For most people, particularly with uncomplicated pregnancies home birth with a midwife is a safe option, even if it’s your first baby.

Some research demonstrated a small difference in outcome for first babies born at home compared with second or more babies, but more recent international research found no difference. We’ll delve into the stats further down.

It’s not uncommon for us to hear people say that they don’t want to plan a home birth for their first baby, ‘just in case’. Usually ‘just in case’ means just in case something goes wrong and medical input is needed. To be clear - only you can decide what feels safe for you when it comes to birthing your baby, and feeling genuinely safe is a good state to be in for birthing. However, it is worth exploring why one place of birth feels safer to you than another. Is it because you actually feel safe there or is it because it’s a societal norm?

In well resourced settings like the UK, there is an assumption that giving birth in hospital is the safest option for all women and birthing people. Research has challenged this assumption on several occasions and we know that iatrogenic harm (harm caused by medical care itself) can be caused by unnecessary interventions that are more likely to occur within a hospital setting.

What the research says about home birth

Overall planned home birth in well-resourced settings, with midwives and access to higher level care if needed, is safe. In 2011 a piece of research was published called the Birthplace in England study. It compared outcomes for women and babies in England across differing birthing settings: hospital labour ward, midwifery-led units and home birth. The results of this research informed the current NICE guidelines around discussing place of birth with women. The Birthplace study found that adverse outcomes for babies were more common in women having their first baby at home compared to women having a subsequent baby at home. It also found that women were more likely to experience a straightforward birth if they had a home birth compared to those planning a labour ward birth. We’ll delve into the numbers further down - keep reading!

More recent research from a Lancet journal in 2019 looked at neonatal outcomes based on planned place of birth. This research encompassed studies from around the world, not just a UK setting. Studies included were however from high resource settings with integrated healthcare systems - i.e. similar healthcare and maternity care systems to the UK. This study found that outcomes for babies were no different whether it was a first or a subsequent birth in women who planned a home birth. A sister piece of research on the same data set published in 2020 concluded that outcomes for women who planned to birth at home were arguably better than those who planned to birth in hospital - for example, lower rates of caesarean birth and instrumental birth. This research hasn’t made it to NICE guidelines yet and might never make it. It is important to share as if you’re having your first baby and would like to plan a home birth, you might be told that it’s safer to give birth on a midwifery-led unit or in a hospital based on the results of the Birthplace study, whereas the more recent research from the 2019 Lancet journal demonstrated no difference in outcomes for babies. It’s just more information to hopefully help you make the choice that feels right for you.

Understanding the numbers: absolute vs relative risk

Absolute risk refers to the actual chance of a thing happening, whereas relative risk may be expressed in terms like, ‘twice as likely’. Being told you have double the chance (relative risk) of something negative happening sounds quite scary, compared to being told the actual likelihood of something happening (absolute risk) e.g. there is a 1 in 1000 chance. A good example is when thinking about neonatal infection risk after waters have been broken for 24+ hours. In our experience women are told the chance of infection doubles - which is true, and sounds quite alarming. The chance of infection doubles from 0.5% to 1% - so there’s still a 99% chance of your baby not getting an infection. Hopefully you can see the importance of using absolute risk when decision making.

To return to the Birthplace study, for the first-time mothers adverse outcomes for babies when birth was planned to be at home were 9.3 per 1000 vs. 5.3 per 1000 for planned obstetric unit births. Adverse outcomes for babies included the following: stillbirth, meconium aspiration syndrome, early neonatal death, neonatal encephalopathy and specified birth injuries including brachial plexus injuries and a fractured clavicle or humerus. Each of these adverse outcomes is rare, which is why they were grouped together and a fracture has a significantly different impact than a stillbirth or neonatal death.

But to put these figures another way, 991 babies out of 1000 were born with no problems at home, vs 995 per 1000 for planned obstetric unit births. Risk cannot be excluded entirely from maternity care unfortunately even with gold standard care, but you are far more likely to not experience an adverse outcome than to experience one - wherever you plan to birth.

How often do first-time parents transfer to hospital?

Transfer to hospital is often a question we get asked when people are thinking about home birth. It’s definitely something to think about and plan for - whilst birth usually works amazingly, there are scenarios that warrant extra input from our medical colleagues in hospital. The Birthplace study found that 45% of first time mothers transferred to hospital from home vs. 10% of women having a subsequent baby. The most common reason for transfer from home was a delay in progress in the first stage of labour (which in medical terms is defined as labour up until the point of the cervix being fully dilated, and that is only known where vaginal examinations are performed). A delay in labour is not generally considered an emergency if all else is well. The majority of transfers from home were considered non-urgent, which may be reassuring to hear. Midwives are highly skilled and trained to observe for signs that things are veering off path, and will either make suggestions to try and get labour back on path or recommend transfer before an emergency situation arises.

Common reasons for transfer during home birth (most aren't emergencies)

Some of the reasons for transfer for first-time mothers in the Birthplace cohort are detailed below. Most transfers occur before the birth of the baby.

