Home birth

[Sheepoverthemoon]

Has asking for a hb been a challenge with the midwife and drs? I'm really keen to have a home water birth (and thought I did my research well) and was really positive for asking, but my friends have been trying to put me off and say that it's a battle to get a hb for your first baby and it's very risky for the first one...
Any advice would be great

[ReallyTired]

I feel stats can be twisted to suit whatever viewpoint you are trying to prove. The type of mother who opts for a homebirth is very different to the type of mother who opts for a consultant led unit. A mother who expects horrendous pain is more likely to become fearful and this can inhibit the birth process.

Individual factors affect the safety of birth place. I believe that for ME homebith was the safest and most sensible option available.

[PenguinsEatSpinach]

Minifingers - Yes, that was my point too.

JCB - You have said "there is a small but very present risk that a home birth could result in a disastrous outcome that could have been avoided had delivery been in hospital. It's tiny, but it's there."

Which is fine, but yes, it is tiny. So tiny it isn't showing up in the stats in terms of outcomes for almost all groups in both home and MLU planned place of birth. It shows up a tiny, tiny amount in homebirth for first timers, but bear in mind that they lumped a lot of adverse outcomes together to give statistically significant outcomes, we aren't talking a standalone risk of neonatal death or long term damage.

Against that background, I feel it is valid to weigh in the equation that, if you choose hospital, there is a much increased chance that you will have an instrumental or surgical delivery. Along with other downsides that are more prevalent in hospital - like emotional trauma to the mother resulting from being left alone and in pain, etc. To some people those won't weigh as negatives, to others they will heavily. And these are less serious, but far higher frequency risks. You would think, as you say, that 'if you needed intervention you'd end up with it anyway' wouldn't you? But the stats don't bear that out. The stats say that, if you take a group of low risk women and some plan home/MLU and some plan CLU, the ones planning CLU are far more likely to end up with sections/intrumentals. Which implies that something in their care or setting is increasing the rates (or, to put it more emotively, that CLUs leave you exposed to instrumentals/sections which could have been avoided).

I dislike the implication (not saying you are, but which you often see in these debates) that it is only relevant to weigh the tiny, tiny (not even showing up in the stats), but obviously catastrophic risk and not the fairly high but less serious risks when making your decision. That's what we do in almost any other decision making process. Except, as you say, humans are famously bad at balancing and judging risk - hence so many people afraid of flying but few of cars.

As regards the seatbelt analogy - seatbelts do all that damage whilst saving you. I think we were talking at cross purposes. If I drive around without my seatbelt I gain nothing on an average journey, and I lose if there is an accident. The equivalent for birth would be if my seatbelt might randomly bruise me or fracture my ribs without there having been an accident.

I also disagree with the idea that a homebirth that ends in a hospital transfer is 'failed'. It isn't comparable to a car only working half the time. It's like saying that the many, many first time mums who want a natural birth and end up with an epidural are 'failed' natural births. I don't think that most people who choose home birth see it that way. They see home as where they would like to be if things are going well and they are comfortable, then hospital as the choice to move to if not. Just as many mothers who choose to labour in a CLU/alongside MLU might choose gas and air and the pool as the favoured choice, and move to further pain relief if they need it. We'd never call them 'failed', so why apply that language to a homebirth transfer when it is really just responding to changing circumstances in a responsible way?

[weebairn]

It's a small point, but someone mentioned it above. I think the reason doctors are usually anti home births is nothing whatsoever to do with evidence and everything to do with the personality types who become doctors.

I have tried to explain statistics to other doctors and they insist on telling me about some random gory anecdote as if it's evidence; it's enough to make Ben Goldacre cry. (Other doctors have found the idea of home births quite normal and sensible including a couple of obs&gynae mates, but they always seem to be less vocal…)

People are often very irrational about birth - this includes health care professionals. That's ok when you are using it to make decisions for yourself, but it does rankle when you try and use your professional status to scaremonger others.

Anyway, I'm a doctor who had a home birth, so not all doctors are opposed to the idea. Several midwives told me (thankfully AFTER the birth) that they had never ever met a doctor who even had a straightforward labour!!! I wouldn't begin to speculate why… but very glad no one told met that beforehand!

