Choosing where to give birth - More than just ‘which hospital looks nicest’

This is a subject that is very close to my heart so do excuse me if I become a bit animated!

Photo courtesy of @thefirsthello

Photo courtesy of @thefirsthello

When I suggest to women at their first appointment (usually termed a ‘booking appointment’) that they have a choice of where to have their baby their reaction is usually one of confusion. Some will say something along the lines ‘yes the GP gave me the choice and I chose here’. I then go on to explain that this means they have a choice of a hospital birth in the delivery suite setting, the birth centre or a home birth and then they look at me with an expression of near horror and mutter something along the lines of ‘surely the reason mothers and babies no longer die in childbirth is because everyone gives birth in hospital?’. Sadly, this couldn’t be further from the truth in the UK today and yet it is so widely accepted. So let’s explore the history a little further.

 

As many Call the Midwife fans will recall at the inception of the NHS in 1948 and right up until the 1960’s, the majority of women still gave birth at home and were attended by a community midwife. While maternal and infant mortality continued to fall throughout the first half of the 20th century, there was still a propensity to frame discussions on childbirth through the prism of risk. With the publication of a government report in 1959, it was suggested that hospital beds should be available for approximately 75% of the pregnant population, however it is worth noting that the purpose of this report was to assess how to better integrate the maternity care provided by the GP, hospital and community services and not an inquiry in to the safety of birth settings. This shift to hospital was further compounded by another government white paper in 1971 stating 'We consider that the resources of modern medicine should be available to all mothers and babies, and we think that sufficient facilities should be provided to allow for 100% hospital delivery. The greater safety of hospital confinement for mother and child justifies this objective'. As a sign of the times and the paternalism that pervaded maternity services and healthcare in general (and still does - another blog for another time!) at that time no one asked to see any evidence to support this statement and excruciatingly no one stopped to ask women where they would prefer to birth their babies! And so began the shift away from home birth and increased acceptance of hospital being the safest place to give birth. Home birth rates dropped to an all-time low of approximately 2% in the 1970’s and have remained around this level ever since.

 

This move from home to hospital with no evidence base, was one of the drivers for Archie Cochrane to set up the Cochrane Library, a world renowned collection of databases that contain different types of high-quality, independent evidence to better inform healthcare decision-making.  He subsequently awarded obstetrics a wooden spoon award as, in his words “The specialty missed its first opportunity in the sixties, when it failed to randomise the confinement of low-risk pregnant women at home or hospital. Then, having filled the emptying beds by getting nearly all pregnant women into hospital, the obstetricians started to introduce a whole series of expensive innovations into the routines of pre- and postnatal care and delivery, without any rigorous evaluation”. In layman’s terms, this translates as creating new models of maternity care despite a complete lack of evidence by telling women that hospital birth was safer, then once women were in hospital introducing a number of interventions also without an evidence base (failing to establish whether they were safe, necessary or acceptable to women, let alone cost effective!).

 

This shift into hospital occurred more than a generation ago and despite government publications as long ago as 1993 refuting the suggestion that hospital birth is in every woman’s best interest and advocating the safety of homebirth and the importance of maternal choice, it remains the status quo. So what actually does the evidence say on the subject of safety of birth setting? In the UK we are extremely lucky that while the incidence of homebirth remains low, it is still an option and we have a skilled midwifery workforce who are able to facilitate home births. In 2011 The Birthplace study was published which reviewed the safety of each birth setting and found that ‘giving birth is generally very safe’ for women considered to be at ‘low risk’ of complications, irrespective of chosen birth setting. It also demonstrated that the rates of birth interventions (forceps, caesareans, episiotomy etc) are lowest in home births with a gradual increase across freestanding midwife led units (located away from the obstetric unit setting), alongside birth centres (co-located with the delivery suite setting, also known as AMUs) culminating with the highest incidence of birth intervention in the obstetric units (delivery suite or labour ward). Now, two things are really important here:

1 – this study looked at ‘intended place of birth’ not actual place of birth (hence why women in the home birth groups had any forceps or caesareans, they were transferred in when it was indicated, they did not have these interventions performed at home as this would not be safe at all!)

2 – these women were all considered to be at ‘low risk’ of complications at the start of labour so nobody can argue that the interventions for the women with planned obstetric unit births were expected because they were high risk as they were not.

So, back to our layman’s terms, what this means is that the likelihood of intervention occurring during birth for low risk women is determined to a considerable extent by choice of birth setting. In view of the fact that birth is ‘generally very safe’ (see above) we are actually doing increasing amounts of interventions above what is necessary in all birth settings except for cases of planned home birth (as the rates of interventions are higher away from home, but the overall outcomes for mums and babies are equally good across all the settings). This brings me neatly on to the subject of iatrogenic harm. Iatro-what? According to the Collins English Dictionary, iatrogenic harm is defined as “an illness or symptoms induced in a patient as a result of a physician’s words or actions”. I think the easiest example to illustrate this is catching MRSA whilst in hospital recovering from a broken leg - it’s not a consequence of breaking your leg, just a consequence of being a hospital patient. While many women are aware of the vanishingly small possibility that they could contract MRSA during their hospital stay whilst having a baby, they are usually completely unaware of the much greater likelihood of other iatrogenic harm such as a forceps delivery or an episiotomy. This is usually because whatever interventions they received during their birth always appear ‘necessary’ in retrospect. However, in view of the evidence to demonstrate that outcomes are safe for mums and babies irrespective of place of birth, but the interventions are highest in the obstetric setting, it is much more likely to be a direct consequence of the obstetric environment & culture causing the high rates of intervention, rather than their home-birth-choosing counterparts being ‘luckier’. This is, I find a particularly good counterargument to the suggestion of ‘it’s better to be in hospital just in case’. Yes, there is no denying there are a few (rare) obstetric emergencies that are easier to manage in hospital than they are at home, and if the likelihood of receiving interventions was the same across all birth settings, then hands down hospital would be the best option, however women and their partners need to be aware that this is simply not the case. In fact, the Cochrane Library estimate the risk of one of these rare complications occurring at a home birth as ‘from a low-risk woman’s once-in-a-lifetime perspective, the risk of encountering such a complication is less than the risk of an average person being killed in a traffic accident during one year’. So effectively, unless the risk of being killed in a traffic accident is so much that you choose never to go out in a car, you are already accepting this level of risk in your life and when the benefits to be gained are a birth with less intervention and therefore greater levels of maternal satisfaction, really women should be more shocked by the suggestion of choosing hospital birth in their booking appointment not home birth!    

  

So, what’s the take home message and why do I get so agitated about this subject? Choice of place of birth is exactly that - choice. It is individual to every woman and her partner and based on the weighing up of risks and benefits that is personal to them. Just like flying, or driving or sky diving or bungee jumping, all of them have risks, some people accept the risk of the rare complications occurring for the benefits they derive from these activities, and some do not.  What’s important is that we recognise that there are risks with every choice in life and when it comes to maternity it is imperative that women and their partners are given unbiased, evidence based information in order to make a decision instead of simply relying on social norm and custom. More radical thoughts from the Positive Birth Midwife…