Choosing your Place of Birth

Place of birth: What are my options?

Any woman, whether she is expecting her first baby, second, third or more, has the right to choose where she wants to give birth. Depending on where you live it may be easier to access some options than others. The main options are:

  • A Homebirth. Women giving birth at home are usually cared for by either NHS or Independent midwives. Mothers can hire a birth pool and use whatever methods they want for managing labour. Midwives usually carry Entonox (“gas and air”) and sometimes opiate drugs if wanted, but if a woman decides to have epidural analgesia she needs 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 with birth-pools in all or most rooms. Normally all forms of medical pain relief are available apart from epidural analgesia, and some offer alternative therapies such as aromatherapy. They usually have a homelike setting to encourage relaxation and the flow of hormones that help labour to progress. There are two types of Birth Centre:
    • - A Free-standing Midwife-led Unit (FMU) is on a separate site, 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. Doctors will usually only be involved if there are medical complications. Otherwise, women who choose to give birth in an OU will be cared for by midwives. It’s possible for a woman to choose epidural analgesia though it may not be available 24 hours a day, or exactly when she wants it. Availability of birth-pools varies a lot, and there may be strict guidelines on who can use them. The environment within an obstetric unit is usually more medical then in birth centres, and this can inhibit the helpful labour hormones. On the other hand, some women feel safer having doctors closer by.

How safe would it be for my baby?

The best available evidence on safety comes from the Birthplace Study 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 thousand 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 thousand. 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, meaning that even in this group where there were serious complications, many of the babies were fine in the longer term.

Some of the negative outcomes for a mother can also have an impact on her baby. When a birth is assisted with forceps or ventouse the baby may suffer 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 will often 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.

How safe would it be for me?

The Birthplace Study showed that it’s significantly safer for mothers with no complicating factors to give birth at home or in a Birth Centre compared to an Obstetric Unit. The difference in the likelihood of all the medical interventions that the Birthplace Study looked at was lower for the women who to plan to birth outside hospitals, either in birth centres or at home. For some interventions this was quite profound.

For instance, first time mothers were twice as likely to have an unplanned caesarean birth if they’d planned to birth in a hospital rather than in a birth centre or at home; and mothers who had given birth before were five times more likely (though the rate in this group is very low). 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.

What if I need to transfer to a hospital Obstetric Unit during labour?

Quite a high proportion of first-time mothers 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 are much lower for those that have given birth before – only around one in ten women. We don’t have the data to know whether the women who were transferred did so from their own choice. (The decision whether to transfer is always be for the birthing mother to make, but sometimes this is not made clear to her).

The most common reason for transfers is that labour is going slowly and the mother wants it to be speeded up artificially. The other main reason is that her midwife has picked up signs that her baby may 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.

In the Birthplace Study, only about 5 or 6 in 100 women transferred from home or an FMU in order to have an epidural, and about twice as many from an AMU.

If a mother decides to transfer from home or an FMU, her midwife will usually accompany her (if it’s by ambulance) or follow her to the hospital (if it’s by car). If transferring from an AMU the mother might be able to walk, or might prefer to be taken in a wheelchair.

What are my options if I’ve been told that I’m “high risk”?

Women are often advised to give birth in an Obstetric Unit if there are concerns over the health of mother or 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.

Birth Centres have criteria for which women they will accept, but they vary from place to place, and it’s sometimes possible for “high risk” women to negotiate a care plan that enables them to labour there.

One of the follow-on studies3 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. There hasn’t been any analysis of “high risk” women using Birth centres.

What if I’m not being offered the choice I want?

If you have been advised to birth in an OU but want to consider other options; or if you’ve been told that a Homebirth service or Birth Centre are not available in your area, the first step would be a discussion with your midwife orf 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. It might also be possible to transfer to another Hospital Trust that offers the services you want. Although the role of supervisor of midwives is no longer statutory, some trusts do still offer this service, and if yours does, you might find support from them. Contact information for all of these people will be available 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.

If you are keen to have a Homebirth and your Hospital Trust is reluctant to support you, another option is to hire an Independent Midwife to provide your care. (link to IMUK) and in some areas private companies are offering midwifery services, some of which are paid for by the NHS.

Some women choose to birth at home without midwife support (known as free-birthing). 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.4

AIMS can provide information and support for negotiating the choices that you feel are right for you.

Further Reading

Birthrights “Choice of Place of Birth” Factsheet birthrights.org.uk January 2013

Birthplace Study

Birthplace Study Follow-on studies

Birthrights “Unassisted Birth: the Legal Position”

AIMS Informtion Page - Freebirth, Unassisted Childbirth and Unassisted Pregnancy

AIMS' book "Am I Allowed"

Which BirthChoices

King’s Birthplace Decision Support leaflet

NICE Intrapartum Guidelines

www.homebirth.org.uk

Written by Nadia Higson

Date: 14/06/2017

Reviewed by Emma Ashworth

Review needed: 08/2019


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