Before birth of the baby:

• Failure to progress in the first stage: 11.2%
• Fetal distress in the first stage: 2.2%
• Meconium in the waters: 5.4%
• Epidural request: 2.8%
• High blood pressure: 0.9%
• Failure to progress in the second stage of labour: 6.7%
• Fetal distress in second stage: 0.6%

After birth of the baby:

• Postpartum haemorrhage: 1.2%
• Retained placenta: 1.8%
• Perineal suturing: 4.4%

Another systematic review found that for the first-time mothers, transfer from home to hospital ranged from 23.4% - 45.5%. This review also found that transfer was more likely when home birth care was provided by midwives employed by a hospital compared to independent midwives. This is likely because employed midwives are working to hospital policies and protocols, whereas independent midwives have more flexibility around this and whilst we are of course required to practice safely and within our scope, we are not required to follow hospital policies. This review also found that most transfers (for all women) occurred in labour, before the baby was born and the most common reason was also ‘slow progress’ (a problematic term in itself but that’s a blog for another day!)

Transfers before birth were identified due to ‘slow progress’ (5.2% - 9.8%) and fetal distress, which means concerns with the baby’s heart rate in utero (1% - 3.6%). Indications for transfers after birth were postpartum haemorrhage (0% - 1.4%) and breathing problems in the baby (0.3% - 1.4%). This study is limited by indications for transfer not being defined in 4 studies, and those 4 studies made up 89% of the total number of women in the 15 studies included in the review.

What a home birth midwife does to keep you and your baby safe

When you invite a midwife into your home to provide you with care and support during your labour and birth, hopefully you’ll have had the chance to meet them beforehand and form a relationship. The conversations you have in the weeks leading up to birth are an important part of keeping you and your baby safe. Understanding how to create an optimal labour environment, how the hormones of labour work and what you and your birth partners can do to support all lay the foundations for keeping birth on track. Possible reasons for transfer should also be discussed, so that you know why your midwife might recommend it.

When you call your midwife in labour, they should check in with you first and foremost about how you’re feeling and about how you feel your baby is. They might ask about movements, or if your waters have gone for example. They might be able to get certain information from simply looking at and listening to you. Experienced midwives quietly observe, yet remain vigilant for any signs of concern.

During labour your midwife will offer certain things to you to assess yours and your baby’s wellbeing, for example taking your observations (blood pressure etc.) and listening to your baby’s heart rate. It’s your choice if you want to have these things or not. NICE guidelines recommend undertaking observations in labour at set times - it’s worth thinking about beforehand if this is something you want and putting that in your birth plan. Your midwife may offer a vaginal examination to assess your cervix, and whilst these can be a useful tool in certain clinical situations they have limited use when used routinely and they definitely can’t predict when a baby will be born.

Most of the time if a transfer is recommended, as the research shows and in our experience, this won't be an emergency or what we sometimes call a ‘blue light’ transfer (an ambulance racing through the streets with flashing lights!). There may be signs that things are veering off path, for example a rising pulse rate might signal dehydration or infection. If we can steer things back to the right path safely at home, we will do our best to. But sometimes a transfer is what’s safest for you and your baby and in our practice we will always endeavour to make sure you are at the centre of that process.

Home, birth centre or hospital: comparing your options

Birth is generally safe, wherever you plan to do it. Research does show that you’re more likely to experience intervention (and potential complications from those interventions) if you choose to give birth on a hospital labour ward - particularly if your pregnancy is uncomplicated.

Giving birth at home or on a midwife-led unit leads to a lower chance of experiencing interventions that are potentially unnecessary and a higher chance of having a straightforward vaginal birth. Outcomes for babies are comparable across all settings. Babies born at home or on midwife-led units are more likely to breastfeed, which is also something worth considering if breastfeeding is important to you.

Some people feel that a midwifery-led unit is a comfortable middle ground between home and a labour ward, but anecdotally we know that midwifery-led units often face closures due to staffing issues and labour wards always take priority. This can be disappointing to call up in labour and discover the midwifery-led unit is shut and be told that your only option is to go to the labour ward. Not only because it wasn’t your plan, but because it significantly impacts the likelihood of you experiencing certain interventions.

The research we mentioned above from the 2020 Lancet journal found that women with uncomplicated pregnancies who even just planned to have their first baby at home had the following outcomes:

• ~30% less likely to have a caesarean birth
• ~25% less likely to have an instrumental assisted birth (forceps or ventouse)
• ~50% less likely to have an epidural (epidurals result in more interventions)
• 25% less likely to have an episiotomy
• No difference in likelihood of a postpartum haemorrhage

Read about if your pregnancy has been labelled high risk but you still want a home birth.

Questions to ask when planning a first home birth

Who do I want to support me at my home birth?

What support techniques can I gather to help me through labour?

What practical items do I need?

What will my midwife or doula supply?

Do I need someone to look after my pet?

How far away is my nearest maternity unit?

How would I travel there?

If I’m booked with an NHS home birth team, how likely is it that midwives will be available to attend my home birth?

Do I have any unique considerations to take into account?

Planning a home birth in Kent

In East Kent, we currently don’t have a dedicated NHS home birth team. Some people are surprised to discover that it could be the case that when they call the midwife in labour, there’s no one available to come out to them. In this scenario, women are invited into the maternity unit to give birth instead, which is optional but worth thinking about what you would want to do in that scenario.

When you book an independent midwife they make a commitment to you to be present and available for your birth to the best of their abilities. We say that to take into account the unlikely but not impossible scenario that we’re not able to make it (we’re talking family emergencies, illness and other things that are outside of our control!). We take on micro-caseloads of women and birthing people to ensure that everyone in our care gets our deep attention. Hiring an independent midwife is the most reliable way to secure a home birth with midwifery support in Kent, and in our experience it’s an investment people don’t regret - even if they don’t ultimately birth at home.