Do not for one moment underestimate the impact your choice of birth place will have on your birth. Spoiler: it’s huge! We may have learnt how to transform even the most clinical environment into a tranquil, spa-like space, but in terms of decisions that need to be made pre-birth, choosing where you plan to give birth is up there as one of the most important decisions you will make in your pregnancy.
When you first see your GP in your pregnancy, you are generally referred for a booking appointment at your nearest maternity hospital. Or perhaps you have gone straight to your local maternity hospital and arranged a booking appointment directly. Either way, it’s important to realise that you are not limited to your nearest hospital. You can in fact ‘shop around’ and, if you want a hospital or birth-centre birth, choose the one that is best for you. In fact, that’s the case for all NHS care: you don’t need to be seen at your nearest hospital. If there is a specialist hospital elsewhere in the country, you can request to be referred there. You actually have a lot of say in the matter! It’s not a postcode lottery.
So how do you decide where is best? Firstly, the internet is your friend here. Lots of hospitals and birth centres have virtual tours available, so visiting their websites and seeing what’s on offer is a good place to start. Some hospitals and birth centres might offer you the opportunity to visit in person too (it’s always worth phoning ahead to see if this is possible). If this is an option, it’s worth taking for a number of reasons. Firstly, it’s good to do a practice run (drive) and learn your way around the hospital/birth centre. These places are often like mazes, so knowing where you need to head in advance of the big day is really useful. Secondly, by visiting in person, the place becomes that bit more familiar, which means you will feel more relaxed when you arrive to give birth.
A fab website is ‘Which? Birth Choice’.4 Yes, the comparison site that is usually your go to if you’re in the market for a new sound system also offers an in-depth comparison of birth place choices. It’s a brilliant resource! You can look up the hospitals and birth centres that are near you and compare what they offer and see how their birth outcomes measure up against the national averages. For example, there are stats available for what percentage of women give birth in water, require stitches, and have an unplanned caesarean or birth without any intervention. You can also find out what is on offer – for example, different types of pain relief, birthing stools, bean bags, dimmable lighting, etc. Knowing what’s available might help you to make your decision, but it also helps you plan for what the space is going to look like and what you might need to bring from home. It’s definitely a good site to visit to help you make your decision.
Another resource that I would recommend looking at, especially if you’re a stat fan like me, is the Birthplace Study.5 The study, conducted in 2012, evaluated the birth outcomes of 64,000 women in the UK, so there was a huge cohort. All the women were considered ‘low risk’, meaning they had no known medical issues that would suggest complications were more likely.
The study compared the birth outcomes for mother and baby in four different settings: obstetric units (traditional labour wards), freestanding midwifery units (standalone midwife-led birth centres), alongside midwifery units (midwife-led units on hospital grounds) and home. The findings were very interesting.
Giving birth at home can be a truly wonderful experience – one without the hassle of having to navigate a journey to hospital or anywhere else, as midwives come out to you and are in a position to give you their full attention. You often enjoy continuity of care, meaning the same midwife or group of midwives will see you at all of your antenatal appointments, your birth and your postpartum visits. There is also the sheer bliss of being able to get into your own bed after giving birth and snuggle up with your newborn baby. All that said, one of the most common reasons women dismiss home as an option is because of the big ‘what if?’ question (which is essentially based on fear): ‘What if something were to go wrong?’ And if you’ve ever been in a situation where you’ve told someone you are considering a home birth, no doubt your news will at some point have been greeted with the loaded remark:‘You’re brave!’ That implies you are doing something risky and dangerous, when the thing is, for a lot of women, it’s not brave at all; it’s a sensible choice and the best place for them. The problem is that we, as a society, are so conditioned to believe birth is dangerous and hospital is the safest place. In reality, intervention rates are much higher in hospitals, even for low-risk women, which actually raises the question: ‘But what if something goes wrong in hospital?’ What if the reason something is going wrong is because you are in hospital? The truth is, nobody should have to justify their birth place choice; it’s your choice and nobody else’s. And there’s no right or wrong choice either. What’s most important is that every woman knows all of her options and is ensuring her choice is a properly informed one, and not one based on fear or conditioning.
One of the most significant findings from the Birthplace Study was that for a ‘low-risk’ second-time (or subsequent) mum, home was the safest place for you to give birth statistically.6 That’s right! If you are having your second or subsequent baby, and are enjoying an uncomplicated pregnancy with no known medical issues (i.e. considered ‘low-risk’), then home is statistically the safest place for you to give birth, with no significant difference in outcome for the baby compared to hospital but with significantly fewer interventions, making it better for both you and your baby.
Interventions include augmentation of labour (using drugs to speed things up), assisted delivery (forceps or ventouse to get the baby out), stitches for trauma (vaginal tears), episiotomies (an incision to the perineum) and caesarean sections. The likelihood of any of these becoming necessary is significantly reduced if you choose to birth at home. Yet, despite the findings of this study being publicly available (perhaps not promoted well enough), the home birth rate across the UK remains at around 2 per cent.
Whilst the above applies to women having their second or subsequent baby, this does not mean that home is not safe if you are a ‘low-risk’ woman having your first baby. For first-time mums the study showed that the risk of the baby experiencing an adverse outcome, although still very low, increased from 5 in 1000 in an obstetric unit to 9 in 1000 within the home birth group. However, the risk of intervention for first-time mums was still lowest at home. The study also found that first-time mums are more likely to be transferred to a hospital – 45 per cent compared to 12 per cent of second-time (or subsequent) mums.7 This does not mean that 45 per cent of first-time mums experienced an emergency at home though. Common reasons for transfer include: wanting more substantial pain relief (an epidural), not dilating as quickly as expected, meconium in the baby’s waters, or other signs that would indicate continuous monitoring might be a good idea. So, whilst the study certainly doesn’t rule out home birth for first-time mums (there are clear benefits as well as risks) it highlights how choosing where to give birth is not always straightforward but requires some careful consideration, research and weighing up of pros and cons. Ultimately, where you choose to give birth has to be right for you; it’s your choice.
With regard to the big ‘But what if something goes wrong?’ question and the common ‘I would rather be in hospital, just in case . . . ’ remark – these comments are tricky to navigate, because there’s no doubt that if something is going wrong you probably would want to be in hospital! But it’s a little more complex than simply choosing to be in hospital because it would be the right place to be if something went wrong, when, by being in the hospital setting, you’re increasing the chances of something going wrong in the first place. It’s certainly not clear cut.
By taking yourself to hospital ‘just in case’, you’re immediately increasing your risk of requiring intervention. Essentially, you are increasing your risk of requiring forceps or ventouse, needing a caesarean, having a tear and requiring stitches or having an episiotomy, to name just a few! All because you want to be in ‘the right place’ in case something goes wrong. But a lot of what might go wrong could potentially be avoided – and certainly the risk significantly reduced – by not being in hospital in the first place, and in fact being somewhere better suited to giving birth.
So, before you rule out home, I’d like to make a couple of points – food for thought, if you will.
Firstly, when you are having a home birth, you will have one dedicated midwife with you throughout your labour and a second one who will join you closer to the point of your giving birth. You therefore have wonderful one-to-one care with a midwife who you are more likely to know because you will have had your antenatal appointments with this home-birth/community team. Having a midwife with you whilst you are in labour, focused solely on you and your baby, is far better than being in a busy hospital where you might find yourself sharing a midwife with another woman. At home you will have the full attention of a midwife who will give you support and closely monitor you, so that if there was any reason for concern you could transfer into a hospital and be attended to at the earliest opportunity.
Secondly, midwives are not risk-takers, especially not midwives supporting women at home, knowing they do not have easy access to a back-up medical team. Midwives, quite literally, have your and your baby’s life in their hands and that’s a big responsibility. If your midwife thinks that you or your baby might need some support, they will recommend you make the transfer into hospital. They will not wait until an emergency has unfolded before recommending going in. Hence the transfer rate – they don’t take risks.
Thirdly, calculate the time it would take to transfer into your nearest maternity hospital by ambulance (with blue lights) and compare that to the average time it takes to transfer from a hospital ward to theatre in an emergency situation. If there is not much difference, then that should reassure you considerably. It is worth knowing that, even if you are in hospital, there is no guarantee that a theatre will be empty and a team ready and waiting for you. Often they will have to bring people in who are on call, or clear the theatre and prep for you, which takes time. If you are transferring in from home the paramedics will have called ahead and all of this will be happening whilst you are travelling in, so that by the time you arrive you can go straight in and be seen by the appropriate person.
For second-time (or subsequent), low-risk women home is the safest place to give birth statistically, with the best outcomes for mums and babies and the fewest interventions.8
Home water birth after trauma – Eshere, a second-time mum
After a traumatic long labour with an episiotomy and ventouse with our first daughter I can happily say hypnobirthing changed our lives!
My second daughter was born in the birth pool at home in under three hours with no pain relief or intervention and no stitches! A completely different experience to our first birth!
I was extremely nervous and worried about the birth as my first labour was so difficult, however, after doing the hypnobirthing course we felt more informed and embarked on some serious preparation.
After a long day of light surges my waters finally broke around 10.30pm. The surges came in fast and intense. Having a slight panic in my own head, as the surges were extremely intense, my husband Tom reminded me of my breathing and I managed to stay calm and focused. The midwives arrived pretty quickly and advised me to get in the pool to ensure baby arrived in the water as we planned. The room was perfectly lit with candles, my affirmations playing on our stereo in the background and the pool ready for action. As soon as I entered the water I felt a soothing sensation. I breathed through each surge as I had been practising in the weeks leading up to the birth and felt my baby move through my birthing canal. It was a truly unique and wonderful feeling that I will never forget. During the transition period I felt for baby’s head and remember talking with Tom and having an intense feeling of excitement that our baby was coming! With a few more surges she entered this world. We really did it!
Birth centres are a fantastic middle ground between home and hospital and the recommended birth place choice for low-risk first-time mums. You can get freestanding birth centres or ‘alongside’ birth centres which are attached to maternity hospitals. Birth centres are midwife-led and are designed to support natural birth with low lighting, birth pools and a calm, private environment. Each birth centre has its own set of guidelines as to who it can accommodate. These guidelines are flexible and it is possible (with a little persuasion and support from a supervisor of midwives) to be accommodated, even if you fall outside of the guidelines.
There are no doctors working within a birth centre and also no epidurals available (these require an anaesthetist). Many interventions cannot take place in a birth centre and should they become necessary would mean a transfer to a labour ward, just as with home birth. In fact, what’s available in a birth centre is not so different to what’s available at home. A birth centre may have more apparatus, such as birthing stools or birth balls, which you may not have at home, but otherwise they are the same: same midwives, same training, same care and same medical equipment.
It’s worth pointing out that interventions (for example, caesarean sections) not being available at home or in birth centres is not the reason that intervention rates show as being lower in these settings – the results aren’t reflective of what’s available at each setting, they reflect the final outcome. In the Birthplace Study, if a woman began her labour at home or in a birth centre and then went into hospital for an intervention, that intervention was recorded against her original birth place choice, that being home or birth centre. Hence, when the study shows that there is a 2.8 per cent chance of needing a caesarean if having a home birth, this is not suggesting that 2.8 per cent of women are having a caesarean at home! Rather, this is the percentage of women who originally intended to have a home birth, but ended up needing to transfer into hospital for a caesarean.
The study proves that the need for intervention is significantly less if planning a home birth or using a birth centre. For example, the risk of requiring a caesarean is 2.8 per cent for a low-risk woman planning a home birth, rising to 3.5 per cent if using a freestanding birth centre, and 4.4 per cent if using an alongside birth centre. The risk for the same low-risk woman increases to 11.1 per cent if planning to give birth on the labour ward. That’s a significant increase and given that a caesarean is major surgery, certainly something to be mindful of when making your choice.
When choosing between home and a birth centre, given that they are quite similar, it might be worth considering things like pets or other children and what your plan would be for them whilst you are in labour, as well as the distance you are from hospital when at home or in a birth centre. Perhaps your home is closer to the hospital than your local freestanding birth centre. Or perhaps your home is quite far from the hospital, but it has a birth centre on site. Transfer time is definitely worth taking into consideration. It might also be worth thinking about how important it is to you to have the use of a pool (home is the only place where you can guarantee yourself an available pool) and also where you feel safest and most relaxed.
If you have a birth centre locally that is attached to a main maternity hospital then you have the added reassurance of being on site should you need extra assistance. This might make you feel more relaxed.
Although you will need to take into account travelling into a birth centre when in labour, the plus side is that once there you don’t have to do much else in the way of admin; a midwife will take charge of sorting the birth pool and you won’t feel you have to do any hosting. The down side is that a pool is subject to availability and sometimes birth centres can get full, meaning you can’t be accommodated and would need to go to the labour ward.
Ultimately, if you are a ‘low-risk’ woman and you choose to use a birth centre you can be happy knowing you’re significantly reducing your risk of needing intervention and improving your overall birth outcomes in comparison to going to hospital.
If you’re under consultant care and don’t fall within the ‘low-risk’ bracket, chances are you will have been recommended to give birth in hospital on the labour ward. This does not mean this is your only option (although you may have been made to feel this way). The first thing worth knowing is that you can always have a home birth – it is your right. Nobody can come to your home and forcibly drag you into hospital against your will. Now I’m not saying that home is necessarily the right choice for you. I’m just saying you always have the right to be supported at home and so you have that one in your back pocket, so to speak.
Birth centres, as I mentioned before, have guidelines as to who can use them. These guidelines vary from birth centre to birth centre and can be flexible. Depending on the reason you’re under consultant care, it is possible in some circumstances to be approved to use a birth centre even though you fall outside of the guidelines. You need to speak to a senior midwife and request what’s known as an ‘out of guidelines care plan’ to be created.
There are many reasons why you might be under consultant care but it’s important to remember that ‘risks’ that have been identified are on a spectrum. Some women under consultant care will be easily accommodated and supported in birth centres, while for others hospital will be the most appropriate place.
If the latter applies to you, you still have options. You will have been referred at your booking appointment to your nearest hospital and now be under its care. You have the right, however, to choose to go to any hospital in the UK. I’m not advocating you travel hundreds of miles to get to the hospital of your choice, but do explore the ones in your local area to find the one best suited to you.
The ‘Which? Birth Choice’9 website has a great comparison tool you can use for free to compare data from all maternity hospitals in the UK. You might find that there is little between the hospitals in your area but there could be a significant difference which would sway your decision. For example, one hospital might have several birth pools on the labour ward, and if you want a water birth this would give you more chance of achieving one than in a hospital where only one pool is available. Or perhaps you know you will be staying in hospital for a short while and one hospital doesn’t permit birth partners to stay outside of visiting hours, while another does. This fact could help you to make up your mind. So, shop around! You don’t get to give birth very often in life, so choose carefully.
Know that if you choose hospital because it feels like the right place for you, then it is the right place for you. Don’t be disheartened by the Birthplace Study if you’re under consultant care, because the study was with ‘low-risk’ women, meaning these statistics don’t apply to you if you fall outside of this category. If you have an existing medical issue, pregnancy-related illness or some other identified risk factor, then hospital could well be the best place for you. The good news is that there is lots you can do to transform a hospital room into a space that feels as cosy and comfortable as home, and by the time you finish this book you will also have your fail-safe toolkit at your disposal to help you remain calm and relaxed throughout the experience.
Lastly, another resource available to help you make your choice as to where to give birth is the NICE guidelines. The NICE guidelines are evidence-based and produced by the National Institute for Health and Care Excellence and are regularly updated as and when new evidence comes to light. What’s also helpful to know is that the NICE guidelines don’t just exist for maternity services but for all health services. The NICE guidelines govern best practice within the NHS and so the advice or recommendations made by your local trust should be in line with these guidelines. You can always search the NICE guidelines online to see what the latest recommendations are for the management and treatment of any medical issue you might experience. And if you’re ever in any doubt that what you’re being told is correct, a quick Google of the NICE guidelines will let you know whether or not the advice you’re being given is up to date as well as help you understand the reasons behind the recommendations that you have been given.
In relation to choosing where to give birth, the NICE guidelines advise that women are informed that they may choose to give birth in any birth setting and be supported in their choice, that low-risk women having their second or subsequent baby should be advised that planning to give birth at home or in a birth centre is particularly suitable for them because ‘the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit’, and that low-risk first-time mums should be advised that planning to give birth at a birth centre is particularly suitable for them because ‘the rate of interventions is lower and the outcome for the baby is no different compared to an obstetric unit’. The guidelines also advise that low-risk first-time mums should be informed that if they plan to give birth at home ‘there is a small increase in the risk of an adverse outcome for the baby’.10
If you’re reading this and you have no known medical issues, then the statistics should speak for themselves: you can see it’s worth at least considering your home or a birth centre as viable options, instead of a hospital labour ward.
It’s all about challenging the ingrained assumptions we have that include hospital being the ‘right’ place to have a baby. The hospital is the right place to have your baby only if you have known medical issues and are likely to need the additional support and assistance that is available there, as well as a specialist consultant’s expertise and input. If you have no medical issues then the stats are in your favour for choosing to birth elsewhere and being cared for by a midwife, an expert in facilitating and supporting natural birth.
