Home Birth Reference Site

What if your doctor advises against home birth?

This page is intended for both parents who have encountered opposition to their plans for a home birth, and for healthcare professionals who have reservations about home birth.

Many experts in childbirth - midwives and obstetricians - believe that home birth is a reasonable option for healthy women with normal pregnancies. There is a large body of research which supports this view - see Home Birth Research for details. There are many midwives who choose homebirth for themselves. There are also doctors who choose to give birth at home themselves, although often concern about the reaction of their colleagues leads them to keep quiet about it. I know of three doctors in my immediate locality who have had homebirths, and these are people I've met through my daily life - not through homebirth support. On this website there are some birth stories from doctors who have chosen homebirth, too.

But, as we all know, there are plenty of midwives and doctors who do not support home birth in general. Their views may be based upon their own experience, or perhaps upon their own interpretation of the research - because there are few absolutes in this area. It may be that they are not aware of recent research on home birth safety; perhaps their job is so demanding that they have little time to read up on the subject.

Your doctor may not be aware of the latest evidence and expert advice

Consider showing your doctor some printed pages from this site and linked sources. The sources that carry most weight are the respected medical journals and statements from professional bodies.

I suggest you supply a copy of the Joint Statement on Home Births (Amended) from the Royal Colleges of the two professions which are the experts on birth in the UK.

Home Births - RCOG and Royal College of Midwives Joint Statement No.2. -April 2007

The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a womanís likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.

See British Medical Journal editorial of 23 November 1996 [1], , and the results of the National Birthday Trust study of home births [2]. If you are outside the UK, your doctor will be able to check the credentials of the publications.

A summary of the issues surrounding place of birth published by the UK's National Perinatal Epidemiology Unit found that:

"There is no evidence to support the claim that the safest policy is for all women to give birth within hospital..For some women it is possible but not proven that the iatrogenic risks associated with institutional delivery may be greater than any benefit conferred" [3]

'The GP's Guide to Home Birth' [4] is published online by Bandolier, a respected journal which looks at evidence-based medicine. It was written by Dr Mary Keenan, a member of the UK Government's Changing Childbirth implementation team. She says:

"Changing Childbirth is not about actively promoting one place of delivery above another one, but allowing the woman to make her own choices on balanced information given to her. Home birth should be one of the options presented. For women with uncomplicated pregnancies it is not a high-risk option..."

"The GP should present the information regarding local options for place of birth to the woman in a clear, understandable and balanced manner."

A famous text on evidence-based practice for doctors and midwives is 'A Guide to Effective Care in Pregnancy and Childbirth' by Enkin, Keirse et al [5]. The latest edition, published in August 2000, says (my emphasis):

"Several methodologically sound observational studies have compared the outcomes of planned home births (irrespective of the eventual place of birth) with planned hospital births for women with similar characteristics. A meta-analysis of these studies showed no maternal mortality, and no statistically significant differences in perinatal mortality between the groups. The number of births included in the studies was sufficiently large to rule out any major difference in perinatal mortality risk in either direction."

"Significantly fewer medical interventions occurred in the home birth groups (including women transferred to hospital), and there were significantly fewer low Apgar scores, neonatal respiratory problems, and instances of birth trauma among the babies..."

"Women who have no factors that contra-indicate a home birth, and who prefer a planned, attended home birth with facilities for prompt transfer to hospital if necessary, should not be advised against this."

Your family doctor may believe that she personally has to attend your labour

Some family doctors worry that they will be asked to attend the birth, and that their experience and skills will not be adequate to cope with an emergency. It is understandable that this would concern them, as the job of a family doctor is difficult enough, without the need to keep up-to-date on obstetric research and practice. However, your doctor will not usually be needed to attend the birth - the lead professional will normally be a qualified midwife.

