Choosing where to have your baby: place of birth
Having a baby is generally very safe for the vast majority of women and their babies; this is why UK maternity services offer women the choice of where they would prefer to give birth. Many women assume that they will have their baby in hospital, particularly where this is their first pregnancy. However, you will be offered a number of options early in pregnancy and can discuss these at any time, as your pregnancy advances. The important thing is to choose to give birth at a location where you will feel the most comfortable. This might mean planning to give birth at home – ie a home birth, or choosing to give birth in a midwife-led birth unit or in hospital. Similarly, the preferred location for your baby’s birth may change during the course of your pregnancy. You may start off expecting to have your baby in hospital and then decide that you’d actually prefer to have your baby in your local Birth Unit; or plan for a home birth only to find that the nature of your pregnancy means that a hospital birth is advised. Of course, there will always be situations where the baby decides to arrive earlier or much quicker than anticipated and even the best-laid plans can ‘fly out the window’!
This article has been written to explain the various benefits and disadvantages associated with each birth location so that you can make an informed choice that is right for you, your partner and your baby. We recommend that you also discuss the different options with your midwife and doctor – they will be able to answer any queries and provide more detailed information about the facilities available locally.
Yours’ and your baby’s safety
When discussing where you might like to give birth, the priority for your midwife and doctor will always be yours’ and your baby’s safety. Therefore, if there are any complicating factors or underlying medical conditions which mean that you and/or your baby will need to be monitored more closely, or are likely to need specialist services you will be advised to give birth in a hospital obstetric unit. This is because these facilities offer immediate access to medical staff and specialist anaesthetic and neonatal services should they be needed. However, where you have a straightforward, uncomplicated pregnancy, the research tells us that there is no evidence that hospital births are safer for all women and their babies. Therefore, when you are considering place of birth you will need to also think about where you will feel the safest, the most relaxed, comfortable and in control. This is because all of these factors can make a significant difference to how you cope in labour and, ultimately, your overall satisfaction with your birth experience.
Choosing where to give birth
When you have your first appointment with you midwife – called the ‘booking’ visit, you will be asked to consider where you would prefer to give birth. It may feel strange to think about the location for your baby’s birth so early on in pregnancy, but your midwife will want you to have plenty of time to consider the various options available. They will help you with this decision by providing you with objective, evidence-based information about the benefits and disadvantages associated with each location. You may already have a pretty good idea of where you would like to give birth and may make your choice at the Booking visit; however, you can change your mind at any time during pregnancy, even where labour has already begun.
Where you have a straightforward, uncomplicated pregnancy, your main carer will be your midwife and you are likely to be offered a wide choice of birth locations. However, where your pregnancy is more complicated and there is an increased risk that you or your baby will need to be monitored more closely, or require obstetric, neonatal or anaesthetic input, you will be advised that your care is shared between your midwife/GP and a Consultant Obstetrician at your local hospital obstetric unit.
What are the options?
A home birth is normally considered to be an appropriate option for women with straightforward, uncomplicated pregnancies where they and their babies are considered to be at low risk of developing any complications during labour and/or birth. Home births tend to be a popular choice for women who are keen to have continuity of care and carer from a midwife that they know, and want to have as natural a birth as possible without medical intervention. Therefore, women who would not choose to have an epidural or Pethidine; wish to avoid electronic fetal heart rate monitoring and believe they would feel more relaxed and in control in the familiar surroundings of their own home, are more likely to choose this option. If you decide to have a home birth, your care during pregnancy, labour and birth will be provided by your local midwives; sometimes with input from your GP. Research shows us that women who give birth at home are less likely to need pain-relieving drugs, are more likely to have a normal vaginal birth, and have fewer cases of fetal distress. Women are also more likely to report a positive birth experience – feeling relaxed, safe and in control, which is linked to better emotional outcomes in the transition to motherhood. However, women should be advised that if a complication arises during labour or birth, they may need to be transferred into their local hospital obstetric unit. Where the location of the home birth is some distance away from the hospital, this distance and the time that it takes to do the transfer are important factors that should be considered because of the potential impact on the mother’s/baby’s health and wellbeing.
