In the 1960s, one in three women in the UK gave birth at home; now the figure is less than 3%. But why? Recent studies show the added risk of a home birth is tiny and that there are many benefits. Here, a mother of two reveals how the extreme language of both camps leaves mothers-to-be feeling lost
Women do not have the right to put their baby at risk." This was the response of the Lancet to American research, published last July, that suggested home birth trebled the risk of neonatal mortality (the death of the baby within a month of birth). The reaction was swift. There is "a concerted and calculated global attack and backlash against home birth," said Cathy Warwick, general secretary of the Royal College of Midwives. The original American research was a "mishmash? that wouldn't have been published in this country," said Professor James Drife of Leeds University. "A powerbase in the US is producing phony research to validate its own role," said author Sheila Kitzinger, a pioneering figure in the home-birth movement. Soon Woman's Hour was debating the "backlash against home birth"; Sam Taylor-Wood, who had her third child at home, used her guest editor spot on the Today programme in December to discuss why her decision was labelled "brave" and even "irresponsible".
In recent years, home birth has become a cause c�l�bre, particularly among a certain slice of the Mumsnet generation who advocate natural labour and "traditional" forms of care, be that from a midwife or the more recently fashionable doula. NHS maternity statistics suggest that between 2000 and 2008, home births in the UK rose by 54% (compared with a rise in the total number of births of 14%), though since then they have plateaued. Since 2007, government policy has stated that "women should be offered the choice of planning birth at home". In Wales the number of women who give birth to their children at home has doubled since 2002, when the Welsh Assembly Government launched an initiative to encourage home birth.
Despite such initiatives, the number of home births remains small, in Britain as in most other wealthy, technocratic countries. In the 1960s around one third of births took place at home in the UK, but today the figure is only 2.7%; in the US it is less than 1%. Holland is unusual among developed countries in having a home-birth rate of 30%. And, as the Lancet demonstrates, it is easy enough to find those who suggest that women who choose to give birth at home are committing a controversial act, even endangering the lives of their babies.
This may be the "controversy" attributed to minority activities, cultural anomalies. Or it may be the wages of a historical legacy: home birth has been "controversial" since the rise of modern obstetrics and the hospital, which moved birth out of the home. Before that there was no controversy, because there was no alternative. Women's experience of childbirth was influenced by watching other family members give birth; now for most women their first experience of being present at a labour is their own. A major change came in the 1970s when the Peel Report advised that most women should give birth in hospital, although its findings were not based on statistical evidence. Now it seems we have lost confidence in our ability to give birth naturally: today one in four babies is born by caesarean, up from one in 10 in 1990.
In our current creaking superstructure of healthcare, the home-birth debate is laced with words such as "risk" and "patient choice". These words transport me back to the nerves and suspense of two recent pregnancies. I've given birth twice in the past four years, and I remember how my ordinary scepticism was destabilised by the edgy protective instinct I felt for my unborn child. I became a supplicant before sundry medical professionals, entreating them to tell me the right thing to do. I was transfixed by talk of risk: the risk of miscarriage in the early weeks, the risk of my baby having Down's syndrome, the risk of miscarriage after amniocentesis, the risks of going beyond 42 weeks without being induced, the risks of induction?
I read about home birth versus hospital birth, felt buffeted one way then the other. Home birth: liberation from patriarchal control of the body. Home birth: unbridled agony promoted by macho women and their atavistic midwives. Modern technocratic medicine has saved you from pain and the fear of death. Modern technocratic medicine has silenced your body. Even in the depths of my confusion, I began to sense a gap emerging between these theoretical extremities and my own far more contradictory experience. Yet I couldn't determine where theoretical extremity ended and individual experience began. And as soon as anyone mentioned a risk to my baby, I doubted myself, felt bound to comply.
