Preparing women for home birth

This article outlines some of the issues involved for women and their partners in deciding whether or not to plan a homebirth.

Cathy Green, Midwife working with the Homebirth Team at Birmingham Women’s Hospital. UK


This article outlines some of the issues involved for women and their partners in deciding whether or not to plan a homebirth. It is intended as a practical tool to enable those working with families to begin or take up the place of birth discussion with women and their partners. It outlines and offers responses to some frequently asked questions and concerns of couples and provides practical tips on preparing for a homebirth that those working with women in the perinatal period may find helpful when discussing plans for the birth of a woman’s current or subsequent baby.


Homebirth accounts for approximately 2% of all births in England (National Maternity Review, 2016) with pockets of the country having significantly lower as well as higher levels. We know many more women would like a homebirth – 10% of those recently surveyed (National Maternity Review, 2016). The Homebirth Team at the Birmingham Women’s Hospital has used a variety of techniques to take our homebirth rate from 0.3% in 2013 to 1.2% in 2016 (Noble et al., 2016). As a former National Childbirth Trust (NCT) antenatal teacher and now as a midwife, I have had the opportunity to meet many couples making the decision about where to have their baby. There are many issues involved in this decision.

Key concerns about choosing homebirth
Safety is voiced as one of the key concerns by women and their partners when homebirth is suggested. Thanks to the Birthplace Study (Birthplace in England Collaborative Group, 2011) we have fully up-to-date information on safety which can be shared with families.

• For women having their second, third or fourth baby and who are ‘low risk’, the safest place to give birth is at home. By choosing a homebirth a woman is less likely to have any form of intervention including forceps or ventouse delivery or caesarean section. The outcomes for the babies of this group of women are the same in hospital and at home.

• For women having their first baby, planning a homebirth again means less chance of any of the above interventions in labour. For the babies of first time mothers, there is a slightly higher risk of complications. In number terms – for every 1000 babies born in the hospital, five will have a problem.  For every 1000 women who plan a homebirth, nine babies will have a problem. It can be helpful to give these actual numbers to women and their partners so they can decide. A very useful tool to help couples visualise the statistics for place of birth outcomes is the ‘Birth Place Decisions’ leaflet (Coxton, 2014).

However, decision-making is a multifaceted process ‘involving personal and non-clinical factors’ (Stone, 2016) and as clinicians, but also advocates for women, we must ensure we talk about evidence separately from decision-making as evidence is not the only thing that informs decisions (Wickham, 2016).  Murphy-Lawless (2007) suggests that when making a decision about homebirth, women are less likely to be reviewing evidence-based data and more likely to draw on common-sense judgements about what constitutes risk in everyday life, acknowledging that scientific evidence is not straightforward given the unpredictability and social nature of birth.
Some women and men see homebirth as an odd, backward, uninformed choice or simply not for ‘people like us’. Our experience at the Birmingham Women’s Hospital is that the demographic of the women who choose a homebirth with our team almost exactly reflects the demographic of Birmingham itself. Women need to see images of all kinds of women having homebirths to feel that it is relevant to them. Having a selection of images to show, or a short video, can have a positive effect on changing some deep seated beliefs about the relevance of homebirth for certain groups of women. Recognising this, we have made video interviews with several of our homebirth women which we have posted on our ‘Home Birth with Birmingham Women’s Hospital’ Facebook page.

Women need to see images of all kinds of women having homebirths

Ultimately, concerns over safety are often not the reason a woman and/or her partner dismiss the idea of homebirth. In my experience, the real issue is the strong cultural association between birth and hospital. The default position for most women when imagining/planning their birth is for it to be in hospital. Changing this mind-set requires a seismic shift in thinking. So how can we promote this shift? Below are some of the key triggers which appear to help women and their partners decide that homebirth may be for them.

Birth stories
Hearing accounts of women’s births first hand seems to have the biggest impact on decision making for women and their partners. We hold regular ‘tea parties’ to which anyone considering a homebirth is invited. At these events, we talk about the practicalities of homebirth and couples get to meet the team of midwives. In addition, we invite new parents who have birthed with us at home to talk about their experience. We also try to bring in a couple whose birth started at home but who were transferred into hospital in labour. Without exception, such couples are positive about their decision to plan a homebirth. Both experiences provide parents-to-be with an insight into the practical and emotional issues around homebirth and have a dramatic effect on chipping away at the deep seated cultural belief that birth in hospital is the ‘right’ thing.

Home comforts
As a team, we take every opportunity to talk to women antenatally about the period after having a homebirth. This seems to resonate particularly with women who have had a hospital birth previously. We may talk about a recent birth we have been at where the woman’s other children woke up and came downstairs to meet their new sibling, with mum tucked up on the sofa with a mug of tea from her own kitchen. We mention how nice it is to have a bath in your own bathroom and that the partner does not have to leave after the birth. These small, practical details can be enough to change someone’s opinion about homebirth or to strengthen their resolve to choose this option, particularly if a previous postnatal experience in hospital was not seen as particularly positive.

