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Choosing Your Place of Birth

You see the two lines on the pregnancy test, tell your doctor you are pregnant and the first question they are likely to ask you is…where would you like to have your baby?

It’s hard to know in that exact moment what the best option will be for you so here’s the lowdown so you can make an informed decision. And remember, you can give birth wherever you like and you are entitled to change your mind at any point.

We often forget that birth used to take place at home until it moved into hospital in the mid-20th century, as the medical-model of birth took over and it became more obstetric-led. Given this shift to the medical model, many understandably believe it is safer to give birth in hospital than it is at home but this isn’t necessarily true. Planning a hospital birth comes with an increased likelihood of unnecessary intervention.

So what are your options for place of birth?

Broadly speaking, there are 3 places where most people give birth:

  1. Home

  2. Midwife-led unit (“MLU”) or birth centre

  3. Hospital (sometimes referred to as “labour ward” or “delivery suite”)
     

Home
For millions of years, our ancestors had no choice but to give birth at home (or wherever they were at the time). In much of the world, that is still the case. In the UK, most births took place at home until the 1960s. The reasons for the move to hospital birth are complex, but it was largely based on statistics which were at best “questionable” and could be argued to have been selectively presented at the time to support the medicalisation of birth for all.

Sixty years on, evidence shows that for healthy women who have had a normal pregnancy, homebirth is at least as safe as hospital birth, if not safer and has a much lower chance of intervention. 

Things to consider:

  • Having your baby at home inevitably changes the dynamic - midwives are guests in your home, you are on your own turf. In hospital, midwives and other staff are in familiar surroundings and perhaps feel more comfortable but you are in an unknown environment with many people around you that you don’t know. For birth to go well, we need to feel safe and unobserved so we have to work harder to facilitate those feelings in a hospital setting.
     

  • Being at home doesn’t mean you don’t have access to medical equipment (if it is needed), midwives bring equipment to deal with complications that can arise and if a situation changes, a transfer to hospital will be arranged and a midwife will accompany you in an ambulance. Midwives are brilliant at spotting any complications early on so there is plenty of time to get to hospital if a transfer is necessary.
     

  • If you are worried about pain in labour, be reassured that feeling safe and relaxed (as you do at home) can make the intensity of labour and birth easier to cope with for many people. You can also opt to use a pool at home (wonderful for managing pain) and you have access to gas and air (entonox). If you feel you need further help in managing pain, you will need to go to hospital.
     

As mentioned above, home birth is as safe as hospital birth (if not safer) if you are healthy and have had a low risk pregnancy. For higher risk pregnancies, it is recommended that you give birth in hospital to ensure the best possible outcome for you and your baby. Having said that, it is your right to choose where you give birth and every situation is unique.


Midwife-led units or birth centres
Midwife-led units (MLUs) or birth centres are run and staffed by midwives. There are no doctors in the units so the level of care and support available is very similar to what midwives can offer if you choose to give birth at home. Some MLUs are “alongside” with a consultant-led delivery suite (ie. in the same building) and others are “freestanding” (ie. geographically separate).
 

MLUs are generally more aesthetically pleasing and less obviously medical these days, often with medical equipment hidden out of sight and some rooms may even feel spa-like with birth pools and colourful but soft lighting. This more homely environment aims to enhance relaxation and allow the flow of oxytocin which drives labour.
 

Things to consider:

  • You need to travel there whilst in labour, and would have to relocate to hospital if issues arose which required medical care – just as you would if birthing at home. Pain management options are the same as for a home birth so if you wanted an epidural you would need to transfer to hospital.
     

  • A birth centre can be a great solution if you want a low intervention, midwife-led birth but do not have suitable facilities at home or don’t like the idea of giving birth in your kitchen or sitting room!
     

Delivery suite/labour ward (in hospital)

When I ask clients to picture where they see birth taking place (not necessarily theirs but any birth), they usually say ‘on a delivery suite in hospital’. This is hardly surprising given this is what we see in documentaries and films. 

The major problem with this is that this (generally) stress inducing and unfamiliar environment can have the opposite effect of what is needed to encourage physiological birth to work. It is very common for someone to be labouring well at home but for everything to slow down or stop when they travel to or arrive at hospital. This is because adrenaline (the stress hormone) often kicks in when they enter this unfamiliar space. Once settled and met with a warm and supportive midwife, labour will often restart but it may last longer than it would have if someone stayed at home.

