Home births are irresponsible

[LadyShapes]

Did anyone see the start of Lorraine at about 8.30? They were talking about what's in the news and one of the stories was about how more women should have home births. The delighful guest they had on to talk about it said that she thought home births were irresponsible and dangerous. She also said she thought natural births were a load of rubbish and she just wanted to be in hospital and have medical intervention (paraphrasing). Oh and she wouldn't have a home birth because she has cream carpets. The other guest just agreed with her, so the that was the extent of the discussion.

Is it me? AIBU to think they shouldn't discuss news stories unless the guests have some kind of informed opinion (I mean, all the infomation I have had from my midwife tells me about the benefits of home births and a natural birth as well as the risks), or they should have read more than just the headline. Or AIBU to be watching Lorraine and hoping for some kind of balanced discussion.

Mitmoo, I agree with you too. I'm sure a home birth can be great for many people who actually wanted a home birth. But I'd hate to think that you could end up with a situation where low risk women were pressured into having a home birth, when they really wanted to go to hospital, as a cost cutting measure. As far as possible, women should have the choice of where and how they give birth.

What I am wondering is: do you think more people might want to go for ELCS so they are sure to go in hospital? As in people who really want to give birth in a hospital?
The thing that pisses me off is that actually MWs sort of guess the position of the baby and in some cases get it wrong. 3 people I know (inc self) were meant to be low risk but in fact had a breech baby and we all went for ECS. I wish they offered a late scan to all, just to check the position, rather than randomly say "yeah you're low risk, you can go to the MLU/ homebirth is fine".

spudulika

Re your response to The Netherlands has one the highest perinatal death rate in Europe and a high and rising rate of maternal mortality. Indeed, the Dutch have become so alarmed at the perinatal and neonatal death rates that the government has convened a variety of investigations to determine the cause

What you c&Ped and linked to is more or less what was suggested in the link I posted.

I think that is the point. When it comes to home birth and midwife led pregnancy care there would appear to a tipping point when you move beyond a small self selected group and make it the mainstream standard of care.

If the UK replicated the Dutch model how quickly would the massive increase in women of all backgrounds and personal circumstance having midwife led care and home birth translate to an increased difficulty in the ability to attribute "low risk" to a pregnancy, with a significant degree of accuracy ?

At what point would the currently teeny tiny number of tragic cases, that relate specifically to the logistics of getting a woman to hospital once time sensitive emergencies are evident, suddenly become statistically significant due to the rise in numbers of birth at home overall, leading to improved visibility\count-ability ?

Would it be necessary to have different standards in different areas ? For example in cities that are comparable to Rotterdam the NHC trust would be obliged to set up guidelines for a more conservative, pre-emptively medicalised form of pregnancy\birth care ?

Would that not set off an outcry given that not every women living in the same place carries the same degree of additional risk associated with that geographical area ?

I think the argument for mainstream, normalised home birth and midwife led pregnancy care suffers from the same limitation that elective c-sections on demand does. As long as it is small, self selecting group the additional risk factors are so small that there is no good reason to deny the choice.

But it seems to me that normalisation takes away the "protective" features of being a small, self selecting group when it comes to choice specific risk. To the extent that you reach a tipping point where the risk suddenly rises significantly and the pile of people who lost the ?low risk, but not no risk? gamble starts to grow at an alarming rate.

I think that happens in good part thanks to the increased difficulty of assessing individual risk in an atmosphere of pressure to conform to the vision of "normal" birth and the sheer weight of numbers carrying a whole new range of factors with them, that are less easy to identify without being extremely intrusive on a non medical level. Intrusive questioning leaves the service open to accusation of operating some kind of socio economic\cultural apartheid system of care among other criticism.

So perhaps the only possible answer to keep additional risk down when it comes to midwife led care and home birth for ALL, would be to increase the amount and level of supervision and testing for all women during pregnancy. Which could be very expensive and perhaps would not go down so well with the women who were pro home birth in the first place, because they did NOT want to be treated like a hugely risk laden pathology.

Perhaps the best solution for people who want home birth is to avoid it becoming mainstream with the result that is starts to employ the sort of anti-risk "management" techniques that they perceive as being one of the worst aspects of hospital managed care and birth.

I would like to see elective c-sections on demand, but I am loathe to participate in popularising or evangelising the choice cos it carries a comparable risk of tipping point to that of home birth IMO.

Okay - in my area they are trying to encourage more HB. I have no doubt this is beacause of money.

