You may not even be aware that there are different choices for where to give birth until you are far along in your pregnancy.
One of the excellent advances in modern obstetrics is that we are able to provide extremely safe choices for women, so they can give birth in a setting that feels comfortable to them.
If you are based in the UK, you have several choices available to you. Exactly which option suits you best will be partly determined by your own medical history, the risks of your pregnancy and whether you are expecting a baby with any known medical concerns. The other contributing factor will also be location. Not all of these options will be easily available in all locations, because you may live too far from some settings to make it a practical choice.
If you are healthy, with a ‘low risk’ pegnancy then the NICE guidelines advise that giving birth in any location is generally very safe for both the woman and her baby.
Common reasons for women NOT being considered ‘low risk’ are:
- Medical conditions such as high blood pressure, diabetes
- Obesity (Body Mass Index > 35 kg/m2)
- Giving birth preterm (before 37 weeks),
- Previous caesarean section or serious complications in a previous birth
- Expecting twins
- Baby is in a breech presentation
You may choose any birth setting (home, freestanding midwifery unit, alongside midwifery unit or obstetric unit) and be supported in that choice.
What are the different options?
There are two key differences between the different types of location:
1. Who has clinical responsibility for your care provided
(midwives or obstetricians)
2. Whether or not the unit is situated in a hospital with on-site
availability of obstetric, neonatal and anaesthetic care
Obstetric Unit (Labour ward/ Delivery Suite)
In an obstetric unit (OU), care is provided by a team of midwives and doctors.
Midwives provide direct care to all women in an obstetric unit, whether or not they are considered at high or low risk, and take primary responsibility for women with straightforward pregnancies during labour and birth.
Obstetrics doctors make decisions around care and perform procedures when pregnancy and birth becomes more complicated.
Obstetric units are always situated in hospitals and have on-site services such as scan machines and operating theatres as well as specialist neonatal and anaesthetic care. Both high and low risk births take place in a delivery suite.
Midwifery-Led Birth Options
In midwifery units, midwives take the primary professional responsibility for labour care.
1) Alongside midwifery units (AMUs) are situated in the same hospital or on the same site as an obstetric unit so have access to obstetric, neonatal or anesthetic care on site. Women may need to be physically transferred to the obstetric unit if they become higher risk.
2. Freestanding midwifery units (FMUs) are not situated in a hospital or site with an obstetric unit or neonatal unit. This means that if the woman needs emergency care or assistance from an anaesthetist eg an epidural, or the baby requires neonatal care they need to be transferred. This is typically by ambulance or car.
3. Planned Home Birth is when a midwife provides care to help a woman deliver at home.
What are the risks?
If you fit into the low-risk category there are some helpful statistics to help inform you as to where would be the best place to plan your birth.
These stats come from The Birthplace Study. It is widely cited in changing the way we plan birth locations, now encouraging more families to consider birth outside of obstetric units where appropriate.
The aim of the study was to answer some of these questions:
- Are there differences in outcomes for the mother and baby between the different birth settings?
- Are there differences between birth settings in costs and cost-effectiveness?
- What features of the maternity care system may affect quality and safety of care in different settings?
The study collected data on care in labour, delivery and birth outcomes for the mother and baby for over 64,000 ‘low risk’ births in England including nearly 17,000 planned ‘low risk’ home births, 28,000 planned ‘low risk’ midwifery unit births (AMUs and FMUs) and nearly 20,000 planned ‘low risk’ obstetric unit births. It collected data between 2008-2010.
The study achieved an exceptionally high level of participation and coverage. Over 97% of NHS trusts providing home birth services and nearly 90% of all midwifery units in England took part. Data on births in obstetric units, which were used as a comparison group, were collected from a
representative, random sample of 36 obstetric units spread across England.
Outcomes in the planned home and midwifery unit births were compared with planned births in the obstetric unit.
They looked only at women who, at the start of labour, were healthy and did not have known risk factors for complications. These include high blood pressure, diabetes, problems in a previous pregnancy or birth, or complications in the current pregnancy.
The findings:
Midwifery units appear to be safe for the baby and offer benefits for the mother. There were no significant differences in outcomes compared with planned birth in an obstetric unit.
In fact, there were fewer interventions, including emergency caesarean sections and instrumental deliveries.
For women having a first baby, a planned home birth increases the risk for the baby. There is a fairly high probability of being transferred to an
obstetric unit during labour or immediately after the birth. This rate was 45% for planned home births, 36-40% for planned midwifery unit births
For women having a second or subsequent baby, the transfer rate is 12% for planned home births, 9% for planned freestanding midwifery unit births and 13% for planned alongside midwifery unit births.
Is it safe for a woman to have a first baby at home?
The study found that a woman having a first baby at home is more likely to have a ‘normal birth’ but there is a fairly high probability (45%) of being transferred to hospital during labour or immediately after birth and there appears to be an increased risk of an adverse outcome for the baby.
Overall, if its not your first baby:
Planning a birth in any midwifery-led setting means you are more likely to have a spontaneous vaginal birth than planning birth in an obstetric unit
Planning birth in an obstetric unit is associated with a higher rate of interventions, such as instrumental vaginal birth, caesarean section and episiotomy, compared with planning birth in other settings
There are no differences in outcomes for the baby associated with planning birth in any setting.
If its your first baby:
Planning a birth in any midwifery-led setting means you are more likely to have a spontaneous vaginal birth than planning birth in an obstetric unit
There is also a higher risk of interventions than planned birth in an obstetric unit.
There are no differences in outcomes for the baby associated with planning birth in an alongside midwifery unit or a freestanding midwifery unit.
However, planning birth at home is associated with an overall small increase (about 4 more per 1000 births) in the risk of a baby having a serious medical problem compared with planning birth in other settings.
How can I choose?
There are several questions you can ask yourself such as:
- Am I likely to want or need medical forms of pain relief? In this case Alongside Midwfiery Units or Obstetric Units would probably be more suitable
- Do I want to be encouraged to have an active birth? Midwifery options would be more likely to keep you mobile and active.
- Do you feel anxious or worried about birth? Where do you think you would feel more relaxed? For some, it is away from machinery and doctors, or for others it is knowing there are obstetric and neonatal staff nearby if required.
References:
1.NICE Guideline for Intrapartum care for healthy women and babies 2014
2. The Birthplace Study 2011
Birthplace in England Collaborative Group, Brocklehurst P, Hardy P, Hollowell J, Linsell L, Macfarlane A, Mccourt C, Marlow N, Miller A, Newburn M, Petrou S, Puddicombe D, Redshaw M, Rowe R, Sandall J, Silverton L, Stewart M. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. British Medical Journal. 2011;343. Full text link