By Caroline Flint

A month ago I booked a woman for a home delivery for her second child who is due next March. I wrote to her GP to inform him that I had booked her and that she would be cancelling her hospital booking. I also asked him if he would be willing to provide medical cover for the delivery, but if he was unwilling to do this I would arrange with the local supervisor of midwives to transfer the patient to the local obstetric unit in the case of any abnormality arising. I also asked the GP if he wished to continue with shared antenatal care with me instead of the hospital.

Having treated the doctor in a professional and polite way, I received no reply to my letter. I then also heard from the patient that when she went to see the GP he tried to frighten her about having a baby at home - quoting instances about seeing women bleed to death at home and telling her about the risks and dangers of home birth. All this to a Gravida two, well nourished, well educated, non smoking woman with suitable housing, whom I delivered of her first child two years ago. The whole pregnancy, labour and puerperium could not have been more normal.

I have not yet met this GP. I am used to working with GPs who are supportive to women and who see themselves as providing a continuum of care which spans the whole family and the whole of life from birth to death. It seems to me that this GP is not only letting down his patient but also his profession. If GPs are not willing to provide a service which women are asking for - I suggest they will lose out eventually.

The other reason I see the GP losing out is that it seems to be more and more difficult for a GP to provide maternity care within the hospital. With the increased closure of GP maternity beds and with the new, more stringent requirements to get on the obstetric list I can see the GP disappearing from full maternity care and only able to provide a minimal antenatal service together with his community midwife.

So what shall I do about this GP? Shall I leave him alone and let him go on frightening pregnant women? Or shall I send him the paper by Rona Campbell and others?' They looked at every birth which took place at home in 1979 and they discovered that when a baby was born to a woman who was unbooked, the perinatal mortality rate was 196.9/1000. The perinatal mortality rate for a woman who was booked for a hospital delivery but actually delivered at home was 67.5/1000, but the perinatal mortality rate for women booked for a home delivery was 4.1 / 1000.

Shall I send one by Damstra-Wijmenga MDz who looked at all the women in Groningen in Holland who had babies in 1981. A table of 1,692 women took part in his survey, of these 11.7 per cent had no choice as to where to deliver, they were women who we would term 'high risk' and they were referred to an obstetrician and had their care in hospital. The rest of the women had a choice: they could deliver at home; they could deliver in hospital and stay for just 24 hours; or they could deliver in hospital and stay for a week.

Damstra-Wijmenga shows that `among those women who had opted for home confinement significantly fewer complications occurred during pregnancy, delivery and puerperium than among those who had their babies in hospital followed by a 24hour stay there or followed by a seven-day stay in a maternity ward. Morbidity was also lower among the babies born at home than among those born in hospital.'

He surmises, `for a normal healthy woman after a pregnancy without complication, it is questionable whether a hospital is, in fact, the "safer" place for having a baby. It should be realized that when a woman decides to have her baby in an environment designed to cope with childbirths in which there is a certain degree of risk, there is a good chance that the hospital facilities will actually be used on her, thus imposing a risk of iatrogenic damage.' are safe for low risk women who are booked with a midwife for a home birth. I wonder, therefore, if my GP points out any of the dangers of hospital delivery to the women who book with him - increased risk of infection, increased risk of intervention, increased risk of separation of mother and baby, interruption in family life with the father being excluded during the postnatal period. It is naive to believe that just by being inside a hospital all risks melt away.

References

1. Campbell R. `Home Births in England and Wales, 1979: perinatal mortality according to intended place of delivery.' British Medical Journal 1984, 289: pp.721-724.

2. Damstra-Wijmenga S. 'Home Confinement: the positive results in Holland.' Journal of the Royal College of General Practitioners, August 1984, pp. 425-30.

January 1986.