Whether you are expecting your first baby, second, third or more, you have the right to choose where you want to give birth. Depending on where you live it may be easier to access some options than others. The main options are:
At Home: where you can have midwifery care from either NHS or Independent midwives. You can hire a birth pool and use whatever methods you want for managing your labour. Midwives usually carry Entonox (“gas and air”) and sometimes provide opiate drugs such as Pethidine or Diamorphine if you want them. A prescription for painkillers might also be obtained from a GP. If you decided to have an epidural, however, you would need to transfer to a hospital obstetric unit.
A Birth Centre (sometimes called a Midwife-led unit or MLU) where all care is provided by midwives. They focus on maximising the chances of a straightforward birth, and usually have a homelike setting to encourage relaxation and the flow of hormones that help labour to progress. Most have birth-pools in all or most rooms. Most forms of pain relief are available apart from epidurals and in some centres, opiates are not given. Alternative therapies such as aromatherapy may also be on offer in some units. There are two types of Birth Centre:
A Free-standing Midwife-led Unit (FMU) is on a separate site and is not attached to a hospital with an obstetric unit
An Alongside Midwife-led unit (AMU) is on the same site as a hospital with an obstetric unit, often in the same building, but sometimes a separate one.
An Obstetric Unit (OU) is a maternity unit within a hospital where doctors are available to provide medical care if needed. These are sometimes referred to as ‘labour ward’ or ‘delivery suite’. Doctors will usually only be involved if there are medical complications. Otherwise, if you choose to give birth in an OU you will be cared for by midwives. It’s possible to request an epidural though it may not be available exactly when you want it. The availability of birth-pools in OUs varies a lot, and there may be strict local guidelines on who can use them. The environment within an obstetric unit is usually more medical than in a birth centre, and this may inhibit the helpful labour hormones. On the other hand, some people feel safer having doctors closer by.
The best available evidence on safety comes from the Birthplace Study1 which compared how planning to give birth in different settings affected the outcomes for mothers and babies when there was no reason to expect complications. The comparison was based on where the women planned to give birth even if they eventually gave birth somewhere else. It excluded women having a pre-term labour or a planned Caesarean birth.
The authors concluded that wherever it took place “birth is generally very safe” for babies of “low risk” women. For mothers who had birthed before, there was no difference at all in the outcomes for their babies between the different settings.
First time mothers who planned birth in an obstetric unit or in either kind of birth centre had almost identical outcomes for babies, with only 5 in every 1,000 having any kind of serious complication.
For first-time mothers who planned to give birth at home there was a very small increase in the chance of harm for the baby compared to any of the other settings, though we don’t know why this was. The risk remains extremely low even for this group – only 9 in every 1,000. It’s hard to be sure what this really means as the figures are a combination of several different things which were too rare to analyse individually, and not all of which had long-term consequences. This means that even in this group where there were serious complications, as in other birth settings, many of the babies were fine in the longer term.
Some of the medical interventions that a mother might experience can also have an impact on her baby. For instance, when a birth is assisted with forceps or ventouse, the baby may experience bruising or small cuts on their face and head. These usually heal quickly but may mean that the baby is more unsettled for the first few days, which can make it harder to establish breastfeeding. Mothers who have had a Caesarean or assisted birth may find it harder to feed and care for their babies in the early days, as well as probably needing longer to recover than those who had a straightforward birth.
It is fortunately very rare for mothers in this country to die during labour and birth, so in this sense all birthplaces are safe.
However, the Birthplace Study1 showed that it’s significantly more likely that mothers with no complicating factors will experience medical interventions if they plan to give birth in an Obstetric Unit rather than at home or in a Birth Centre. In this sense, these out of hospital settings are safer for the mother. The difference in the likelihood of all the medical interventions as well as the harms such as excessive blood loss, that the Birthplace Study1 looked at was lower for the women who planned to birth outside hospitals, either in birth centres or at home. For some interventions this difference was quite profound.
For instance, first time mothers were about twice as likely to have an unplanned caesarean if they’d planned to birth in a hospital rather than in a birth centre or at home (16% vs. 7-9%).
For mothers who had given birth before the chances of a planned caesarean were much lower than for first-time mothers, but they were still five times more likely to have one if they planned to birth in hospital compared to other settings (5% vs 1%).
Mothers planning birth in hospital were also more likely to have the birth assisted with forceps or ventouse.
Overall, around 80% of first-time mothers who planned a birth at home or in a Birth Centre had a straightforward birth, compared to only 60% of those that planned a birth in an Obstetric unit.
Women who planned to birth in hospital also appeared to have higher rates of problems like severe tears and blood loss requiring a transfusion, although these were rare in all settings.
The outcomes for those mothers that chose an Alongside Midwife-led Unit were not quite as good as for those choosing home or a Freestanding Midwife-led unit, but still significantly better than for an Obstetric unit.
Quite a high proportion of first-time mothers in the Birthplace Study1 transferred to an OU during labour or just after the birth (around a third of those planning birth in an FMU, slightly more for an AMU and just under half for a homebirth). Transfer rates were much lower for those that had given birth before – around one in ten women.
A follow-up analysis of the Birthplace Study data2 found that the most common reason for transfer from home or an FMU was that labour was going slowly and the mother wanted it to be speeded up artificially. The other main reason was that a midwife had picked up signs that the baby might not be coping well with labour. Midwives are trained to spot these warning signs early, so the transfer can normally be done in plenty of time and in a calm way.
