By Caroline Flint

Childbirth is very much a normal part of life. All of us were children and were born to mothers and fathers; many of us are mothers or fathers ourselves; it is an integral part of life and of the community. Babies are conceived in our own beds or on our own sitting room floors and pregnancy takes place during everyday life - there is a pregnant woman on the bus, the local shop assistant is pregnant, and the woman next door.

When the woman next door has her baby it will grow up next door, it will be breast or bottle-fed in the house next door, it will be loved and guided and sent to school and take exams and start work all from the house next door.

In 1987 the only event in that family's life together which will not happen in the house next door is the birth of that baby.

If this were obligatory for safety no one would question the wisdom of putting a woman into an alienating environment for her confinement. Yet more and more evidence is challenging whether a hospital actually is the safest place for the normal low-risk woman to have her baby.

I have worked as a midwife in hospitals considered to be among the foremost in trying to humanize the environment. Nevertheless I have observed that the accumulation of expensive equipment in a maternity hospital makes it almost obligatory for it to be used, such as electronic fetal monitoring and ultrasound. Both have some benefits, especially for women at risk, but their validity for women going through an uncomplicated pregnancy and labour remains very much in question.

The effects of gravity on the fetus encourage the dilation of the cervix; and lying in bed means the uterus is leaning back on the great blood vessels of the body and so restricting the circulation to the fetus. Imagine the difference when a woman is labouring at home. Instead of going somewhere strange, the woman is visited by the midwife. She will be watching television, sitting in the garden, in the bath, lying on her bed in whatever position she has chosen to adopt. It will be her choice, and the equipment to help her take up her chosen position is there in her own house - ordinary settees, baths, cushions, carpets or stools.

At home the woman is an individual. Because the environment is hers and the midwife is the guest, the relationship between them is subtly altered. When the midwife wants to do something to the woman she will automatically explain and ask her permission. Yet a woman who steps inside a maternity institution has to undergo a wide range of routine tasks as a matter of course, often without explanation,

Some of these routines are appropriate and right for some women, not for all. Many of them are inappropriate and unevaluated. Apart from the ethical questions, the implications of giving all women certain treatments are enormous.

Today when most homes have hot and cold running water and satisfactory heating and when most women are fit and healthy during pregnancy, it is sensible to compare the cost of keeping a woman in hospital with that of caring for her at home.

Staying in a hospital bed for 24 hours costs a minimum of £160. Most women are in labour for up to a day and, according to the Hospital In-patient Enquiry (Maternity) the average length of stay after delivery is 5.5 days. For the average woman the cost to the NHS is a minimum of £880, plus the cost of antenatal care, being in the delivery suite, fetal monitoring (£6 for scalp electrode, £4 for the recording paper) and analgesia. Add the cost of her partner's visits by bus, train or car and it can be seen that the decision to deliver all women in hospital was a very expensive one. In comparison, the cost of a community midwife at the top of her salary scale, with the additional costs of her car, phone and uniform, is no more than £60 a day.

Recent evidence supports a greater use of community midwives. Campbell has assessed every birth taking place at home in 1979. Not surprisingly, she found that those women who had not booked into hospital and who had not booked a community midwife were at very great risk, with a perinatal mortality rate (infant deaths) of 196.9 per 1,000.

Surprisingly, those who had booked for a hospital confinement and then delivered at home, either because of a precipitate labour or because they didn't leave for hospital in time, had a high perinatal mortality rate of 67.5 per 1,000.

But perhaps the greatest surprise to those who believe that babies can only be delivered safely in hospital was the perinatal mortality rate for those women who had booked with a community midwife and who had their babies at home - 4.1 per 1,000. Campbell surmises that if she had been able to find out what happened to the 10 per cent who were transferred to hospital, their perinatal mortality would probably have doubled to 8 per 1,000 - showing that a booked home confinement is a safe option for the woman at low risk of complications.

Damstra-Wijmenga looked at women who had opted for a home confinement in 1981 in Holland, comparing their results with a group of comparatively low risk women. The women who delivered at home experienced much less professional intervention than the comparable group in hospital, and their babies were born in better condition. He suggests that women at low risk may be in danger of hospital-induced complication when entering an institution which is geared to the pathology of birth.

