Home birth: putting evidence into practice and promoting choice

This blog is linked to Life lesson 1 How to prepare a conference talk  – living and learning also published yesterday, 8th June 2016.

Having come from a wonderful conference on home birth organised by the University of Bradford Midwifery Society, which I enjoyed enormously and was privileged to be invited to speak at, my key messages about Home birth: putting evidence into practice and promoting choice are these:

Why does the issue matter?

How women give birth is a political and human rights issue. From a feminist perspective, it is a women’s rights issue. Individuals and organisations have lobbied to raise awareness about home birth and the need for home birth services to be offered to women routinely. Choice of place of birth has been official policy since the early 1990s, yet the rate of home births remains low at around 2-3% for England overall. There seem to be obstacles in the way. We need to understand what they are.

Who stands to benefit?

Birth place decisionsThe Birthplace in England study, a large, prospective cohort study of direct relevance to our maternity services, showed that pregnant women at low risk of complications (generally, women who are healthy with a straightforward pregnancy, and no previous obstetric complications) are more likely to have their whole labour and birth without the need for medical procedures (epidural, episiotomy, forceps, ventouse or an emergency Caesarean section) if they plan for a home birth rather than book for care in an obstetric unit. For ‘low-risk’ women who have previously had a baby, planned home birth is very safe. For ‘low-risk’ first-time mothers, there is a small additional chance of an ‘adverse’ outcome, but the absolute risk is still very small.

What are women saying?

Women responding to NCT surveys told researchers what they found helped them have the kind of birth they wanted. The things they rated most important in descending order were:  a birthing pool or a large bath; en suite toilet / bathroom; a comfortable, adjustable bed; low lights or adjustable lighting; privacy and quiet. Women who had a home birth reported having access to these things more often than women who had their labour and birth in other settings.(See NCT report on Better birth Environment accessible at: http://www.arquitecturadematernidades.com/sites/default/files/nct2003_bbe_report.pdf

How might clinical outcomes, experiences and wellbeing be enhanced?

There is evidence that clinical outcomes, women’s experiences, start in life for babies and long-term wellbeing can all be enhanced if women are offered the opportunity to plan for a home birth.

What shall we do?

  • Be proactive in suggesting home birth as an option to women whose pregnancy is straightforward. Offer it first or second as a birth option, not as the afterthought or final option.
  • Aim for a home birth rate of at least 5% in your local authority area. We (NCT BirthchoiceUK) have hypothesised that unless there is a critical mass of 1 in 20 pregnant women having a home birth there probably isn’t sufficient infrastructure in place to offer the service universally, there may be too few community-based midwives to offer home birth pro-actively and – crucially – women and men will not know others in their neighbourhood or friendship groups who have planned for a home birth, so it won’t seem like a ‘normal’, achievable, mainstream option. (see Location, Location, Location, NCT https://www.nct.org.uk/get-involved/campaigns/pregnancy-birth-campaigning/location-location-location)
  • Provide women with positive information about home birth. Share the other practical issues including letting first-time women know about transfer rates and the small additional risk to their baby. Discuss this openly and in context. Let the woman decide and support her decision-making. Use the information summary published as part of the NICE Intrapartum Care guideline. https://www.nice.org.uk/guidance/cg190/chapter/1-recommendations Use infographics to show what the numbers mean visually (e.g. Kirstie Coxon decision support: http://www.midwiferyunitnetwork.com/generic/
  • Encourage women to attend local home birth groups, online home birth communities and networks. Midwives need to know about good links to suggest.
  • As midwives, run regular groups for women and couples interested in home birth and invite women and their partners to attend. As women/couples to help run the groups.
  • Provide continuity models of midwifery care. Give women a mobile phone number for contact at any stage. Experience suggests that women respect this and don’t abuse it.
  • Discuss with women and men planning for or considering a home birth ways of preparing for labour and birth. Know of good books to recommend, such as The Homebirth Handbook (Vermilion) by Annie Francis, published June 2016.
  • Talk to women about the joy, comfort, intimacy, convenience and cleanliness of a home birth. Discuss positively how birth is a special social occasion filled with emotional significance and a rewarding physical challenge, rather than a clinical episode.
  • Discuss the benefits for babies of straightforward birth, not being separated from the mother after birth, skin-to-skin, easier start to breastfeeding, all of which can be enhanced in the setting of home.
  • Acknowledge that women and men are on their own territory at home. The midwives are guests in their home. The power dynamic shifts.
  • Talk in a matter of fact way about how birth doesn’t always go according to plan and if a women needs an epidural or she or her baby need assistance, that’s what the hospital is for. It’s all about having the best experience in the particular circumstances.
  • Collect and share (with permission) women’s and men’s accounts of their labour and birth and the hours /days afterwards.

 

NB: There is debate later in the afternoon about how much information women want about possible ‘risks’ and risk assessment. Four women attending the conference who had had a home birth felt the discourse around risk was unwelcome and dispiriting. Often a constant source of negativity throughout pregnancy. This prompted discussion on how much information is needed for informed decision making.

NICE Intrapartum Care guideline. https://www.nice.org.uk/guidance/cg190/chapter/1-recommendations Use infographics to show what the numbers mean visually

Birth Place Decisions, Coxon K. decision support: http://www.midwiferyunitnetwork.com/generic/

Location, Location, Location, NCT  Available at: https://www.nct.org.uk/get-involved/campaigns/pregnancy-birth-campaigning/location-location-location 

Singh D and Newburn M (July 2006) Feathering the nest, Midwives 9;7,266-269. Available at: https://www.rcm.org.uk/news-views-and-analysis/analysis/feathering-the-nest-what-women-want-from-the-birth-environment

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