But what this means is that when you have your booking in app and they give you all the bumpf you also get a tiny flyer that says if you are a low-risk pregnancy and are interested in a HB, you can ring the HB team and speak to them about it.

That's it.

There is absolutely no pressure, no sales pitch.

I was interested, so I rang them, I had loads of questions and I was happy with the answers. If I hadn't been interested nothing would have been said at all.

I don't think spud was preaching actually, she has just been presenting some well researched facts about homebirth & I'm grateful for that after some of the anecdotes on this thread.

HB isn't for everyone but it is for some. I have never met a woman who didn't have her babies best interests at heart but some of the talk on here about women choosing homebirth for their nice experience regardless of the consequences for the baby is nothing more than reinforcing negative stereotypes.

I have only heard of one woman refusing a transfer after days of labour but that wasn't in this country.

And FWIW, of course there will be some
HB which don't work out well for mum or baby or both. That's a risk, all birth comes with risks. Same as hospital birth presents different risks for "low risk" mothers.**

We each weigh up the risks and the unique circumstances of our situation and make our decision don't we? Like Dita said, better to do that with the facts though and not based on anecdotes or someones belief.

My friend was a MW at a large hospital and said it became like an in-joke with her colleagues that a woman became high risk as soon as she walked onto labour ward. She said they had a culture of managing births (syntocinon, ventouse, purple pushing etc) because they were so short staffed they needed to get women out of Delivery suite quickly. I doubt HB had too much impact on labour ward pressures - only 3% of births happen at home anyway.

Shouldn't we be arguing for more NHS midwives and more choice for women?

**realise I have overused the word 'risk' apologies.

I have no doubt this is because of money

That is a valid consideration.

If I hadn't been interested nothing would have been said at all

People interested in savings would avoid being seen as forcing the issue. It is in their interests to be seen as reacting to public desire rather than creating it.
They are better off being seen as unbiased, to avoid suspicions and accusations of cost cutting being placed above access to health care setting in.

The pro home birth lobby can be relied upon to evangelise and popularise on their behalf. So why risk being seen as trying to push women into a choice thanks to economic consideration when the grass roots movement raises less suspicion, is far more persuasive due to their inherent passion for the choice, cover the expense of promotion and will get hit with the bulk of the backlash if the stats don't later pan out as they predicted ?

The health care system will need time to catch up and re-jig in response to a logistical change in demand for access to specific choices. So it makes sense to let the choice bubble up under the steam of growing popularity until it reaches critical mass.

And then, and only then, will the powers that be start to limit access to more medicalised health care UNLESS the woman can "prove" that she is high risk enough to deserve it. (Note the expat and Dutch women in Holland who have been forced to go to Flanders or elsewhere to give birth because their doc would not sanction the hospital birth they wanted)

You can tell from the above that I suffer terminal cynicism when it comes to our political overlords. Probably comes from living in Italy. Where it pays to be as cynical as humanly possible.

Fastweb, I think you make an excellent point, that one of the only ways to assess who is 'low risk' is to increase scanning and monitoring in pregnancy, thus re-medicalizing all of that.

You can't reduce the no of scans/monitoring as drastically as they have in the UK to save money (in a lot of countries, it's much more frequent), then make guesses about who is 'low risk'.

Personally, I don't consider any first birth low risk. My own experience and of all my friends (with the odd 2 hour exception) is that first births are often lengthy, require more pain relief and have that potential to just go wrong very easily.

My own preference is for more midwife-led centres next to hospitals, where I think you get the best of both worlds. I have been that home birth gone wrong, careering along in an ambulance with the light flashing, and it is a bit stressful although I was only taken in as a precation and went on to have a natural birth with only one brilliant midwife.

Hi Ladies, have read this thread with interest.

I had a fantastic homebirth with my first daughter 17 years ago - amazing. For my second I obviously opted for a homebirth and had a pool set up. My labour was very different, I remember thinking "this is way more painful than the first time" - but ploughed on regardless. I had two midwives and a student. At one point they had trouble finding baby's heartbeat - but only for a moment. At one point midwife did say that if I didn't progress that i may have to transfer - but very low level of concern. Eventually gave birth and baby was "back to back". He did not breathe and they tried to resus him on my living room floor - I knew that he was not going to live - instinctively. What ensued was a trauma of biblical proportions - my son and partner being rushed off in ambulance, me following in another ambulance. My 7 year old daughter was being shepherded around by my friend in order to shield her from what was happening. Nightmare.

