that 100% of births should occur in a hospital setting. Slammed for a lack of evidence to support this recommendation, nonetheless, its publication lead to a massive reduction in the rates of home birth. It was only during WWII that hospital birth became the norm. By the time the clock ticked midnight into 1975, 95% of births happened in a hospital.
So what’s safest?
Many of my contemporaries having babies (I am now 35 and have had three children in 2016, 2018 and 2020) very much see hospital birth as the norm and home birth as essentially a risky thing. Admittedly, when I was pregnant with my first, the idea of giving birth at home never even crossed my mind. As I was a “high risk” pregnancy, due to my high BMI, it was never even presented as an option. By the time I was pregnant with my second, however, the trauma of the first birth lent itself to my husband and I loving the idea of home birth. In early pregnancy, I dedicated myself to learning more about home birth. I thought I knew it was more risky, but having struggled mentally during labour with baby 1, I thought it was worth the risk. So I decided to look into it more. What I discovered surprised me.
How safe is any home birth?
The evidence is clear. Home birth is not only safe – it is, in some cases, safer for the majority of women. The reduction in interventions (and therefore the risk of iatrogenic harm) is a major selling point in favour of home birth. When you think about the differences between the two settings, it’s hardly a surprise. When our pets are pregnant and about to give birth, they don’t travel away from their sanctuary – they hole up in a warm, dark space – usually a wardrobe or under their owner’s bed – and give birth somewhere they feel safe and protected.
Giving birth under fluorescent tubes, with people you’ve never met, milling about and putting pressure on you, lest you “fail to progress” is so against the nature of physiological birth, it’s no wonder hospital birth results in more interventions. My own first labour was augmented with syntocinon – synthetic oxytocin – presumably because stress caused my contractions to slow down. After the shift change of midwives, I started to lose energy and momentum. I was also stressed by being prevented from eating (I had gestational diabetes and had thrown up my dinner from the night before after being a little too liberal with wonderful entonox). I did all I was told during that labour – from having an epidural as a matter of course (in case my fat body couldn’t give birth naturally and I’d need a caesarean, they said) to readily agreeing to induction because of the gestational diabetes, I simply toed the line entirely.
Unfortunately “doing as you’re told” isn’t always the protective act you’d hope when it comes to labour and birth, though. Whilst I avoided induction, as my daughter decided to come at 39w gestation, the rest of it was not as beautiful an experience as I’d hoped. Whilst I narrowly avoided an emergency caesarean, I did beg for an episiotomy as I was so exhausted. The midwives encouraged me to “birth the baby before the doctor comes” but I wasn’t really interested in a competition. Nor was I all that interested in the end result of the labour by that point: I simply wanted it all to be over. Which wasn’t the way I’d imagined I’d feel about my daughter’s birth at all.
The evidence: explored
According to The Lancet, which published a systematic review and meta-analysis in 2018, just four months after my hoped for home birth had resulted in caesarean:
“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[…]
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.”
Indeed the Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study, 2011, concluded the following: “Women planning birth in a midwifery unit and multiparous women planning birth at home experience fewer interventions than those planning birth in an obstetric unit with no impact on perinatal outcomes.” In 2015, a study, known as the Perinatal and maternal outcomes in planned home and obstetric unit births in women at ‘higher risk’ of complications: secondary analysis of the Birthplace national prospective cohort study concluded “The babies of ‘higher risk’ women who plan birth in an OU appear more likely to be admitted to neonatal care than those whose mothers plan birth at home, but it is unclear if this reflects a real difference in morbidity.
How safe is a home birth during a pandemic?
Many home birth services were suspended at the height of the first wave of the Coronavirus pandemic: the main reason being that paramedics were unable to provide category 1 (the highest emergency level) support for those giving birth at home. There were also concerns about sending midwives into a home setting with respect to distancing from other members of the household and the extended amount of time that the requisite two midwives would have to spend potentially exposed to Coronavirus in any asymptomatic but infected household. The viral load on those midwives was a consideration all hospital trusts had to factor in.
However, there is no question that, when you purely look at the safety of a birthing dyad – mother and baby – it is quite clear that a home birth is safest for them. At a home birth you have just two midwives, the birthing person, the birth partner and any other members of the extended family, who can be asked to distance. This limits potential transmission to any of the family within the home. With Covid-19 restrictions on visiting, antenatal appointments, scans and attendance at birth (usually you must be in established labour – 6cm – before your chosen birth partner can join you) people having babies are struggling for support.
Midwives do have policies designed to protect themselves and can of course wear as high a level of PPE as they think is prudent, but given they are in someone else’s home, they may feel uncomfortable insisting that, for example, the birth partner wears a mask or that other occupants of the home may not be present. This all serves to make the environment more tense and thereby will affect the birthing family’s experience. It’s essential, then, that the midwives attending feel comfortable doing so. Their hospital trust have a duty of care to them, too, at least under the Health and Safety Act 1974, if not just morally and ethically.
