why are homebirth rate so low

[McHappyPants2012]

www.walesonline.co.uk/showbiz-and-lifestyle/health-and-beauty-in-wales/2011/02/05/wales-delivers-on-home-birth-rates-91466-28109298/

after watching 'call the midwife' it seems to me homebirth was quite common in the 1950.

when did hospital birth become a common

Actually I kind of get where Molly's coming from - there is a shortage of midwives (or rather of funded posts for midwives). The majority of women give birth in MLU or CLU's. It seems wrong that 1-1 care during labour is only (more or less) guaranteed for HB.

I wonder if the issue is one of quality of care rather than place of birth - I am struggling to understand why MW's are able to deal with a range of emergencies at HB's (like shoulder dyscocia / PPH) but not in a hospital setting, leading to increased interventions in hospital. IS it something to do with medical dominance over CLU's and MW's feeling unable to stand up to doctors, or MW's who work in CLU's feeling deskilled in managing complications? OR maybe that Community MW's are more experienced, therefore CLU's are staffed with less experienced MW's?

I also guess that when a HB is out of the question (aware I COULD have requested one, but with 7 x major gynae surgeries and preexisting diabetes, I wasn't willing to take the risk - and MW said they couldn't do the sliding scale insulin at home or manage the high risk of uterine rupture) - why should I have to accept less-than-adequate care in a CLU?

Where should we put more midwives - in CLU's so that the majority of women who birth there get better care? In the community to increase rates of HB? If we invest in community MW's would this lead to less investment in CLU's, and therefore even worse care?

Hope this makes sense....midday musings at work.

I find it interesting that in the 1950s all the women gave birth on their backs, there were very few c sections. I think the big difference is that they put their TRUST in health professionals. They did not stress so much.

Something that is sort of glossed over in all the research is the impact of the increasing average age of women having babies and increase in complications it is causing.

samstown I'd be surprised if the link between intervention and infant mortality rates that straightforward.

I think reallytired makes such a good point about women's expectations, I find it quite sad how few of my friends during their first pregnancies had any faith in themselves to be able to deliver a baby safely and expected to have an awful time during labour and childbirth.

And YY to ReallyTired - there seems to be an increasing amount of mistrust in medical professionals which I do believe doesn't help in labour. I trusted my medical team 100% and had no expectations as to how my labour would or wouldn't be. No hopes or wishes for the birth other than to both get out alive and well. For me, well included recovering from c-sec!

Actually my very medical birth was fantastic. Hospital at 8pm on a Monday. Induction started at 9pm. Nothing overnight. Second pessary 10am the next morning. Cramping and pains but nothing worse than 12 years of stage 4 endometriosis. Got to go in birthing pool while labour began - was amazing as had been told I couldn;t be in water due to continual monitoring needed and sliding scale insulin once I began dilating. Third pessay and attempt to break waters at 3pm on the Tuesday - not dilated enough. Pain increased massively - had lovely lovely gas and air, plus another examination - only 0.5cm dilated. Sometime overnight DS became tired (as was I by this point) so I was on the bed on monitors, and my consulatant was called in at 6am on the Wednesday - she was there within 35 mins. By this point my blood sugars (and therefore DS's) were unstable. I had DS by EMCS that morning. Consultant gave us all the options (syntocin drip, going home and trying again in 24 hours, C-Sec) - we chose c-sec because it was the option with the least risk. All midwives on the CLU were fantastic.

I get so so fed up of being told it's a 'shame' that I had a medicalised, high intervention birth. I got a healthy happy DS. I wouldn't change that for the world. I have a horrific hypertrophic c-sec scar which is still (14 months on) painful and vile to look at. But I got a healthy DS.

RT,
maybe fewer women in the 1950's had c-sections, but there was also a much greater infant mortality. The aim of a birth is to end up with a healthy baby and mother, not to avoid medical intervention.

It makes me really angry when some women try to make it a competition, or act as if it should be some magical experience, and tell people that it is a shame they had a medicalized birth. Why is giving birth to a healthy child a shame in anyway shape or form. Do they think the child will have an unhappier life because it was removed from you stomach rather than your vagina? If a c-section is the less riskier option at the end of the day then there is no shame from having one. All harping on about natural childbirth does is put pressure on women, and make them think that becuase something is natural it is automatically best. Yes birth is a natural even which has gone on for millenia, but then until relatively recently, and then only in the western world it is one of the biggest causes of death for women and infants. We would never discourage a woman from using IVF because it is not natural, so why try to discourage them from medical intervention if that is what they want? Can you imagine anyone getting away with saying to a woman who had children by IVF that it was such a shame they had to resort to medicalized conception?

