Nadia Higson shares the results of an exploration of what is on offer to women
Most women who want one are able to achieve a homebirth – but all too often this is in the face of obstruction from their carers, and more than half of pregnant women are never offered this option. These are the main findings of the AIMS homebirth survey. Although this was an informal, exploratory survey, it raises a number of concerns and we believe that more systematic research is needed to understand the extent of the difficulties that women currently face in exercising their choice for a homebirth.
Women were recruited to take part in the survey by email invitation and by a link on the AIMS website, and were also asked to forward it to other women who might be willing to share their experiences. The invitation stated:
‘AIMS is concerned at the increased numbers of appeals from women who are having, or who have had, problems booking a homebirth, or getting a midwife to attend when they called in labour. In order to better understand what is happening around the countr y we would like to hear your experiences, particularly if you have had a baby in the last year.’
A total of 571 women completed the sur vey at least in part. As a self-selected group, their experience may not be representative of all mothers in the UK, especially asthe wording of the invitation may have disproportionately attracted responses from those who had had problems gaining support for a homebirth.
Another limitation of the survey is that although the majority of the women gave birth within the last four years, some were recounting experiences from many years ago. However, there appears to be little difference in the experience of these women and those who gave birth more recently.
Whether or not the women would have liked to have a homebirth (and 92% of the sample would have done so), well over half of them (58%) were not offered this choice. Of those who were offered it, the vast majority (92%) received this information from a midwife, and this was usually fairly early in the pregnancy (almost 75% by 12 weeks). Around 3% of women stated their preference for a homebirth without waiting for it to be offered.
A fifth of women were told that they could not have a homebirth … and many had to fight to get one.
It is clear that many carers did not recognise a mother’s right to choose a homebirth regardless of any risk factors which may apply. Almost a fifth (104/525) of the women who wanted a homebirth were specifically told that they could not book one. The main ‘gatekeepers’ appear to be midwives (for 78% of the mothers who were told they could not have a homebirth), followed by obstetricians (39%) and GPs (16%).
For almost a quarter of this group (24/104), midwifery staffing issues or reluctance by midwives or the local health service to support homebirths were given as a reason. Comments included ‘Midwives’ lack of experience, distance from hospital (we are 8 miles away!!)’; ‘The “quota” for homebirths for that month was already full!’ and ‘We don’t do them anymore’.
Other main reasons given for not booking a homebirth were previous caesarean birth (25%), first baby (13%), 3rd or subsequent baby (9%), mother’s BMI (9%) or a ‘large baby’ in this or a previous pregnancy (8%).
Although most of the women who had wanted a homebirth were eventually able to book one, and many were full of praise for the supportive care that they received from their midwives, more than one in ten (56/525) said that they were not able to book a homebirth; and for others it took considerable determination to achieve one. Just under a quarter (85/374) of the women who had a homebirth reported meeting resistance from midwives and/or consultants:
‘Eventually my hospital accepted I was having a HB and accordingly sorted out an on-call rota ... but it took time, letters of protest and a lot of effort on my part to get them to change.’
‘Getting homebirth felt like getting a visa for N Korea ... made pregnancy so stressful.’
‘In order for me to have the homebirth I wanted I had to book a private midwife at considerable financial cost.’
The majority of women in the sample who booked a homebirth were able to give birth at home (74.5%), but at least 3% transferred to hospital care during pregnancy, 12% at the start of or during labour and 3% for induction of labour. (The remainder did not answer these questions.)
‘When I rang to say I was in labour and had booked a homebirth I was told that no midwives were available.’
Of the 60 women who transferred to hospital during labour, 22% did so solely or partly because care was withdrawn. This was most often due to a reported lack of staff to attend the woman at home and was the second most common reason for transferring, following lack of progress in labour (25%). The other main reasons were concern over the baby’s well-being (20%) and because the waters had been broken for more than 24 hours (17%).
It is interesting that over a third of the mothers who transferred for reasons other than lack of staff were unhappy with that decision; and also that around half of those who transferred did not then require any medical interventions.
Over 90% of those mothers who gave birth at home were very satisfied with the experience, rating it 8 or more out of 10. They frequently described it as ‘amazing’. As one mother put it: ‘It was quite simply one of the best experiences of my life.’
Almost all of the women who gave birth at home (98%) would choose to book a homebirth in another pregnancy, and so would a large majority (88%) of those who wanted to but did not give birth at home. This includes almost all of those who transferred to hospital care in pregnancy or labour.
Many women described how birthing in familiar surroundings at home had made them feel safe, relaxed and in control:
‘It felt very natural to be at home in my most familiar and relaxed environment without external distractions. This allowed me to get into my own zone for giving birth.’
‘I felt very safe and comfortable at home. All my wishes were respected.’
‘I felt empowered to be able to give birth to our baby in our own home.’
Those who had experienced birth both in hospital and at home often commented on the differences:
‘I had a previous poor experience in hospital where I felt abandoned and uncared for. I had a subsequent wonderful homebirth … the difference to my care was amazing.’
‘My two previous labours and births were overly managed in my opinion and ended in caesarean sections due to a cascade of interventions.’
‘... in hospital … I was treated without respect and disempowered during my first labour.’
Women who birthed at home felt this made it ‘a part of family life’ and ‘made life with older child much easier to manage, he was also much more involved’. They also appreciated not having to travel in labour or to stay alone in hospital afterwards, but rather being ‘able to be at home with my new baby, husband and other children straight after the birth’.
Another benefit for many was the reduced need for interventions and the fact that being relaxed at home helped them to cope better with the pain:
‘Lack of pressure and home comforts made pain relief unnecessary.’
‘The pain was manageable and the labour very quick.’
Most were very positive about the care they had received from their midwives, especially those who had used an independent midwife, but a few had experienced a lack of support in labour from NHS midwives.
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