Why do most births happen in hospital, and has it ever been safest?
We are most definitely at a point in time where going to the hospital to give birth is the normal and expected route for women to take. Homebirths accounted for just 2.1% of births in 2017 (ONS), compared to over 95% in the early 1900's. Why would you not go there to have your baby? There are doctors, beds with stirrups, more pain relief options and machines to let you know what your body is doing? It's definitely what we are shown on TV and in movies, it's where we were born and what our friends experience was usually too. Those who do choose homebirth, are often subjected to worried looks, nervous questions and even doubts about their commitment to their babies wellbeing! Given so few women give birth at home today, it no wonder others hold it on a strange pedestal, assuming that it must be dangerous, only for those with nerves of steel and pain thresholds to match, or available to just those who meet certain neat criteria in regards to their health.
So is hospital birth always safer? Can home birth be safe? And why did birth move from the home to the hospital?
As mentioned above, not all that long ago in the early 1900's, birthing at home cared for by a midwife and surrounded by familiar, loving faces - maybe your mum, aunt, or sisters was the norm. The emotional needs of women were well supported and birth was seen as a normal, physiological event. Anaesthesia was available, but wasn't widely used during childbirth.
As doctors started to take over the role of midwife more often, the number of women opting to birth in hospital began to rise and specific 'lying in hospitals' began to open. Alongside this, a phenomena called Twilight Sleep started to gain popularity - a cocktail of Morphine and Scopolamine was administered to mothers to put them to sleep for the duration of labour. Sounds bliss doesn't it - go to sleep, wake up to find you've had a baby, no memory of the event or of any pain you may have experienced! The reality was far from it... Women were fully removed from their birthing experience, frequently needed to be strapped down to their bed or to have their heads padded to prevent injury as they thrashed around in pain / discomfort in this drug induced state with limited ability to work with the process. Babies central nervous system's were affected by the cocktail, often leaving them drowsy and with breathing difficulties. The Morphine didn't fully remove women's pain, but the Scopolamine acted as an amnesiac meaning women remembered nothing of their struggle. As such women fought for their right to access Twilight Sleep for birth. It was only later that we learned the drugs contributed to increased deaths in both mothers and babies, and photos and stories emerged of women bound to their beds, writhing in pain and covered in their own excrement for the duration of labour.
by the 1930's more and more birth's were happening in hospital (though the majority still happened at home), and more and more interventions were happening to mums and babies, as obstetric doctors (male, of course. Midwives had largely been dismissed as unsuitable and unqualified to care for women in labour now and blocked from training as doctors) focussed almost exclusively on the aim of a 'safe delivery of baby' - viewing childbirth as a pathological process, rather than a physiological one, and one in which the needs and health of the baby mattered more than the needs and health of the mother. Something women had been doing with minimal fuss for millennia, was suddenly in need of fixing, by men!
Twilight Sleep was in full swing and birth would often be done to the woman, rather than being something they did themselves. A sedated women is a woman unable to engage with her birthing instincts, the messages her baby and her surges send her, or even push effectively for baby to move down through the birth canal, so of course, intervention became routine, not something saved for IF and when it was needed. In fact birth would often look a little like this: Twilight Sleep would be administered, drugs were used to dilate the cervix, the perineum would be cut and baby would be forcibly extracted often with forceps. The placenta would then be removed, perhaps more drugs to help with the bleeding, then the mess created by the doctors would need to be stitched back up. I'm bloody glad I wasn't giving birth in the early half of the 20th Century, aren't you! Shockingly, was only during the 1960's that the use of Twilight Sleep finally came to an end.
Between 1960 and 1980 the rate of home births dropped staggeringly, from over 33% to just 1% (yes ONE percent!!) after birthing in hospital was enshrined in NHS policy in 1959 when there was a target set, to have 70% of women birthing within a hospital, but why? The reasoning behind this was obstetricians agreeing that the primary goal of NHS maternity care was to be the physical safety of mother and baby, which they decided was going to be best achieved in hospital where they could oversee labour and birth. Then in 1970 policy changed again to recommend 100% of women give birth in a hospital after The Peel Report was published and implied that hospital birth was safest. It was widely criticised though for a lack of evidence to support this claim, and for the lack of communication with women about their needs and experiences. Since birth became more medicalised, it is clear that the emotional and spiritual needs of women during pregnancy have been largely disregarded, with male driven medical models focussing purely on physical outcomes. It was at least the 70's which saw men invited into the birthing room, though the tone for male birth partners today was likely set back then - when men were brought in without a role, to watch their birthing partner endure high levels of medical intervention even if pregnancy and birth had been largely straightforward so far - it's no wonder men today still feel lost at sea in the birth room, feeling they don't serve much purpose or provide help to their partner (SO untrue, you only need to attend a Supernova Hypnobirthing Course to see that!).
Women now wanted to give birth in hospital, they had been told it was safest, that medical advances and technology would improve their experience, and knowing that most women they spoke to had 'needed' intervention of some kind during their own births, understandably led women to feel that it would be logical for them to be close to that equipment, the pain relief and other drugs too, just in case. What wasn't always made so clear were the disadvantages of a hospital birthing environment - lack of privacy, the increased intervention rates, the focus purely on the physical not emotional wellbeing of women. It wasn't a truly informed decision as the experience of others and the information available was biased.
By the 1990's it was clear that every woman birthing in a hospital was an unsuitable and unsustainable model, and policy was changed once again, this time to encourage more women to birth at home. Unfortunately the damage to the reputation of home birth was done. After such strong and long lasting messaging from the medical community, that hospital was where birth was safest to happen, women simply did not trust in the U - turn in advice. Their trust in their own birthing abilities had been eroded after decades of excessive and unnecessary intervention 'proving' that women simply weren't capable of physiological birth most of the time, doctors had been painting birth as a pathological problem which they needed rescuing from in hospital for generations. This lack of trust in the safety and biology of birth, and of women own abilities, is something that even now in 2020 is still true of most people I speak to about birth: Homebirth = Scary, risky and old fashioned/lower quality care. Hospital birth = safer, medical advances and technology to support birth,
essential care. So is this viewpoint true? In short, no.
A major study in 2011 (Birthplace Outcomes Study) concluded that 'Giving birth is generally very safe... Midwifery units appear to be safe for the baby and offer benefits for the mother.... and For women having a second or subsequent baby, homebirth and midwifery unit births appear to be safe for the baby and offer benefits for the mother'. As well as the emotional and spiritual benefits of birthing at home (thats one for another blog!), the benefits offered by midwifery units and home birth include a significant and substantial reduction in the chance of an unplanned Caesarean section, instrumental delivery and episiotomy. To me this says that for the vast majority of women, birth at home is actually SAFER than on an obstetric hospital ward, because I am yet to meet a mother working towards a birth with these interventions as standard! Even when looking at 'High Risk' women, the same benefits are offered to women, and babies appear to be as safe or safer being born in a midwifery unit or at home, with the study finding 'The risk of ‘intrapartum related mortality and morbidity’ or neonatal admission for more than 48 hours was lower in planned home births than planned OU births'.
Now this isn't to say that home birth will be suitable or preferable for everyone, there are SO many variables to consider including maternal preference, but I think it's really important that we change the language surrounding birthplaces to reflect the evidence we have available so that families can make a truly informed decision about their place of birth, rather than a misinformed or fear based decision made because of outdated and unproven expectations of birth.
So perhaps you're now curious about the idea of home birth, or wondering if you can bring some of the benefits of home with you to the hospital if that's the birthplace of choice for you, I'm always delighted to talk homebirth so feel free to drop me an email with your questions, concerns or experiences. Or you can find me at Cake Club (I'm usually there on a Monday in Westcliff) for a good chat over a cuppa, or sign up today for a complete Antenatal Hypnobirthing Course which will help you prepare for a positive and empowered birth in any location. If you'd prefer to get your antenatal prep in smaller bitesized chunks with a focus on building friendships and connecting with your bump, then Pregnancy Relaxation is for you!