Great news for women in the UK! The midwives' professional body, the Nursing and Midwifery Council, has published guidance for midwives on homebirth in March 2006. It makes it clear that midwives should support women's informed choice, even if that means the midwife should improve her training and skills, or if her employer claims that it does not have the resources. It states that the denial of a homebirth service affects women just as much as denying them a hospital birth service. You can view a .pdf copy of original circular here: NMC Circular 8-2006. The article below has not yet been updated to take account of this development, but most of its content is still relevant.
Home Birth UK mailing list - a home birth support group by email. Members have a huge range of experiences of planning home birth all over the UK and elsewhere, and you may well find someone else in your area, or someone who has considered homebirth in similar circumstances to your own.
UK Local Homebirth Support Groups - online and regularly updated by group coordinators.
It used to be the case that every woman in the UK had a legal right to a home birth service, which meant that the local Health Authority was obliged to provide a midwife or doctor to attend her home birth. However, in recent years it has become apparent that the legal situation has changed.
Women in the UK still have a right to a home birth, insofar as there are no laws forcing a woman to go to hospital - so she has the right to insist on staying at home to give birth. What is disputed is the Health Authority's obligation to provide a home birth service (ie an attending midwife or doctor) to every woman who requests one. It may take some negotiation to arrange a home birth if the Health Authority is unsupportive, but with perseverance, it can usually be done. It is government policy that, where it is 'clinically appropriate', the NHS should support a woman who intends to give birth at home .
For more discussion of the legal status of home birth in the UK, see Home Birth and the Law. The right to refuse hospital treatment is discussed in detail in 'Can a mother be forced to attend hospital?'
In the UK, normal pregnancy and childbirth care should come from midwives (as recommended by the government's 'Changing Childbirth' report). Home births are normally attended by Community Midwives. You can book a home birth direct with the Supervisor of Midwives at your local hospital. Simply call the hospital switchboard and ask to be put through to her, or ask for an address to write to her at.
You do not need the permission, or even the approval, of your family doctor to arrange a home birth. You do not even need to discuss the matter with your GP, unless you want to. Your GP would not attend the birth apart from in exceptional circumstances; most GPs have little experience or training relevant to attending home births, and they will not have the experience or skills of a community midwife. The role of a GP in family healthcare is extremely valuable, but GPs are generalists; midwives are the experts in normal pregnancy and childbirth care, so it should not be considered disrespectful to your doctor to seek maternity care from a midwife.
If you are worried about discussing home birth with your family doctor, please see Is your doctor against home birth? - it has links to some articles that you might consider showing her, including guidelines for GPs on their responsibilities in this situation.
Experiences of booking a home birth is a collection of real-life examples of how women went about arranging home births in the UK.
See also the Association for Improvements in the Maternity Services (AIMS) booklet, Choosing a Home Birth. The full text is available on the AIMS website.
The UK has many fully qualified independent midwives who are highly experienced in attending home births, and who support them fully. If you want to arrange a home birth without hassle, then this is your best option. See booking a home birth with independent midwives for more details.
Before booking a home birth, or if you are not sure whether you would prefer a home birth, you might find it helpful to talk to other people who have had home births in your area. They can tell you how easy or difficult it is to arrange a home birth there, and direct you towards any particularly helpful midwives. Talking to other people who have given birth at home can be a great confidence boost - it helps to know that there are lots of other women, just like you, who have done it. See Home Birth Support Groups in the UK for contact details.
Women planning a home birth are sometimes told that the local health authority may not be able to provide a midwife on the day, because of staffing problems. If you hold out for a home birth in these circumstances, you may feel guilty that you would be taking midwives away from other women who need them on the labour ward. This is an understandable concern, but going along with it is unlikely to help other women in your area in future, as there will be little incentive for the healthcare providers to improve their service. It is important to remember that staffing levels are the health authority's responsibility, not yours. You may sympathise with their problems, but remember that where there's a will, there's a way. Trusts which are fully supportive of home birth find a way around this problem; so can yours.