My main point remains: both options are safe and it's fine to have a preference. If a home birth needs things that can't be done at home; well you go to hospital, with your midwife. That's not a failure of a home birth, that's just the way labours go sometimes.

[whereisshe]

It's a good point weebairn. The psychology of birth is just as important as the physical aspect, given how mood alters the hormone release etc. And a "safe place" to give birth in means different things to different people; personality type and experience play a big part in that.

The GP who came to do DD's newborn check actually told me I was "brave" for having a home birth whereas I think women who have c-sections are far braver! I do know one ob/gyn who tells me she'll consider a home birth but only for the second baby. And my GP who did the 6 week check (who is preggers) told me it was "hospital all the way" for her...

Another aspect in addition to humans' inability to accurately perceive risk is our tendency to share the horror stories rather than all the stories, and to prefer anecdote to data (as someone once said, "data is not the plural of anecdote"). People who say 'I had a lovely safe home birth' get told they are lucky and then forgotten (boring story). People who have to transfer for complications are talked about and remembered. Also those are the births that validate the expectation of home birth 'failure' that some people have. There's definitely confirmation bias at work.

[ReallyTired]

I think that ignorance is bliss when you are labour. Having a good midwife that you can trust implicitly makes for a better birth experience. I imagine that its hard for doctors to put their medical knowledge aside and act like a cow (in labour!)

Certain activities like having sex or giving birth do not require intelligence. I expect that many professional women over think things.

[weebairn]

My best mate is a midwife and she was there. My mum was a midwife too. I guess I am more sympathetic to indoctrinated by midwifery than most doctors

(Not that I am taking credit for having a straightforward labour; I know i was fortunate!)

[LaVolcan]

The psychology of birth is something which seems to be completely overlooked, IMO.

Similarly, telling someone how wonderful the CLU is if, XY or Z occur, may well reassure some, but terrify the life out of others.

[LaVolcan]

Was it just down to good fortune though, weebairn? I believe that it's already known that one to one care given by a known attendant leads to better outcomes.

[weebairn]

I think I gave myself the best chance; but there's still luck involved. I never want anyone to feel like they "failed" at home birth because their labour developed complications: sometimes it just happens. There are also high risk women who are advised to have babies in hospital with full monitoring etc and that's what I mean by luck I suppose: i was not one of them and had more choices. You are absolutely right about one to one care though - isn't that supposed to be the greatest factor influencing a good outcome? That and free antenatal care.

I wish these threads wouldn't' get bogged down so much in the rare disasters and talk more about the problems you are actually likely to experience. For me, the problem with home birth is not the tiny chance of a catastrophe (which also exists in hospital) - but issues with being demoralised if you transfer, etc. I mean you talk to a thousand women and what are the main problems? Poor postnatal care (and sometimes during labour), wanting pain relief they couldn't get, people who felt scared, unsupported, unable to deal with the pain, not listened to, poor breastfeeding support, overstaffed wards, a discrepancy between pushing breastfeeding antenatally and not supporting it postnatally…

[Astonway]

It is all about your attitude to risk. I am by nature a pessimist and so opted for hospital for both as I knew that I would not be able to live with the thought that I had prioritised my personal experience over the safety of my baby should anything have gone wrong. But I ended up with a useless midwife and being blue-lighted at midnight from a local cottage hospital unit to the big cheese anyway! Then it was fine and I was away with the fairies for much of it anyway so I have no recollection of detail. Not on any drugs as it was not painful just powerful; my brain sort of took charge and sidelined me. DH was my watcher!

[weebairn]

But I don't think home births are prioritising your personal experience over the safety of your baby as there is no bigger risk to your baby.

To play devils advocate, you could say that about epidurals (personal experience prioritised over baby safety) - but I would never dream of suggesting a woman shouldn't have an epidural if she wants/needs one.

I wanted to optimise my chances of breastfeeding too. And I'd not heard great reports of hospital breastfeeding support. That wasn't to do with my personal experience, it's because of very demonstrable better outcomes for baby!

astonway that all sounds very stressful ;glad your DH stepped up!!