In some situations your midwife might want to call upon a doctor in an emergency, but she can arrange cover from another doctor if your family doctor is not comfortable with this. Your family doctor should certainly not be required to have any specialist obstetric skills - if these are needed, you should transfer to hospital. The GP's Guide to Home Births elaborates:

"Most GPs involved in home birth should not offer interventional obstetric skills. When there has been a deviation from the normal course of labour an ambulance with paramedics should be called and the woman transferred to a fully equipped maternity unit."[4]

The GPs' professional body, the Royal College of General Practitioners, put out a joint statement with the Royal College of Midwives in 1995 [6] which said:

"Women wishing to arrange a home birth should be able to do so. General practitioners who do not wish to provide care for home births should refer women to a local midwife or the local supervisor of midwives (or to a general practitioner who does provide full maternity care)."

The 'GP's Guide to Home Birth' mentioned above would be particularly helpful for a doctor with these concerns. It explains the responsibilities of a family doctor when a patient has a home birth, and discusses legal liability and other issues which your GP might have reason to worry about.

There are some surprising misconceptions among family doctors about home birth. The UK family doctors' magazine, 'Pulse', had an editorial in September 1999 [7] explaining that many GPs did not support home births, primarily because they "do not have the time, skills or inclination to spend hours with women in labour..". The editors of this journal were unaware that, in the UK at least, there was no reason why a GP should attend a home birth.

It was left to Mary Newburn, head of policy research at the UK's National Childbirth Trust, to correct this misunderstanding. She wrote to 'Pulse' explaining that the GP's role was to give women information about their options, and to refer those interested in home birth to a midwife who could make the necessary arrangements.

If this respected publication can be so misinformed about the doctor's role in a home birth, it would not be surprising if some individual doctors were also misinformed about what might be expected of them. Their negative reactions to the idea of home birth might reflect the thought that their own skills would not be adequate to cope with an emergency, rather than a realistic assessment of the safety of home birth attended by a specialist midwife.

Bedfordshire obstetrician Malcolm Griffiths has described how he obtained the support of local GPs for a policy supporting home birth [8]. He found that many family doctors were concerned that they personally would be responsible if anything went wrong, and that they might be called on at short notice, or out-of-hours, to attend a birth. He focussed on the following issues, which are quoted directly from the article:

  1. Make clear that there is no increased risk for low-risk women choosing home birth
  2. Make clear that neither the process nor the organization of care required input by GPs
  3. Ensure that midwives and GPs both understood that most GPs felt they had no practical skills to contribute to even the most straightforward home birth, and certainly that they shouldn't be seen as back-up to midwives.
  4. State that if problems arose during a planned home birth that the back-up to the midwife would be via paramedics who would 'evacuate' the mother and/or baby to the hospital
  5. Acknowledge the demise of the Flying Squad

Griffiths also arranged for speakers from the NCT and from the Changing Childbirth Implementation Team to talk to GPs, with contributions from local midwives who supported home birth. He found that the GPs who attended his seminars were pleased to support home birth requests once their responsibilities had been clarified.

"It all went so well that problems due to home birth requests have evaporated".

In situations where the GP does not think that a woman is a good candidate for home birth, she is referred to an obstetrician where risk factors are discussed:

"..other options are considered (such as Domino birth...) and the woman is empowered to make the final choice" (my emphasis).

Are you a good candidate for home birth?

It is possible that your practitioner supports home birth in certain cases, but believes that your particular circumstances make it inadvisable. Opinions vary about the suitability of certain candidates for home birth. Some doctors advise against home birth for reasons which many others would consider no problem - if you have a low haemoglobin level, or are having your first baby, for instance. More controversially, some practitioners will support a mother in planning a home birth when she has a previous caesarean section, or is expecting a breech baby, while others consider this too risky. See 'You can't have a home birth, because...' for more information on some of these situations.

If your doctor considers that you are not a good candidate for home birth, it is important to find out her specific reasons for this. You can then seek advice elsewhere, for example from AIMS or your local home birth support group. You can also get a second medical opinion - in the UK, you can ask for a referral to an obstetrician. It is often possible to arrange a private consultation with an obstetrician who is generally supportive of home birth, and AIMS can advise you on this. Independent midwives will also usually provide a consultation for a fee which is refundable if you later book them for midwifery care.