Some may dismiss this as selfishly putting your own 'birth experience' ahead of other people's problems, but this trivialises important concerns. Firstly, homebirth is not simply about 'birth experience' for most of us; there is robust evidence that it reduces the risk of complications in normal labours, leading to a halving of the caesarean and assisted delivery rate compared to planned hospital birth (see the NBTF study for one very good reference for this). Now the majority of women in the UK still prefer to plan a hospital birth, but where a woman has looked into her options and made the decision for a homebirth, if she is asked to come into hospital because of staffing difficulties then she is being asked to double her risk of ending up with major abdominal surgery - hardly a trivial concern. She is also being asked to increase the risk of her baby being delivered by vacuum or forceps, which can harm the baby, and of contracting a hospital-acquired infection. It does not seem unreasonable to want to avoid risks in childbirth where possible. Moreoever, research on the cost of homebirth has shown that it costs the NHS less, on average, than hospital birth - even after accounting for transfers. So in planning a homebirth you are aiming to reduce genuine medical complications of birth, and save the NHS money. It's not just about the 'birth experience'.
If women are persuaded to abandon their home birth plans on the grounds of staff shortages, the health authority will have no incentive to improve its services for other women - so by holding out for a home birth you are helping to improve choice in your area, and helping to make midwives' jobs more interesting - and you are also saving money for the NHS (see below).
While sympathising with the health authority's staffing problems, you can ask the community midwifery manager what they are doing to resolve the situation. Advertising vacancies is insufficient - perhaps providing their midwives with more autonomy and job satisfaction, for example with the opportunity to attend births at home, would improve their retention of midwives. Many midwives are positively keen on home births and enjoy the opportunity to practise in this way. Sometimes a community midwifery manager will ask for volunteers for an 'on call' rota for a planned homebirth, if she suspects that regular staffing arrangements will be insufficient. Midwives who are keen to increase their out-of-hospital experience, or who just feel strongly about supporting women's choice, can volunteer. They are not expected to do this for nothing; sometimes they swap shifts with others, and sometimes they are paid overtime as 'bank midwives' for extra shifts.
Every health authority has access to what are called 'bank midwives', and most use them regularly when they have staffing problems in the hospital. These are midwives who work on a temporary basis, sometimes for just one shift at a time (a bit like supply teachers). Some will be midwives who are employed by the same health authority, who are taking on extra work - doing overtime - and others will be midwives who want to work part-time but who have not obtained a permanent part-time job, or midwives who are currently taking a career break to look after their own children, but will work occasional shifts, or semi-retired midwives. All 'bank midwives' are all fully-qualified midwives. If there was a genuine shortage of midwives on the labour ward then the health authority should always be able to arrange cover on the ward from a bank midwife, thus freeing up a community midwife to attend home births. It is less common for bank midwives to be sent to attend homebirths as a midwife attending a homebirth needs some skills and experience which differ from those for hospital work.
In some areas, independent midwives work as 'bank midwives' when they are not needed by their own clients. On occasion, independent midwives have attended home births on behalf of health authorities who could not arrange cover from their own employees. Sometimes such arrangements are made in advance - when people talk of arranging an 'extra-contractual referral' to an independent midwife, they mean that an independent midwife would be booked to attend you, but would be paid directly by the health authority.
You may be told that homebirth is very resource-intensive because it requires two midwives to attend your labour. While many believe that having two midwives present for the birth of the baby is ideal, it is not a legal requirement nor is it universal practice. Where there are staffing shortages, one midwife may attend your labour and call for backup only if she thinks it necessary; you could suggest this to your local team. My fourth baby's birth was attended by a single NHS midwife, who did not call for backup because she knew the unit was very busy and did not anticipate problems. Some independent midwives routinely attend births alone, calling for backup only if their observations suggest a higher risk of complications. See 'Safety in Numbers?' by midwife Chris Warren for a discussion of the pros and cons of attending births in pairs.
See 'Home Birth Bullying' from AIMS for suggestions on dealing with this situation, and also 'Home Birth Alert' for a sample letter to send to your health authority. If you still have difficulty in arranging your home birth, please contact Beverley Beech of AIMS - she is very experienced in supporting women in this situation, and would far rather that people contacted her, than fought on alone.
Many homebirth advocates feel that it is still important to stand your ground in this situation. If the labour ward is really this busy, is it a safe place for you to labour? You do not need to feel guilty about making the labour ward manager's job harder; while she may have a tough job, you are having a baby. She has ward crises every week and, by next week, will have forgotten that you ever existed. You, on the other hand, will remember this baby's birth for the rest of your life.
To the best of my knowledge, and from discussions on the Homebirth UK email group, in every case where a mother has insisted that she is staying at home and that she expects a midwife to be sent, a midwife has indeed been sent out. It is important to make clear that you will not accept a paramedic, nor will you accept transfer to hospital in an ambulance if one is sent out.
