Do You Have the Right to Choose a Home Birth If You're High Risk?

There is good evidence to show that home birth is a safe option for women, birthing people and their babies if they fall into the ‘low risk’ category and have had healthy, uncomplicated pregnancies. The most recent research to support this is from the 2020 Lancet series on home birth outcomes. But what if your pregnancy is considered ‘high risk’? Is home birth still a safe option for you and can you still choose it?

To go back to basics, in the UK you have the legal right to choose where you give birth, regardless of your risk status during pregnancy and even if your decision seems incomprehensible to somebody else. As long as you have mental capacity, you have the right to choose. Birthrights explain this clearly here. Anecdotally, we know that home birth is usually discouraged if a pregnancy is considered high risk and NICE guidelines do not recommend home birth unless the pregnancy is low risk and uncomplicated.

Why "High Risk" Isn't Black and White

Risk is a spectrum and it’s too binary to just put women and birthing people into a high or low risk category. Let’s use the example of gestational diabetes. Where someone has been diagnosed with gestational diabetes (GD), their pregnancy automatically becomes classed as high risk. However, if blood sugars have been controlled by diet throughout pregnancy, the baby has not been exposed to the risks of high blood sugars (hyperglycaemia) – in essence they are the same as someone who does not have GD. On the other hand, someone who has had uncontrolled blood sugars throughout their pregnancy and required multiple forms of medication has a very different risk profile in that their baby has been exposed to hyperglycaemia and the associated risks of this (read more about those here under ‘interventions’). So whilst both pregnancies are classed as high risk, we cannot compare someone with controlled gestational diabetes to someone with uncontrolled gestational diabetes. And just to clarify, someone who has controlled blood sugars during pregnancy is not better than someone who has had more difficulty maintaining normal blood sugars and who may require medication to support them – we’re all built differently and for some, diet alone will not maintain normal blood sugars. Regardless of this, both those with controlled and uncontrolled gestational diabetes have the same right to plan a home birth.

What Counts as High Risk in Pregnancy?

Some women and birthing people may have a whole host of ‘red flags’ or risk factors – bunting in fact! Having a medical condition where the impact on pregnancy is perhaps uncertain will likely result in a high risk label. These people will likely benefit from multidisciplinary team input during their pregnancy for an individualised care plan to be made – but it could also be the case that their medical condition may be very unlikely to affect labour and birth at all. There is not enough research to assess the safety of place of birth for specific medical conditions – so recommendations are therefore based on professional opinion. In our experience, medical opinion will err on the side of caution – obstetricians are understandably more comfortable on a labour ward, where lots of monitoring of women and babies can happen. This doesn’t necessarily mean that the labour ward is the best option for place of birth for all women and birthing people with ‘high risk’ pregnancies – but what it does mean is more exposure to interventions that may not be necessary. Birthing in hospital carries its own set of risks.

What Does the Research Say About Home Birth for High Risk Women?

There is some research on home birth outcomes for women and babies where the pregnancy is considered to be high risk. We will be exploring the data from the 2011 Birthplace in England Study, which whilst was a very large study, is now over 10 years old and more research is needed.

An analysis of the Birthplace in England study looked at perinatal (baby related) and maternal outcomes for 8180 high risk women. 1489 of these women planned a home birth and they were compared to 6691 women who planned a labour ward birth. Women who had a multiple pregnancy (ie twins) were not included. The criteria for high risk is listed below. 

Medical conditions that defined a pregnancy as high risk in the Birthplace analysis were:

• confirmed cardiac disease
• hypertensive disorders (high blood pressure)
• asthma
• group B strep.
• hyperthyroidism
• diabetes
• epilepsy
• ‘other’ medical.

Obstetric or fetal conditions that defined the pregnancy as high risk were:

Complications in previous pregnancies:

• postpartum haemorrhage
• caesarean section
• retained placenta

Complications in current pregnancy:

• pre-eclampsia or pregnancy induced hypertension
• gestational diabetes
• BMI >35 at booking
• post term pregnancy (42+1 – 44 weeks)
• small for gestational age
• ‘other’ obstetric / fetal complications

Baby Outcomes: Planned Home Birth vs. Planned Hospital Birth for High Risk Women

This analysis looked at adverse outcomes related to the baby (perinatal) including:

• stillbirth after the start of labour
• early neonatal death
• neonatal encephalopathy
• meconium aspiration syndrome
• brachial plexus injury, fractured humerus or clavicle
• admission to a neonatal unit within 48 hours of birth for more than 48 hours

The overall number of these adverse outcomes was small (41) within the study population. The risk of perinatal adverse outcome was lower in high risk women planning a home birth compared to high risk women planning a hospital birth. For women and birthing people having their first baby, the chance of an adverse outcome related to the baby was 27.7 per 1000 (2.7%) planned home births vs. 46 per 1000 (4.6%) planned labour ward births. For women having their second or more baby, these figures were 12.3 per 1000 (1.2%) planned home births vs. 26.8 per 1000 (2.6%) planned hospital births. When comparing high risk women with low risk women, the risk of adverse perinatal outcomes increased for those planning a home birth, however if there were no complicating factors at the start of labour – this increased risk was not seen. 

