The way that the NHS is now selling home births – normal, safe, often better than a hospital delivery – takes some adjusting to, and not just for the makers of scented candles. Until very recently, its negativity about home births still infuriated the National Childbirth Trust. The 2007 National Institute for Health and Care Excellence (Nice) guidelines advertised the advantages of hospital care, with its enticing offer of “epidural analgesia”. If the longer term impact is unclear, Nice’s revised opinion of domestic childbirth must immediately reassure the home-birth inclined, but nervous, that they ought to give it a go. Moreover, its arguments for avoiding hospital are disturbing enough to make converts of women who, until now, believed their home could never be as safe, delivery-wise, as hospital, no matter how comprehensively lagged with tarpaulin and festooned with fairy lights.
Although most headlines about the Nice guidelines accentuated the positive – that home and midwifery units are best – this remarkable advice could equally have been summarised as NHS labour wards are grimy and dangerous, avoid. Discussing the recommendations, Professor Mark Baker, Nice’s clinical director, said: “A home birth is generally safer than hospital for pregnant women at low risk of complications who have given birth before.”
By safer, since mortality rates were the same in low-risk groups, he perhaps means there were fewer cases of intervention and infection. Does his evidence compare like groups with like? Given the existing screening, it cannot be extraordinary that women who don’t want intervention, either at their home or in a midwife-led unit, end up not having it. Pain, once among childbirth’s more immediate associations, barely featured in last week’s discussions. But as anyone who read Amelia Hill’s powerful description will recall, epidurals cannot be administered by midwives. Thanks to Nice, women can now be in no doubt that epidurals, although they reduce pain, are no longer considered a medical asset, presumably since they increase the use of forceps and ventouse. Of course this message is not new: members of the natural childbirth lobby have been warning for decades, some convincingly, some not, about nature, trauma and paternalistic meddling. Perhaps it bears out their suspicions that the media only accepted the line of Sheila Kitzinger – guru of natural childbirth – when it emerged, somewhat rephrased, from Professor Baker. But it surely comes to something when you hear a senior public health clinician telling mothers to stay away from hospitals, even when, in the low-risk home-birth group, 12% will require an ambulance transfer to one of these hospitals. For first-time mothers (who are not considered suitable, by Nice, for home births), the transfer rate is 45%.
We can only hope the professor is right and that enough ambulances (London mothers might want to reconsider) and one-on-one midwives (unlikely) are in place to deal with the forthcoming surge in home-birthing numbers, which will surely include first-timers who now fear epidurals more than pain, ditto catching clostridium difficile. If so, it may not be long before Nice’s novel and cost-cutting approach to childbirth is emulated by other NHS specialisms. Every home birth saves the service at least £380.
While the removal of appendixes or the larger limbs is probably inappropriate on anything smaller than an eight-seater kitchen table, one can think of many other procedures that would save millions, if done at home, while the patient benefited from proximity to a scent diffuser and cups of tea and a loyal retinue of friends and relatives. For the undecided, one of the most persuasive arguments for home birth has always been the photographs of ecstatic couples in well-appointed homes; she installed in a giant paddling pool or on a birthing ball, the partner, fellow NCT alum, busily empathising at her side when not checking the lights, the endorphin-promoting playlist or scent diffuser.
As the natural childbirth movement has gained converts, so the number of recommended home-birth accessories has multiplied, with encouragement from the relevant suppliers, into something more commensurate with a crowning lifestyle moment. Massage oil, a birthing ball, TENS machine, movie cameras, a well-filled birth pool, scented candles, music, presents for older siblings and a special post-partum feast appear to be fairly standard, supposing the experience is be fetishised into one of hyper-natural bliss, something the mere absence of obstetricians cannot guarantee. Even our less demanding experts on home birth stress the importance of sound and lighting choices, while true connoisseurs recommend what is basically a romantic mini-break, with added placenta. Blithers one: “It might surprise you to know that the perfect environment for making love is also the perfect environment for giving birth.”
And what of those whose usual environment for the above is a bedsit? The people who can’t, alas, recreate her proposed “candlelit room with a roaring fire”? One hears of others without the resources, even, to set up a paddling pool or find the hot water to fill it. Then there are the older children, who, unminded, will require feeding and nit-combing as soon as the carpet has been cleaned. Underlying Nice’s proposal for the expansion of home births must be the expectation that these will more closely resemble the glossy, NCT-cultivated ideal than countless, much less photogenic experiences in cramped properties with neither champagne in the fridge nor that most precious of birth accessories, a doting partner. And even lucky owners of appropriate boilers – combis can play havoc with a birth pool – may know enough about their co-parent to be satisfied that Britain’s most truculent obstetrician would make, in comparison, a sensitive and congenial attendant.
Add to these the unpredictability of childbirth, variously attributed to evolution or a malignant deity, and no wonder anecdotes from women who failed to achieve a Kitzinger are commonplace. Then again, so are crowing accounts by women who were lucky enough to triumph, amid surging whale music and gusts of clary sage, over the obstetrical dilemma: bitter reading, sometimes, to those who only got a baby out of the whole thing.
Kate Figes has written eloquently on the sense of failure experienced by parents who failed to realise the natural birth ideal. And now Nice, in its Gwyneth Paltrow-style iteration, confirms to women who cannot have or greatly fear an intervention-free birth that their experience is, officially, inferior. In fairness to the natural birth campaigners, whose work here is surely almost done, it was never their job to provide alternatives. But given the obvious advantages to the well-organised and affluent in any system where home births, with a personal midwife, are safer than a hospital, a responsible health service must surely address this unfairness. It could, of course, lend disadvantaged mothers a sun-drenched kitchen in, say Notting Hill, equipped with aromatherapy diffuser and optional dad.
Alternatively, why doesn’t the NHS actually deal with its deterrent infection rates, uncosy wards and over-interventionist obstetricians? The only conceivable explanation is: £380 a time.
