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

When I chose where to give birth I was told that home births had a tiny increased risk of fatal or serious negative outcomes - because of time delay in transfer to hospital if something major happened - but that it was tiny. And that hospital births were more likely to lead to unneeded intervention.

I didn't care if the increased risk to me and my baby was tiny - it was more important for me to have a haelthy live baby. So I chose hospital.

You have asked why women don't choose home births and people are telling you. So I think YAB a bit U to get annoyed at women telling you why. They may be wrong in some of their assumptions, but this is still why they chose a hospital birth.

I agree with what you say (and the evidence says) about being in hospital increasing the chance of CS regardless, that homebirth is safe and that hospitals are not the only safe place for women to have babies (which is why I am planning HB despite not being considered low risk for labour) or that the public would accept medical intervention being used unnecessarily in any other area.

However, talking a woman who honestly believes that a hospital birth is safest for her and her baby into having a home birth she doesn't really want could make her labour stall as much as a woman who really wants a home birth but is pressured to going into hospital.

Blindly choosing one or the other just because it's the done thing amongst your own friends and family and not understanding the risks or benefits of each setting doesn't seem sensible to me. Ultimately what we have to do (on both sides of this fence) is present the evidence to each other and then say 'these are the facts - you have to choose what you feel safest with', and then allow each other to make an informed decision bearing in mind our own circumstances and needs. It's that simple :)

Thanks for clarifying Fliss (sorry, bit late coming back to thread!) I was a bit alarmed by what I'd heard so glad things are being done differently.

because there are a lot of people who are not in fact low risk, but who are thought to be so. I was one, but given I gave birth at 29 week after a placental abruption I am never going to be low risk again

With smaller hospitals/units increasingly closing and distance to hospital becoming longer, homebirth suddenly seems a more attractive option. I didn't consider HB for either of my DDs, but after DD2 arrived in the car at the side of road, if I was to have another baby, I think my risks would be substantially reduced by staying at home.

I had terrible care in the hospital with my first child, nothing all that traumatic by many peoples standards, but lack of staff meant I wasn't seen my a MW until I was ready to push, despite having been at the hospital for several hours.

DC2&3 were born at home, fantastic MWs and the added bonus that got some pain relief.

Homebirths aren't for eveyone, but I still wish that I'd had DC1 at home.

shagmund exposing them to strangers, routinely and regularly subjecting them to vaginal examinations, and making them lie on a bed is 'intervention' enough to make lots of labours go pear shaped.

This didn't happen in my hospital birth - OK there were strangers in the waiting room to check in and I'd never met the MWs before, but if I'd gone for the hb option the MWs would still be strangers given the size of their team.
VEs not routine, and I never lay on a bed until giving up on the hospital MLU and having an epidural. The hospital (3rd largest del suite in UK) has rearranged its del suite to encourage women to labour on all fours, use birth balls, and tries to be a place where intervention is a last resort, as well as building the MLU.

So more reasons why you can't compare 'hospital' births as many of them may be more like modern hbs than 1970s or USA production-line hospitals!

Also I had the full NCT lowdown on hb in my area and was told that the MW would have g+a and pethidine, maybe some oxygen, but not ventouse, forceps, ventilator, incubator or other bits of routine hospital kit that someone mentioned upthread.

"When I chose where to give birth I was told that home births had a tiny increased risk of fatal or serious negative outcomes - because of time delay in transfer to hospital if something major happened - but that it was tiny. And that hospital births were more likely to lead to unneeded intervention"

I'm hoping that if you were told this it's because it was your first baby, and it was since the latest research was published (in November last year) because if it wasn't your first baby, or if you were told this before November, you were being given advice which was not based on current accepted best evidence.

"Nothing is worth the risk in my opinion"

But by going to hospital, healthy women are quite clearly putting themselves at increased risk of having an emergency c/s.

In the latest study into place of birth, nearly TWICE as many women who opted for a hospital birth ended up having an emergency c/s compared to mothers in free-standing midwife led units or at home.

And surgery puts you at increased risk of death - from thromboembolism, from infection, from bleeding.

The risk is very small, but real.

If you are a healthy woman and you opt for a hospital birth you are putting YOURSELF at increased risk of death from surgical mishaps.

And on current best evidence you are not any more likely to come home with a well baby.

Flisspaps - I don't believe in anyone being pushed into making any particular choice, just in, as you say, women being presented with the best available evidence, and then supported in their choices.

In any case, there aren't enough midwives available at present who are experienced in homebirth, to make it a safe option for vastly increased numbers of women.