The Lancet's report demonstrates how emotive the issue is. It is also an example of the fraught relationship between statistics and the individual. Published in the American Journal of Obstetrics and Gynecology, the research is defined as a "meta-analysis" ? an analysis of past studies of home birth and hospital birth in North America and Europe. All this data ? derived from different countries, from several decades, but no study from Britain more recent than the 90s ? was crunched together into sundry percentages and "findings". The key finding, said the authors, was that the risk of neonatal death is trebled by home birth. The percentage rose from 0.04% for a hospital birth to 0.15% for a home birth. Yet the risks for perinatal mortality (death of the baby up to a week after birth) were similar for home and hospital birth. Home birth was also found to reduce the risk of interventions for the mother (episiotomies, epidurals, caesareans etc).
Should a risk of 0.15% deter you? Is it real ? and relevant to the UK ? anyway? If a woman opts for a home birth here, is the risk of her baby dying definitely trebled, in Yorkshire as in Cornwall, in Powys as in Perthshire? Each woman, each baby? One of the authors of the American report, Dr Joseph Wax, suggested that the findings were "likely to be applicable to the UK". Only likely, not definitely. For every meta-analysis from the US you can find another report, such as the Dutch study of 2009, which concluded that planning a home birth was as safe as planning a hospital birth, "provided? the availability of well-trained midwives and through a good transportation and referral system".
How do women choose between home births and hospital births? I can only really speak for myself: the matter is so private, bound up with traits of personality, autobiography, circumstance. When I was pregnant for the first time, I thought at first I'd have a home birth. I hadn't spent a night in hospital since my own birth and fragile infancy. (I was induced a month early by doctors who told my mother that the x-ray showed ? for certain ? that I was full-term. When I was born I was dramatically underweight, clearly premature. I was put in an incubator for two weeks; separated from my parents.) So perhaps this was significant. Also, I was attracted to the idea of giving birth where I lived. I didn't want to be stranded in a hospital after the birth, calibrating the hours by the arrival of the drugs trolley, my partner banished each evening. Still, a month before I was due to give birth I was living in a tiny flat with no bath, scant room for a birthing pool, a half- broken church clock outside the window tolling furiously every quarter of an hour. I quite hated that flat, and I had no desire to give birth in it. So I booked myself into the John Radcliffe hospital, Oxford. I was faintly ambivalent about that, but then I was faintly ambivalent about the prospect of giving birth anyway.
A few friends had told me labour was painful. One explained how it made her understand what it was like for soldiers in the trenches, when their limbs were amputated in field hospitals without anaesthetic. A few others had told me it wasn't as painful as they had expected. But what had they expected? I spent 36 hours in pain, a remorseless, probing pain which escalated even as I struggled to "manage" it, as the midwife encouraged me to do. As I wondered how I could possibly manage something that rolls you around like a crocodile, drags you deep down, so you can't catch a breath, so you think you must be dying, I was given various "strategies for coping" ? a Tens machine buzzing at my back. Suggested "labouring positions", though no one compelled me to move my limbs in a prescribed way. Anyway, after a while I couldn't move at all; I was bent double in a rocking chair, inhaling gas and air like an addict. Someone explained ? so calmly it enraged me ? that I was only a third of the way through. I was very tired; I felt as if I was being repeatedly impaled. So I asked for an epidural ? I remember the midwife telling me it would take 10 minutes to work. Contorted on a thin, creaking hospital bed, staring crazily at the clock, I was indifferent to controversies about birth, technocracy versus the natural way and the rest.
My son was born 12 hours later, weighing nearly 11lb. I narrowly escaped a caesarean. It was gory and agricultural, and then there was the moment of surreal joy when I first held him. My daughter, too, was born in a hospital, for another complex of reasons. Neither birth "traumatised" me, as we are sometimes told they might. They are engraved on my memory, but as if I dreamed them. Yet I do, fairly distinctly, recall how kind and professional the midwives and doctors were.
