International Homebirth Day 2020
Today is International homebirth Day and I am taking a moment to reflect on my 3 births, 2 of which were at home.
For many homebirth seems like a risky idea, and many say things like, 'Oooh, you were so brave!'. This is said by those who assume that hospital is safe and anywhere else is not. At this point in time I cannot imagine wanting to go anywhere near a hospital unless I absolutely had to, but that was also my feeling when there wasn't COVID to consider.
Home birth is not the right choice for everyone, but it is a good option for many of us. There are risks and benefits to everything and each individual should choose what is right for them. That said, many people make the choice to have their baby outside of the home based on the assumptions that are prevalent in our culture, and often do not know all of the benefits and risks. So, I thought I'd outline some of the key points to consider when you are thinking about place of birth.
I have had two home births, one in water and one out of water, but I am in no way saying that everyone should be at home. My first birth was in a hospital, with extra monitoring, as my daughter decided to come earlier than we were expecting. Fortunately she was fine and healthy, and we didn't need any assistance for the birth, or after she was born, but the reassurance that she, and I, were fine during the labour was wonderful.
What is homebirth?
Before we go into the Benefits and Risks of the different birth place options, it is a good idea to define what we actually mean by homebirth, midwife led birth centres and hospital birth.
When I am teaching there is often confusion between homebirth and freebirth. Freebirth is where you choose to birth without a medical birth attendant and is legal in the UK. Although most freebirths are homebirths, most homebirths are attended by one or two midwives. In some areas there is a midwife and an assistant in attendance. Homebirths are also a free service provided by the NHS. Many areas have great teams of midwives who run homebirth services, meet with you before your birth, attend your birth and provide you post natal care. There is a great deal of variation across the country, and you many find that some homebirth services are suspended due to the COVID pandemic. If you feel that homebirth is the right option for you but you are not being given the support please contact www.aims.org.uk for ideas on how to proceed.
Homebirth: homebirth is attended by at least one midwife, in your home, for free.
We also, in many areas, have Midwife Led Centres (MLC's). These go by many names, for example, Birth Centre, Home from Home Unit, 'Name' Suite. The idea of a MLC is that it is as close to a home environment as possible, as we know that the hormones needed for labour work best when we are comfortable and relaxed. They are centres that focus on physiological birth, with midwifes in attendance. Midwives, by the way, are amazing, autonomous professionals, who's focus is on supporting straight forward birth However, they have extensive training to notice when things deviate from normal and are highly skilled to deal with emergency situations - more on that later.
Some MLC's are separate from a hospital, and are often called Stand Alone centres. There are others that are on a hospital site, and others that are a number of rooms within a hospital. These are often called Alongside MLC's. Again, there is huge variation around the country, please ask your midwife for details of what is available in your area.
MLC's: MLC's can be away from a hospital, next to a hospital or in a hospital. They are run by midwives and the focus is on straight forward birth.
Then we have our Obstetric Units. Again, there are many names for these, e.g. Delivery Suite, Labour Ward, OU. This is the sort of thing most of us imagine when we think of giving birth, the sort of environment that we see in films, documentaries etc. Here we have midwives (notice how we have midwives wherever we give birth? Amazing individual's aren't they!?), doctors, anesthetists, consultants etc.
Obstetric Unitls: Obstetric Units are hospital based, have midwives and other medical staff.
Now that we've got that cleared up we can start thinking about what we get in the different places of birth.
What is available for me in the different settings?
When I talk to parents about place of birth they generally have 3 things that are concerning them.
1. What drugs/comfort measures can I have in the different places?
2. What if?? What if baby needs help when it's born? What if there's an emergency?
Ok.. .so drugs/comfort measures.
Many people have an idea that if you're not in a hospital that that's it, you're on your own. I'm here to tell you, that isn't the case. In most places, if you have a home birth, you have access to Gas & Air, pethadine (regional variations here, so talk to your midwife if you think you might like it), TENS, water, everything that you would have at a MLC or hospital. The only thing that you cannot access unless you're in the hospital is the epidural, as you need an anesthetist for that.
There are also other things, like being mobile, keeping occupied, feeling safe that all contribute to your comfort levels.
What if. . . .?
In reality this is the biggie. This is the one that all parents ask about. Mums and birthing people are often concerned about baby's wellbeing and many worry that baby will need help breathing when they're born. We have telly to thank for this idea that babies need to be whisked away, or, if you grew up in my era, hung upside down and spanked until they breathe! (Is it any wonder most of us have negative ideas of birth?!?).
I am reliably informed, from the many wonderful midwives that I work with, that the vast majority of babies breathe all by themselves, very well, in the first few moments of life. Little physiology lesson here: babies are still attached to the placenta via the umbilical cord when they are first born, so are getting their oxygen from mum, not their own lungs to begin with. So even if they don't take their first breath immediately, they are often just fine as long as their umbilical cord is left in tact. NOTE: KEEP UMBILICAL CORDS INTACT!!!! (did I say that loud enough? :D). https://www.bloodtobaby.com/what-is-bloodtobaby https://waitforwhite.com/
Of the tiny number of babies that do not take that first breath by themselves, most of them will when their faces are gently rubbed with a soft towel, or blown on gently. This encourages their 'breathe reflex'.
