Caroline Flint's Midwifery Essays

Delivery at Home

Allowing women who wish to have a home delivery may make them feel more relaxed and secure during labour, says Caroline Flint

On the day you read this article, 20 babies will be born at home in England and Wales. This is a small number with the 1,580 who will be born in hospital. But it is likely that each birth at home represents a struggle by the parents to achieve having their baby at home.

They may have had the senior midwife coming to their house to `test' their commitment to home birth by trying to persuade them to have their baby in hospital and leave soon after the birth. They may have had an emotional reaction from their GP who probably doesn't favour birth at home. The midwife who attends them may have spent time initially trying to persuade them to have the baby in hospital. On the other hand, she may have arranged for them to see a GP who was not their usual one so that they had a sympathetic GP to support them.

They may, to their surprise, have had their request treated as normal. The midwife may have been pleased at their decision. Or they may have engaged an independent midwife who does nothing else but home births. Or their GP may be one of the few in this country who favours birth at home and supports women asking for it.

Brave

Whichever way, the decision will have caused a stir among the couple's friends and relatives. They will have been besieged by people telling them how brave they are.

Home birth is such an emotive subject that it never goes unremarked. Despite the numerically few births at home in 1989, their effect is all out of proportion to their numbers.

Why'? What is it about birth at home that is so controversial? Why do people choose to have their baby at home?

I sometimes reminisce on my choice of a home birth for my first child in 1965. Having worked in maternity hospitals, I knew that they were not restful places and that women had problems in sleeping when so many mothers and babies were crammed into one large room.

So the main reason for my choice of a home birth was that I wanted as much rest as possible after the birth - to sleep in my own bed with my own dear man beside me.

Shared event

That also is a great benefit of having a baby at home - both parents learn together how to bath a baby, how to change its nappy, the delights of winding. The father of the baby also has a greater part to play in providing care for his wife: cooking her meals, washing sheets, knickers, endless babygrows. It may be exhausting, but it makes the birth of the baby, and the becoming of a family, a shared event right from the start.

In 1965, I had no problem in arranging for a home birth, since about 30 per cent of women had their babies at home in those days. It was an accepted part of life. No-one suggested that I was brave or even foolhardy; I was just having a baby.

Another reason for choosing a home birth is to stay in control of the situation. Even in labour, the woman is the hostess. The medical personnel are the visitors.

It is the mother's house, her domain. Even what is available to drink and the availability of clean towels is controlled by her. For some women, this is a paramount reason for a home birth. They don't want anything `done to them' without their willing agreement, and it is extremely hard for this to happen to them in their own home.

Safer

A more recent reason for choosing to have a home birth is that some women genuinely feel their baby will be safer at home than in hospital. Some women become frightened by the number of `routine' procedures which are likely to come their way if they give birth in hospital. They feel they may be putting their baby at risk.

An instance is the routine rupture of membranes at a certain stage of cervical dilation, which is common in many hospitals. Many women are well versed in the literature surrounding childbirth and aware of the work of Kitzinger and Caldeyro Barcia.

They have shown that artificial rupturing of membranes increases pain of labour, decreases the women's ability to cope with the pain of labour and is more likely to end in an instrumental delivery than when the membranes are left intact to rupture spontaneously (usually at the end of the first stage of labour).

Women know about the work of Kumar and Robson which shows that when women have their membranes ruptured artificially during labour they are less likely to feel attachment to their baby and more likely to feel distant from their baby. Women want their baby to be born in optimal conditions and they don't trust that these are necessarily the conditions which prevail in their local maternity unit.

This sentiment was voiced in the controversial gathering together of research and studies into birth made by Campbell and McFarlane. They propose that, according to all the available data: `There is no evidence to support the claim that the safest policy is for all women to give birth in hospital'.

Morbidity

An equally compelling statement is that `There is some evidence though not conclusive, that morbidity is higher among mothers and babies cared for in an institutional setting'.

Even with the large body of research which has now been amassed to show that childbirth at home is a safe option, many people are frightened by the prevailing philosophy in maternity care - `What if something goes wrong?'

The whole of maternity care at this moment is geared to this concept of abnormality and pathology. Surely, with those thoughts uppermost in the care-givers minds, it is more likely that things go wrong.

Women are so susceptible during pregnancy and labour, it is surely much easier to be at home with the concept that `things will go well'. Then, if things do begin to go badly, transfer to hospital is in order.

References

Schwarcz, R. and Calddyro-Barcia, R. (1887). `Amniotomy', in Anderson, Chalmers and Turnbull (Eds). Elective Delivery in Obstetric Practice, Oxford University Press. Campbell, R. and MacFarlane, A. (1987). Where To Be Born: The Debate and the Evidence, Oxford: National Perinatal Epidemiology Unit.