Amazingly the A&E team managed to resus my son - but he was brain damaged and we had him for three days before withdrawing life support.

This was an terrible tragedy and I take full responsibility for what happened. I chose a homebirth, I was in control. In hindsight maybe I should have said, this feels different - but trusted the midwives - nobody knew he was back to back.

The pathologist said to me that birth is the most difficult journey a human being will make - and some don't make it. I accept this, I have to.

However, I am still an advocate for homebirth - and would never try to put someone off. All the medical proffs said that the outcome would most likely have been the same in hospital - but maybe they were just saying that. But really its about choice, respect and dignity and high quality care wherever you live.

I have had two ELCS since and they were amazing - but its not the same as giving birth naturally. It just isn't.

Thanks for reading.

fastweb
My understanding of the concern re. the Dutch study and its limited geographical was NOT that as the population increases so the number of problems become apparent. My understanding was that, when the population included in the study was analysed, it became apparent that a substantial number of women came from severely disadvantaged socio-economic groups - and one of the impacts of this was that a substantial number of women had had NO antenatal care at all. Receiving no antenatal care is acknowledged to increase risk (through increasing unknowns) for birth in any location. A substantial number of women also had a poor diet - again, a known risk factor for birth.
The criticism was that basing the study on a geographically limited population - and this geographically limited population in specific - gave a result that was perhaps more reflective of other shortcomings in maternity care rather than suggesting that home birth was, in and of itself, increasing the risks of birth.

Mitmoo
I do suspect that a drive to normalise birth is partly driven by cost. However, I do also believe that maternity services could be provided in a much more effective manner by utilising resources more efficiently.

There is a growing body of research to show that when you need expert medical care you are better off travelling further to a specialist centre where genuine experts in the field will be there 24/7 and can care for you rather than being taken to the nearest hospital. This article from the Independent discusses the some of the issues.

Many women, as has been shown in this thread, choose a hospital birth because they want to be near the experts "just in case". And yet once you get out of normal office hours, most "consultant led units" won't actually have a consultant on site - if your birth develops complications and you need help from an obstetrician you will almost certainly be seen by a junior member of the obstetric team, who may need to spend a significant period of time on the phone to their more senior colleague(s) as they don't have the personal experience to fall back on. This article (sorry for the source, I read it elsewhere but this is what google found me today) illustrates the point - your baby is 30% more likely to die if born out of office hours due to a lack of experienced staff on duty (and this came from a study that considered millions of births, so definitely shouldn't have suffered from small numbers)

Doesn't that suggest that the "safety net" of birth in a consultant-led unit is at least partially an illusion?

So what do we do? Given the financial constraints, do we really want to push for 24-hour cover by consultants in all existing maternity units? Are there even enough consultants to do that? Would we not be better off supporting a model that has the potential to be safer in addition to cheaper?

The concept of centralising specialist services is one that many people feel very strongly against - but that reaction can be ill-founded and based on a mistaken understanding of the facts.

I do, however, have deep concerns about how this can be implemented wrt maternity care. If you DO need/choose to go to a consultant led unit that is now further away, it is imperative IMO to ensure that women don't get sent home again once their there. So maybe a greater investment in community MWs to visit women at home who are in early labour to support them in that location and help determine the appropriate time to take themselves in. I also think it would be incredibly important to supply a middle ground (be it in the form of a MLU or otherwise) for women who do not want a full on HB but also do not want to travel to a specialist unit.

I was talking to an IM yesterday who remembers days when they had obstetric "flying squads" - I'm not sure they'd a CS in a community environment but the intention was to get obstetric support to births that had turned complicated rather than bring the births into hospital. Would that be worth considering again?

I know that its possible to argue that by centralising specialist care you'd be reducing choice - and that is something I'm very uneasy about. However, I also feel quite strongly that the system we have at the moment is on its knees and struggling. I suspect that hospital birth is less safe than people perceive it to be due to staffing issues. Something has to change. With the best will in the world, the money is not available to get more consultants, more anaesthetists, more MWs and more beds such that every woman does have a genuine free choice of going to a well equipped hospital within a 10 mile radius or being supported at home. (At least not unless we want to see more cuts in other areas)

So how do we best spend the money to try and make a significant improvement in the state of maternity care in the UK? I don't know what the answer is but I can see that its an incredibly difficult and emotive question to try and answer, and that there will be huge public resistance to some solutions - possibly for all the wrong reasons.