Birth preparation talk
As a student midwife, I had an elective placement with a team of community midwives in Torbay in the south-west of England where there is a particularly high home birth rate. I was keen to see what made a difference there. One thing that particularly stood out for me was the point at which midwives discussed where the baby would be born. This was left until around 34 to 36 weeks as it was felt a woman would be more focused on such a discussion at this point in her pregnancy. The Head of Midwifery for this Trust, which has a homebirth rate of 12%, explained that place of birth should never be a tick box question at the beginning of pregnancy. She compared this to being asked in March what you would like to eat at the office Christmas dinner. In most parts of England, women are ‘booked’ at the beginning of pregnancy and encouraged to choose their place of birth then. The issue is generally not raised again. At the Birmingham Women’s Hospital, the Homebirth Team, working closely with community colleagues, is taking a different approach. In an attempt to promote the idea of homebirth, our team is currently offering a ‘birth talk’ to all low risk multiparous women who are currently planning a hospital birth. We see this as an opportunity to revisit the option of homebirth, dispel some of the myths and provide the practical information women and their partners need to make a fully informed choice about where to have their baby. In addition, all community teams are fully briefed on the outcomes of the Birthplace Study (Birthplace in England Collaborative Group, 2011) and around 34 to 36 weeks, will begin discussing the best place of birth for women based on the women’s parity and pregnancy ‘risk’ status. It is hoped that this two-pronged approach will increase the number of women choosing homebirth. Early results are proving positive as we have had a number of women deciding on a homebirth late in pregnancy when they had not really considered it before. Where women remain undecided, we have also begun to offer home assessment in labour. Women can call us when they are in early labour and we attend and offer support and care. If the woman feels relaxed and would like to continue her labour at home, we remain with her until after the baby has been born. Some women need to be in labour to really know where they want to give birth.

Women may need to be in labour to know where they want their baby to be born

Once a woman and her partner have decided they would like a homebirth, our team takes over the antenatal care. A priority for our team has been to provide continuity of care wherever possible as we know this offers significant benefits for mothers and babies and women report high levels of satisfaction (Sandall et al., 2013). Because we get to know our women and have relatively small caseloads, we are able to spend the time needed to prepare families for homebirth. These discussions take place at various points in the pregnancy, very much led by the woman, but with the ultimate objective of being fully prepared by 36 weeks.  Some issues that come up in the antenatal period are as follows.

Arrangements for other children
What to do with other children is an issue some women are concerned about. We advise that there should be someone available to care for the children should they wake up or become distressed during labour, or should the woman need to transfer into hospital. This could be a neighbour or relative available at the end of a phone. In reality, this has rarely been a problem – women seem to have a sense of when it is safe to give birth and for many this is once they have put their children to bed for the night or sent them off to school for the day!

Who can be at the birth?
Some women wish to have many people around them for birth; others want a private event. Most of the homebirths we have attended have been quiet and intimate, but a few have involved large numbers of friends and/or family members and take away pizzas!

Using a birth pool
We advise women to think about getting a pool. We are great advocates for the use of water in labour, with 60% of women we care for using water to relieve pain in labour and a home waterbirth rate of 46% (Noble et al., 2016). We know that immersion in water can make labour quicker and more straightforward. Women also report high levels of satisfaction with using a pool for labour and/or birth (Cluett & Burns, 2009). When the pool arrives, we advise the couple to practise inflating it and to check that the attachments fit the tap – both things they will not want to struggle with for the first time once in labour!  Linked with water for pain relief is the issue of entonox (gas and air). Most multiparous women will have used entonox at some point in their previous labour and are relieved to know that it will be available at home.
If a woman chooses not to get a pool, we have a discussion about where she thinks she would like to give birth. This is a useful opportunity to talk about upright positions for labour and to dispel any myths about the need to give birth on a bed – something the woman may have done at a previous hospital birth. Many women envisage giving birth downstairs, with the sofa proving helpful to kneel on or against whilst pushing. The discussion on where in the house to give birth provides an opening to mention our equipment and setting up a resuscitation area. We explain that we do this for every birth and reassure couples that some initial help with the first breath is occasionally needed. Rather than worry couples, this information seems to reassure them that we are fully prepared for every eventuality.

Transfer in labour
 
Couples sometimes ask (and we will always tell them if they do not) about how and why they may need to transfer to hospital in labour. We tell couples that safety is our first priority and that if we feel there is a need to transfer, this will be via the 999 ambulance service. A discussion of the issue of transfer seems to reassure couples rather than induce anxiety. A recent review of our statistics shows that our transfer rates are well below those of the Birthplace Study (Birthplace in England Collaborative Group, 2011). In this study, the transfer rate for primiparous women was 46% (ours is 38%) and 12% for multiparous women (ours is 6%). We have also had no adverse outcomes for mothers or babies (Noble et al., 2016).