I had my first two in hospital then the second two at home mostly because my labours got quicker so staying at home seemed the less stressful option. The care I received in my own home was much better and I have happy memories of those two births. I am low risk and have easy labours despite largish babies. For people like me i think it is a good option, I always felt a lot safer at home than in hospital which led to a better experience, of course whether I was 'safer' in real terms is a question for debate I suppose. Not doing it again though, in either location!

Quite Kelly - I'm just not sure why medical intervention has come to be this awful thing, when it does in fact save lives (mum and child).

I do appreciate that for many, the lack of control, fear, physical complications, disrespectful attitudes of medical staff etc lead to unhappiness and in a number of cases PTSD post birth - but that's sometimes used as a way of affirming a medical intervention = bad IYSWIM?

I'm on the side of women being empowered to give birth in whatever way they feel most comfortable - be that an ELCS for a first time low risk pregnancy, or an unassisted freebirth in a field (extreme example but you get my point) - provided they are a. adequately and honestly informed of ALL possible risks and benefits and b. take responsibility for their choice and its possible outcomes.

I also think there is much pressure from the medical establishment to have what they perceive to be the 'safest' (and often quickest) birth - but equally ,there is a huge amount of pressure from a range of sources about a 'natural' birth being the best option - I think for many, it probably is, but the judgementalness that then follows if you DO have interventions, of pain relief, or whatever is immense.

I have a friend who desperately wanted to give birth naturally. She had been to hypnobirthing, NCT, NHS antenatal classes - and came away with this idea that if she had an ounce of intervention, let alone a c-sec or epidural, then the baby wouldn't bond, there'd be problems with BF, there were higher rates of ADHD - all kinds of random problems associated with medical intervention. She was terrified. We were pregnant at the same time and I really struggled (knowing I would have an induction early, which may lead to c-sec and epidural) with all the info about how awful motherhood was going to be for me because of this. She ended up with a crash c-sec and PTSD.

I do wonder sometimes how much the pressure about the 'right' way to birth, alongside the expectation about the experience, adds to peoples experience of disappointment and possibly trauma.

horrible,
the former head of thr RCM was speaking in the guardian recently saying that the pressure on women to avoid intervention makes her very angry as she saw many women who were upset simply because they felt they had failed by having intervention. If you feel like birth is some sort of test you have to pass and you fail if you have medical intervention (can you imagine men being discouraged from accessing medical help and being made to feel like failures of they did get medical help), then that might effect the bond with the baby, but medical intervention will not. One cannot tell which women had medical intervention by looking at their relationship with their child.

Necessary medical intervention is a wonderful thing, saves lives, no question.

Unecessary intervention is a bad thing.

There is a risk/ benefit analysis to be dive for everything. If something is done unecessarily, then the risk/ benefit ratio is massively skewed to risk. For example, the unecessary inductions carried out on perfectly healthy, low risk women for no reason other than protocol. SIL needed an induction. (she had OC.) the risks of leaving DN in situ outweighed the risks of induction. My induction was performed according to protocol, and my perfectly healthy, low risk pregnancy neatly ended in disaster, with foetal distress caused by the induction drugs.

I did my own risk/ benefit analysis for my next two births, and chose HB as it carried fewer risks for me. I was technically high risk with DS2, as it happens, as he was 42+3 when he deigned to make an appearance. He wasn't post-mature though.

HB isn't right for everyone, but CLU birth is equally so. It's the default in many areas, leading to many women thanking HCP for saving them from situations that are entirely iatrogenic in nature.

Totally agree Kelly will look up the article. I think my friend had a rather stringent natural birth advocate for her hypnobirthing course as the ONLY material she was given was on the horrendous effects of medical intervention - nothing balanced about the pros and cons.

Tho similarly my 2 hour long NHS antenatal class didn't talk about induction or csec at all, and the NCT rep I contacted about their classes said they wonuldnt be massively suitable for my planned induction - I got stuck with very little info about birth! Luckily my consultant was ace and spent hours discussing it with me (I saw her ever 2 weeks from 10 weeks pregnant).

Maybe more info about intervention would reduce the fear that women have of it?