Of the even smaller number of babies that do not respond to the above, all midwives have access to what is called a bag and mask. It does what is says on the tin: it is a tiny little mask, that fits over the mouth and face of the baby, with a little inflated bag attached to it. The midwife simply gives the bag a gentle squeeze and the lungs inflate. There is no machinery needed and baby often needs only a gentle nudge to breathe.
Which brings me to 'What if...?' for mum or birthing person. What if it's like Eastenders and there's an emergency?? If we're at home, surely that's catastrophic!!
Mmm. .. well, yes, if it was like Enders, it probably would be. But lets have a look at some facts. Firstly the main reasons for transferring from home to a hospital. This information is found at the Birth Place Study that looked at 65,000 women.
1: desire for epidural. NOT an emergency. When you're pregnant, look into what labour is like, educate yourself on comfort measures and your hormones so you are more aware of the physiology of birth. Epidural is a wonderful asset when needed, but it is not always necessary.
2: Failure to Progress. I detest this phrase, but it's how it's written in the study. In effect, this means that labour has slowed down, or plateaued. Sometimes there is a reason for this, and this is why we have highly skilled midwives in attendance, as they can look at everything that is going on and communicate with you their thoughts. However, in itself, NOT an emergency. Things have slowed so moving to a hospital may be sensible.
3: Meconium in the Waters. For those of you who do not know, meconium is baby's first poo. Sometimes it is released during labour and for some this is not an issue at all. Sometimes it can be an indication that baby is not as happy as they could be, but again, that is why we have our midwives as they are trained to notice what is 'normal' or not. Having meconium in the waters isn't necessarily a bad thing, but sometimes, not very often, baby can inhale some of the meconium as they are born. This can be dangerous to the baby so your midwife may suggest moving to a hospital, as a precautionary measure, so that baby can be monitored after it is born. So, during labour: NOT an emergency.
When I go through these 3 points with parents they often look at me quizzically, "Those are seriously the main reasons for moving from home??". Yes. Yes they are.
They then generally say something along the lines of, "BUT, what IF it IS like Eastenders?? What if we DO have a proper emergency and we NEED to be in hospital??"
Ok, for that, let's build a picture.
You're at home. Labouring. With your things around you. Space to move. Your telly, your music, you fridge (what do you mean I'm food obsessed??). You have one midwife looking after you. She/he is in your home, a guest. They are monitoring you regularly, writing notes. They have nothing else to be doing. Their focus is on you, and you alone. If things deviate from 'normal' they are going to notice very quickly. Side note, most of us have this idea that when things go 'wrong' in birth it all happens in one moment. The midwives that I work with say that often there are flags, little things to notify you as labour unfolds. Labour rarely happens like it does on telly!
Going back to our little scene: Your midwife notices some changes, and brings them to your attention. IF there is an emergency unfolding they will have had training to deal with it at that moment, they will call the ambulance and let the hospital know you are transferring in, with details of what is occurring. They will then travel with you in the ambulance and often come into the hospital with you (this may be different at the moment in some areas due to COVID).
Now, many of us think that if we're in a hospital when the above is unfolding that there is a theatre prepped and waiting for the next emergency. This is not the case. In a lot of cases, when the midwife makes that call to the hospital, the team will be alerted, they will need to get everything ready, and that can take time. It can take 20 minutes, 40 minutes, and in some cases much longer. It obviously depends what the 'emergency' is, but it takes time. Time in which you are moving from home to the hospital.
If we take the same scenario as above, but starting in a hospital or MLC the timings are generally very similar. The midwife will communicate with you on what is happening and the suggested next steps. If you need to be in theatre, the same process happens as above, with similar timings.
Some of the other 'What if's' that I get asked about are bleeding after birth. All midwives, in all settings, have an injection that can be given to mum to stem bleeding. The first management of bleeding is generally the same wherever you are having your baby, and it starts with your midwife. The other concern is suturing, "If I'm not at the hospital and I need stitches, do I have to go in?". In general no. Midwives are awesome seamstresses. My midwife at my last birth was particularly proud to show off her handiwork :D. They also carry the local anesthetic, and gas & air, should you desire either/both.
The last concern that is always mentioned in class, and I hate to generalise, but it is often the dads and partners who worry about this; MESS.
I know that the media portrays birth as a gruesome scene but actually that is another exaggeration. There are always exceptions, of course, but generally birth is no gore fest. All of the midwives that I have worked with, who have attended hospital and home births say, to a person, that home birth is far tidier than hospital. Homebirth midwives bring 'to incinerate' bags with them and take anything away that is messy. In my experience, if you make some yummy treats for you midwives, they will put the first wash on too! My good friend, who is an Independent Midwife, says that Lemon Drizzle cake is a favourite ;).