HairyFrotter
"Well I would want to look at ways to design labour suites and other ways to minimise the difference in home/hospital environment. It shouldn't be the case that women should have to be an ambulance ride away from emergency care should they need it."
I think that would be an improvement - but it still doesn't address the reasons why I personally would prefer to stay at home. For me, being in my own home is a fringe benefit. The real reasons are that being at home is the only way I can ensure that I'll have continuity of care through the entire pregnancy birth and post-natal period, and the only way I can ensure that I will have a MW giving me 1-to-1 care while I'm in labour. IMO, from my own experience and from the research I'ver read, both of those elements are fundamental to improving birth outcomes.

So sorry to hear about your terrible tragedy Raven.

Raven - I'm so sorry things went so badly wrong for you. Finding out my baby had died (and dealing with the aftermath) was probably the hardest thing I've ever had to do and I wish no-one else had been in a similar situation.

Dial M: That is the reality isn't it? Births by their very nature are unpredictable and the levels of care should be the mother's choice not a cost cutting measure.

Even with a hospital birth I had eclampsia, needed an emergency c-section, haeomoraged (eek sp) then spent a few days in intensive care. My SIL had a perfect pregnancy, birth going well initially then it all went pear shaped and the baby spent her first two weeks in intensive care.

It has cost cutting written all over it.

Oh Raven, how tragic and what a balanced view you give despite the outcome. Birth is so different for us all isnt it - some people give a few pushes and its over, some labour for days and days, we are bombarded with info, 'have a HB, I had one and it was fab', go to hospital, I had a friend who would have died if she had had a HM'. Have pain relief, dont have pain relief etc.

TBH - I think there is a place for both but lets not dreamily think that one overides the other

Mitmoo - to reiterate a point I made upthread, I've got very cynical about "I/my baby would have died if we'd not been in hospital" stories. I'm sure there are instances where it is true (and I'm not passing any form of judgement on you or your situation from the details you've given).

From talking to friends where I have been able to find out what happened, they have always started out with "we'd have died if we'd had a home birth" but common points turned out to be:

• they had high risk factors to start with so would have been at home against medical advice.
• they had inadequate care in hospital, which arguably caused the emergency situation that their presence in the hospital then "saved" them from.
• the problems developed over time, although they may not have been acted on until they had become an emergency situation.

In none of them was there an emergency situation that developed with no warning such that there would not have been time to transfer in.

To repeat - that is not to say that emergency situations cannot and do not develop fast, just that (from my experience) they do so a lot less often than anecdote would have you believe.

Tangle: Thank you for sharing your anecdotal evidence and to others who have shared some heartbreaking accounts.

I am sure however that you'd agree births can take a dangerous turn of events at no notice, without warning when immediate specialist intervention would be essential and this is by no means an extremely rare occurence?

Mitmoo
"I am sure however that you'd agree births can take a dangerous turn of events at no notice, without warning when immediate specialist intervention would be essential"
I completely agree with this.

"and this is by no means an extremely rare occurence?"
This is where I am less sure. All I can fall back on is two sources of information:

• Anecdotes where I know the full story, which indicates that a lot of situations later described as "shit hits fan" scenarios could have been prevented with better care and earlier intervention.

• Hard research from studies such as the National Birthday Trust Report, which found that in one year, out of 5,971 women who planned (ie were still intending a HB at 37 weeks, regardless of whether they changed their minds or needed to transfer during labour) a HB there were 5 stillbirths or neonatal deaths - the same number as experienced by the 4,724 comparable women who planned a hospital birth. A rate comparable to the national average at the time of the study, and a difference too small to be considered statistically significant.

Presumably, at least some of the 5 deaths in the planned HB group occurred after a transfer - suggesting that the rate of complete utter obstetric emergency is somewhere around 1/1,000 or 0.1% (although I accept that this doesn't consider babies who suffered survivable birth injuries, such as happened so tragically in Riven's case). Is 0.1% "extremely rare"?

I would dearly love to see some up to date research (based in the UK, as the systems in other countries can be so different as to make the results meaningless in a local context) that considers these issues. In a hospital setting I think it would be very useful to know many "emergencies" were preventable. Updating the National Birthday Trust Study would also be a valuable exercise as maternity practices in the last 20 years have changed - has that made the difference between home and hospital more pronounced, smaller or inverted the relationship?