But there should be a gradual move towards widening provision, and informing women of the clinical benefits.

Also vastly increased resources put into providing more birth centres as these are associated with excellent outcomes. Particularly free-standing units.

I've had a hospital birth and a home birth.

When I was in hospital I was completely ignored for about two hours, with no midwife near me. I ended up crawling on the floor trying to find the buzzer (which had fallen on the floor) to call the midwife as I was fully dilated and needing to push. Had I had a cardiac arrest or a haemorrage in that two hours (and who knows how much longer it would have been before I saw a midwife had I not made the efforts myself to see one), no-one would have been any the wiser.

At home I was attended by two midwives at all times. I think my chances would have been much better there, to be honest, because at least someone would have seen something was going wrong!

My midwife would not have agreed to a home birth for me if I hadn't agreed to going into hospital if it came to pass that things weren't going smoothly.

"So more reasons why you can't compare 'hospital' births as many of them may be more like modern hbs than 1970s or USA production-line hospitals"

Individual experience will vary.

But the evidence speaks for itself.

Women who opt to give birth in a CLU are more likely to:

• have care from 4 or more members of staff
• have care from someone they've never met before
• not have one to one care in labour

and they're twice as likely to have an emergency c/s as women labouring in a free-standing midwife led unit or at home.

And are more likely to end up in an HDU or in intensive care than women being cared for at home or in a free-standing midwife led unit with no medical facilities.

SydSaid Of course, you know that it was never up to the midwife to agree to you having a home birth, regardless of whether you agreed to transfer in to hospital at any point, don't you

At the risk of appearing really thick (and it's a risk I'm willing to take)- the evidence that shows that more women who have a hospital birth have abdominal surgery... Why is causation assumed? Is it assumed or is there other evidence?

What I mean is, how do we know that being admitted to hospital was the cause of the abdominal surgery? Could it not be said that women who need abdominal surgery are more likely to have a hospital birth?

Again, apologies if I am being dense, but would appreciate an explanation. You can use big words though, I'm usually alright with those

"The hospital (3rd largest del suite in UK) has rearranged its del suite to encourage women to labour on all fours, use birth balls, and tries to be a place where intervention is a last resort, as well as building the MLU."

I think the proof of the pudding and all that.

I'd encourage women to look at the emergency c/s and instrumental rates at their hospital of choice.

The hospital may well have a gorgeous birth centre, encourage mobility in labour and all that, but if they have an emergency c/s rate which is 30% higher than a hospital 3 miles away which is serving a similar population, I'd be wanting to know why.

tethers The 'abdominal surgery' referred to is a CS - if you have a hospital birth, you're more likely to have a CS as you're more likely to have intervention eg a drip to speed things up because you're not following The Graph of Progression, then an epidural to help with the pain, then baby might get distressed by the synto and so needs to come out

Women who are known to need a caesarean will therefore definitely be more likely to have a hospital birth, even an ardent HB supporter like me will concede that it's not possible to do a CS on the sofa at home

I would, but I've just bought a new sofa

Thanks Fliss. I am still a bit confused as to where the causation evidence is, though; when you say "The 'abdominal surgery' referred to is a CS - if you have a hospital birth, you're more likely to have a CS as you're more likely to have intervention eg a drip to speed things up because you're not following The Graph of Progression, then an epidural to help with the pain, then baby might get distressed by the synto and so needs to come out", could it not be said that -and I'm just playing devil's advocate here- the evidence showing that women who have interventions are more likely to have a cs could be read the other way round?

That is to say, where is the evidence that the intervention/hospital location causes the cs? Could we not also conclude that women who ultimately have a cs require more intervention/hospital admittance?

Please be patient with me...

Lots of my friends have had wonderful home births.
My 1st birth was awful, required forceps as she was in the wrong position. Next 2 were sections, placenta praevia & refusing to budge!

My gran had 7 children. 4 lived. 4 died at birth, in the 50's. She grieved for those babies till the day she died. All were born at home apart from her last. She was a great advocate of hospital births. She thinks being in hospital would have saved her babies. Personally I think modern medicine would have saved her babies, but I never said that to her.

I am on the fence if I am honest. It's up to the person giving birth.

For me, it was because although I know childbirth is natural, without medical assistance when necessary, it can also be very dangerous. For that reason I felt no desire to put the health of my child or myself in jeopardy

I should add that my hospital births were great. I felt supported and listened too but I was also willing to take medical professionals advise when offered.

