Ever wonder why so many women are scared off by the thought of a home birth?

[foxytocin]

These questions [[
store.aqa.org.uk/qual/gcse/qp-ms/AQA-3561-H-W-QP-JUN09.PDF from AQA]] give an insight into our mindset.

3 (a) Suggest four advantages of having a hospital birth.
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3 (b) Name three types of pain relief usually available in a hospital.

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Where was the mention of home births here - or the disadvantages of hospital births.

As I understand it, hospitals are expected to set up home birth teams whose members are not on a hospital team rota. A woman who opts for a home birth is therefore not taking away staff from women who have chosen to labour in hospital.

When a hospital finds itself in a position where they require more staff, they are to hire them in from bank midwives. It is akin to a school suddenly finding itself short of staff for whatever reason. They buy in cover; they don't tell the kids to go home or go to another school because they don't have the legal staffing ratio.

Since even with 2 midwives attending one woman well (2 midwives for a short period of time) a home birth is still cheaper than a hospital birth then something is going wrong where hospital births are still more expensive if it involves an epidural.

I also don't know of any longitudinal study which looks at the cost of hospital vs home birth over the longer term. The risk of birth injuries to women and babies which are higher in hospital births (comparing low risk with low risk here)would lead one to believe that the long term cost of hospital births extend beyond the postnatal stage. While some injuries have short term consequences others have life long cost and impact. And also the less dramatic damage caused by birthing in hospitals like the higher risk of PND, poor bonding in the early days if motherhood and failure to establish breastfeeding all are multifactorial issues but are also ones which hospital location and care during birth will also impact.

Having a living baby, as vital as it is, is not the only reason why women want to labour in the best location, where ever she thinks that is so the gap between the differences in these outcomes need to be narrowed.

The problem is that women need to advocate for 1 to 1 care in hospitals as well as at home as hospital births are coming off badly under the current conditions.

I really don't have a strong opinion on this: I do wonder about the costings, though. I could have wanted a home birth all I wanted but as labour hadn't started 48 hours after my waters broke (and my grandmother lost her fifth baby due an infection in this very circumstance), the chances of me labouring at home on ds were slim.

As I was induced, I faced the inevitable "cascade of intervention" etc. So I have no doubt that my birth was probably very much more expensive than a low risk woman's hb.

As I mentioned, I come from a country where people do indeed pay to give birth. So the idea of paying for either a homebirth or a hospital birth does not fill me with fury.

I now work in the NHS and I don't particularly like the oft-quoted "sense of entitlement" that well, it's what women have a right to so it's outrageous etc if it's not provided. I understand why people feel like this, I do.. but I see a system cracking under the strain and think it's a good deal more complex than that.

I don't think it would be any harm if people who could afford to paid something towards their healthcare. I appreciate that this is a deeply unpopular view to hold on NHS services and, in general, I am not in favour of privatisation per se. However, when it comes down to things the NHS have a struggle resourcing (whether that is an excellent cmmunity midwifery team, a state-of-the-art MLU or anaesthetists on call for epidurals in the hospital), I am not outraged by the idea that those who can should contribute.

Of course a low risk, uneventful hb with an appropriately qualified available team is going to be cheaper than the bells-and-whistles in hospital, but I don't doubt that if we were all guaranteed the possibility of an uneventful hb with a successful outcome this wouldn't even be a debate. It sounds lovely to me. On the other hand, knowing that when my grandmothers birthed at home that both of them lost babies, and knowing that my own baby didn't fee inclined to move from my body and had to be coaxed out etc etc and then had a low Apgar score etc.. well, it doesn't convince me that we are talking about equivalent risks.

And tittytittybangbang, I don't understand your point about me needing a theatre delaying a high-risk cs - when you are prepped for emcs, your original risk is frankly irrelevant. At that moment, you need the theatre: it is not a choice. Choosing to birth at home using public funds is a choice. I don't judge people for making it, but I would feel more comfortable making such a decision if I could contribute financially to it. I can't, so I won't.

arses, I come from a country where people also pay for medical care and it is a 3rd world one.

I also pay a national insurance contribution here which afaik, is to look after me in situations like antenatal care, labour, delivery and PN care. In 12 yrs of contribution, this is all I have ever required.

