The issue of patient choice in healthcare is nowhere more fractured than in the subject of homebirth.
Patients, as consumers, believe their freedom of choice is sacrosanct. However, the UK’s National Health Service (NHS), faced with ever-increasing financial and resource pressures may not be in the position to provide this choice. Similarly, healthcare professionals may only be willing to offer choice when it is clinically appropriate. These differences of opinion create, on occasion, significant tensions between midwives, obstetricians and women.
This schism was demonstrated in last year’s editorial in The Lancet1 that stated:
‘Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk. There are competing interests that need to be weighed carefully.’
The lines were drawn and the debate still continues. The homebirth rate in the UK was 2.7 per cent in 2009.2 This contrasts with 33 per cent in 1955.3 Proponents of homebirths state that childbirth is a natural process and ensuing health policies have over-medicalised this process. Subsequently, they say, hospitals births have led to the increase in caesarean sections and interventions which do more harm than good. After all, as the statistics show, it was only two generations ago, when homebirths were the norm.
On the other hand, as doctors, we are well aware of the unpredictability of birth and our focus therefore has to be in ensuring the safety of the mother and baby, balanced by their individual needs. The fact is, patterns of childbearing have changed over the decades. There are now more complex pregnancies as a result of lifestyle trends such as the increase in the numbers of older first-time mothers and the rise in maternal obesity. These factors have an impact on whether a hospital or a homebirth is recommended.
Maternity services within the UK involve midwives, GPs and specialists, including obstetricians, anaesthetists, neonatologists and others as required. In contrast to most countries, all healthcare, including maternity care, is free at the point of access for all patients entitled to such care. Historically, antenatal care was shared between midwives, GPs and hospital-based specialists, but over the last ten years, the input from primary care has lessened. We expect this trend to reverse since GPs hold the vital key: knowledge and information about a woman’s medical history. They should have a greater role in maternity, working collaboratively with midwives and obstetricians.
In the UK, birth can take place at home, in a stand-alone midwifery unit, a co-located midwifery unit or consultant-led unit with access to ultra specialised support, such as level 3 neonatal care. The availability of these services, however, is constrained by geographical and financial imperatives.
In theory, a mother has the choice of delivery in any unit. Choice has been gaining political leverage and various publications have been produced in the UK trying to argue the case for extending choice.
The Cumberlege Report, Changing Childbirth4, published in 1993, advocated a return to ‘normal’ birth, in the face of what was then perceived to be the rapid medicalisation of childbirth. At the time of publication, it was considered a radical document and interpreted by some as a threat to patient safety. Many obstetricians were concerned about the unpredictable nature and outcome of labour and believed that a hospital birth was the safest option. These arguments have been plagued by the absence of robust data on outcomes for mothers and their babies.
Maternity Matters5, a discussion document produced by the Department of Health in 2007, argued that high-quality and safe maternity services should go hand-in-hand with the rights of patient choice. Parallel to these developments, the RCOG and the Royal College of Midwives published a joint statement6 that made the case for planned homebirths for uncomplicated pregnancies. This approach was shown to result in better continuity of care and a good birth experience for the mother.
This was followed by ‘Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour’7, which took the quality agenda further. In this report, the focus shifted to placing the woman at the centre of care. The importance of professional integrity and respect between maternity professionals, together with increased input from senior clinicians on the labour floor was emphasised.
More recently, ‘High Quality Women’s Health Care’8 argues for a more balanced evidence-based approach around a network of providers. This document concentrates on the premise of having: ‘the right care, in the right place, with the right staff with the right skills and the right outcome.’
There is broad acceptance now that some women need very complex interventions while those with low-risk pregnancies could deliver safely in a range of settings. With all these factors in mind, how then can a woman make the best decision on the most appropriate place of birth for her and how can a doctor advise the patient accordingly, against a backdrop of the increasing complexity of problems impacting on pregnancy? The challenge for us is in obtaining the good-quality data.
The National Perinatal Epidemiology Unit (NPEU) at the University of Oxford has completed a study of 80 000 women to compare the maternal and baby outcomes of birth planned at home, in different types of midwifery units and in hospitals with obstetric services. The study aims to establish what proportion of mothers and babies require transfer during labour or after birth from other birth settings to obstetric units, measuring duration of transfer and whether such transfer is acceptable in terms of safety. This study, when published, should define the parameters and assist women and professionals in decision-making.
In anticipation of this study, what other reliable information have we got at the moment? Recent data9 indicate that neonatal death rates treble for planned homebirths, but emphasise that the death rate was very low. The same study showed that successful delivery at home results in less medical interference, with less morbidity. A recent study,10 showed what can be achieved when maternity services are organised and good-quality care is offered.
The National Institute for Health and Clinical Excellence (NICE) intrapartum care guidelines11 contain sections on place of birth from published literature up until 2007. There were slightly higher perinatal mortality rates related to intrapartum events and neonatal complications with homebirths. Frustratingly, there is lack of robust data on short- and long-term outcomes for babies. Interpretation of these studies is difficult due to inclusion of high-risk cases in the homebirth populations.
This guidance provided clear criteria on defining risk to assist in the decision-making process on the place of birth. There are two categories: firstly, medical conditions suggesting increased risk and therefore the need for a planned delivery in an obstetric unit; and, secondly, the existence of other obstetric factors justifying a hospital birth. The NICE guidelines also state that giving birth at home increases normal delivery rate with less intervention. In addition, a normal delivery in the first pregnancy was found to have a reduced intrapartum complication rate in subsequent pregnancies.
The prevailing advice therefore is that homebirths are a safe option in uncomplicated pregnancies and they should be encouraged. However, these women must have quick access to emergency transfer to an obstetric unit as part of their birth plan.
Alongside the medical issues over the choice of place of birth, there are the economic and resource considerations. A hospital birth is more expensive because of the hospital overheads. Although a homebirth may be cheaper financially, it is resource-intensive with regard to the need for one-to-one midwifery care.
Our responsibility must be to relay the evidence to women in a gentle, supportive and informed way. Extreme polarisation does not help the woman. At times, decisions will be made that do not accord with our own standards and guidelines, but obstetrics is not unique in such dilemmas. Other domestic, social and cultural elements will influence a woman’s decision and these must be respected. We must support her and ensure that the appropriate emergency protocols and services are available.
Future policy over the place of birth will be greatly influenced by the much-anticipated NPEU Birthplace study.