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This article is written very much from the heart as I home birthed my second baby. Two reasons – first I had only just made it to the hospital with number one – his head was showing on admission – and secondly I felt I had ‘to put my money where my mouth was’, as a midwife who actively promoted home birth! Without doubt, it still is one of the most special experiences so far in my life.

Unfortunately, fear is the factor that puts many mums off even looking at home birth. Yet health professionals, who use evidence to convey information, are left flummoxed by home birth statistics! Too many do not analyse the research and are biased towards hospital as that is ‘the normal’. When the research is carefully examined and analysed, it shows that home is actually the safest place to be. There are many reasons why this can be explained.

1. Women who are fearful tend to self select and book into hospitals

2. Women who chose home birth tend to be more relaxed about birth and therefore do better

3. Women and their LMCs make good choices about their suitability for home birth

4. LMCs recognize signs of difficulties before or during labour and transfer women into an appropriate place to birth.

Of these points above I believe that number 3 is the most important as it shows that women and their LMCs are working together in a partnership. This is great as our aims and goals are always the same – midwives (and obstetricians) always want a happy and healthy mum and babe at the end of the process.

‘Home birthers’ are often seen as being ‘whacko’ for even contemplating home as a suitable place – but why on earth not? If it was that dangerous to birth at home then we would not be here today, as it is only in the past 50 years that women have been encouraged into hospitals. Women were told that having baby in hospital would decrease stillbirth and abnormalities of birth. The statistics do not confirm this; in fact stillbirth and birth problems are the lowest in the world in the country that has the highest home birth rate – Holland. Food for thought indeed….

So what does the evidence show?

Lets look at 3 pieces quickly.

1. The government figures. Approximately 2% of women chose to birth at home throughout NZ overall, this figure has remained fairly constant in the past 25 years. There are areas with a higher home birth rate than others; examples include West Coast of South Island up to 60%, Waiheke Island around 30%.

2. The Auckland Home Birth Association published results from a 20 year study in 1997. This research showed the home birth perinatal mortality rate (number of babies who die) was not significantly different from the rate for a selected low risk group at National Women’s Hospital. Almost a third of babies who died had lethal anomalies, where place of birth would make no difference. The conclusion was that home birth was a safe and increasingly popular, though minor option for NZ women from 1973-1993.

3. A Danish study published in 1997 looked at several different countries research on home birth to ascertain if home birth was a safe option. The results measure mortality (death), morbidity (serious injury to mother or baby), baby APGAR scores (a score given showing adaptation to the ‘outside world’ in the first 5 minutes of life), maternal lacerations and intervention rates. Similar low risk women were matched to the home birthers. The results showed that a similar number of babies died in each group, babies had higher APGAR scores (this is good!), mothers had fewer lacerations (this is very good!) and fewer medical interventions happened in the home birth group. (Interventions included use of hormone drips to accelerate labour, episiotomy, operative vaginal birth – ventouse or forceps, and caesarean sections. The conclusion was that home birth is an acceptable alternative to hospital for selected women and leads to reduced medical intervention.

Considering a home birth?

First, do some reading. Do not rely solely on the Internet as very little on the web is refereed or scientifically based unless it is through a reputable site examples - NZ home birth Association website, the NZ college of Midwives site, (UK) Association for improvement in Maternity services - AIMS. Anyone can put anything up there, including horror stories, which are not good for you! But do look at some of the good home birth stories available on the coffeegroup.org website, they are lovely. Look in the local library for good books such as Sheila Kitzinger’s “Homebirth” or Sally Inch’s “Birthrights; A parents’ guide to modern childbirth” - both are slightly dated and written from the battling* English women’s perspective, but are packed full of good information (*battling is what many women have to be prepared to do to get a home birth).

Talk to your LMC and find out if they are a believer or not!!! There is a certain type of midwife who will home birth and many who will not.

Talk to your partner, but do not tell the family at this point as they will usually tell you that you are mad……

Remember that the decision to birth at home cannot be made until you have established in labour, as long as your midwife knows that you are planning a home birth, making the decision at this point is sometimes the best time.

What do I need?