Now that we've looked at some of the technicalities now we can start thinking about Benefits and Risks of each place.
Note about Risk: risk is a strange thing. You can look at stats, listen to experts, read reports etc, but risk is individual. A couple of examples that I use when teaching are: crossing the road. When I cross the road on my own, I risk assess in a particular way. If I am crossing the road with all 3 of my children, I risk assess in a different way. If I am on one side of the road, my youngest is on the other side of the road, there's a lorry coming and he's about to step into the road, I risk assess in a different way again. The situation is the same, but my assessment and actions vary based on my circumstance.
The other example I use is Bungee Jumping.
I love bungee jumping.
Most people look at me like I'm crazy (so, no change there then!). To me, I look at the chance of something bad happening and I think that the benefits far outweigh those tiny risks. Others look at the risk and decide - NOT ON YOUR NELLY!!
Risk is all about what YOU do with the information you are given.
So, going back to benefits and risks. You will look at the information and you will choose what is right for you based on that information. I am not here to try and persuade you one way or another, I want to give you a full picture so you can make informed decisions.
There are risks all around us, in all places. If you are at home, there may be an emergency that could have been dealt with in a hospital.
In your own home, you may feel comfortable and relaxed, where we know the birthing hormones flow more readily. Stay in your 'safe space'.
Partner can be with you at all times (if you want them)
Practical aspects - e.g. food, drink, space, your bed, your entertainment, mobility
Midwife is a guest in your space
Less contact with Covid
No need to move from your home
Can sleep in your own bed following birth
Access to water, if wanted
Taken from the Birth Place Study.
OU = obstetric unit
FMU = Freestanding Midwifery Unit
AMU = Alongside Midwifery unit
All women represented here were 'low risk'.
Closer proximity to hospital; increased risk of infection, increased likelihood of intervention (see chart above from Birth Place Study)
Not quite home, can disrupt birth hormones
Home from home atmosphere may increase feelings of comfort and relaxation, which we know increases flow of birthing hormones
May be closer to a hospital than home if transfer is needed
Midwife led so focus is on physiological birth
Risk of infection. This is particularly relevant at this time of the pandemic. Although everything is being done to reduce the risks of transferring the virus, there is more contact in a hospital setting. Even in times before COVID-19, infection rates are increased within hospitals.
Iatrogenic risks. These are risks relating to illness caused by medical examination or treatment. There is a clear increase in rates of intervention when we are in a hospital environment (see above chart from Birth Place Study).
access to medical assistance, monitoring, expertise if it is needed
Where do I want to have my baby?
Now that we've outlined some of the key questions that parents ask in relation to place of birth we can start thinking about where YOU want to give birth.
There is no 'one size fits all' answer, it is all about what is right for YOU.
Where are you going to feel most comfortable and relaxed? Is it where you are surrounded by your things, in your own space? If the answer is yes, then a homebirth may be right for you. Is it surrounded by medical equipment and doctors? Then a hospital may be the right choice for you.
Do you have additional needs in your pregnancy? Have you been flagged up as 'high risk'? This does not necessarily limit your options. If you would like to have a home birth, the choice is yours. I would highly recommend talking to your midwife, or, if you have one, a consultant midwife about your choices. If you do not feel you are getting the support you want, or not being heard, there are Independent Midwives who you can have a consultation with. They work outside the NHS and can sometimes give a wider scope of choice. You can do a search for IM's near you and book a chat (this doesn't mean that you need to employ them for your whole pregnancy, although that is a very good option, if you are able). AIMS are also very helpful in finding all of the options available to you and how to access them.
If you do decide that you'd like to have a home birth, talk to your midwife about it. If you have a homebirth booked it opens up your options. If you decide, in labour, that you'd really rather be at the birth centre, or hospital, you can go. No one will bar your entrance because you said you wanted a homebirth! It is far easier to do that than be in labour, decide you're happy at home and then stay put. There is a duty of care that says someone must be sent to attend, but if there are no available midwives, then paramedics are sent. I love paramedics, they're awesome, however, they are used to emergencies and they are not always aware of physiological birth, so often want to whisk you away to hospital.
A last little note; if you decide that a homebirth is for you, make sure your midwife can find you at 3am, in the dark. It is nigh on impossible to see door numbers in the dark! Balloons on gate posts, or front doors work really well :D.
Wherever you decide to have your baby remember that your birthing hormones are released best when you're confident and calm. If you find that your birth place changes during birth, focus on staying calm and relaxed wherever you are. Educate yourself on what you can do during pregnancy, labour and birth to ensure that if your journey changes direction you can stay calm and focused throughout.
And, remember good biscuits.
Good sites for birth place options: