Home Birth Reference Site

“Can I have a homebirth, if....?”

Are you a good candidate for home birth? The reasons below are sometimes given to suggest that a woman should not plan home birth. Follow the links to assess the evidence for yourself, and to decide if home birth is right for you. I think nobody is helped by lumping together all possible 'risk categories' as blanket exclusions for home birth. In some cases, you will be at higher risk of needing emergency intervention - or of your baby needing resuscitation. In other cases, the increased 'risk' is of slow progress - what you are 'risking' by planning a home birth is disappointment and inconvenience if you have to transfer to hospital, rather than risking your own or your baby's health.

Note *:

A midwife or doctor cannot decide whether a woman can, or cannot, have a home birth. It is the woman's choice, and hers alone. Health professionals may give her advice, but it is up to her whether she accepts their recommendations. Anyone who tells a woman that she is not "allowed" to have a home birth misunderstands their own authority. See Home Birth in the UK for more details.

It is not up to me to tell you that home birth is "too risky" for you because of your individual circumstances. I am not a midwife or a doctor; I want to help you locate information and opinions to help you make your own decision, rather than tell you what I think you should do. We all have our own individual thresholds where we would decide that the benefits of having emergency facilities available outweigh the negative aspects and risks of hospital birth. Some women are better able to labour in a hospital environment than others - you will know better than anybody else just how the environment around you is likely to affect you in labour.

There are certainly many situations listed on this page where I personally would prefer to be in hospital. It's not a competition to see who can have a homebirth in the riskiest situation, and I'm certainly not suggesting that homebirth is always the best choice. This is about your baby and your body - you will live with the memory of this baby's birth for the rest of your life. Make sure it's the right decision for your family.

Topics covered on this page:

See also "But what if....?", which looks at what would happen if a problem occurred at a home birth.

"Can you have a homebirth, if...?"

"This is your first baby"

You are more likely than others to transfer to hospital for slow progress, but this is rarely an emergency situation. Many women do have their first babies at home. See 'First Babies at Home?' for more discussion of the issues.

"You have had too many children"

- not a reason to avoid home birth on its own, if you are healthy. Your past births are a better guide to your prospects. See 'Grand Multiparas and Home Birth'.

"You are too young"

- some research suggests that teenage mothers have less risk of complications than women in their twenties - so being young is no reason to dissuade someone from a home birth. See 'Young Mothers and Home birth' for the evidence.

"You are too old"

- plenty of older mothers still have home births, even for first babies. There are some increased risks to older motherhood, but as ever, your general health is important too. See 'Older Mothers and Home Birth'.

"Your home is unsuitable"

- because you are in a tower block / rural area / tent / whatever. The time it might take to transfer to hospital is one factor to consider when planning a home birth, but it is not the only factor. People have home births in a variety of different accomodations - from tiny flats, short-term rented accomodation and friends' homes, to detatched houses. The most important factor is that it feels right to you. Nobody can deny you a home birth on the grounds that your home is 'unsuitable'. Sarah, for example, gave birth to her first baby on a narrowboat. The Albany midwife team had a home birth rate of around 40%, despite drawing most of its clientele from deprived estates in South London, where the flats are often cramped. If you are told that your home is unsuitable, see 'Home Birth in the UK', and contact AIMS for advice.

You have a previous assisted delivery (forceps or ventouse birth)

- so do many women who go on to have a home birth for the next baby! eg Charlotte, Sarah, Gillian, Kirsten, Diane, Jo, Louisa, Tikki, Helen, Pat, Julia, Sian and Jane. Bear in mind that there is a possibility of your needing to transfer in second stage, but most women with a previous assisted delivery find that they can push their next baby out themselves - even if that baby is significantly larger than the first. The reasons for the assisted delivery will probably not occur next time around; assisted delivery is more likely if you plan a hospital birth, more likely for first babies in general, and especially if you have an epidural.
The RCOG (Royal College of Obstetricians and Gynaecologists) guidelines on operative vaginal delivery say: "Women who have experienced an operative vaginal delivery should be encouraged to aim for a spontaneous vaginal delivery (SVD) in a subsequent pregnancy. The likelihood of achieving a svd is approximately 80% even for women who have required more complex operative vaginal deliveries in theatre." . This means that your chances of having an uncomplicated vaginal birth are actually higher than those of a first-time mother, despite your history.