At times, after the birth of my son, I wondered if we might both have died, in another era, without the Lethe of the epidural. It's impossible to know. My experiences can be immediately counterbalanced by those of friends, including one who gave birth at home in two hours; her husband helped her deliver the baby while talking on the phone to the hospital. She felt no pain at all, simply mild discomfort, and recovered within hours.
Sheila Kitzinger had five children at home. She describes how "when you are on your own territory you don't have to think about what you are doing. You are able to express the powerful emotions and excitement of birth." Kitzinger's daughter, Tess McKenney, had a "wonderful" water birth with a first baby who was just as heavy as mine: "The only injuries I sustained were red marks where my back rubbed the side of the birthing pool.") Equally, a hospital will not inevitably dull the senses or force a woman into an escalating series of interventions. Abigail Reynolds, an artist, had a violent, elemental labour, without analgesics: "I felt as though I was in a dark forest howling away among the scrubs and prickles, performing some solitary act. I was sweating and struggling about on the bed. The midwife told me to stop screaming because I needed all the energy I had for pushing?" The location? Guy's and St Thomas' Hospital, London.
In Birthing AutonomY, Nadine Pilley Edwards argues that much of what purports to be science or analysis might equally be called opinion or ideology: "Knowledge does not stand outside culture, but is shaped by the core beliefs and values of any given community or society." In Britain the Royal College of Obstetrics and Gynaecology and the Royal College of Midwives jointly support home birth for "low-risk" pregnancies, emphasising that "women have less pain at home and use less pharmacological pain relief, have lower levels of intervention, more autonomy and increased satisfaction". However, in America (as in Australia and New Zealand), the College of Obstetricians and Gynecologists (ACOG) has stated its "long-standing opposition to home births" and advised women not to be "influenced by what's fashionable, trendy, or the latest cause c�l�bre". These are markedly different institutional opinions.
This reveals a crucial problem for mothers-to-be trying to decide what to do: professional opinion is completely divided. Highly qualified, experienced doctors and researchers will tell them wildly contradictory things. Philip Steer, professor of obstetrics at Imperial College School of Medicine, suggests that first-time mothers should give birth in hospital because they simply don't know if they are likely to have a good labour or not: "The figures for home births are that one in 20 women who eventually have a successful birth will need to be transferred to hospital at some point during the labour. But when you are considering first-time births, that proportion rises to one in four. Transfer is very bad."
However, Lawrence Impey, consultant obstetrician at the John Radcliffe, doesn't believe all first-time mothers should automatically go to hospital: "People forget that with home birth women are more relaxed. If you make someone scared and nervous, then you are more likely to have a complication. There's also the fact that the first labour sets up other labours.'
Michel Odent, who popularised water birth, suggests the terms of the debate are too simplistic: "People are contrasting home birth or hospital birth, but in fact at the present time, in urbanised society, we have to reconcile the privacy that home can offer and what hospital can offer? An environment that is perfect for one woman is not the same for another." Yet all three of these professionals agree on one thing: the mother-to-be must decide for herself.
So a pregnant woman in Britain is gently, with lots of benevolent talk of choice, consigned to a labyrinth, in urgent need of a ball of twine. That might take the form of a single strand of really good advice from someone who knows her well and whose opinion she trusts. During my first pregnancy I felt a strong need for such guidance; with the second, I also had a few convictions. But they only applied to my particular case. Each labour is completely unique, can neither be preceded nor repeated. It seems fitting that childbirth returns you to the sphere of private influence, to close relationships with individuals, away from the torrential assertions of the internet or the miasma of risk assessments. The people to avoid in the end are the evangelists who advocate one policy for all women. Or the scaremongers hoping to attract your gaze. Nothing could be less susceptible to dogmatism than motherhood and birth. As Odent says: "You can have a preconceived script, but you must be able to change."
Joanna Kavenna is the author of The Birth of Love (Faber, �12.99)
Source: http://www.guardian.co.uk/lifeandstyle/2011/jan/30/home-births-womb-of-my-own
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