The midwife brings nearly everything with her. Linen is provided (and laundered at) the hospital, spare drawsheets, plastic protectors and blue disposable pads are provided. All drugs (oxygen, resuscitation stuffs) and ‘drips’, delivery packs, the midwives bring suturing equipment and monitoring equipment. I ask for;

• An angle poise lamp (in case suturing is required)

• An extension lead with at least 2 sockets

• Ice ready in the freezer

• A new kitchen paper towel roll

• A bucket

• 4 supermarket carrier bags

• An empty ice cream container and lid (2L)

• 1 pack of sanitary towels – No Frills please

• 2 hot water bottles or wheat packs

• A good heater

• Decaff coffee for me…..

You see – nothing special really – except for my coffee!

Who is there?

Whoever you want! We enjoy sharing births with the whole family and friends if that is what you want. My only proviso is that someone must be available to care for wee ones apart from Dad, if they get scared or fretful (or start playing with my electric suction machine) Dad needs to be available for the Mum – undivided attention. Who do we bring? – Although in NZ we are legally allowed to undertake a home birth without calling a second practitioner in, we always try to get a ‘second’ to arrive in time for the birth. The only times that I have not called for a second have been when I’ve walked in and the baby has literally been born within the first 15 minutes of my arrival. Thinking logically, although the risks are small (I’ll talk about risk next) I’m always aware that the mum could have a dramatic haemorrhage at exactly the same time the baby decides that it would rather not start breathing yet…. I really want to be able to concentrate on the mum and leave the baby care to my second. Your LMC will always ask you first, but as home births are relatively rare, we are always absolutely delighted if we can bring a student midwife or a less experienced midwife as a third person. Clearing up and getting you settled with baby at the breast afterwards is always easier with 6 hands than 2. And yes, we do all of the clearing up!

Risks

Sometimes home is the safest place and you reduce risk if you have had a rapid labour before, as at home you have privacy, heat, and a telephone. There are risks everywhere! You and your baby’s risk of getting an infection are far greater if you birth in hospital! I consider three risks for any birth, not just home births. You will see it’s the skills and experience of the LMC that counts, not the place of birth.

This is the saddest one for me, as I know I have to tell a woman that she needs to have transfer into hospital and get help. Unfortunately, it is part of our job to recognize the abnormal from the normal, and to act on it before either mother or baby becomes distressed. If it just isn’t working and we’ve tried everything we know at home to get it working then we just have to give in gracefully and accept help. The most common problems here are i) contractions not increasing – getting stuck at ??Cms dilatation of the cervix, or ii) in the second stage – realizing that mum cannot push baby out. Failure to transfer in can result in fetal distress and endanger the baby’s wellbeing.

Haemorrhage.

Haemorrhage can happen to anyone, anywhere, the WHO gives ‘an inevitable haemorrhage rate of 10% of all births’. (Midwife’s tip – ask your LMC here PPH rate for the previous 3 years from her stats – if it is anywhere near 10% don’t go with her!)

The LMC has a ‘checklist’ in her brain of who is more likely to haemorrhage than others. This checklist may include things like having extra water around the baby, being anaemic, or knowing the placenta has an extra lobe. Often when you discuss a home birth she will advise of your suitability according to reasons like this.

All LMCs carry emergency drugs and intravenous infusions to counteract the effects of rapid haemorrhage and are trained to provide emergency treatments. The midwife is the first person to diagnose and treat this situation whether at home or in hospital and therefore has the greatest expertise in doing so. As far as I am concerned, I do exactly the same whether you are at home or hospital should you haemorrhage. I can usually stop the heavy bleeding, replace fluids if required and diagnose the cause. IF the cause is something that will not go away – example a lobe of placenta stuck inside – the woman must be transferred into hospital to have a D & C in theatre. She may come home straight afterwards if she feels well enough. The majority of women do not need to go to the hospital.

Baby not breathing.

This is not that common, and often there are plenty of ‘clues’ that show up before to warn us – baby’s heartbeat, meconium stained liquor, speed of the labour etc. Transfer into hospital may be suggested during the labour if the LMC believes you will arrive at the hospital in time. If the birth is too close remember that the midwife is the first person to diagnose and treat this situation whether at home or in hospital and therefore has the skills to manage this situation. All LMCs carry emergency drugs and equipment enabling infant resuscitation. Once again, as far as I am concerned, I resuscitate babes the same way at home or in hospital, using similar equipment. I carry 60 minutes of oxygen and can ventilate a baby at home if required to, until an ambulance arrives.