"You have a previous bad tear or episiotomy"

The worry is that you will have another bad tear and will need to transfer to hospital for stitching. Yet the risk of severe tearing is smaller at a home birth, particular as many bad tears are associated with assisted deliveries, which do not happen at home. You may have more chance of a gentle, controlled second stage at home, in a position thought to reduce the risk of tearing - such as on all fours. Although your risk of having another tear is higher if you have previously had a bad tear, you are still less likely to have this problem with a second or subsequent baby than with your first. It is up to you to decide whether you want to take the risk of having to transfer to hospital after the birth for repair - women who have transferred after the birth nearly always say that they are still glad they gave birth at home; they just wish they hadn't had to transfer afterwards. Read more about perineal tears and third-degree tears on the Association of Radical Midwives site. Birth stories from women with previous bad tears, or bad tears in this birth: Kirsty Crowther, Joanne, Philippa, Antonia, Kelly and Helen.

"You have a previous postpartum haemorrhage (heavy bleeding after birth)"

- you'll need to look at the circumstances of your postpartum haemorrhage (PPH) and find out if they are likely to recur. There is lots on this on the separate page on postpartum haemorrhage and home birth. Midwives can treat PPH at a home birth just as they would in hospital, but in fact PPH is less likely to occur after a home birth. This is mainly because PPH is most likely after interventions such as induction or augmentation of labour, assisted delivery or caesarean section, and none of these will be happening at home.

"You have had a previous caesarean section"

- You have a small risk - no more than 1 in 200 - that your scar might rupture. The effect of scar rupture can be devastating, and if it happened, you would need an emergency caesarean very quickly. On the other hand, a home birth probably maximises your chances of having a safe and intervention-free birth. Home birth may be right for you, but make sure your choice is informed - see the VBAC Pages.

"Your Haemoglobin count is low"

- you are anaemic, iron deficient, etc.. - not usually an obstacle to having a home birth. It does not make you any more likely to have a postpartum haemorrhage, but it does mean that you could find recovery tougher if you do lose a lot of blood. See draft article on Homebirth and Low Hb and, for example, birth stories from Claire, Jayne, Elaine, Fiona and Jenni.

"You have Group B Strep (GBS, Group B Streptococcus, Haemolytic Beta Strep)"

- a bacteria which is present in the vagina of up to 30% of women, and which can, rarely, cause a serious infection in the baby. You may be told that your only option is to have intravenous antibiotics in labour, in hospital. But a positive GBS test alone does not put your baby in a high-risk group for infection, and the antibiotics carry risks as well as benefits. For most women, a positive GBS result is of little significance. See Group B Strep and Home Birth for more details.

"You have low platelet levels"

- may be a sign of a transient, non-serious condition which affects about 5-7% of pregnant women, or occasionally something more serious, such as HELLP syndrome, a severe form of pre-eclampsia. Once you have a good idea of the condition, you can make your decision. In the first case, home birth is often no problem at all. See Low Platelet Levels - Thrombocytopenia during Pregnancy from the UK Midwifery archives for more info. Jillian had a homebirth with low platelet levels, but she did transfer to hospital because of blood loss due to retained placenta.

"You have high platelet levels"

The concern is about blood clots occurring when you are in labour. I don't have any more information on this condition at the moment, but Emma's Story describes her negotiations during pregnancy and a successful home birth despite high platelet levels.

"You are on anticoagulants or have a previous DVT"

- Helen Wood has written a brief article about homebirth on anticoagulants, after DVT (deep-vein thrombosis), which includes her birth story and her decision process. Fay took Clexane throughout her second pregnancy after a DVT during her first, and had a trouble-free homebirth. See also the RCOG guidelines on Thrombosis risk-reduction during pregnancy and birth.

"You have diabetes"

Whether you have gestational diabetes which has developed only during pregnancy, or pre-existing Type 1 or Type 2 diabetes, insulin-dependent diabetes, there are precedents for women having homebirth. Women who make this choice generally ensure that their glucose levels are well-controlled and monitor their babies very carefully for hypoglycaemia. See the Diabetes and Homebirth page for more.