Given all this, it sounds as though hospital may be the worst place to be but for some, it is absolutely the right place to give birth, either out of choice or due to complications. Some people may feel safer and more comforted in hospital or if you are considered high risk, you will be advised to give birth on a delivery suite to ensure the safety of you and your baby.

There are things that can be done to make a delivery suite more homely, such as keeping lights low and curtains closed, playing music, using familiar scents and so on so do explore this when you arrive or ask in advance how the healthcare team can help to facilitate a calm and cosy environment. And don’t forget, the bed can always be moved well out of the way!

What should I consider when choosing where to give birth?

There are of course factors to consider when choosing where to give birth but remember, it is your right to choose!

 

Questions to ask yourself may include:

  • How has your pregnancy been to date? Are you considered low risk and has it been straightforward? Or do you know that you or your baby will need extra medical support in the first few hours/days? Obviously if you are planning a caesarean birth or an induction, you will need to be in hospital.
     

  • If you have given birth before, what was your experience and is there anything you would have changed in hindsight?
     

  • What do you plan to use to manage any pain? Are you hellbent on avoiding an epidural and want to use movement, hypnobirthing and a pool or are you open to medical forms of pain relief?
     

  • How close are you to each place of birth? Does the distance from your home to the hospital mean that a home birth is more or less tempting?
     

  • Is using a birth pool important to you? Statistically, you are far more likely to be able to use a birth pool if you are birthing at home or in a birth centre than if you are at hospital.

 
How safe is it to give birth at each birth place?

If you have had a low-risk pregnancy it is actually safer to give birth in a midwife-led birth centre or at home than in a hospital. What is deemed to be "safe" in a pregnancy that is classified as "high" risk is less clear and very much dependent on the characteristics of your pregnancy. 

Midwife-led birth centre

A large national study (Birthplace in England national prospective cohort study, BMJ 2011) found that for women with a straightforward low-risk pregnancy, birth is as safe for babies in a birth centre as it is in hospital, with the added benefit of lower intervention and complications, including reduced rates of caesarean and instrumental births, episiotomy and perineal trauma.

Home birth

In 2019, a large data review (Hutton et al, 2019) was published in The Lancet. The authors of that review found that “The risk of perinatal or neonatal mortality was not different when birth was intended at home or in hospital.” Ie. for low risk pregnancies, it is as safe to give birth at home as it is in hospital. Many people think that it is only safer to give birth at home if it is your second (or a subsequent) pregnancy, however these statistics found no distinction between first and subsequent pregnancies.

Additionally, giving birth at home has many other benefits compared to a planned hospital birth, such as:

  • 40% less likely to have a caesarean

  • 50% less likely to have forceps or ventouse

  • 70% less likely to have an epidural

  • 55% less likely to have an episiotomy

  • More than 40% less likely to have a severe tear

  • 75% less maternal infection

  • More than 30% less postpartum haemorrhage
     

These statistics on safety come from studies for low risk pregnancies, however it is important to note that there may be instances where you are classified as high risk and it may be that a) that classification is not appropriate, or b) you would still benefit from birthing outside of a hospital setting. It will be a personal decision based on the unique characteristics of your pregnancy.

Are your options removed if you are considered to be high risk?

It will very much depend on your pregnancy. Some pregnancies are unjustifiably classified as high risk and will benefit from midwife-led environments or birthing at home. It is always worth having a discussion with your healthcare team and challenging the recommendation of a hospital birth if you are set on a home birth or birthing centre. You need to find out what the risks are that are specific to you and the research and evidence behind these so you can make an informed decision.

One such example is planning a home birth after caesarean (HBAC): women giving birth at home were 39% more likely to have a vaginal birth after caesarean than to have another caesarean, compared to women having a VBAC in hospital (Bayrampour et al 2021). 

Final thought

Ultimately, when choosing your place of birth, you need to feel safe in your decision. There is no point choosing somewhere that you don’t feel safe as your body simply won’t relax and labour will not progress in the same way.

If you’d like to explore your place of birth in detail and talk through the specifics of your pregnancy with me, I offer birth planning power hour(s) sessions. You can also find out more about my birth, postnatal and overnight offerings by reading the different sections of my website. 

 

I’d love to hear from you if you are looking to hire a doula, either in-person (Wiltshire and beyond) or virtually! x

January 2024

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