By Jolyon Ford

The model of care and the location of care are obviously closely related. As can be seen, some providers offer home birth services, others are based in a hospital.

According to US data, nearly 100% of births were outside hospitals in 1900, 44% in 1940 and 1% by 1969. Since then 98-99% of births have been in a hospital. The same pattern is seen in most developed countries. After the Second World War, the ability to manage infection with antibiotics and haemorrhage with new drugs, surgery, anaesthesia and blood transfusion resulted in a significant drop in maternal death rates. In addition, standards of maternity care improved. Hospitals gained the reputation as the safest place to have your baby, although this may have been due to improvements in practice rather than the location of the birth.

Home birth has continued in small numbers in most developed countries, accounting for around 0.5-2% of births in Australia, the US and the UK, 3-4% in New Zealand but as high as 20% in the Netherlands. The recent empowering of women to make informed choice about their care has resulted in an increase in homebirth numbers in the last decade. Sitting somewhere between a home and a hospital birth is a birth centre. These are freestanding or connected with a nearby hospital and provide a low intervention service for low risk women.

Most national organisations acknowledge the right of women to make an informed choice about their location of birth but also advise that consideration is given to the individual circumstances and that those who are considered higher risk should have their birth in a hospital. Speak to your practitioner or do some investigating to find what services are available for you locally. There is no harm in arranging an appointment with a practitioner to discuss your options before you commit.

HOSPITAL BIRTH

Hospitals vary significantly from small rural hospitals to large city centres. Not surprisingly, smaller hospitals tend to manage lower risk cases and large town or city hospitals manage ones of greater complexity. This can mean that you plan to have your baby at your local hospital but if you go into labour very prematurely or develop an early complication such as pre-eclampsia you may be advised to transfer to a bigger hospital where more resources are available. Fortunately, these complications are rare and most women will give birth in their planned hospital. If you have medical issues, speak to your team about whether this would influence the location of birth. Most maternity hospitals provide midwifery and obstetric care (sometimes GP obstetricians), anaesthetic support for epidurals and if surgery is needed, operating theatres, paediatricians and neonatal nurses for newborn care, often in a dedicated neonatal unit or special care nursery, pathology for blood tests, radiology for ultrasound, a blood bank or access to blood products in case of bleeding, and the support of other practitioners in the hospital if needed. Hospitals will have access to other services such as a diabetes unit, and allied health support including physiotherapy, dietetics and social work. This gives them the ability to manage anything from a normal birth through to medical or pregnancy related complications.

Hospital birth

[ + ] Most hospitals have services to cover normal birth, routine and emergency investigations and the management of problems if they arise. They have urgent access to emergency care and a range of specialist services. Larger hospitals provide high levels of expertise for rare and complex problems.

[ − ] Provide a more medical model of care that can be associated with higher levels of intervention.

Larger hospital-based services can seem less personal and may not be able to offer one-to-one care. Some smaller hospitals do not offer all services and transfer may be required if preterm birth or more complex issues arise. Private hospital birth is expensive and may not completely be covered by insurance.

BIRTHING UNIT

Some areas have birthing units that may be on the same site as a hospital, or freestanding in a town or neighbourhood on their own. In the UK, New Zealand and the Netherlands this accounts for around 10% of births. The care is provided by midwives and there is a strong focus on supporting women towards a natural birth with low levels of intervention. They use less technology and so tend not to use continuous fetal monitoring, vacuum or forceps to assist the birth. Some pain relief options are available, but procedures such as epidurals, instrumental birth or caesareans are not. If issues arise that require medical care, a transfer to the hospital is arranged, which can sometimes delay the care. In one UK study around a third of women having their first baby are transferred, but only 12% having their second required this.

Birthing units have a strong relationship with a local hospital and clear guidelines on when to transfer care. They are not suitable for women who may be at risk of difficulties in labour, or those with medical conditions such as blood pressure problems or diabetes.

Women in birthing units are more likely to achieve a natural vaginal birth, have one to one care in labour, and satisfaction levels are high. Intervention is lower, even when compared to similar low risk women labouring in a hospital.

Birthing Units

[ + ] Midwifery led care for low risk pregnancies. Strong focus on natural birth. Good outcomes for vaginal birth rates and lower levels of intervention. No evidence of additional risk for mother or baby.

[ − ] Around 20% still require transfer if requiring epidural or other medical assistance. First labourers more likely to require transfer. Potential delay in accessing emergency assistance whilst being transferred.

HOME BIRTH

Around 1-2% of women have their baby at home. Home can be a warm friendly environment with home comforts, a supportive group around you and for family or close friends to play a more active part in the birth. Many women hire an inflatable pool or use the bathtub for the support and relaxation of water. The room can be set up with music, soft light and aromas to suit your preferences. It is suggested that this more relaxed environment may reduce some of the stress hormones and allow your natural labour hormone, oxytocin, to work more effectively. There is no doubt from studies that women who labour at home have a greater likelihood of a natural vaginal birth and a lower caesarean section rate. A review of the published literature on place of birth in 2018 found evidence that low risk women who planned a homebirth had a much higher chance of having a natural vaginal birth (91% vs 54%) and so less chance of needing a caesarean (2.1% vs 9.6%) or an assisted vaginal birth with an instrument (6% vs 14%). These differences may not all be due to the location of birth. Women that choose home birth are more likely to be physically healthy, motivated, less likely to have social or medical risk factors, and so we would expect them to have better outcomes as a group. There have been very few trials that randomly allocate women to home or hospital birth so the effects of the differences in the two groups is hard to measure.

People may wonder if the reduced access to all the emergency treatments that hospitals have is a problem. In an emergency, there is no doubt that immediate life saving measures can make a difference. Examples include a very heavy bleed after the birth (post-partum haemorrhage), an eclamptic seizure or a baby that is not breathing.
A home birth midwife is trained to initiate important life-saving measures whilst calling for help and arranging an urgent transfer to hospital.

In almost all cases, this is sufficient until you get to the hospital where further care can be given. Whilst it is possible that this delay may cause problems, the chances of it happening are rare. For this reason, home birth is safest when you have a skilled home birth midwife who has a good relationship with the local hospital and a clear protocol on when transfer is appropriate. When looking at low risk cases, the safety outcomes for mother and baby are similar or a little better for homebirth compared to hospital birth. So a well organised homebirth program for low risk women is considered safe.

Studies have also shown that when higher risk women labour at home complication rates including the loss of the baby (9.3 in 1000 vs 3.5 in 1000) are more common than in hospital. In one study, the commonest risk factors for a bad outcome at home were having a previous caesarean and being post-term (over 42 weeks).

Transfer rates into hospital vary. In a review of 15 studies from around the world, around 39% of women in their first labour required a transfer during or after the birth. For women having their second baby or more, the transfer rate was 10%. Overall, only 3% had emergency transfers.

Home birth

[ + ] Your own environment, home comforts and a relaxing, less stressful ambience. High chance of vaginal birth and less chance of having a caesarean, instrumental birth or epidural. As safe as hospital for low risk births. High levels of satisfaction.

[ − ] Service not available in all areas. Private home birthing can be costly (but cheaper than private hospital birth). May require transfer into hospital (more common in first labour). Some emergency treatments are only available in hospital. Higher risk of newborn death for high risk pregnancies labouring at home.Dr Jolyon Ford is an Obstetrician and author of Pregnancy Wellbeing