[ReallyTired]

Astonway Are you suggesting that I prioritised my personal experience over my baby' safety. Seriously in MY situation home was the safest place to give birth. I made an educated decision that a home birth was the least risky option for my family. Everything was so fast we would have never made it to the hospital.

I believe that I was lucky. I am lucky to be in good health and not have had had pregnancy complications. I had a very good community midwife as well.

Having a good birth experience is ultimately down to luck.

[PenguinsEatSpinach]

Astonway - That sounds very scary.

But I agree, your language is very emotive and also quite inaccurate. A lot of things we do in labour could be accused of 'prioritising our experience'. Like pethedine, which we know can have an effect on the baby (albeit a minor one). Or choosing the local cottage hospital over the big unit (not referring to you specifically, and I realise that you may not have had a choice. But many women do have choices and make choices like this because, for example, it means lesser transfer time when they initially go in). But we don't use that type of language about other things.

Also, dismissing it as 'personal experience' makes it sound wishy washy and wanting whale music. But what if we phrased it as 'taking account of likely effect on mental health for the benefit of both herself and her baby', which for many women who choose home birth would be a more accurate descriptor of what they are taking account of (it certainly was for me with my second birth, which was at home). There are also factors which have nothing to do with 'experience' - like reducing the risk of forceps for both me and my baby after having them first time round.

[MummytoMog]

I wouldn't have felt comfortable at home for my first delivery - I was left very much to my own devices in hospital, allowed to move around, and encouraged to do what I felt like doing. Unfortunately DD was very very stuck, and we had a horrible trip to theatre, a spinal and forceps, then quite a poorly baby. The ten minutes to get me into the theatre was bad enough, and we were a good half an hour away from the hospital. If you are close to the hospital, and you feel ok about the possibility of transferring anyway, then why not start at home? And stay open minded about going to hospital. I personally would have been fine to delivery my second child at home but poor DH is a bit scarred from DD's delivery, so we went to the midwife led unit. Which was lovely, really lovely. Expecting DC3, and again I would be happy to deliver at home, but I'd rather DH felt safe and secure. Which he wouldn't at home.

[JanePurdy]

weebairn my DH is a doctor, we have planned two homebirth (the first ended up as a hospital transfer) - his colleagues have always been very surprised! To generalise, I think doctors get trained in a very risk averse fashion & become very aware of what can go wrong.

If we have a DC3 we will absolutely plan a third homebirth. For me the criteria are: do we live close enough to a hospital to transfer safely, and has it been a straightforward pregnancy thus far.

To answer the original question in the OP, I haven't had any problems with reactions from doctor/midwives in planning a homebirth.

[Jcb77]

I got involved with this thread because it was stated early on that 'It takes ~30+ mins even in a hospital to prepare for a crash section. This time is similar or lower for people transferring in for a homebirth'
Neither parts of this statement are true (although the second half might sometimes be just about feasible). If they were taken as true, then it might well make a significant difference to a decision making process.
As has been pointed out, the situations in which being in hospital actually stops a baby or mother dying are tiny. Not large enough to reach statistical significance. Statistical significance however is not the same as personal significance.
A home birth is in general very safe. With many pros (for some) over a hospital birth. In general a hospital birth is very safe. With many pros (for some) over a hospital birth.
Whether you take the incredibly tiny risk of an unexpected event happening so quickly that you are too long away from a hospital to get there in time (assuming that you could be helped even in the hospital - not always the case) if a matter of personal risk acceptance.
I have also tried to point out that bare numbers do not give the whole story (the vast clinical differences that are covered by the arbitrary cat1 and cat2 sections definitions for example).
There are those who have planned and had a very successful home birth. Brilliant.
There are those who have planned a homebirth and have had to be transferred for whatever reason that have described themselves as having 'failed'. Which is awful.
I think to have a homebirth though, you actually have to deliver at home, otherwise it's a home labour? No?
I also see more than enough women who have planned a hospital birth who say they have 'failed' if it doesn't go according to their plan which is equally horrible.

It is a very emotive subject about which we all have our own views, preferences and experiences.
Yes, doctors do tend to be risk averse (I certainly am) and a good job too - for their patients! But everyone is moulded by their experience and will reach conclusions because of that.