Klein has shown how women and their babies have fared much better when assessed in early labour either at their home or in the GP's surgery by a community midwife. They actually had longer labours than women in a comparable group who had all their labour care in the obstetric unit, but they went into the maternity unit more advanced in labour; they received less analgesia; they had fewer instrumental deliveries; their babies had higher Apgar scores and less need of admission to special care.

Tew analysed the results of the most recent survey of British births (1970). She suggested that even when allowance is made for greater numbers of women at greater predelivery risk when looking at the figures for hospital births, perinatal mortality is significantly higher in consultant units than at home or in GP units. The outcry to refute her findings was speedy and shrill, but Tew is a statistician of standing and no-one has yet produced facts to disprove hers.

Women have been asked about where they would prefer to give birth, in recent surveys carried out by Woman's Hour and the Health Visitors Association. Fourteen percent said they would prefer to give birth at home; and this is after 15 years of intensive conditioning on the part of the medical profession that birth should take place in hospital. Perhaps the time has come to review this philosophy.

If the selection of women for home birth is sensible, including only those who have good social support, are nutritionally sound, are over five feet tall, have had no uterine surgery and no medical complications, the results should be excellent as long as there are good facilities for easy transfer to hospital. Women could give birth in the comfort and peace of their own homes, the midwife could be happy in her role and the NHS could use the money saved.

If we are not yet ready for this step, perhaps it is worth looking at Klein's ideas for assessing women at home in early labour. As O'Driscoll says, `the most important single item in the management of labour is diagnosis' perhaps by assessing women at home we should have fewer women in our labour wards who are not really in established labour. And how comforting it would be to a woman when she rings in the night wondering if she is really in labour to hear the reply `All right, we'll send the midwife round'.

We should be looking at birth at home as a viable choice for women - some randomized controlled trials along the lines of the Know Your Midwife project at St George's Hospital in Tooting, London. A group of five or six midwives could work together and look after 200-250 women a year throughout pregnancy, labour and the puerperium. A list of criteria (as suggested above) should be drawn up and 750 women a year should be selected as suitable for home delivery; the women could be randomized on a 1:2 basis so that annually 250 women would be the control group having their babies in hospital, as at present, and 500 would be offered birth at home.

In the present climate half of these women would refuse, leaving three groups: 250 having babies in hospital, 250 having their babies at home and 250 who were offered a home-birth but opted for hospital. The results could be analysed over a four-year period giving a realistic evaluation of home birth. It is also of paramount importance to find out how the women feel about the experience and what their preferences are.

There are currently around 157,000 qualified midwives but only 26,500 are practising - one out of every five. This huge wastage represents a tragedy of lost hopes and lack of job satisfaction. If my suggestions could be practised, would we have room for all the midwives who would come rushing back, as well as enormous benefits to mothers and babies?

References

Caldeyro-13 arcia. Physiological and psychological bases far the modern and humanized management of normal labour. Scientific Publication No. 858, Centro Latinoamericano de Perinatologia y Desarrollo Humano.

Campbell, R. (1984). `Home births in England and Wales, 1979: perinatal mortality according to intended place of delivery', British Medical Journal, 289, 22 September. Damstra-Wijmenga, S. (1984). 'Home confinement: the positive results in Holland', Journal of the Royal College of General Practitioners,.

Klein, M. (1983). `A comparison of low-risk pregnant women booked for delivery in two systems of care: shared care (Consultant) and integrated general practice unit', British Journal of Obstetrics and Gynaecology, 90, pp. 118-128.

Tew, M. (1985). `Place of birth and perinatal mortality', Journal of the Royal College of General Practitioners, .

Flint, C. (1985). `Labour of love', Nursing Times, January 30 and Poulengeris, P. (1985). `Under the microscope', Nursing Times, February 6.

O'Driscoll, K.(1980). Active Management of Labour, W.B. Saunders.

Spring 1987