Since HBs are cheaper, just as safe and have better long term outcomes for morbidity then maybe it ought to be the default setting for all women. If one transfers for an epidural then the cost of the epi is billed to the parents. And if a birth is high risk then it is like home births, automatically covered by the NHS?

Not I would want but by the arguement you are posing, a possibility none the less.

Yes, possibly foxytoxin. I suppose I think that choice shouldn't necessarily be funded, whereas avoiding risk should be.. I'm trying to think of an equivalent in my field, and can't draw a parallel.. but then I guess what the "core offer" is in terms of speech and language therapy is that you have an assessment and are given exercises etc but if you wanted a therapist to do these with you, you would pay yourself?

It's not that I agree with patients having to pay, as I said. It's just that I wonder sometimes if the whole system (across most disciplines) is very thinly stretched and the issue with that is that, campaign as we all might, it gets nowhere. As a patient and a practitioner, I would rather access high quality services that match clinical recommendations and pay a bit more for it than pay the basic amount that we do in NI (high as it is) and have a service that doesn't match an evidence-based quality of care.

So, if hbs are indeed cheaper, then why not offer it as a default and make the choice for epidural cost. Except, I suppose, this would be perceived as guilting women into enduring pain to avoid cost.

I know none of this is simple. I simply take issue with the idea that we should all be campaigning for more, more, more with the NHS when resources will be further and further stretched as the population grows.

There is a different dynamic between a hospital and a homebirth. At home you are in your enviromnent and the midwives are your guests. In a hospital enviromnent you are the guest and the midwives own the space.

There needs to be an educated choice where mothers give birth. I think that provided mothers meet certain criteria they should be given the option of a homebirth.

This may be unfair, but I do not think that high risk mothers should be allowed an NHS homebirth. It is stupid to have a homebirth you are expecting twins, have a breech birth, VBAC or there is some other serious complication then hospital is the best place.

However when a homebirth is refused there needs to be proper appeals proceedure and a clear explanation why a homebirth has been refused. Especially as there are di*kheads like my GP who thinks that all homebirths should be illegal.

My SIL is a MW and when we were both pregnant (our babies are 1 day apart !) we discussed homebirth particularly in relation to an emergency/crash section. She said it takes about 10 minutes for the theatre to be made ready/staff to scrub up so if a HB MW rings in with an emergency transfer this would take place while you were en route.

Also the likelihood is that if you're at home being monitored 1 to 1 a birth problem is going to be picked up a lot quicker that in a hospital where mw/patient ratios are much higher. HB midwives do not take risks with their patient's safety and to my knowledge at the first hint of trouble you transfer. Meaning that all the women with shoulder dystocia etc would never have completed a HB as the MW would have transferred to hospital.

"I don't really agree with this. It is a luxury IMO."

Did you have gas and air or pain relief in labour ? I hope you paid for it. I didn't have any pain relief and I don't see why I should pay for you to have that luxury

Why don't you educate yourself on the costs of HB v the average hospital birth ?

"No.. but I would feel strange if I thought my choice stopped another woman from being able to use a ward."

So if you needed a heart transplant would you turn it down because you were denying it to someone else ? Why should we accept what is often shite care in hospitals just to be nice ? Women should be up in arms about the relentless cutting of maternity services, mainly by men.

Fibilou, I think I responded to those points..

I doubt a midwife with a baby's life in her hands cares at all about the hospital being sued at that moment in time, more about saving the parents and child from a lifetime of hurt I would imagine.

I have had 4 children all different and the last was the most traumatic, having been almost pressurised into a home birth by the community midwifes I thank goodness and Riven who's story made me trust my own instincts to go to hospital that day. My boy got stuck and whilst i'm sure everything would have been fine at home too I'd never have forgiven myself if anything had gone wrong.
But there was very little monitoring, right up until the last moments everything was text book and then in seconds it all seemed to go horribly wrong and there's no rhyme or reason to it.

Librashavinganotherbiscuit: Re your Obs Vs Regs on duty comment - if you read the full night birth paper and the RCOG statement on it, you'll see that the researchers noted that perinatal mortality and adverse perinatal outcomes were lower in units where consultants were present overnight and that RCOG links this to a body of evidence supporting greater consultant support to more junior medical staff around the clock.

"the reason operating theatres are not open all night anyway is the stats of people dying on the table after 10pm is much higher."