I believe there are two key reasons why so many women choose to give birth in hospital compared to a birth centre or at home. Firstly, women believe birth is a risky and dangerous activity that involves high levels of drama and that people’s lives are on the line (thanks TV). Secondly, women believe birth will be horrifically painful and assume that they’ll need all the drugs going. Given that epidurals are only available on hospital labour wards, I believe this is a big factor in women choosing hospitals over birth centres and home.
Hopefully by reading this book and learning more, you will begin to feel more confident about your body’s ability to birth your baby, and will be able to use your techniques to stay calm and relaxed, so you won’t need an epidural. It’s worth knowing that gas and air are available at home and in birth centres.
We need to break the fear that surrounds childbirth by changing the stories that we tell, so that women feel less frightened and more confident in choosing a home birth or birth centre, if they’d like to. By being frightened about birth, and starting your labour from a place of anxiety, fear and panic, you’re immediately producing adrenaline and making things more complicated than they need to be. It’s a bit like a self-fulfilling prophecy! When you fear that birth will be painful and that lots of horrible things will happen, you start birth from a place of fear. You then produce adrenaline, progress is slow and painful, and, as a result, you require pain relief and assistance. The whole experience confirms your belief that birth is horrible, you tell your friend and so the cycle continues.
But it doesn’t have to be this way! And I hope that by the time you finish this book you will really believe that it’s possible to give birth in a very different and very positive way and to feel hugely empowered by the incredible experience.
Do not underestimate the impact your environment has on how you feel and how your birth pans out. Choose an environment in which you can feel relaxed and comfortable, an environment that is conducive to natural birth, if that is what you’re hoping for. And when you think about it, home is usually all of those things: safe, familiar, comforting and relaxing. But if home is not a sensible option for you, you are now equipped with the tools to make any space your own oasis of calm.
Positive water birth in hospital – Holly, second-time mum
For all you first-time mums, my first birth was only negative because I felt totally unprepared and had no tools to help guide me through the process, so you are all off to an incredible start in welcoming your baby into the world.
The birth of my little boy started with irregular surges on Wednesday the 20th. I didn’t notice that they were of any significance until around 2pm as I had been experiencing mild period-type cramps on and off for the previous two weeks.
However, after a morning of frantic cleaning while my little boy was at nursery, I sat down for a cuppa and noticed that the mild surges were coming every four to seven minutes, lasting around four seconds. At this point, I felt a bit in denial as my waters broke with my first son before I had any surges, but this hadn’t happened this time round.
Anyway, my husband came home from work and we timed the surges for a while. They continued to come at irregular intervals until about 1am. Up until this point I had put our candles out, used my essential oils and liquid yoga room spray and can honestly say it was a relaxing, if not surreal, experience.
I rang and spoke to the midwives when I felt the time was right and they told me to come in to the hospital. As I expected, the change of location slowed down my surges for a while, but the midwives were very relaxed and very keen for me to dim the lights, get the candles back out and spray my sprays, which was great.
I had a slight wobble and decided I wanted some kind of pain relief (not because I was actually in pain, but I think I felt overwhelmed) as I went into established labour. But my husband was really supportive and talked me back around and the midwife really reminded me to continue with my up breathing (which is amazing for focus).
As the sun came up, the sky looked like it was on fire and was so amazing to see – it made the whole process feel quite magical. I continued with my up breathing and when I was expected to be about 7cm the midwife ran the birthing pool for me.
I spent two hours in the pool, using gas and air for the surges and had lavender on a muslin to smell, which was really relaxing. We also had our playlist on in the background.
When I transitioned into the down stage of labour the sensation and the uncontrollable push from my body were incredible to experience. My midwife was so supportive and didn’t want to interfere at all, she just knew from the change in my noises that I was ready to deliver my baby.
I think the difference between my first labour and second labour was the ability to allow my body to do its thing and not fight against a very intense sensation. I can honestly say that I didn’t find this experience painful, and actually found it quite nice/satisfying because I was so in awe of what my body was doing. I kept the affirmation that ‘my surges are not stronger than me because they are me’ firmly in my mind and because of this I feel that I had the best experience of my life so far.
My little boy came into the world at 9.46am on the summer solstice in the most incredibly calm way and I am still on the biggest high imaginable. John Lennon’s ‘Beautiful Boy’ was playing as I delivered my little boy, and I know I will never be able to hear this song now without crying.