Here is some advice from Shawn Walker of the Norwich Home Birth group:
Over the past three years, we have seen this a lot among our group in Norwich / Norfolk. Here's what we recommend if it may happen to you:
- Have someone with you who is not your partner or mother or other close, emotionally involved person. This person should have ideally had a successful homebirth herself and at a minimum be entirely supportive of your plans to do so, comfortable advocating for you in a situation where you are being told that there will be no midwife sent, and able to be calm in such a situation.
- Prepare your supporter by practicing the 'broken record' technique with her. No matter what they say, your supporter should keep replying that you are going to give birth at home and are expecting a midwife to be sent. When they say they definitely won't send one, she should keep playing the record -- 'Clare is going to give birth at home and we look forward to seeing a midwife.' Needless to say, you should not be involved in this exchange -- you have enough to do! And we recommend that someone other than your partner be the spokesperson, so that your partner can concentrate on you. At no time should your advocate say, 'Okay' or 'I understand' or try to reason with the person on the phone. Just keep playing the record.
- Don't think of it as preparing yourself for a fight; think of it as preparing not to fight by being clear about your position and having support to keep strong in that position.
My doula colleague and I have been successful with this technique many times, even when they are absolutely insisting they will not send someone. The only time it wasn't successful was when a close family member did the advocating -- and that person was very concerned about there not being a midwife. None of the couples who chose not to have another supporter with them chose to stay at home when told they had to come to hospital. When you think about it, that's a lot of pressure for a dad-to-be to be under in such a situation.
Norwich Birth Group -- www.norwichbirthgroup.co.uk
The available evidence suggests that there is no case for refusing home births on grounds of cost. Because of fewer interventions, complications and hospital stays, planned home births cost less, on average, than planned hospital births. Costings for planned home births include the cost of transfers to hospital, and of hospital treatment thereafter.
The National Birthday Trust report on home birth in the UK found that the average cost of planned home birth to the NHS was less than the average cost of planned hospital births. In that study, Henderson and Mugford reported that:
Costs for antenatal visits and tests, staff presence in labour and delivery, procedures and pain relief in labour, perineal damage, and most importantly, days in hospital, all confirmed the greater cost of hospital delivery. 
I am aware of only one other study on this matter in recent years - 'The Cost-Effectiveness of Home Birth', by Anderson and Anderson in the USA. It concluded that:
The average uncomplicated vaginal birth costs 68% less in a home than in a hospital. 
If your health authority is unwilling to guarantee you a home birth service because of cost or staffing problems, please contact AIMS for advice. A sample letter which you might send to the Supervisor of Midwives is available on the AIMS website.
If you have had difficulty booking a home birth in the UK, one of your first places to find support is the Homebirth UK email group. Its members have a huge range of experience and have, between them, dealt many different scenarios; if you email about your situation, you may well receive replies from other women who have been there, done that, and you can find out what worked for them. It is a friendly and informal group. You can join at http://groups.yahoo.com/group/homebirthuk
You will probably also find it helpful to contact your local Home birth Support group
If you can possibly find time to write a letter or email, there are several organisations and individuals who either should be told about your problems, or may be able to help:-
Association for Improvements in the Maternity Services (AIMS) is a campaigning organisation which can advise if problems persist after you have contacted the email group or your local homebirth group. The AIMS website includes a sample letter to send to health authorities which are not supporting women in their plans to give birth at home.
The National Childbirth Trust Policy and Research Department is keen to hear from women who have had difficulty booking a home birth. They are planning to generate media attention to this issue and would also like to forward complaints to the Minister of Health. They would like to hear from low-risk women who have been told that they cannot have a home birth, or who have been booked for home birth but were told they had to go to hospital during labour because they could not be provided with a midwife.
If you have been given a particular reason why the health authority is not supporting you, please do seek a second opinion. Have you been told that you are an unsuitable candidate for a home birth? Perceptions of what is 'appropriate' for a home birth vary widely between areas and you may find that homebirth is not unreasonable in your situation after all.
1. Home Births - The report of the 1994 Confidential Enquiry by the National Birthday Trust Fund, The Parthenon Publishing Group, 1997. p204.
2. The Cost-Effectiveness of Home Birth, by Anderson RE; Anderson DA (Dept.
of Economics, Centre College, Danville, KY 40422, USA. )
J Nurse Midwifery, 44(1):30-5 1999 Jan-Feb
3. See 'Home Birth and the Law: Your Rights in the UK' for references.
This page updated May 2010
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