Unless or until more research is done all we can do is refer to data that is old and bat around anecdotal information. Our personal perception of risk (both in an absolute sense and what we deem to be acceptable) will be highly dependent on our individual life experiences.

Ultimately I don't have strong views on where other women choose to have their babies (although as may have become apparent, I do have strong views about assumptions being presented as facts ). What I do feel strongly is that women should:

-have access to accurate and current data so that they can make a decision informed by facts rather than hearsay (and that includes hearsay provided by their HCPs, who should know better)

• to be supported once they have made an informed decision (and supported to review their decision should their circumstances change)
• to be able to labour and birth in a place where they feel safe
• to have support during labour from a HCP that they trust.

I have no complaints about DD birth, and this was in hospital. However, it was a very long labour, she was back to back, which resulted in an epidural and a ventouse delivery - I also had an episiotomy.

I recovered very quickly, and the MW's were lovely - the postnatal ward was vile though - rude staff (and under-staffed), and I hated the lack of privacy and was desperate to get home.

I am now 28 wks pg, after 4 mc's, with the baby I thought I'd never have - yet I still want a HB. I am hoping to be able to stay more relaxed, and enjoy the privacy of my own home, but I am more than willing to accept that I may end up in hospital.

After an initial shaky start from 1 MW, who was anti-HB (seemingly because she thought women get too disappointed if they can't have one), I have had another MW appointment today, and the MW was lovely - she was so positive, and said that she thought that it's the best place to have a baby (obviously, if you are able to or want to).

I do have some concerns about things going wrong - but I also have those concerns for a hospital birth too.

I just think that the choice is down to the individual, and people need to respect those choices and not make people feel bad/selfish/ill-informed for the decisions that they make.

Tangle

That is the point. Rotterdam is not the sole pocket of Europe where socio-econ and cultural elements have relevance when it comes to good outcomes of pregnancy and birth.

Do similarly deprived pockets of the UK for example share the same elevated maternal, perinatal and infant mortality figures ?

Could it be that, by making midwife led pregnancy care and home birth the norm people (including those at elevated risk) have started to devalue the need for and importance of some kind of medical oversight cos ?pregnancy is not a pathology, I?m fine??

Do the stats highlight that a more medicalised approach can significantly impact outcomes for the women whose social features place them at elevated risk, simply by being seen as the norm and influencing people?s willingness to participate in health care during their pregnancy ?

If we introduce the Dutch model of midwife led care and home birth countrywide how can we protect the women at elevated risk due to social factors from that additional risk ?

How do we identify them ?

How do we do that without more intrusive risk assessment that requires people to release greater amounts of social information to their care giver ?

How can you persuade people to participate in more intrusive risk assessment if the paradigm is one of ?birth is natural and does not require extraordinary medical involvement cos it is not a sickness? which may distort peoples? vision of their personal risks and the need for greater rather than lesser oversight and testing ?

Would it have to come down to taking maternal choice in pregnancy care and birth off the table in certain areas, in the name of playing a numbers game ?

How can we work out where the tipping point is between "self selected\micro culture" and "doing the normal thing, cos that is what you do", where outcomes start to look less healthy thanks to a lack of self selection and an increased population of participants ?

I am not anti home birth, I was born at home, my mum was singularly unimpressed by her later hospital birth with my sister in comparison to my own birth.

I want women to have a choice.

Not least cos I was given NONE when I gave birth and ?experience? is not a invalid factor to consider IMO. Took me years to get over the rage and sense of impotence I felt at having been forced to have a natural birth ?cos it is hospital policy?.

It also ensured that my son was deprived of any siblings, cos you'd have to threaten to fuck me backwards with a large spiky cactus before I?d consider giving birth again.

All the same I think this study has raised interesting questions that relate to the ?geo-social? impact of a normalised culture of home birth, rather than the purely logistical\medical aspects of home birth. I don?t think that ?Rotterdam being what it is? is necessarily a confounding factor to the point where the study becomes irrelevant, given that the social issues there do not exist in that one place in isolation.

fastweb - I think we're broadly agreeing :)

To me, though, the problem with the Rotterdam study is that it has been interpreted as "HB is not safe" - when that is not what it says. To me, it would be more accurate to say "Birth is more risky if the mother is malnourished and has received no antenatal care - regardless of the place of birth." Surely the solution is to improve antenatal care (and we're not talking having a 3rd scan in the 3rd trimester here, we're talking seeing a MW at any point during pregnancy) and making sure people know what a healthy diet is, know how to prepare one and have the means to be able to afford it. My recollection is that the groups in question were not well educated women enjoying a better than average lifestyle and consciously deciding their intuitive knowledge of their bodies was such that the "risks of intervention" in the form of standard antenatal care outweighed the benefits such care would supply - but that they were in some of the poorest socio-economic groups and were unable to access antenatal care, however much they might with to do so.