I wanted to correct an inaccurate statement that might have had a significant bearing on a decision and to try to give some insight into why bare statistics don't paint the whole picture.

OP - whatever you chose, you will almost certainly be fine. If you're happy to accept that quite a few homebirths end up being transferred in labour, usually with plenty of time, and that the statistically insignificant risk of something awful happening might have been preventable if you were in hospital, then fine! Home births do have their advantages and you know it's something you'd rather then that's your decisions. I would say that you should ask the questions and if hcps are unsupportive then try to find out why. If it's because of generalised population based risks that you've already decided you're happy accepting with, then push for a home birth. If it's because of something specific to you, or your area, then take that on board too and if you're still happy with your personalised risk, then go with it. And good luck with whatever you chose.

[Jcb77]

Mini fingers - yes, about the jncreased rates of intervention in CLUs. I know. Hence grumpy. And I don't have the choice of an MLU.

Penguin - the seatbelt analogy. Maybe is would work better if we considered an excessively tight seatbelt. It doesn't hurt you randomly. There has to be a trigger and perhaps it causes more damage in lower speed crashes than not wearing one. A risk-averse, over cautious seatbelt perhaps? But not a random one.

[Minifingers]

"The type of mother who opts for a homebirth is very different to the type of mother who opts for a consultant led unit. A mother who expects horrendous pain is more likely to become fearful and this can inhibit the birth process."

In my experience as a homebirth contact for the NCT for several years, when I spoke to dozens of women contemplating a homebirth, women opt for out of hospital births for all sorts of reasons, but one of the main ones is a fear of hospitals/needles and a previous traumatic delivery.

[Minifingers]

Jcb77 - I also didn't have the option of an MLU (wasn't low risk), so I opted for a homebirth.

[LaVolcan]

I think to have a homebirth though, you actually have to deliver at home, otherwise it's a home labour? No?

Well, for statistical purposes, like the Place of Birth study, no, it was whether the labour started at home. Otherwise you are faced with the scenario of things almost certainly only going wrong in hospital, so valid comparisons about the place of birth couldn't be made.

I also see more than enough women who have planned a hospital birth who say they have 'failed' if it doesn't go according to their plan which is equally horrible.

But sometimes I think women should be more annoyed that they have been failed by a system which is not responsive to their needs.

[PenguinsEatSpinach]

JCB- Ok, deal. A risk averse, overcautious seatbelt.

[Jcb77]

Mini - glad it worked well for you. I'd very possibly go for an MLU if there was one attached to a CLU here, but there isn't. And for me and this pregnancy, a hb is too much of a step I the opposite direction. Ah well.

LaVolcan - unless you're induced, don't all labours start 'at home'? From a stats point of view I can see that the intended place of delivery is counted, not the actual place, sure. But I haven't met many women claim to have actually had a homebirth if they actually delivered in hospital..... Whatever the initial intent.

Penguin - yay! :)

[LaVolcan]

Jcb77 - I think you are splitting hairs a bit. Yes, if you transfer you are likely to say that you planned a homebirth but it didn't work out that way, or if you accidentally have a homebirth when you planned a hospital birth, then yes you would say you had an unintended home birth. What you would say if you give birth en route, I am not sure.

I think you can see why the distinction is necessary for statistical purposes or else we are back to the statement that of course more things go wrong in hospital. Without this distinction it would not have been possible to tease out that low risk women in hospital are more likely to have interventions, without there being the trade off of a better outcome for the baby.

Incidentally, although you state that those who have to be transferred describe themselves as having failed, I wonder whether that is the case? Perhaps someone who needed to transfer for more assistance could say whether they felt that they had failed or not?

[weebairn]

Jcb

I don't think it's always a good thing for doctors to be toooo risk averse. "First do no harm…"

I say this as an acute med doctor. We don't admit everyone to hospital who chips up to A&E, and we don't give everyone full body scans. For very good reasons.

[weebairn]

LaVolcan I have a friend who did most of her labour at home and speaks of it very proudly. She was then transferred and had forceps in the end, but she mostly says to people "I laboured until 9cm at home in a pool".