I think many women believe that they always know better than the doc/midwife in the room, hence they dont like the hospital experience

I see what you mean tethers, as in the women who will ultimately end up having a c-section regardless of where they initially plan to have their baby will end up in hospital sometime between going into labour and having that c-section, but the fact that you have to have a c-section in hospital must therefore imply that you are more likely to have a c-section if you go to hospital when in fact you are 100% likely to go to hopsital if you need a c-section!

I get the intervention leading to intervention thing and I think that's the crux of Shagmund's point - one intervention does tend to lead to another in many cases.

Tethersend 'That is to say, where is the evidence that the intervention/hospital location causes the cs? Could we not also conclude that women who ultimately have a cs require more intervention/hospital admittance?'

Hospitals have been excusing their high CS rates for just this reason. The recent 'Place of Birth' study dealing only with 'low risk' women matched for this and the findings were very clear cut - a low risk woman going into a CLU has much more chance of intervention than if she stayed at home or went to a MLU.

It's a good question though and one which ought to be asked - why are there many more interventions in CLUs - it's riskier for the mother and isn't offset by being safer for the baby. One strong factor is believed to be the lack of continuity of midwifery care and lack of one to one care.

damn, wrote a long post and lost it.

hospital birth: takes average 2.5 hours longer than HB (even given the 'stalling admission' tactics employed by telephone triage staff) - vastly higher rates of intervention for all births, for first births, as safe as MLU
MLU: vastly lower rates of intervention than CLU, as safe for baby in first and subsequent births -
HB: vastly lower rates of intervention than CLU, slightly lower than MLU also..slight 0.4% uplift in 'adverse outcome' for first mothers, actually marginally safe for babies of second-time mothers..than CLU

this study was of 60000 low-risk mothers, controlled for age, socio-economic status etc..

i wonder at the increased risk in first time HB..as it wasn't found in the 'actual' stats, only in the corrected (is an older wealthier first-time mother giving birth to a larger baby (HB babies average 4oz larger!) really at lower risk of the 'adverse outcome' listed? their correction suggested so...)..also most of these outcomes would be taking place in hospital due to the 45% transfer rate...begs questions about post-transfer communication and care.

i would say the birthplace study definitely did say that CLUs need to look at reducing their intervention rates -

also by making CLUs nicer places, MLUs did not have quite the same 'slowing' affect on labour (a bit slower than average home birth still) though they are still an unfamilar location

i really wonder how they expect women to walk in labour on hard floors.

One of my friend's daughters had a very traumatic first birth in hospital following an uneventful low-risk pregnancy 3 years ago. The hospital was extremely busy and she was left unattended with just a monitor and her DH. To cut a long story short the midwives did not pick up the fact that the baby was in difficulties until too late. Then they stalled the decision to give her an EMCS. The result was a baby that was severely brain damaged due to lack of oxygen, baby died 3 days later.
She had a home birth with her second baby. Second baby is now 2 years. old. Had she had a HB with the first baby the problems would probably have been picked up quicker as the MW wasn't trying to manage 2 or 3 births at the same time.

My SIL is a MW in a very, very busy unit and tells some frightening stories of the results of MW understaffing.
I'd rather take my chances with one-on-one care at home thanks than be stuck in the corner of an overworked maternity unit.

My gorgeous friend had a very "fast" home birth on the weekend. It was a planned homebirth but she had no midwife because they couldn't get through in the snow. Delivered by husband. Had to be transferred because of a tear but the ambo couldn't make it up her street so she had to traipse up to the High Street at 2 in the snow in her dressing gown, ugg boots and the umblical cord hanging between her legs!!!

I have had a hospital birth and a home birth and must say I would pick a homebirth anyday over the hospital. Yes things can go wrong but they can in a hospital too, by the time the hospital sets up rooms ready you will have had just as long a wait as it would be to transfer in. When I was in the hospital e was pretty much just left alone and had to call the midwife in because I wanted to push, at home I had two midwifes and an midwife in training there for me whos whole attention was on me and my baby which means if anything was wrong they would of noticed faster than in a hospital. It also let me relax more being around my own things rather than in a very cold looking hospital. There are lots of studies that will show both ways, at home you tend to be more relaxed which makes for an easier birth. I was told with my second pregnancy I pretty much had to have a homebirth as I labour to quickly which means I by the time I know im in labour im not far from pushing think 25minutes from 5cm to baby being born, with my first born 9cm after 2hours.

I always laugh at the mess comments within 30mins max of me giving birth no-one would of none I had giving birth at home and the midwifes cleaned it all up, and sound well my next door asked 4days after I had giving birth if I was ok as she had not seen me out for a while for my partner to tell her that was because I had, had the baby, no-one heard a thing!