Yes, I understand that there is evidence that time of day affects surgical outcomes across the board. However, it looks like the reasons for this are still being explored. A key potential influence noted in many relevant papers is the question of overnight staffing, in terms of seniority, experience and numbers.

There doesn't seem to be a definitive position and I don't think that it's officially used as the grounds for scheduling operations on the NHS.

I would be interested to know if there is anything more conclusive or up to date on this issue.

Ah toga that maybe the case but your argument was based on the fact there were no staff at the hospital and they would have to be bought in, I was pointing out this isn't true there will be qualified to do c-section staff on-site 24/7, whether they are any good or not is another issue.....

"And tittytittybangbang, I don't understand your point about me needing a theatre delaying a high-risk cs - when you are prepped for emcs, your original risk is frankly irrelevant. At that moment, you need the theatre: it is not a choice."

The point I was making was that low risk women giving birth in hospital appear to DOUBLE their risk of c/s. If there are low risk mothers having avoidable c/s then that is putting higher risk women at risk. Of course there's no choice as to whether to go to theatre once the problem has arisen. But there is a choice to be made prior to this as to whether you are going to put yourself in a situation in the first place where you're more likely to experience a complicated labour.

OK ? it wasn't my intention to imply that there were no staff at the hospital whatsoever! (I shall be more careful of my wording in future...)

I am noting that the most senior medical staff , who would be automatically consulted for advice / decisions / actions about more complex cases and developing emergencies in the day, and whose presence on-site is associated with lower levels of negative birth outcomes, are not immediately accessible at night.

In a complex emergency case, it would be normal to call them in to the hospital. Even in a less complex case, or where a registrar is unsure whether an emergency is developing or not, it isn't unusual for them to phone the on-call consultant for advice and a decision on whether a more experienced pair of hands is needed.

Sure, if either mother or baby are clearly in danger and the consultant isn't answering his or her phone, I hope that the registrars would take the decision to perform a crash caesarean.

Perhaps registrars do perform more emergency caesareans during the day (I can't find any figures on relative numbers performed by registrars vs consultants). This makes sense from a training perspective since they will need to gain surgical experience.

However, it is the presence of consultants, not registrars, which is a factor associated with lower levels of negative outcomes in emergency birth situations.

If something went so seriously wrong in a homebirth that a woman needed to be bluelighted to hospital for an emergency caesarean (rather than an epidural and some sleep to counter extreme exhaustion), the chances are that a consultant would be called in at the other end.

I have not read the whole thread but I just wanted to comment on something arses has said.

"I don't think it would be any harm if people who could afford to paid something towards their healthcare. I appreciate that this is a deeply unpopular view to hold on NHS services and, in general, I am not in favour of privatisation per se. However, when it comes down to things the NHS have a struggle resourcing (whether that is an excellent cmmunity midwifery team, a state-of-the-art MLU or anaesthetists on call for epidurals in the hospital), I am not outraged by the idea that those who can should contribute."

The danger of this is that it creates a two tiered health service, where those who can afford 'treatment' such as a HB have access to it, while those who can not don't despite the fact that it might be the best option for them. Now I know that you point out that it should be those who can afford it. But I am really fearful that by introducing an element of privatisation it will create different levels of care to those who have and have not the funds. Ultimately the poorer loose out.

Ops, that bit was supposed to be in bold.

For me it's not about the relative safety of homebirth compared directly with hospital birth. It's in the event of the tiny tiny chance that in the event of an otherwise normal, healthy pregnancy, and a normal healthy birth, things STILL can go wrong. Admittedly it's a very very low occurence, but sometimes, just sometimes, something that is meant to go perfectly goes wrong, the Mum has an uncontrollable bleed, or there's a prolapsed cord, or the baby is in distress. Sometimes there is not time to get to hospital and sometimes as a direct result of NOT being in hospital, the baby dies or is severly disabled.

I'm very very sorry if what I've said upsets anybody, but it's true...

The only reason I would ever plan for a home birth is if my previous labour had been so fast that there wasn't time to get to the hospital.

Again, I'm sorry ifany of this offends,but it's just my opinion.

(btw - if my sister had been a homebirth she most likely would have died)

(Haven't read the whole thread...)