What’s it like to have a home birth?
All in all, my home birth was a magical experience. I started having contractions as early as 22nd August but my son was not born until 11 September. We called out the midwives that first night and were close to calling several times again on various evenings until, on 10 September at around 8:30pm, the day after a stretch and sweep, my waters broke. Being that I was birthing at home “outside guidelines”, because it was after I’d had a caesarean, I was disheartened when the midwives decided that things were not progressing and that they would leave. Disheartened, I got back in my pool and was in a great deal of pain as the contractions continued. They came closer together and were even stronger than before so we called the midwives back a few hours later, after calling my parents to come and take care of our two, older children. Sienna, 4, and Rousseau, 2, were convinced there was a monster in the house after hearing my contraction-induced moaning and I was suddenly worried what would happen if I needed to transfer in for a repeat caesarean – having previously been convinced it wouldn’t be necessary, I was suddenly struggling with the pain. After so long of having what’s called prodromal labour, I was exhausted from constant contractions and the anxiety around the increase in Covid cases across the country was making me suspect home birth could again be suspended. That day I’d done an interview with local TV station, KMTV, talking about my fears about this very such problem.
In the end, Ares was indeed coming. The midwives returned with entonox and boy… was I glad to have it. So glad in fact that I blew through the remaining 1.5 tanks (I’d used half the first time they attended) and we were on. From waters breaking to Ares’ birth, at 7:30am, the whole labour was 11 hours. The most primal and intensive experience of my life, his birth put me firmly in control of my environment and my body. When I’d finally done all the work and he emerged, in my home, all I could shriek was “I did it!” “I made him and I did it!” I was truly elated and felt so very healed from the varied trauma of my first two births. I loved my body again and felt so connected to my own being that I felt the anxiety and historical grief melt away.
‘Advocating’ for the birth you want? It shouldn’t even be in our vocabulary
I had to advocate hard to get the birth I wanted – I had done so much research into home birth in preparation to birth my second child that I know everything I needed to about my rights and the NHS’ responsibilities to me under the law. Of course, we hadn’t factored in the suspension of home births across the UK due to an unprecedented pandemic – but I did know the (small) risks involved when wanting a home birth after caesarean (HBAC). It wasn’t long after my first son was extracted from me that I began reading about HBAC and I carefully scoured the literature for all the factors involved in successful vaginal birth after caesarean (VBAC) to inform my decision to birth my last child at home.
To sum up this weighty defence and advocation of birthing at home, the evidence is persuasive and significant. Historically, women have birthed in their own environment for far longer than they have within hospitals. Whilst I’m not against intervention, it’s hard to really know which interventions were truly necessary. The medical profession will always, of course, err on the side of caution. But survival of mother and baby alone is not the only marker of a good birth. So many of us play down our own traumatic births – and the horrendous experiences of others with “well at least baby is healthy. At least we made it.” Ares was born during Birth Trauma Awareness week (7-13 September 2020) and so many laid bare their traumatic experiences on social media that I felt almost guilty, despite my own history, that I’d had such a wonderful final birth. Logically, I knew I deserved to have a good birth – notwithstanding the historical trauma, everyone should have a good birth. That’s the point. Normalising birth trauma and brushing it off if everyone made it through alive is just unacceptable.
We can have better births and we should never underestimate the importance of informed consent, personal choice, bodily autonomy and sovereignty. Countless stories of obstetric coercion, abuse and violence under the blanket of “because Covid-19” are out there of late, from all over the world. One shouldn’t need to know the system inside out to be able to get a good birth. Once I had come down from the elation of my greatest birth of three, I realised something quite sad. I was celebrating not having been traumatised from the final birth I’ll ever have. Not to have been devastated by iatrogenic harm, discompassionate medical staff and a lack of postnatal care. I’d had a good birth. Sad really. It’s not much to ask for.
For more information on what improvements the NHS is making to maternity, a good place to start is: https://www.birthrights.org.uk/2020/01/30/idecide-a-new-consent-tool-is-on-its-way/ which talks about the development of a new tool to “help healthcare professionals to support women to make informed decisions in labour”. I hope to hear more about the project as it progresses as it sounds amazing.
AIMS is another good resource for anyone wanting to know more about their rights, get independent advice and get wise to all things better births – https://www.aims.org.uk
For social media support there are many Facebook groups. One of the largest is Home Birth Support Group UK – https://www.facebook.com/groups/homebirthsupportuk/ with 6k members
If you have a high BMI, it’s unfortunately likely that you may experience stigma, discrimination and even false information and barriers to the birth you want. If you need help with this, visit http://Bigbirthas.co.uk and the associated Facebook group https://www.facebook.com/groups/bigbirthaspsg/ run by the lovely – and helpful – Amber Marshall.
I used this group a lot for understanding facts and myths around birthing when I had a high BMI (around 46) in my first two pregnancies.
You can also read the weighty tome Better Births: Improving outcomes of Maternity Services in England at the NHS England website at https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf
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