The benefits and risks of home birth in your situation depend not only upon you and your baby, but also upon who will be looking after you during the birth. Obviously it is safer if you have a midwife who is experienced and well-informed in matters relevant to your circumstances. If you want to guarantee that you will be attended by a midwife who is an expert in a particular field, then you will probably have to hire an independent midwife.

If, after researching your options, you agree that home birth is not the best choice for you, then hopefully you will feel confident about that decision and will be able to devote your energies to organising a hospital birth to meet your needs - rather than feeling that you have been 'bullied' into a hospital birth.

It's your choice

In the UK, every mother has the right to remain at home to give birth, irrespective of the opinion of her healthcare providers. Whether she has the right to the support of a midwife in planning her home birth is less clear - see 'Home Birth in the UK - Your Rights' for more details. It is government policy that women should be supported in their plans for a home birth where 'clinically appropriate':

"I certainly hope that when a woman wants a home birth, and it is clinically appropriate, the NHS will do all it can to support that woman in her choice of a home birth" [9], and:

The Government want to ensure that, where it is clinically appropriate, if a woman wishes to have a home birth she should receive the appropriate support from the health service. At the end of the day, it must be the woman's choice. [9a]

Listen to the opinions of your medical advisors, but remember that there are other experts who might well have a different view on the matter. Your doctor or midwife can offer you advice based on her own experience, but you do not have to take that advice. Ask what evidence the advice is based on. Ask what particular details of your own case lead her to advise against a home birth. It is not an insult to your doctor to ask these questions; it just shows that you are an intelligent adult who wants to know more about her options.

It is unfortunate that some healthcare professionals still use phrases such as "You will not be allowed a home birth if..." and "You have to go to hospital if..". Such language implies that the woman has no choice in the matter, and that the practitioner is able to make decisions on her behalf. Where the woman's right to give birth at home is at issue, this is simply not true.

It would be preferable if doctors and midwives could acknowledge the mother's choice explicitly - for example, "I am concerned that you are at increased risk of having to transfer to hospital for slow progress because this is your first baby, but it is up to you to decide whether that is a risk you want to take. Would you like contact details for some independent organisations which can provide you with more information?"

If you are not comfortable with your practitioner's attitude towards home birth, you could consider hiring an independent midwife. Independent midwives are usually experts in home birth, staking their reputations (and livelihoods) on a safe outcome. More information is available about booking independent midwives in the UK.

You could also seek advice in the UK from the Association for Improvements in the Maternity Services (AIMS), an organisation which often helps women arrange home births in the face of opposition from their GPs.

Other pages you might find useful on this site:

You can't have a home birth, because... - home birth in special circumstances.

If you don't get on with your midwife, think about doing something about it. She might be as unhappy with the relationship as you are.

Home birth support groups in the UK

Booking a home birth in the UK

References

[1] British Medical Journal No 7068 Vol 313, 23 November 1996

[2] Home Births - The report of the 1994 Confidential Enquiry
by the National Birthday Trust Fund
pub. The Parthenon Publishing Group, 1997.

[3] Where to be born? The debate and the evidence
By R Campbell and A McFarlane, Published by National Perinatal Epidemiology Unit, Oxford (1995)

[4] The GP's Guide to Home Birth, by Dr Mary Keenan. Published by Bandolier
(www.jr2.ox.ac.uk/Bandolier/band32/b32-8.html)

[5] p250-251, 'A Guide to Effective Care in Pregnancy and Childbirth'
By Enkin, Keirse et al , 3rd Edition, published by Oxford University Press, August 2000.

[6] 'Responsibilities in Intrapartum Care: Working Together' - a joint statement from the Royal College of Midwives and the Royal College of General Practitioners (October 1995)

[7] Pulse, editorial 11 September 1999 , and response from Mary Newburn 2 October 1999

[8] Home Birth - getting all-round support for a rational policy, by Malcolm Griffiths, The Practising Midwife, September 1998, Vol 1 No 9, p12-14

[9]House of Lords debate on maternity services, Hansard 12 Jan 2000 : Column 743:

[9a] Hansard 20 Dec 2000 : Column 734

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This page last updated: November 2008

Home Birth Reference Site - www.homebirth.org.uk
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