You may be expecting a small baby

- the main concern about a small baby is why it is small. Is it 'constitutionally small', ie just smaller than average because, for instance, you are? Or is it much smaller than expected considering your own build? If the baby appears very small compared to your own height and build, then the worry is that it may have other problems - for instance, it may be suffering from intra-uterine growth retardation (fetal growth restriction) or a chromosomal abnormality. See "Small babies and homebirth" for discussion the issues and links to birth stories.

"You may be expecting a big baby"

- worries about whether the baby's head or shoulders will fit through your pelvis. Plenty of big babies are born at home - and plenty of babies which were predicted to be 'big', turn out to be average-sized. See 'Big Babies and Home Birth'

Your pelvis may be too small”

If it is too small, labour doesn't progress, and you transfer to hospital in good time for a caesarean - disappointing, but not usually an emergency in the sense that you need treatment urgently. See brief article on "Your pelvis may be too small". See also the story of Ziva's birth for a lovely example of how a petite mother can give birth to a large baby. Kate is only 4'11" with size 3 feet, but she had her 7lb first baby at home.

"You are too big / heavy / overweight "

- Large women are more likely to suffer from diabetes and blood pressure problems in pregnancy, which might affect your decision regarding home birth. There is also an increased risk of shoulder dystocia, but it is not clear whether this persists independently if you do not have gestational diabetes. Apart from these issues, though, weight alone should not be the deciding factor. Whatever your weight, you can still make an informed decision to plan a homebirth, as did Rachel, Helen, Genevieve and Carolyn. A wonderful site packed with information on pregnancy for large women is Plus-Size Pregnancy, by KMom. See also this discussion from the US Midwife Archives - 'Is Weight a Contraindication for Home Birth?'.

"You are having twins"

- worries about the birth of the second twin mean that a home twin birth is not common, but it does happen. See "Twin birth at home?" for links and viewpoints.

Your baby is breech (feet- or bottom-first)”

- As with twins, breech birth at home is unusual and does carry significant risks, but it does happen - see 'Breech birth at home' for more.

You have pre-eclampsia / high blood pressure

- nobody denies that pre-eclampsia can be life-threatening to mother and baby, but the issue here is that different practitioners have different views about which situations are dangerous, and which are not - and not all cases of high blood pressure are due to pre-eclampsia.Jen Vaudin wrote about her transfer to hospital birth for pre-eclampsia, followed by a home birth, again with worries about the condition. See also Sarah's story. Emily's blood pressure rose to 100/96 in labour, but mother and baby were fine. Faye had protein in her urine, but her baby arrived at home two days before her appointment to discuss induction. Diana had an elective caesarean for pre-eclampsia after twelve days of hospitalisation and five failed attempts at induction. Charlie had high blood pressure in late pregnancy and transferred when it remained high after the birth. Melanie Renowden's blood pressure was high at the end of pregnancy but was fine in labour.

You have asthma

- Women with asthma do seem to be higher-risk for certain complications - eg preterm birth, having a small baby, and developing high blood pressure (see Refs [1]. However, you can cross these bridges if you come to them - if you went into labour preterm you could transfer to hospital care, and likewise if you develop blood pressure problems. If a small baby is suspected then, again, you could consider your options. Approximately 1 in 25 adults in the UK has asthma, and many women who have home births also have asthma. Birth stories from women with asthma: Rachael, Carolyn, Kirsty Nicol.

You have Multiple Sclerosis

- women with MS can and do have home births; independent midwife Susan Burvill has published an article in Practising Midwife magazine about a client with MS who she supported. Contact Susan via her website for more info.

You have ME/Chronic Fatigue Syndrome

- women with ME can and do have home births as well - see Clair's and Jennifer Vaudin's birth stories for more details, and contact her for more information. See 'Homebirth with ME' for more info.

You have had surgery on your cervix

- eg laser surgery or similar for pre-cancerous cell changes. Occasionally scar tissue from the operation slows down the dilation of the cervix, and this could mean that you transferred to hospital for slow progress. However, in the vast majority of cases, previous cervical surgery does not cause any problems. If scar tissue does prevent dilation then some midwives have helped women overcome this by stretching the cervix during labour. See Birth after cervical surgery on the US Midwife Archives, including suggestions for breaking up the scar tissue by what sounds like a stretch and sweep, and some case histories where this has been very successful, and also The Cervix: UK Midwifery Archives.
Birth stories: Jenni had a cone biopsy for cervical cancer and went on to have Lydia at home, Angela had laser surgery for CIN II. Hannah had laser treatment when her first baby was 5 months old, and says "It's never caused any problems, well, apart from once being mistaken for a prolapsed cord (I guess it must be a weird shape LOL) and I've had 5 children since :o)". Terri writes: "I've had my cervix cryo-cauterised & then cauterised years ago. My first labour was induced & after 3 days & 4 prostin tablets I wasn't dilating but once I got going after ARM it opened no problem. Last time I went into labour naturally & from first twinge to giving birth was about 5hrs.. "
Sarah was not so fortunate; after a very fast labour for her third baby, she had non-urgent cervical surgery and was assured it would not affect subsequent births, but in fact scar tissue caused her labour to stall. She transferred to hospital where, eventually, the scar gave.

You have an abnormal uterus, eg bicornuate

- so does Naomi and Bronwyn. This may make your baby more likely to assume a breech position if there is restricted space at the top of your uterus.

You have Symphysis Pubis Dysfunction (SPD) or Pelvic Girdle pain.

Pelvic Girdle Pain (PGP)is a painful condition which can occur when the pelvic ligaments soften during pregnancy. Pregnancy hormones cause these ligaments to relax, which allows movement of the pelvic bones during birth. Some women's ligaments soften more than others, and a great degree of softening can cause instability of the pelvic joints, and particularly the pubic symphysis, which is a joint at the front of the pelvis. While it can make pregnancy painful, it may make the second stage of labour easier as the pelvic ligaments stretch easily to allow the baby's head to pass through. It does not necessarily make labour more painful, although it can do. It is often recommended that women with this condition avoid having an epidural, because if anaesthetised below the waist, they may open their legs too wide, which can make the condition worse. For more info, see discussions on SPD from the UK Midwifery Archives. I suffer from this condition myself and, while I curse it in pregnancy, I love the 2-5 minute second stages it gives me in labour! Birth stories: Gina managed to climb out of a birth pool after her baby's head was born, but before its body arrived, despite PGP. Rachel S, Sarah M, Angela H, and another, and another!, Kate M, Sarah Ockwell-Smith, Rebecca, Sarah H, Cerys.

You're two weeks post-dates; you'll just have to go into hospital to be induced.

That phrase "have to" should be banned from use in maternity care, along with "allowed" and similar phrases which hide the fact that the decision is yours. But are you really "overdue" anyway? Read "Overdue, but desperate for a home birth?" to find out about dating your pregnancy accurately, and the issues regarding post-dates pregnancy.

Your baby is too early; this area only does homebirths from 38 weeks

This is a recent development, and does not seem to be strongly evidence-based. Term for a normal pregnancy is 37 - 42 weeks, as defined by the World Health Organization. Many health authorities continue to support homebirth from 37 weeks, and many women continue to have planned homebirths from 37 or even 36 weeks, regardless of their area's policies. See 'Homebirth before 38 weeks' for more.

"Your waters have been broken for 24 hours; you'll just have to go into hospital to be induced"

Uh-oh - "have to" again. While the risk of infection does undoubtedly rise after your waters break, any cut-off is arbitrary and you always have the option of looking at your individual situation, monitoring your and your baby's health, and deciding to take each hour as it comes - 'expectant management'. If you have risk factors such as a positive Group B Strep result, any rise in your temperature, or any signs that the baby's heart rate is not reassuring, you might wish to choose earlier induction. In fact, in the UK, until very recently the official guidelines were that expectant management was appropriate for up to 96 hours after rupture of membranes - from the National Institute for Clinical Excellence. The guidelines were changed in 2008 to state that it was appropriate to offer induction after 24 hours, but I have not been able to trace any change in the evidence base for this. Birth stories from women who have had prolonged rupture of membranes: Jennie, Wendy, Suzanne, Genevieve and Clare remained at home, while Lonnie transferred to hospital. Ruth Gallagher's first baby, Hazel, was born at home weighing 9lb 10oz, six days after her waters broke.

"There is meconium in your waters"

Meconium is the baby's first poo; it's like thick, sticky greenish-black tar, and if the baby passes it before birth then it may be a sign that the baby has been in distress. Sometimes a distressed baby can breathe meconium into its lungs, and become ill as a result. Because meconium can be a sign of foetal distress, most hospitals have a blanket policy that if your waters break and meconium is seen, they recommend transfer to hospital. Yet meconium can also be passed simply because the baby's gut is mature, and in this case the risk of any danger is low. It's a complicated topic, but if the baby's heart rate appears to show no signs of distress and there is no other reason to suppose that the baby may be in trouble, then many midwives and mothers think it is reasonable to remain at home. For a detailed discussion, and birth stories, see "Meconium in the waters".

You have mental health issues

Do mental health issues really limit your birth choices? How, and why? Siobhan was told that she 'had'to have her first baby in hospital because she has manic depression; her subsequent babies were born at home. Contact the Association of Radical Midwives and AIMS to discuss your options if you are told that your mental health makes you unsuitable for home birth.

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"Your baby has a suspected abnormality

- Do you need to have a hospital birth so a paediatrician can check him over?" Depends what the suspected abnormality is. If it is something which could weaken your baby and leave him more likely to go into distress during labour, so that emergency intervention may be needed, then maybe a hospital birth is the best choice. Ditto any condition which is likely to need immediate and urgent treatment at birth. However, if the suspected condition is not life-threatening, you could have a homebirth and then take your baby to hospital to be checked by a paediatrician a day or two later. You may find that different doctors have different opinions about the urgency of the condition. Some mothers have found it helpful to consult a specialist in the condition, rather than an obstetrician. Rather than discussing homebirth in the first instance, ask whether there is likely to be any problem with a vaginal birth, and whether the baby is likely to need immediate assistance after birth. If there are no immediate concerns on either count, then you can consider whether birth out of hospital might still be appropriate for your baby. Birth stories of babies with suspected and actual abnormalities: Jo-Anne's story, or Claire, both of whose babies had kidney problems identified by ultrasound scan. Kirsten's son's scan showed several 'soft markers' for Downs, including a dilated renal pelvis. Cleft lip and palate are common abnormalities, and in most cases will not rule out homebirth - see page on Cleft Lip/Palate and Homebirth for more info. Emma's baby had a serious abnormality which was not detected before birth - oesophageal atresia. She had him at home, and transferred to hospital after the birth when problems were suspected. She values the peaceful bonding time they had at home. Anna-Luise 's daughter had undiagnosed spina bifida; she needed resuscitation at home and transferred to hospital, where she had surgery soon afterwards. Nicholette's son was born in a low-tech birth centre with undiagnosed spina bifida. On an external site, you can read about Archie, who had an undiagnosed, but serious, heart condition; his parents write: "The labour and birth went well and relatively quickly, and Archie seemed healthy and pink when he was born, with very good apgar scores. However, the midwife was not entirely happy with the snorting breathing noises he was making, so after an hour or so we were sent off to Poole Hospital to have him checked out."

Your baby's head is not engaged - the head is too high.

The worry is that, firstly, maybe the baby's head is too big to engage in your pelvis, and secondly, that if your waters break with a gush while the head is still high, the umbilical cord could be washed down in front of the head, resulting in a cord prolapse - a serious emergency. These issues are discussed on the page about High heads.

You have a thyroid problem - hypothyroidism

So did Danielle, Debbie Dooley and Genevieve; it's not necessarily a problem.

You have Obstetric Cholestasis / Intrahepatic Cholestasis of Pregnancy

This is a problem with the mother's liver which can cause the baby to die suddenly in the uterus, before or during labour. It is thought that the deaths may be caused by sudden heart arrhythmias. However, relatively little is known about its cause, or the exact way that babies can be affected. Standard management is to deliver the baby by 37 weeks; with this approach, the risk of stillbirth is approximately 1%, which compares to other pregnancies. After 37 weeks the death rate rises, although it is difficult to find statistics which tell us how much. This makes it very difficult to make an informed decision, and to balance the risks of inducing labour early against those of OC. The issue with homebirth is that, if the baby goes into distress in labour, he or she could die extremely quickly, without a steady progression of warning signs which would allow timely transfer. The RCOG guidelines note that this can also happen in hospital, even with continuous monitoring.