I also notice that the organisations thta push "natural" births are keen to publicize any bad reports of intervention and happy to ignore any good reports. For example NICE have said that planned c-sections are just as safe as natural births and there is no reason not to offer these to women even if the woman can give birth naturally. A recent BMJ study fund that it was safer for first time low risk mothers to give birth in hospital, and the RCOG do not say home birth is safer they say there is no reason not to offer it to low risk women. They do not advocate one type over the other. Yet certain organisations just push for non-intervention.

kelly2000,

I don't think that we disagree. I am not against intervention for people who need it. Ofcouse we have made amazing progress with both maternal and infant mortality. In the 1950s 25 out of 1000 babies were still born and now its about 11 out 1000.

I doult that woman in the 1950s had a magical birth experience. They had the indignity of being shaved and having an enmena between contractions.I was refering to a 1950s mindset. They were calmer and more accepting of advice. Sometimes ignorance can be bliss.

I feel that pregnant women should be open minded about childbirth. How on earth do you know if you are going to need pain relief or not. In many ways rigid birth plans are plain daft.

I'm just not sure why medical intervention has come to be this awful thing, when it does in fact save lives (mum and child).

Because it's not always handled as well for other women as it was for you and because it isn't actually always necessary. The sad fact is that, you were one of the lucky ones, too many women receiving substandard medical care during labour and delivery, sometimes this includes unnecessary medical intervention. The experience of these women is leading to distrust that medical professionals are going to act in the best interests of both them and the baby. Whilst there is no disputing that top of the list of desired outcomes for any labour is a healthy baby, women are not just incubators, they deserve a high standard of care, good levels of communication and respect from HCP through the process.

I do agree however, that women need to go into labour with an open mind, and fixation on needing to have a natural labour to bond with a baby does no one any favours.

Birth was one of the biggest causes of death for mother and child in the past because of:

Risk of infection (it wasn't until Semmelweis in the 19th century that people actually realised that they should be washing their hands before inserting them in women). Childbed or puerperal fever was a major cause of death.

Lack of antenatal care to pick up things like eclampsia, heart problems, diabetes, malformed pelvises, multiple births, HELLP syndrome etc.

Lack of anaesthetics, aseptic environment and antibiotics after C-sections and birth in general. Women with stuck babies could labour for days whilst their dead baby either rotted inside them or had them removed in pieces. Dehydration and exhaustion, blood loss or infection would often kill the mother.

Lack of skilled professionals. Lots of doctors left university to deliver babies having seen only one natural delivery. Midwives were discredited but at certain points in history you were more than twice as likely to die under the care of hospitals than giving birth at home, not least because you were exposed to unfamiliar germs and would often be sharing a bed with two other women in a filthy environment. When the hospital then became the place to be for upper and middle class mothers they often had again a higher death rate than the poorer women who had to stay at home. Doctors were the only ones allowed to use forceps and there is evidence from diaries that they used them to earn their bigger fee and justify their presence, rather than midwives who were skilled in other techniques.

Inability to deal with premature babies or birth defects.

No way of detecting things like rhesus incompatibility that can lead to stillbirth

Prevalence of diseases that are now treatable. Syphilis and other sexually transmitted infections, scarlet fever and the following rheumatic fever that damaged hearts. Rickets where the pelvis could become so malformed there was no way a baby could get out. Vaginal and uterine prolapse, fistulas. High blood pressure, undetected cancers/tumours or polyps.

Placenta previa, placental abruption could not be detected and prove fatal nowadays without scans.

Hemmorage-no way to stop this

Lack of universal medical care so many women were too poor to afford doctors and any intervention they might need

Martha Ballard-a midwife in colonial America delivered 996 babies in her lifetime. Out of those 996 births, four mothers died.

Most of those factors have now been removed through knowledge about bacteria etc and excellent ante-natal care. I was told about the small risk of haemorrage (lessened by the fact I had one successful birth with no problems) and the risk of shoulder dystocia (for which i had two or three of the risk factors) but I had confidence in my midwife that she could deal with this, she had done it before and was able to allay my fears.

There is no shame in having a C-section but it wouldn't have been my choice. But I wouldn't tell someone who was planning one or who had had one that they were wrong. I would have had one if it had been indicated as a necessity for me. Likewise medical intervention and a hospital birth.

I would expect other people to respect my choice.