Maternal Outcomes: How Does Place of Birth Affect Your Birth Experience?

The analysis also looked at adverse maternal outcomes requiring obstetric input, including:

• augmentation (speeding labour up with the hormone drip)
• instrumental birth (forceps or ventouse)
• caesarean section in labour
• general anaesthesia
• blood transfusion
• 3rd/4th degree perineal tear
• admission for higher level care (eg high dependency unit or intensive care unit)

The second outcome looked at was straightforward vaginal birth, which was defined as a vaginal birth that occurred without the following:

• a caesarean section in labour
• an instrumental birth
• a blood transfusion
• 3rd/4th degree perineal tear

Planned home birth was associated with significantly lower rates of interventions and adverse maternal outcomes requiring obstetric input and significantly higher rates of straightforward vaginal births, than planned hospital births. 

For high risk women having their first baby, planning a home birth resulted in 73% having a straightforward vaginal birth, compared to 51% who planned a hospital birth.

For those having a second or more baby, the percentage of vaginal birth if home birth was planned was 92% vs. 74% if planning a hospital birth. More women who planned a labour ward birth had multiple complicating risk factors compared to those planning a home birth, which may be a contributing factor to the difference in straightforward vaginal birth rates. Transfer rates for women and birthing people from home in the study population were 39% for those having their first baby and 14% of those having their second or more baby.

The Birthplace analysis gives us insight into outcomes for high risk women who plan a home birth, compared to those planning a hospital birth. It shows that on the whole, adverse outcomes are for women, birthing people and their babies are low – even when considered high risk. We definitely need more research on high risk women who are planning to home birth, both in terms of the physical outcomes for them and their babies, and in terms of their experiences of planning a home birth with a high risk label.

A Risk Factor Is a Consideration, Not a Guarantee

Just because someone has been labelled high risk doesn’t mean that they should automatically be excluded or dissuaded from having a home birth if that is their plan or wish. Having access to a multidisciplinary team can be useful to draw in different expertise and help assess what things need to be considered for pregnancy, birth and the postnatal period. However, most obstetricians and midwives in the UK do not attend home birth or even see true physiological birth, so they are unlikely to be thrilled at the prospect of a home birth, particularly where someone is classed as high risk. But each woman or birthing person needs to be looked at as an individual and as healthcare professionals we need to figure out how we can best support them to have a positive birth experience – even if their choices seem incomprehensible to us and do not align with our beliefs about what is best. There are of course scenarios where a hospital based birth for someone with a high risk label is the safest option (eg. pregnancies complicated by placenta praevia or where there is a known fetal condition requiring surgery)

Place of birth discussions need to primarily take into account what the woman or birthing person wishes to happen, what the risks of their choices may be but also, something which is often missed, what the benefits may be in planning a birth at home even with a high risk label. If first time, high risk birthers have a 73% chance of having a straightforward vaginal birth at home, compared to only 51% in hospital, and if their babies are less likely to experience an adverse perinatal outcome at home compared to their high risk counterparts in hospital – we need to be discussing that with women. Home birth is not for everyone, but a high risk label should not automatically exclude someone from considering it.

We are fortunate (despite the numerous valid reports on our inadequate maternity services) that most of the UK is well connected to maternity units, we have skilled midwives and systems in place to transfer women and babies to hospital in the event that further care is needed. We need to support high risk women and birthing people if they wish to give birth at home because they have a legal right to make that choice. The law supports women. Working collaboratively with women and birthing who plan to birth at home is likely to result in better outcomes than declining them care or trying to coerce them to change their mind. Women and birthing people understand that birth is not without risk – we need to respect that.

If you choose to hire us as your independent midwives and fall into a higher risk category, we can liaise with the local NHS multidisciplinary team (only if you wish) as part of your pregnancy care. This can be useful when something is out of our scope of practice or area of expertise, but ultimately it is your choice if you wish to have this additional input or not.

How We Support High Risk Women Planning a Home Birth

If you’ve thought about home birth, but thought it might be out of the question due to a pre-existing medical condition or a previous pregnancy issue, get in touch to see how we can support you to birth at home.

We also provide pregnancy and postnatal care to women and birthing people who plan to give birth in the hospital, so if home birth doesn’t feel quite right for you, we can support you non-clinically during your birth in other settings.