Historical background

The reason for the move from home to hospital is multifactorial, but was due in part to pressure from professionals. Reasons for general practitioners' lack of involvement in maternity care include:

• Perceived lack of skill or experience.
• Fear of litigation.
• Changes in out-of-hours' arrangements.
• Increased workload during working day.
• Unacceptable encroachment of off-duty time.
• Poor remuneration.

However GP obstetric care still exists in GP-led maternity units around the country. They are generally highly valued and provide excellent care. They maintain close links with consultant-led units should problems arise.

Epidemiology

• In the 1930s about 80% of deliveries occurred at home.
  • In 1960 this had fallen to 33% of births in England and Wales.
  • By the 1990s this was down to approximately 1%.¹
• There has, however, been a slight increase in recent years in the popularity of home births following the move to a more flexible service based on the needs of mothers and babies.
  The average home birth rate was 2.7% in the UK (2008).² There is marked regional variation, rates being as high as 13.6% (e.g. in Devon), and 21% on the Isles of Scilly.²

Attractions of home delivery

Studies into women's descriptions of home birth experiences have produced qualitative data on increased sense of control, empowerment and self-esteem, and an overwhelming preference for home birth.^3,4,5

Recent figures show that:⁶

• Caesarean section rate is currently around 24.6%.
• Instrumental delivery rate is 12.2%.
• Induction of labour rate is 20.2%.

The desire to be in a friendly environment and in control, not subject to unnecessary interventions, is a very strong incentive for requesting home delivery.
The following are given as reasons for choosing home delivery, based on research for the National Birthday Trust:¹

• Avoid unnecessary intervention - 31%.
• More relaxed in a familiar environment - 25%.
• Previous home birth - 11%.
• Fear of hospital setting - 10%.
• Continuity of midwife care - 4%.

Criteria for home delivery

None of the interested expert panels, e.g. the National Institute for Health and Clinical Excellence (NICE) or the Royal College of Obstetricians and Gynaecologists (RCOG), publishes explicit guidelines for whom is suitable for home delivery, although local consultants may do so. NICE recommends that place of delivery be discussed at booking and home delivery offered, if appropriate.^7,8 Many factors need to be considered in consultation with the patient. These include:

• Personal, family and social reasons.
• Medical and obstetric issues.

Alternatives may also be discussed, such as early discharge, domino scheme and GP maternity unit if one still exists.
Childbirth can be dangerous, although this should not be exaggerated and, if an emergency occurs that demands the facilities and expertise found only in a consultant-led unit, there is danger and delay during transfer.

• There is little doubt that, for those at increased risk, the facilities of a consultant unit offer the safest place for delivery but, for those at low risk, the situation is much less clear.
• The list of contra-indications to home delivery which is given below is far from exhaustive and it may seem as if those suitable for home confinement are an exclusive few, but this is untrue.

Social conditions

If a woman requests a home delivery the community midwife will perform an assessment, including visiting the place of the intended confinement.

• It does not have to be palatial but it should be adequate.
• There should be adequate standards of heating, lighting and hygiene.
• There should be a telephone in case of need, although in these days of mobile telephones the need is less clear.
• There should be adequate social support. This may be a husband (or partner), mother or even mother-in-law.
• There should be someone to help look after existing children and provide such support that she can be relieved of usual household duties in her time of need.
• Should it become necessary to transfer her to hospital this should not be unusually difficult. This includes problems such as tower blocks with lifts that are rarely functional, and remote farmhouses down inaccessible tracks which ambulance crews would have difficulty finding and then using without risk to their vehicle.

Obstetric risks

• The risk of adverse outcome is higher for a first baby than for a second, with a lower risk still for a third but, for fourth and subsequent babies, the risk is greater than for the first and rises progressively.
• The first baby is best born in an hospital environment.
• The adequacy of the maternal pelvis is untested and the experience of childbirth is new.
• Maternal age is a significant risk factor and, whilst it is impossible to be dogmatic, a general rule may be that the appropriate age for home delivery is over 20 but under 35 years.
• The term 'precious babies' may seem inappropriate as all babies are precious but some are conceived only after a long time of trying and perhaps only with medical intervention. It is a basic truth that those who have problems with fertility have problems at all stages and, hence, those who have difficulty to conceive are more likely to miscarry and more likely to have complications in labour.
• Similarly, whilst no baby may be regarded as disposable, if a 'precious' baby were to die it would be much harder to have another. Hence, any difficulty in conception must be regarded as a contra-indication to home delivery.
• Such complications as breech presentation, unstable lie, multiple pregnancy and hypertensive disease of pregnancy (pre-eclampsia) all necessitate hospital delivery.
• A history of antepartum haemorrhage may suggest that the placenta is inadequate and so there is risk of fetal distress in labour.
  • An early threatened miscarriage is probably not such a risk.
  • Intrauterine growth retardation suggests an inadequate placenta and demands careful monitoring.
• Labour should be spontaneous and at term - that may be defined as between 37 and 42 weeks' gestation - but some obstetricians would be stricter than that.