Just read above- medical intervention can affect bonding with a baby, not in every case of course and other factors can be involved. But some interventions can interfere with the production of oxytocin and other 'love' hormones. A mother who has had intervention could find it more difficult (note not impossible) to have skin to skin due to either position, medication, the process of being stitched, having to have paeds work on the baby immediately etc. Also sometimes a mother who has gone through a difficult birth that has caused her emotional/physical pain afterwards may find it hard to accept the baby that caused that pain, no matter how taboo that sounds.

The organisations mentioned above do not advocate homebirth, no, but neither do they say its a dangerous thing to do. I would imagine that most members of the RCOG don't regularly attend homebirths and their comment reflects that, anything further would surely be seen as a criticism of their workplace and methods.

"Hemmorage-no way to stop this"

Apart from the use of ergot - an old midwive's remedy for bleeding after birth. Now synthesized as 'ergometrine' and used along with syntocinon (as 'syntometrine') for third stage (helps mums birth placenta and controls bleeding)!

Have to say R2PeePoo - I LOVE your user name. Inspired!

I have never known anyone to make a rigid birth plan (but maybe thats my area and an age thing)

Thanks shagmund

I forgot about ergot, but I guess it also wouldn't have been available to everyone

I also forgot about malnutrition and vitamin deficiencies in both recovery from the birth and labour itself. Things like scurvy, jaundice, pellagra and beriberi and damage caused by previously suffering from them.

Illnesses also like rubella and measles which can damage baby and mother.

And anemia

"Quite Kelly - I'm just not sure why medical intervention has come to be this awful thing, when it does in fact save lives (mum and child)."

No - it's not medical intervention per se that's the problem.

Which some of you here REALLY don't seem to get.

The problem is that some hospitals have MASSIVELY higher emergency/assisted/induction/augmentation/episiotomy rates than others serving similar populations, and their outcomes in terms of neonatal mortality and morbidity are no better. And the emergency c-section rate among HEALTHY, LOW RISK mothers is just going up and up and up.

There's a very strong belief among midwives and doctors that poor staffing levels and of lack of continuity of care are at least in part behind the very high levels of emergency c/s that we see in some hospitals. There's certainly CLINICAL evidence that women who are cared for by case-loading teams are less likely to have an emergency c/s, no matter what their risk status during pregnancy. There's also evidence that once a labour becomes complicated, having a consultant involved in her care makes a mother more likely to achieve a normal birth.

It absolutely does my head in to see mums on boards like this rabidly DEFENDING the current incredibly high intervention rates, when pretty much everyone who's involved with delivering maternity care is deeply concerned about the damage that it's doing to women and babies.

"For example NICE have said that planned c-sections are just as safe as natural births and there is no reason not to offer these to women even if the woman can give birth naturally."

Women who've HAD a planned c/s have worse health outcomes than women who've HAD a vaginal birth. They are more likely to go home with a serious infection/have a catastrophic bleed/emergency hysterectomy/end up in ITU. But they are as safe for mothers OVERALL as planning a natural birth within a system where 14% of planned natural births result in an emergency c/s, which is the least safe mode of delivery.

Of course the emergency c/s rate is only that high for women planning a hospital birth. For healthy women planning an out of hospital birth the emergency c/s rate is less than a half of that. And for healthy second time mums planning an out of hospital birth the emergency c/s rate is very, very low indeed, and therefore they'll have a different set of risks to balance out when working out if a planned c/s is really as safe or safer for them and their baby compared to planning a vaginal birth.

Kelly -On a personal note, my first birth ended in a forceps delivery. I went home with a very bruised, jaundiced baby and had weeks of breastfeeding difficulties which I think were linked to the fact I'd had a very difficult birth. At the time I felt really grateful for having been 'rescued' from difficult delivery by the doctors. But later I reflected on how the poor care I'd had had might have contributed to me needing an assisted birth in the first place. I could have gone around raging at people for talking about active birth - I certainly didn't have one of those - for making me feel bad. Ditto anyone who flagged up the association between epidural use and forceps deliveries in first time mums (I'd had an epidural). But actually I didn't feel bad at all. I just felt cross. Not with myself, but with the poor quality of care I had. I only realised quite how bad it was when I had my second baby and had a really outstanding midwife and properly individualised care.

"saying that the pressure on women to avoid intervention makes her very angry as she saw many women who were upset simply because they felt they had failed by having intervention"

You know, I agree that there is no point encourage women to question intervention, if you're then going to send them to give birth in hospitals with a 30% c/s rate, where one in five labours is induced.

So yes - you're right. No point encouraging women to want a normal birth if they're not likely to have one. Even though they very well might have had one, if they had better care in labour.