BUT, let's FORGET about the home birth/hospital birth etc - the OP was quoting from the SHITE Child Development GCSE (I think?) which is a load of old balls and completely irrelevant and out of date...

Don't let your teenage children opt for this crappy GCSE...

(Getting off my high horse now)

Yes, but Summerhols, in the one tier system everyone loses out.

An adequately funded public system for those who can't afford it, with higher-earners funding identical levels of service for themselves, is my ideal e.g. similar to disadvantaged 2 year olds being provided with free nursery places but higher earners (such as me) paying for similar placements (because we can).

I wouldn't want an American system where you can't get behind a hospital door without paying, but certainly what I hear about private vs public births in Ireland is that there is very little difference in terms of outcome etc. I don't know stats so am basing this on unscientific anecdote, though (and, well, my mother who is a private patient just spent a week on a trolley because of poor resources so maybe Ireland is a poor example..).

Ireland is a poor example as home births are nearly non existent and they are also trying to make them illegal. I understand.

I don't know if that is relevant to the public/private debate about healthcare, though? In the same way that the mention of the nursery places have ostensibly nothing to do with birth but illustrate a point that you can cater for those without money while expecting those with funds to pay, while offering an equal service to both?

The homebirth situation in Ireland, as I understand it, relates to a fatality and was a kneejerk reaction. I don't agree with it. It also potentially relates to a fundamental lack of resourcing across all services (whether you are a public or private patient) meaning that, I am guessing, they don't feel homebirths are safe in the current economic climate?

We are very lucky here that healthcare is as well-resourced as it is for all patients.. yet there is still a lot of moaning and mythering about it and I do shake my head and wish that people had some appreciation of the positives of the NHS instead of, as I said earlier, always saying "not enough!", "more!".

In some ways, Ireland is a perfect example to include to illustrate what happens in an underfunded health service regarding choice for women, where even those who pay to give birth face inadequate service, long waits and having to birth alone on trollies in corridors. That's what happens when the money runs out (as has, obviously, happened spectacularly in Ireland). In some ways, I suspect private patients are funding whatever is actually left in terms of service as the public coffers have dried up.

The NHS will, hopefully, not suffer as deeply as the Irish system as the UK isa stronger and more resilient economy even in the face of severe recession. However, it does face substantial and growing deficits as the population increases and budgets start to shrink/be pushed for "efficiency measures". I wonder what impact this will have on the training and supervision for all staff involved in birth?

Having those who can afford to contribute voluntarily to their services where they can would ease the pressure on all resources is not an ideal answer, and I know it sounds ultra-Tory, but given that the current government has some pie-in-the-sky notion that all of society will be offering free services in their skills area to make up for shortages in public funds, it is not as drastic as it may sound. I am, fundamentally, a socialist - but I can see that there is a crisis looming and that there is some merit to the Tory notion that we can't always be looking at what we can get from the state, but at what we can also give to the state/our community/fellow citizens.

I know it isn't straightforward or easy. People aren't really decent enough to pay out for something they don't see themselves as receiving "product" from e.g. better service for them vs those not paying from, so a two-tiered system does tend to arise from changes to healthcare involving additional payments from some but not all.

I don't see this as pertaining to homebirth vs hospital birth or any aspect of any one NHS service in particular. If it were categorically proven that homebirth was the cheapest option and that epidurals etc needed to be paid for off insurance in this equation this would also, as I mentioned, make sense. I don't know enough about different types of births to be categorical about how this could be achieved: my concern is for the NHS as a whole, that a 100% free-at-the-point-of-service (regardless of patient risk/choice etc) seems realistically unsustainable right now.

Jareth, I see your point but you are discounting entirely those births that end up with complications precisely because they are in a hospital.

Births that might have laboured intervention free had mum not been prone and continuously monitored;

births where the lack of one-on-one MW support and supervision in an understaffed hospital meant that a birth becomes an EMCS, rather than a planned transfer in and planned CS (more likely with the one-on-one care at a HB);

births where the natural cascade of hormones which brings on labour ceases because a mother is in unnatural and uncomfortable surroundings, leading to induction, epidural, CS etc.

There are many birth complications that can be avoided by a MW-led HB for some women. I believe women should have the right to choose but they should be able to make an informed choice, based on the evidence, not on the fear factor.