In summary, home delivery is acceptable if the pelvis has been previously tested by a normal vaginal delivery and there is no reason to expect anything but an uneventful normal labour.

Medical risks

Significant disease may add to the risk of labour for both mother and child and so should indicate hospital confinement.

• The most common significant medical condition is diabetes in pregnancy. This includes gestational diabetes. This will require intensive monitoring of both mother and child in labour.
• Cardiac disease in pregnancy usually represents a risk and essential hypertension puts the placenta at risk.
• Well controlled asthma should not be a problem.

Perinatal mortality is mainly associated with extremes of maternal age, nonwhite ethnicity and high social deprivation.⁹

Responsibilities

GPs are unlikely to be involved directly in intrapartum care, although it can be negotiated as an enhanced service. The practitioner must be appropriately trained and regularly updated.

• Midwives are autonomous and may refer directly to hospital if the need arises, saving crucial time and exercising their own skill and judgement.
• They may well suture the perineum themselves if this is required, although a GP may still be asked to do this.
• They may also be asked to check the newborn baby the following day.

GPs are responsible only for their own acts and omissions and do not have any vicarious liability for a midwife who is responsible for her own actions regardless of where she works.
In the case of litigation the Bolam principle states that a GP should be expected to act with the skill and knowledge of a GP, and not an obstetrician.

It is important to have an understanding with the woman about action to be taken if matters do not progress as anticipated. It may be useful to document these in advance of the delivery:

• This may be signs of fetal distress including meconium-stained liquor or failure to progress.
• The midwife is the patient's advocate and wants all to go well but if, in her professional judgment, transfer to hospital is required, it must be understood that this must be and there is no time for arguing or negotiation.
• Home deliveries are a wonderful experience but the safety of mother and baby must be paramount.
• Complications can occur, even in low-risk cases.

Safety of home confinement

The review of the diverse evidence available on home birth practice and service provision demonstrates that home birth is a safe option for many women.¹⁰However, this is not to define safety in its narrow interpretation as physical safety only but also to acknowledge and encompass issues surrounding emotional and psychological wellbeing. Home births will not be the choice for every woman.¹¹
In the last triennium report from the Confidential Enquiry into Maternal and Child Health (CEMACH):¹²

• Twelve women whose deaths were classified as being directly related to pregnancy had midwifery-led care, of whom three were assessed to be substandard because of poor midwifery practice.
• A further five women whose deaths were classified as being directly related to pregnancy had care shared between the midwife and GP yet, although care was deemed to be substandard in three of these deaths, there was no evidence of poor midwifery care.

However, these few cases do highlight the problem of inappropriate midwifery-led care being provided for known or potentially higher-risk pregnant women.

• The last CEMACH report highlighted the need for a national guideline to help identify those women for whom midwifery-led care would be suitable. NICE guidelines (2008) provide an algorithm for normal antenatal care.⁷
• Another issue concerning midwifery care revolved around a failure to recognise deviations from normal and failing to refer the woman for medical opinion. In these cases a number of risk factors were identified which highlighted the need for joint medical and midwifery care and, although there were clear indications requiring referral to an obstetrician or other specialist, inappropriate midwifery-led care continued.
• Care pathways, within a managed and functioning maternity and neonatal care network, are good examples of how care may be co-ordinated, woman-centred and clinically driven.
  • A good example of a care pathway is the All Wales Normal Birth Pathway which includes telephone advice, a patient information sheet, an active labour pathway and partograms.¹³
  • Initial findings have shown a marked increase in normal birth, with a corresponding reduction in Caesarean section with no difference in mortality or morbidity.¹⁴

It is unreasonable to compare perinatal mortality in home and hospital confinements as all complicated cases go to hospital and this will adversely affect figures. The following considerations make the prospect of definitive gold standard evidence unlikely in the near future, although there have been calls for the research for some time.¹⁵
The most recent Cochrane review states that there is no strong evidence to favour either planned hospital birth or planned home birth for low-risk pregnant women.¹⁶

• They have to be compared with similar low-risk cases in hospital but this classification has to be prospective and not retrospective.
• Those who insisted on home confinement against professional advice must also be excluded.
• Perinatal mortality rates in low-risk groups are so low that enormous numbers are required to get statistical significance if that is the end point.
• Other end points may be more open to variable judgement.
• In terms of comparing like with like, it is also important not to compare groups from different countries.
• There must be analysis by intention to treat so that someone who starts labour at home but has to be transferred to hospital as an emergency, is classified as a home birth.