It was uncommon for mothers to have transferred in order to have an epidural – just under three out of every 100 first time mothers who planned to birth at home and just over two out of every hundred who planned to birth in an FMU. For those who had birthed before the numbers were much lower – four out of every thousand for homebirths, and three out of every thousand for FMUs.
If you decide to transfer from home or an FMU, your midwife will usually accompany you (if it’s by ambulance) or follow you to the hospital (if it’s by car). If you are transferring from an AMU, you might be able to walk or might prefer to be taken in a wheelchair.
Pregnant women and people are often advised to give birth in an Obstetric Unit if there are concerns over their health or that of their baby, or if there are any factors that might make complications in labour more likely. You may be happy with this. If not, you still have the right to choose a homebirth, but may find that your Hospital Trust is reluctant to support this. (You may find our template letter Booking a Homebirth helpful if you are having difficulty with this.)
Birth Centres have criteria for which women they will accept, but they vary from place to place, and it’s sometimes possible to negotiate a care plan that enables you to labour there even if you are classed as “high risk”. According to Birthrights3 “Any decision to refuse a woman admission to a birth centre must be backed-up by evidence which supports the decision. For example, if a woman is refused admission because of a particular risk factor in her pregnancy, there must be clear clinical evidence that additional risks may arise during the birth that cannot be safely managed in a birth centre.”
Another of the follow-on studies4 using the Birthplace Study data showed that for women with medical or obstetric risk factors, planning a homebirth actually reduced the chances of the baby being admitted for hospital care in the first few days after the birth, compared to planned birth in an OU. There seemed to be no significant difference in the likelihood of other serious harm to the baby, however the number in this study was too small to be certain about this. For these women planned homebirth was associated with an increased probability of having a straightforward birth compared with planned OU birth.
There hasn’t been any analysis of “high risk” women using Birth centres, as the numbers are too small.
If you have been advised to birth in an OU but want to consider other options; or if you’ve been told that support for a homebirth or a Birth Centre is not available in your area, the first step would be a discussion with your midwife or consultant. If you are not happy with the outcome of the discussion, you could ask to speak to a Consultant Midwife or the Head of Midwifery. In some Trusts in England there are Professional Midwifery Advocates whose role includes advocating for maternity service users, but not all Trusts provide this. In Scotland, Wales, and Northern Ireland, there is a similar role for “supervisors” (see the AIMS Journal article “What is a Professional Midwifery Advocate (PMA)?”) Contact information for all of these people should be available on your NHS Trust or Board’s website or from the maternity ward in your local hospital. You can just phone them up and ask for the information without giving out your name, or the reason why you want their details, if you would prefer not to discuss your situation with anyone else.
It might also be possible to transfer your care to another Hospital Trust or Board that offers the services you want.
If you are keen to have a Homebirth and your Trust/Board is reluctant to support you, another option is to hire an Independent Midwife to provide your care.
Some pregnant women and people choose to birth at home without midwife support (known as freebirthing). This is legal. It is also legal for a relative or friend to support a woman who is labouring without a midwife present, as long as they are not acting in the capacity of a health professional or giving medical or midwifery care.5
The AIMS helpline can provide information and support for negotiating the choices that you feel are right for you.
At the start of the coronavirus pandemic many Trusts/Boards suspended support for homebirths although others continued to provide it. Similarly, some closed some or all of their Birth Centres and others kept them open. In some places these service restrictions were lifted during summer 2020 but may or may not have been reimposed since then. The situation continues to change from week to week.
Your Trust or Board should, however, be making information on the current state of their maternity services available to service users in a readily accessible form. Some are proving better at this than others. Another source of information is the But Not Maternity's spreadsheet. This is a Status List of NHS Trusts and Partner Restrictions, which is being maintained by a group of volunteers. It covers all Trusts/Boards in the four nations of the UK but is not guaranteed to have the latest information.
If you want to request support for a homebirth, AIMS has a template letter Homebirth and Coronavirus which you can adapt and send to your Trust/Board.
If you are considering freebirthing, there is information and a list of resources here Freebirth, Unassisted Childbirth and Unassisted Pregnancy.
Further information on the latest guidance about maternity services in the pandemic is available on the AIMS Birth Information page Coronavirus and your maternity care
1. National Perinatal Epidemiology Unit “Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study” BMJ 2011;343:d7400
2. Chapter 5 in Hollowell J. et al “The Birthplace in England national prospective cohort study: further analyses to enhance policy and service delivery decision-making for planned place of birth” Health Services and Delivery Research, No. 3.36 2015
3. Birthrights factsheet "Choice of place of birth"
4. Study 5 on the NPEU webpage www.npeu.ox.ac.uk/birthplace/birthplace-follow-on-study
5. Birthrights factsheet "Unassisted birth"
NICE Guideline “Intrapartum care for healthy women and babies” 2017 Section 1.1 “Place of Birth”
Written by: Nadia Higson
Reviewed by: Caroline Mayers
Reviewed on: 04/03/2021
Next review needed: 04/03/2023
AIMS supports all maternity service users to navigate the system as it exists, and campaigns for a system which truly meets the needs of all. AIMS does not give medical advice, but instead we focus on helping women to find the information that they need to make informed decisions about what is right for them, and support them to have their decisions respected by their health care providers. The AIMS Helpline volunteers will be happy to provide further information and support. Please email firstname.lastname@example.org or ring 0300 365 0663.
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