From what I know, most women who choose a HB in the UK tend to be from the opposite end of the socio-economic spectrum (more highly educated and higher income than average). I accept that there are some women in the UK who do turn their backs on antenatal care for exactly the reasons you give - but to my knowledge they are a very small minority and I'm very dubious that this is the root cause of the problem in Rotterdam.

I guess to me the issue is not "if we normalise HB too much people might start to think all antenatal care is unnecessary" so much as "if we normalise HB there is a risk that this might happen and so we need to maintain the public health message that good antenatal care is vital to a safe outcome in a home environment". Discouraging an increase in HB to try and prevent a problem that may not exist seems to be throwing the baby out with the bath water.

(Just to add, I can't find the articles I read before but my recollection is that the interpretation was that the women were not avoiding antenatal care through active choice but because it was either unavailable or hard to access - they hadn't made an active decision that they didn't "need" antenatal care as they weren't ill, they just didn't have the option to receive it in a practical manner. My comments are therefore coming from this starting point - if I've got that wrong then please point me at the appropriate data and I'll have a big rethink!)

"How can we work out where the tipping point is between "self selected\micro culture" and "doing the normal thing, cos that is what you do", where outcomes start to look less healthy thanks to a lack of self selection and an increased population of participants ?"
Arguably, this is exactly what has happened with hospital birth in the UK - it has become normalised and poor outcomes are increasing as the system cannot cope with the rising load

Being slightly less flippant, I don't think anyone here is saying that it would be good for the UK to reach a 50% HB rate, especially if that change was to come about purely as a cost cutting exercise. I do think that an increase in the HB rate would benefit women, babies and the NHS's budget - but it has to be through women choosing a HB, not because she is forced into one against her will.

What frustrates me and depresses me the most is experience's like your own - women (and babies) who suffer because they are ignored and belittled. Yes, of course everyone wants a birth to end with a healthy mum and a healthy baby but to me the mental health of the mother is an integral part of that and one that is too often ignored or trivialised.

"When it comes to home birth and midwife led pregnancy care there would appear to a tipping point when you move beyond a small self selected group and make it the mainstream standard of care"

Fastweb - you speak as if there is clear proof that the large number of mothers having their babies at home in the Netherlands is the primary cause of their higher perinatal death rate.

This is one study - criticised for its methodology - which links perinatal outcomes with the model of care.

And even the authors of the study have not concluded that home birth is not necessarily at the heart of the problem.

There are dozens of other studies from the Netherlands which don't find a link between poor neonatal outcomes and home birth, and certainly UK studies don't.

As for your comment about self-selecting groups. Yes, there is some truth in this. In particular women who give birth at home are more likely to be highly educated (not that - in my experience - this tends to have a positive effect on birth outcomes, actually the opposite I'd say........). As for age - they tend to be older than your average mother, though the National Birthday Trust study on which many of the current recommendations are based matched the groups for age, within 5 years.

"by making midwife led pregnancy care and home birth the norm people (including those at elevated risk) have started to devalue the need for and importance of some kind of medical oversight cos ?pregnancy is not a pathology, I?m fine??

Nothing would suggest that this is the case. Midwives - when they're doing their job well -are highly vigilant for signs that something isn't right with a pregnancy, and there are clear protocols for identifying and dealing with problems. These apply no matter who provides your antenatal care or care in labour. And pregnancy isn't an illness and therefore it doesn't need medical input UNLESS PROBLEMS ARISE which is where midwives come in. This is their skill: identifying and referring on. There is nothing to suggest that the rise in enthusiasm for natural birth over the past ten years has discouraged midwives from being vigilant about the health of a mother and baby. If anything it's emphasised the importance of the mother receiving care which is solely focused on her needs, rather than the needs of the institution in which she's giving birth.

"I want women to have a choice"

I think we all do, but in a system dominated by fear mongering and an obsession with risk, people start to lose sight of that.