There are, of course, many rare and terrible things which can happen during any labour, even for women who are textbook low-risk; the fact that you develop a known risk does not take away any choices. We all know that birth involves risk; our choices around birth are about choosing which risks we prefer to take, and how the balance of risks and benefits of home versus hospital weighs out for each individual family. Unfortunately, with OC it is difficult to quantify the risks of expectant management, ie waiting to see, rather than active management, ie delivering the baby early. Here are some sources which may help you:

Birth stories: Gemma changed her homebirth plans when she developed OC.

Obstetric Cholestasis Support Website - UK group - www.ocsupport.org.uk

Itchy Moms - US website supporting women with OC - www.itchymoms.com

RCOG guideline on Obstetric Cholestasis - from the UK's Royal College of Obstetricians and Gynaecologists. It is clear, well-referenced and quite honest about how little is known. - www.rcog.org.uk/resources/Public/pdf/obstetric_cholestasis43.pdf


"They just don't do home births in this area"

See 'What if your doctor is against home birth?', and if you live in Britain check out 'Home Birth in the UK', and contact AIMS for advice.

There is a shortage of midwives.

See 'Booking a Home Birth in the UK' for more information.

You might also be interested in these pages:

'What if your doctor is against home birth?'

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

Broken links?

In case you have trouble with any of the links to other sites which are mentioned above - here are the addresses of the web pages:

Discussions from the UK Midwifery egroup, on the Association of Radical Midwives' site (www.midwifery.org.uk):

Epidurals - www.radmid.demon.co.uk/epidural.htm

Anaemia or low iron count - www.radmid.demon.co.uk/anaemia.htm

Low Platelet Levels - Thrombocytopenia of Pregnancy - www.radmid.demon.co.uk/platelets.htm

Low birthweight babies -www.radmid.demon.co.uk/twobabies.htm

Shoulder dystocia - www.radmid.demon.co.uk/shoulders.htm

Gestational diabetes - www.radmid.demon.co.uk/gdrefs.htm

Twin birth - www.radmid.demon.co.uk/twinbirth.htm

Breech Birth Issues - www.radmid.demon.co.uk/breech.htm

Gestational Diabetes

'All About Gestational Diabetes' by KMom


Open in new window
(www.plus-size-pregnancy.org/gd/gd_index.html)

Diabetic Birth Without the Drip, on the AIMS website - www.aims.org.uk/Journal/Vol12No4/diabetes.htm

Diabetes UK website pregnancy section - www.diabetes.org.uk/pregnancy

 Diabetes UK intro to gestational diabetes - www.diabetes.org.uk/pregnancy/gdm.htm

Other Issues:

AIMS (Association for Improvements in the Maternity Services) - www.aims.org.uk

AIMS article on twin birth

US Midwife Archives - 'Is Weight a Contraindication for Home Birth?' - www.gentlebirth.org/archives/lrgmoms.html

'Do you have to be skinny for a home birth?' on the BirthLove site - www.birthlove.com/pages/stories/fat.html

Plus-Size Pregnancy, by KMom - (www.plus-size-pregnancy.org).

RCOG guidelines on Thrombosis and Embolism during Pregnancy and the Puerperium, Reducing the Risk (Green-top 37)
http://www.rcog.org.uk/womens-health/clinical-guidance/reducing-risk-of-thrombosis-greentop37

References

[1] Maternal asthma and pregnancy outcomes: a retrospective cohort study, by Liu, Wen, Demiissie et al, American Journal of Obstetrics and Gynaecology, Vol 184, No 2, Jan 2001, p90-96. If you look this up on Medline and click 'related articles' you will find more on the same subject.


This page is still under development, as time allows. If you have any suggestions to add, or have information on or experience of home birth under particular circumstances, please contact me on angela @ abcde.homebirth.org.uk
(REMOVE 'abcde' to get the correct email address - a provision to stop my email address being inundated with junk mail)

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