Midwifery-led unit (MLU)
If you choose to give birth in a midwife-led unit, your labour care will be provided by midwives. MLU facilities are designed for use by women who have straightforward, uncomplicated pregnancies because they are strongly focused on normality in childbirth and aim to offer a home-from-home setting. Birth rooms/suites are usually furnished with low beds, floor mats/mattresses, birth balls, rocking chairs; subdued lighting and will often include water birth facilities too. This means that they don’t have the equipment or immediate access to obstetric and anaesthetic services that are needed to undertake medical interventions such as epidurals, augmentation of labour (with oxytocin) and continuous electronic fetal heart rate monitoring. Midwifery-led units can be referred to in a number of different ways depending on where you live. In England and Wales they are commonly called Birth Centres or Midwife-led units; in Scotland they are called GP Units or Community Maternity Units and; in Northern Ireland they are referred to as Community Midwifery Units. MLUs are a popular choice for women who don’t want a home birth but would feel more relaxed in a home-from-home environment. As before, where the MLU is some distance away from the local hospital obstetric unit, women will need to consider the potential need to be transferred to hospital and the time that this might take.
Alongside midwifery unit (AMU)
Alongside midwifery units and GP units are often found on the same site and/or in the same hospital building as a hospital consultant obstetric unit. They are defined as, ‘A clinical location offering care to women with straightforward pregnancies during labour and birth in which midwives take primary professional responsibility for care. During labour and birth diagnostic and treatment medical services, including obstetric, neonatal and anaesthetic care are available, should they be needed, in the same building, or in a separate building on the same site. Transfer will normally be by trolley, bed or wheelchair’. Giving birth in an AMU often appeals to women who would prefer a home-from-home birth environment, but feel more secure in the knowledge that there is quick access to obstetric, anaesthetic and neonatal services should they be required. For some women, this might include the option of being able to have an epidural for pain relief if they suddenly decide they want this. See also our article, ‘Pain relief options for labour and birth’.
Research shows us that women who plan to give birth in an AMU are more likely to have a normal vaginal birth with an intact perineum (no stitches) and are less likely to have an epidural or an episiotomy (a cut in the perineum). Women also report greater continuity of care and more consistent advice, resulting in their being more satisfied with the care they’ve received.
Free-standing midwifery unit (FMU)
These are facilities that are located some distance away from a hospital consultant obstetric unit – potentially several miles. FMUs are defined as, ‘A clinical location offering care to women with straightforward pregnancies during labour and birth in which midwives take primary professional responsibility for care. General practitioners may also be involved in care. During labour and birth the full range of diagnostic and treatment medical services, including obstetric, neonatal and anaesthetic care, are not immediately available but are located on a separate site should they be needed. Transfer will normally involve car or ambulance’. An FMU is often a popular choice for women with straightforward, uncomplicated pregnancies and those having their second or subsequent baby (following previously uncomplicated labours and births). In more rural parts of the country a FMU may also be a more convenient option rather than travelling extra miles to get to the nearest obstetric hospital. However, women still need to have a low-risk pregnancy to be able to book to give birth in an FMU. Research shows us that women giving birth in FMUs are more likely to have a normal vaginal birth; FMUs are also associated with a lower incidence of induction of labour, reduced need for pain-relieving drugs (particularly epidurals and Pethidine) and fewer episiotomies.
Hospital obstetric unit
These facilities are defined as, ‘A clinical location in which care is provided by a team, with obstetricians taking primary professional responsibility for women at high risk of complications during labour and birth. Midwives offer care to all women in an obstetric unit, whether or not they are considered at high or low-risk, and take primary responsibility for women with straightforward pregnancies during labour and birth. Diagnostic and treatment medical services including obstetric, neonatal and anaesthetic care are available on site’. Where women have complicated pregnancies/obstetric histories or have underlying medical conditions such as heart (cardiac), kidney (renal) or metabolic (endocrine) disease, they will always be advised to have their baby in a hospital obstetric unit. However, women with low-risk, uncomplicated pregnancies may equally choose to give birth in a hospital obstetric unit, because this is their preferred location.
Hospital obstetric units are by definition highly clinical areas and because the majority of women giving birth in these locations have high-risk pregnancies, there is an increased likelihood that labours will be ‘actively’ managed. This means that women’s care is provided in accordance with hospital guidelines and policies – these indicate the accepted length of each stage of labour and the interventions that should be considered where labour progress is not as it should be. One such intervention is the augmentation (speeding up) of labour contractions using intravenous Oxytocin (a hormone drip). Research shows us that labour interventions are associated with an increased incidence of assisted births using forceps or the ventouse and operative births by caesarean section.
Independent midwifery care
Independent midwives are fully qualified midwifery practitioners who are registered with the Nursing & Midwifery Council (NMC) and are self-employed. They do not work for the NHS and they charge a fee for the care/services that they provide. The majority of Independent midwives hold agreements with their local NHS Trust maternity services so that the women in their care can be transferred to the hospital obstetric unit should any pregnancy or labour complications arise. Women advised against having a home birth because they are deemed to be ‘high-risk’, will often choose to employ an independent midwife because they will do their best to support the woman’s personal preferences. Many independent midwives are skilled and very experienced in providing a home birth service to women having a vaginal birth after caesarean section (called VBAC), women expecting twins, and those whose baby is lying in the breech position (bottom first). Independent midwives can also provide the continuity of care during pregnancy, birth and during the initial weeks of motherhood, that NHS maternity services aren’t able to guarantee. Further information about the services that Independent Midwives provide is available at: independentmidwives.org.uk
Transfer during labour
Apart from those booked to give birth at home; all women will expect to travel to their planned place of birth. In the majority of cases, women will transfer from their usual place of residence to their ‘place of birth’ once labour has begun. Exceptions to this are where there are pregnancy complications that necessitate hospital admission before labour begins eg where the membranes rupture prematurely, or women are admitted for induction of labour.
There are however, circumstances where a woman will need to be transferred into a hospital obstetric unit during labour. These include: (i) where the baby is showing signs of not coping with the labour contractions – called fetal distress and there are changes to the rate and pattern of the baby’s heartbeat (see also ‘Monitoring your baby’s heart rate in labour’); (ii) where the baby has its bowels open (poos) into the amniotic fluid (the waters) around the baby – called meconium-stained liquor; (iii) where there is a delay in labour progress and the cervix is not dilating as it should be – called failure to progress; (iv) the baby is found to be breech and, (v) the mother is requesting epidural pain relief.
The midwife caring for the woman at home will always explain their concerns and the reasons why they are recommending transfer into hospital. It is understandable that transfer into hospital can be a very upsetting and traumatic experience for labouring women, especially when their expectations of a home birth unexpectedly evaporates; however, the recommendation to transfer to hospital is made where there is a genuine clinical need/concern.
Transfer for neonatal care
There are occasions where women unexpectedly go into premature labour or have complications in pregnancy which mean their baby(s) will need to be delivered prematurely. Most of the time, the hospital obstetric unit and on-site neonatal services are able to plan for the baby’s admission to the Neonatal Unit (NNU)/Neonatal Intensive Care Unit (NICU). Very occasionally however, unexpected demand for NICU cots can exceed availability and in these circumstances, women and their babies will need to be transferred to another hospital where NICU cots are available. Transfer can be done when the baby is still in utero (inside the womb), or soon after their birth. This can be incredibly unsettling and distressing for parents; particularly where the unit they are being transferred to is out of region and a significant distance from their home, family and friends. The maternity and neonatal staff will be very aware of this and will offer lots of support. Every effort is made to transfer the mother and baby back to their local hospital NNU/NICU as soon as a cot becomes available.
Transfer following home birth
Even where your baby is born at home, there are circumstances where you and/or your baby may need to be transferred into your local hospital obstetric unit. This tends to be the case where the placenta (afterbirth) cannot be delivered – this is called retained placenta or where there is complex perineal trauma that needs to be repaired (sutured) in theatre (see also ‘Severe perineal trauma: Third and Fourth degree tears’), or there is significant bleeding – called postpartum haemorrhage.
Where the health and wellbeing of the newborn baby is causing concern, your midwife and doctor will always err on the side of caution and will recommend that the baby is checked over by the hospital neonatal team. This can be the case where your baby is showing signs of infection or difficulty with their breathing ie respiratory distress (is breathing rapidly, making a noise when they breathe out – called ‘grunting’).
I’ve changed my mind!
You can change the preferred location for your baby’s birth at any time during your pregnancy and even once your labour has started. Sometimes, women find that they need to reconsider the location for their baby’s birth because complications develop during their pregnancy. The reasons why women often have to reconsider where they give birth are commonly due to developing pregnancy-induced hypertension (raised blood pressure in pregnancy), being found to have placenta praevia (low-lying placenta), or having a post-term pregnancy (going overdue). Women may also change their mind about where they wish to give birth after speaking with their midwife and doctor, and exploring the different options available in greater detail. Where women have access to accurate, evidence-based information they can make an informed choice that is right for them and their baby.
Whatever location you choose for your baby’s birth, your midwife and doctor should always respect and support your decision. You have plenty of time to think about your preferences, but equally, you have every right to change your decision at any time. Where your midwife and doctor are recommending a specific location, they will explain the reasons for doing so. Unfortunately, it is also a fact that women’s choices can sometimes be limited by the availability of facilities and maternity staff trained/experienced in providing a home birth service. Where you have concerns about the choices/resources available in your area or queries about the recommended location for your baby’s birth, you may wish to talk these through with one of the Supervisors of Midwives at your local NHS Trust. They can help you to consider your options and can act as an intermediary and your advocate, so that your wishes are met while ensuring that you and your baby are as safe as possible. Also see our article, ‘Support for parents: how supervisors of midwives can help’.