Meant to add - if the hb rate in the UK shot up quickly it would present a huge number of difficulties, mainly because of the lack of experience of the majority of hospital trained midwives when it comes to physiological birth.

I'm really fearful of inexperienced home birth midwives bringing hospital practices into the home and inadvertently making birth more dangerous for women. In the 1950's, when masses of women in the UK had home births, there was a career path that a midwife could follow - either to work in the community delivering babies at home, or going into hospital practice, and an acknowledgement that the two routes required different skills, training and experience.

by making midwife led pregnancy care and home birth the norm people (including those at elevated risk) have started to devalue the need for and importance of some kind of medical oversight cos ?pregnancy is not a pathology, I?m fine

Actually, one of the things that's a huge HUGE shame about how fringe home birth is in Australia, is that its proponents have a tendency to get very over-zealous about their cause in reaction to the bias. There is deep systemic distrust between the obstetricians and the homebirth midwives, and they're really positioned as two camps in direct, antagonistic opposition.

One of the things that this means, in turn, is that a few midwives are incredibly reluctant to recommend transfer in borderline cases as it's seen as 'failure'. It also means that obstetricians have been known to make homebirth transfer women feel really unwelcome when they do get to hospital, don't afford them respect, and potentially this worsens the outcomes (there's no real studies on this, because we're talking a few people a year, this is anecdotal).

One of the OTHER things it means is that there's a huge crossover between homebirthers and people who are deeply suspicious of the 'medical establishment' in general. So a lot of homebirthers are also anti-vax, to take one example. So, over here, homebirthers are far more likely to reject medical scrutiny during their pregnancies. Which, IMO, does heighten the risk of an eventual bad outcome (although it has to be said that here, as in other developed countries, home birth has the same statistical outcome as comparable lowrisk hospital births).

So I actually think that a wider acceptance of home birth would do the opposite of what you're surmising - it would lessen the feeling of homebirthers that we're at odds with the medical establishment and have to stay 'off radar' as much as possible. I don't know how much that resonates with UK homebirthers, but it's true here.

(Lisianthus, yeah, it's covered by Medicare in some states and not others; a Newcastle friend of mine had a completely free home birth recently. In South Australia it's not covered, although my midwife is going through the long and tortured process to be approved as an individual provider).

Agree so much with what you say Tortoise

Homebirth needs the support of obstetricians and the wider medical community for it to be viable. You need to have really good systems of referral in place, and relationships of trust between midwives and doctors. It's better in the UK than it is in Aus. The RCOG are broadly supportive of home birth, though individual obstetricians aren't usually very enthusiastic!

"there's a huge crossover between homebirthers and people who are deeply suspicious of the 'medical establishment' in general"

Interestingly - women who've experienced childhood sexual abuse are more likely to opt for a homebirth than the general population.... issues around control and power......

Tortoise
"So I actually think that a wider acceptance of home birth would do the opposite of what you're surmising - it would lessen the feeling of homebirthers that we're at odds with the medical establishment and have to stay 'off radar' as much as possible. I don't know how much that resonates with UK homebirthers, but it's true here."

I think you could be right. My personal experience is that since DD1 was born I've been identified as having a clotting anomaly, for which they recommend prophylactic anticoagulation therapy on a daily basis during pregnancy. When discussing this (with 2 consultants - one obstetric, one haematology), we pushed hard to find out what risks this might increase during the birth - none. Any additional risks of PPH - none identified. Any other additional risks due to the underlying condition - none that we know of. So there shouldn't be additional risk in a HB then...

Cue 15 minutes of being told how we were "far too high risk" for that, we'd never find a MW to support us, there was a "logical" risk... - but you'd be fine for the MLU and/or water birth.

Neither DH nor I could get a word in edgewise to try and establish what they were concerned might happen at home that wouldn't happen in a MLU. I'm not dead-set on HB to the extent that I'd go against all medical advice to have one, but equally I don't want to go into hospital to avoid a risk that I don't even understand. And given the consultant's attitude when we tried to discuss it I don't see how I can find out easily what these risks are that make me "too high risk" for a HB, yet leave me at no increased risk in a hospital or MLU. All in all, it doesn't encourage a trusting and open relationship and makes me reluctant to try and discuss my concerns and queries with the very person who should be best placed to answer them.

So in a way I guess I'm at risk of exactly what we're talking about - turning my back on some areas of medical care. Although because I find them rude, overbearing and not open to a polite discussion rather than because I place no value on their knowledge and experience.