Gosh - bet David Cameron would love this thread.

Tories can carry on cutting maternity services and midwife numbers, intervention rates carry on going up and up, and the only response of women is to bitch about the NCT and the RCM for daring to point out that this state of affairs is harmful to women and babies.

"and now its about 11 out 1000."

But you know what Reallytired, the stillbirth rate hasn't gone down much, if at all, in the past two decades, despite a HUGE risk in the level of interventions in birth.

Big thumbs up to Shagmund - you tell it like it is.

The people currently most worried about high levels of medical intervention are clinicians - doctors and midwives - there is loads of work going on in the NHS to reduce unnecessary intervention. Check this out, for example.

And the reason why most people wouldn't dream of having a home birth is because the Daily Mail and others have instilled it into everyone that home birth = death. Which is simply not borne out by the research evidence.

Thanks boob

I sometimes think modern women are suffering from stockholm syndrome in relation to the birth culture.....

I don't think you know what Stockholm syndrome is.

Comparing health professionals to violent kidnappers or hijackers gives the impression you have lost the plot. Doctors and midwives do their best and are caring people.

I think there needs to be more balance for women who access antenatal classes, about the realities of intervention and csec etc. If these areas were covered in as much detail as other elements of labour, in a balanced and unsensationalised way, then perhaps more women would feel confident about making an informed choice in labour - rather than feeling obliged to accept offered intervention unquestioningly. If you don't know why certain things are suggested, or the alternatives, or the balance of risks and benefits, then most of us (I think) naturally defer to those in authority.

I didn't find there was this balance in my antenatal care. The classes I accessed and attended focused on natural labour, with very little mention of any interventions bar epidural.

I think one thing we can all agree on is the need for more (and better) ante, peri and post natal care. Better and more informative classes (not the 2 hours I got - interestingly, DH had 10 hours of Dad's Classes via Surestart). One-to-one midwifery care during labour whereever labour takes place. Increased support in the post-delivery period.

I'm booked to have a home birth (my first) with DC3 in roughly 4 weeks' time. I opted for a home birth this time not because I want to be at one with nature, or because I view it as some way to show myself to be superior, or because candles and whale music are guaranteed to bring my child safely into the worls, but because the difficulties I encountered with my first two births were a direct result of institutionalised, ritualistic 'care' in hospital. I am an individual in my own right, with a brain in my head and an ability to make decisions about the welfare of myself and my children, and that was never recognised in hospital. (And that's not some kind of veiled suggestion that people who choose a hospital birth are incapable of independent thought; just my experience of how the hospital staff treated me!)

DS1 required resuscitation when he was born (something which can be provided by the highly experienced midwives who will attend my HB) but only as a direct result of the 'cascade of iterventions' which took place during labour. As a former critical care nurse, it's taken some time for me to feel comfortable with leaving behind the 'security blanket' of modern technology and be confident in the skills of the midwives and the sufficiency of the equipment they carry.

I have no issue with hospital births, or those who choose to birth in hospital. It's an individual choice based on a whole lot of different factors. I do take exception, however, to the suggestion that women who choose to birth at home are irresponsible and determined to do so at any cost. When I had DS1 it never occurred to me to research options - after all I was in safe hands wasn't I? Or so I thought. This time round, because I am deviating from the 'norm', I have read thoroughly and extensively about my birth options. I didn't suddenly decide that I was doing it my way regardless of risk.

I live I am area which has a home birth rate of less than 1%. My HB decision was met with considerable resistance from hospital midwives. Despite this, the community midwives who visited at the weekend to "book" my HB were masively supportive. They assured me that, particularly as I have latex allergy and other problems within unknown allergens, they feel that I'm safer at home for as long as everything remains 'normal' They also explained that I'll be closely monitored and we'll start to discuss our plan of action at the first sign that we might have to consider transfer or intervention. Try reiterated that a blue light transfer is very, very rare (but does happen) because the 1:1 care means that most problems are identified before they really become a problem. With a history of pre-eclampsia, it's my intention to transfer at the first sign of potential trouble without any resistance whatsoever. In fact, if I develop Pre-Eclampsia again I'll be begging for ELCS after my experiences with DS1.

I can't see any need for criticism of people's informed birth choices, particularly when the one thing they all seem to have in common is people's views on whats best for them as an individual and for their baby. What's nice to see is so many empowered women making informed choices - whatever they are - about their bodies and their babies, rather than being blindly led (as I was!) by the instructions of HCPs.