New advice encourages more home births

"More women should give birth at home, advice suggests," reports The Guardian after draft guidelines produced by the National Institute for Health and Care Excellence (NICE) recommended that women with a low risk of complications in childbirth should be encouraged to either give birth at home or at a midwife-led unit.

The guidance has been revised after new evidence has become available since its original publication in 2007.

As part of the new guidance, NICE proposes revising its recommendations on the most appropriate place for women to give birth if they are at a low risk of complications. It is this aspect of the recommendations that has received the most media attention.

These draft guidelines about the care of healthy women and their babies during childbirth are open to consultation.

What do the draft recommendations say?

The draft recommendations say that low-risk women (women without medical conditions or other factors that put them at increased risk) who have given birth before should be advised to plan to give birth at home or at a midwifery-led unit (freestanding or alongside).

"Alongside" midwifery-led units are based at hospital sites next to traditional obstetric labour wards, while "freestanding" midwifery-led units may not be at a hospital site.

Low-risk women who haven't given birth before should be advised to plan to give birth in a midwifery-led unit (freestanding or alongside). This is because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit.

How is risk assessed?

NICE has published a number of tables listing factors that may increase the risk of complications during birth and require admission to an obstetric unit.

These include having:

• a chronic condition such as asthma, lupus or epilepsy
• certain ongoing infections
• a previous history of pregnancy-related complications, such as pre-eclampsia
• risk factors that make the pregnancy more likely to develop complications, such as if the mother is expecting twins or the mother is obese

Your midwife should be able to provide more detailed advice about whether your pregnancy is low or high risk and why this is the case.

But the final decision about where to give birth is ultimately yours. You will never be forced to give birth at home or at a midwife unit if that is against your wishes.

What are the pros and cons of home birth?

The advantages of giving birth at home include:

• being in familiar surroundings where you may feel more relaxed and able to cope
• you don't have to interrupt your labour to go into hospital
• you will not need to leave your other children, if you have any
• you will not have to be separated from your partner after the birth
• you are more likely to be looked after by a midwife you have got to know during your pregnancy
• you are less likely to have intervention such as forceps or ventouse than women giving birth in hospital

However, there are some things you should think about if you're considering a home birth:

• You may need to transfer to a hospital if there are complications. The Birthplace Study found that 45 out of 100 women having their first baby were transferred to hospital, compared with only 12 out of 100 women having their second or subsequent baby.
• For women having their second or subsequent baby, a planned home birth is as safe as having your baby in hospital or a midwife-led unit. However, for women having their first baby, home birth slightly increases the risk of a poor outcome for the baby (from 5 in 1,000 for a hospital birth to 9 in 1,000 – almost 1% – for a home birth). Poor outcomes included the death of the baby and problems that might affect the baby's quality of life. 
• Epidurals are not available at home.

How has the guidance been received?

The Royal College of Obstetricians and Gynaecologists said it supported the recommendations as long as issues around emergency back-up options and the assessment of pregnancy risk were resolved.

The Royal College of Midwives welcomed the change in guidance, but said more investment in midwifery is needed to implement these changes.

The National Childbirth Trust (NCT) also welcomed NICE's proposed changes.

However, the Birth Trauma Association has concerns over the research that was the basis for these recommendations, and fears that this guidance could put women at risk.

How do I get involved in the consultation?

Consultation is open until June 24 2014. If you wish to take part, you will need to register as an individual stakeholder, or contact the registered stakeholder organisation that most closely represents your interests and pass your comments to them.