Capturing the correct data for births at home

June 6th 2021 was global International Home birth day. It may have passed your notice; there was even no mention of it from the Royal Colleges in statements or press releases.

Why does the day exist? The International confederation of midwives points to the reasons on Twitter with the reminder:

“A woman has a right to make an informed decision to give birth at home supported by a midwife. However, not all nations have the legislation or health systems that support planned home birth. Governments should work towards a maternity system which includes this option”.

The indication is that birth, and home birth in particular, is political. For those in many countries the opportunity for a home birth may be restricted by medical control that insists birth is in a hospital setting, or unsafe in home settings due to the lack of local midwifery care to be available for support. The day exists to raise awareness that women have a right to make choices to give birth at home with midwifery care. The Birthplace study provided the evidence that planned birth at home in the UK is a safe option, particularly for those who have had a previous birth. A systematic review and metanalysis of 14 studies published in the Lancet provides data that planned home birth globally is a safe choice. The ICM clearly point out political leaders should have home birth on the agenda.

This year for the International day of the midwife the theme was “Follow the data-invest in midwives”, to ensure appropriate data is collected to impact maternity care. But what is the picture about home birth in the UK? The data for the number of births in the UK is yet to be released for 2020, which is late for making any ongoing plans with the continued pandemic. We do know, however, that the Covid-19 first lockdown brought a knee-jerk reaction from most Trusts to suspend home birth services initially. Birthing women and people, however, were indicating they would feel safer in the home away from the hospital environment, with their partners present. The human rights charity Birthrights issued a statement supporting home birth with appropriate personal protective equipment (PPE) for staff and joint guidance from the RCM and RCOG provided support to return to home birth services. We are yet to ascertain how many were freebirths. Some midwifery managers successfully reinstated home birth services quickly and safely.

The latest available data for England and Wales (2019) shows only around 2% of births were at home. It has not been so easy to locate information from elsewhere. Data around numbers of home births in Scotland does not appear to be centrally recorded; those for Northern Ireland are not easy to find. In contrast an annual audit of home births with self-employed midwives is carried out in Ireland, with the latest data in 2017 showing 160 home births took place. The difficulty in locating data was pointed out by the National Maternity and Perinatal Audit in 2019:

Unfortunately, the NMPA is currently unable to report on planned place of birth at any point in pregnancy owing to poor data quality (p14).

They also estimated 2% as the number of home births.

Numbers may be clear enough, but they do not paint a complete picture. The UK data do not tell us, for example, whether these births in a woman’s home had a midwife with them or not. It does not tell us how many women chose to freebirth? Of the 13389 English births over 300 of these were babies with birthweights less than 2500g. How many were precipitate births or late abortions? It does not tell us how many of these births were planned to be at home.

In addition to the birth at home figures a further 1080 were born “elsewhere”, 80 of these of less than 2500g birthweight. This data, I am informed, cover births not in the person’s home or in a hospital or birth centre setting. These figures hide a lot of information. How many of these births took place as ‘born before arrival’ (BBA)? This term is used when the birth takes place before the person gets to the planned place of birth, or, in the past, before the arrival of a midwife at a planned home birth. The number is not collated in all Trust areas and does not tell us if the woman had chosen to freebirth at home (with a doula sometimes) and then arrived at a unit to have the baby examined. It also does not tell us how many women do not get to hospital in time- labour progressing in a straightforward way- but quickly. How many of these women had called in and “told” by the maternity unit to “come in” and end up giving birth by the roadside or in a car park? We often only know these from a local news report praising a partner or taxi driver with support from a 999 call. Why are we not considering it would be safer for the labouring woman to stay put, to get a midwife to her with equipment to support her and examine her before deciding it is safe to move? NICE includes home assessment in their intrapartum guidelines (Recommendations | Intrapartum care for healthy women and babies | Guidance | NICE) and this practice has been shown to increase home birth rates by the renowned Albany practice model.

Currently though we need to wait for national data to be released, and especially to wait for the impact of development of continuity of carer models. Reported data from some areas is showing increase of home births where caseload models are in place (Worcester teams- 7.7% home birth vs 1.4% trust-wide). Here is hoping that ALL data around birth at home will be collated soon in order to demonstrate exactly what is going on.

Dr Jenny Hall
June 2021