One problem with interpreting data, whether websites or papers in journals, is that they tend to be written by enthusiasts with an entrenched position and this applies to both sides of the argument.

The role of the general practitioner in the future

GPs are no longer the main providers of antenatal care for women with low-risk pregnancies.
Nevertheless the contributions that they can make are still very significant. GPs are 'experts' in:

• Managing uncertainty
• The early presentation of illness
• Managing and minimising risk

There is a risk that changes in midwifery care will lead to GPs becoming de-skilled, although they will still be the first to be involved if the family or midwife suspects something may be wrong. This role needs to be recognised (and supported by midwives) and encouraged.
They need to maintain their skills and professional development to be able to provide excellent care for all pregnant or recently delivered women, including those at higher risk or in emergency situations.
Clinical issues for general practitioners should centre on:¹²

• Preconception advice and care.
• Identifying seriously ill women.
• Recognising red flag signs and symptoms in women who need emergency referral.
• Breathlessness may be due to pulmonary embolus.
• Severe headaches may be suggestive of hypertension or subarachnoid haemorrhage.
• Ectopic pregnancies continue to be missed, and can mimic gastroenteritis.
• Puerperal fever is not a disease of the past.
• Heartburn may be ischaemic heart disease.
• Recognising when women need 'fast-track' referral for urgent conditions.
• Mental health problems in pregnancy and after delivery.
• Substance misuse and its effect on pregnancy.
• The health of refugee and asylum-seeking pregnant women.
• The risks of obesity in pregnancy.
• Communication issues:
  • Telephone consultations.
  • Referral letters and providing complete information.
  • The increasing emphasis on midwifery-led care.
  • Changes in out of hours' (OOH) primary care services.

Document references

1. Zander L, Chamberlain G; ABC of labour care: place of birth. BMJ. 1999 Mar 13;318(7185):721-3.
2. Home Birth Rates (by UK area), birthchoiceuk.com website
3. Andrews A. Home birth experience 2: births/postnatal reflections. Br J Midwifery 2004;12:552–7
4. Munday R. Women's experience of the postnatal period following a planned home birth; a phenomenological study. MIDIRS Midwifery Digest 2004;13:371–5
5. Paddison J. Home Birth a Family Affair: A Qualitative Research Case Study of Home Birth and Social Boundaries. Wigtownshire: Impart Publishing; 2005
6. NHS Maternity statistics, 2008-9
7. NICE; Routine antenatal care algorithm, 2008
8. Intrapartum care, NICE Clinical Guideline (2007)
9. CEMACH Perinatal Mortality 2007, published June 2009; 5th annual report
10. Home Births, Royal College of Midwives and Royal College of Obstetricians and Gynaecologists (2007)
11. Changing Childbirth, Dept of Health; Report of the Expert Maternity Group. London: HMSO; 2003
12. CEMACH - Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer - 2003-2005. December 2007
13. HOWIS. All Wales Clinical Pathway for Normal Labour. NHS Wales. September 2006
14. Langley C; A pathway to normal labour. RCM Midwives. 2007 Feb;10(2):86-7.
15. Dowswell T, Thornton JG, Hewison J, et al; Should there be a trial of home versus hospital delivery in the United Kingdom? BMJ. 1996 Mar 23;312(7033):753-7.
16. Olsen O, Jewell MD; Home versus hospital birth. Cochrane Database Syst Rev. 2000;(2):CD000352. [abstract]

Internet and further reading

• The GP's guide to home birth, Bandolier, October 1996
• Drife J; Data on babies' safety during hospital births are being ignored. BMJ. 1999 Oct 9;319(7215):1008.
• Campbell R, Davies IM, Macfarlane A, et al; Home births in England and Wales, 1979: perinatal mortality according to intended place of delivery. Br Med J (Clin Res Ed). 1984 Sep 22;289(6447):721-4. [abstract]
• Bullough C, Meda N, Makowiecka K, et al; Current strategies for the reduction of maternal mortality. BJOG. 2005 Sep;112(9):1180-8. [abstract]
• Campbell R. Home versus hospital delivery. Analysis was flawed. BMJ (letter). 1996 Jun 29;312(7047):1673

Acknowledgements