What kit will I need and will there be a lot of mess?
The main ‘kit’ a woman needs for a homebirth is a large quantity of towels, for baby and for mum, particularly if using a pool, and one or two plastic sheets to cover furniture. Couples are relieved to know that even though there is unlikely to be much mess, any waste is disposed of by the midwives. This includes the placenta unless the couple wish to keep it. Several of our families have kept their placentas to add to smoothies, cook with onion and garlic, plant in the garden or even to make into a piece of art!

Managing the pain of labour
Many of the primiparous women we care for have attended antenatal classes provided by the Birmingham Women’s Hospital, which focus on breathing techniques, movement and upright positions. We do not provide a particular antenatal education session for homebirth women because we take the approach that everyone is likely to need something different and we are able to provide individualised preparation. For some women, we offer a one-to-one hypnobirthing session; for others, our 34 to 36 week talk will include a practical session on relaxation, breathing, positions and movement for birth, including a discussion of strategies based on their own coping repertoire. Homebirth women tend to have an innate sense that they will be able to cope in labour, and at least want to try to see if they can cope! If labour is straightforward, this determination, coupled with being in a relaxed, supportive environment, usually results in a woman coping well with labour and birth. It can be helpful to point out to women planning their first baby at home that no woman having a homebirth with us has ever transferred to hospital in labour for more pain relief.

Homebirth women often have an innate sense that they will cope in labour
For women having their second or subsequent baby, birth preparation will vary according to the woman’s previous birth(s). Some women will be quite anxious about their ability to cope, based on a previous traumatic experience in hospital. For these women, we focus on issues of relaxation, breathing and movement and also talk about the likelihood that this birth will be much quicker and that their coping strategies will not have to be employed for too long! We also aim to unpick some of the issues from the previous birth which caused distress if these have not been discussed earlier in pregnancy.

Early labour
An important part of any antenatal birth preparation is discussing coping strategies for early labour. For primiparous women, the ability to remain calm, hydrated and nourished in early labour is vital, whether having a home or hospital birth. Women booked with us know they can call us for advice at any point in their labour and that if they need support, we will come out to them in early labour. Knowing someone is at the end of the phone who will come when needed seems to help women cope for longer before calling us. If we visit a woman in early labour, we have the opportunity to remind her and her partner about coping strategies and this appears to give them the confidence and strength to cope with what can be a long latent phase.
For multiparous women, our advice is somewhat different. We know that second and subsequent babies can make a quick appearance after the start of labour. We advise all our multiparous women that they should not wait too long to call us and that we would rather come for a false alarm than miss the birth of the baby! This does mean that we may make several visits, but it also means that we have missed very few births.

Conclusion
In an environment where the vast majority of births are in hospital, it is a challenge to find ways to help women question deeply held beliefs. However, women prioritise their baby’s and their own safety (Paranjothy, 2001) and we now have the evidence that homebirth is safe. When women and their partners recognise that birth is a ‘deeply social act’ (Murphy-Lawless, 2007), they begin to see the advantages and relevance for them of homebirth. Through a combination of information giving, story- telling and continuity of midwifery care, the number of women choosing homebirth has increased in Birmingham. Caregivers in the antenatal period have the opportunity to dispel myths and to offer birthing women an alternative discourse outside the cultural norm.

References
Birthplace in England Collaborative Group (2011) Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: The Birthplace in England national prospective cohort study. British Medical Journal,  343:d7400.
Cluett E.R., Burns, E. (2009) Immersion in Water in Labour and Birth. Cochrane library. <available at> http://www.cochrane.org/CD000111/PREG_immersion-in-water-in-labour-and-birth. Accessed 20th May, 2016.
Coxton, C. (2014) Birth Place Decisions. London, Kings College. <available at> http://www.nhs.uk/Conditions/pregnancy-and-baby/Documents/Birth_place_decision_support_Generic_2_.pdf. Accessed: 20th May, 2016.
Murphy-Lawless, J. (2007) Homebirth – a realistic possibility. <available at> https://www.rcm.org.uk/news-views-and-analysis/analysis/home-birth-–-a-realistic-possibility-part-one. Accessed 20th March, 2016.
National Maternity Review (2016) Better Births – Improving outcomes of maternity services in England. A five year forward view for maternity care. <available at> 
https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf. Accessed, 30th May, 2016.
Noble, S., McAree, T., Pretlove, S., Cheatham, C., Cross-Sudworth, F. (2016) Homebirth Service End of Year Report, April 2015 - March 2016. Birmingham, UK, Birmingham Women’s NHS Foundation Trust.
Paranjothy, S., Thomas, J. (2001) Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit - National Sentinel Caesarean Section Audit Report. London, RCOG Press.
Sandall, J.S.H., Gates, S., Shennan, A., Devane, D. (2013) Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews (8):CD004667.
Stone, M.H. (2016) The evidence and the decision are two quite distinct things. British Medical Journal, 353:i2452.
Wickham, S. (2016) Evidence and decisions: Two different things. <available at> 
www.sarawickham.com. Accessed 26th May, 2016.

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