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The GP's guide to home birth

Many GPs are fearful of any involvement or even discussion of home birth, despite the Changing Childbirth [1] philosophy of choice. Yet continuity and control for women is increasingly becoming part of mainstream practice.

A recent statistical review found "There is no evidence to support the claim that the safest policy is for all women to give birth within hospital" ... and "For some women it is possible but not proven that the iatrogenic risks associated with institutional delivery may be greater than any benefit conferred" [2].

The numbers

Home births accounted for only 1.8% of all deliveries in 1994. The perinatal mortality rate for all these home births is 7.8 per 1000 live births; that for hospital is 8.9 per 1000 live births [3]. A survey to determine the intended place of delivery at the onset of labour of all births occurring at home in 1979 found that, of these births, only two thirds had been booked for delivery at home. The perinatal mortality rate for planned home deliveries was 4.1 per thousand births while for births at home which were planned to occur in consultant units it was significantly higher at 67.5 per thousand births [4].

But it is difficult to compare directly the perinatal mortality rates for home and hospital as more complex deliveries occur in hospital. A feasibility study into conducting a randomised controlled trial on hospital versus home births showed that only 2% of women were considered suitable by the obstetricians and would consent to randomisation [5]. So it is unlikely to be much clearer in the future.

Perceived risks

Although we have seen that home birth does not appear to be high risk in terms of perinatal mortality for women with normal pregnancies, there is evidence that women who request home birth are indifferent to any increased risk compared with those who do not seek it [6]. The GP should present the information regarding local options for place of birth to the woman in a clear, understandable and balanced manner. In order to fully inform the pregnant woman, the GP must be fully informed. Also, it is important that the women understand just what their GP could do, or could not do at a home birth.

GPs who do not wish to provide care for home births should refer women to a community midwife, supervisor of community midwives at the district maternity unit, or to a GP who provides full maternity services, solely for maternity services. It is important to remember that midwives are professionals and personally accountable for their own actions and decisions. There is no question of vicarious liability for the GP for the actions of any midwife.

If a GP is involved in intra partum care, and an unfortunate event proceeds to litigation, the GP would not be judged by the standards of a consultant obstetrician, but by those of a GP with similar skills and standing (the Bolam Test).

GPs do not have to attend a home birth even when the woman has been accepted by them for full maternity care unless asked to do so by the midwife. However, even if a GP has not accepted a woman for maternity services, he or she is obliged to attend an obstetric emergency if requested, even if the woman is no longer on his list, just as he or she would be for any medical emergency.

Where the midwife feels that the GP is supportive, the likelihood of transfer to hospital is reduced [7].

GP's role in home births

What then is the GPs role in home births? Most GPs already involved in home births feel that their role is primarily to support the woman and the midwife, to spot early deviations from the normal course of labour along with the midwife, and effect early transfer into the obstetric unit. Most GPs involved in home birth should not offer interventional obstetric skills. When there has been a deviation from the normal course of labour an ambulance with paramedics should be called and the woman transferred to a fully equipped maternity unit. A flying squad is almost never appropriate and it is unlikely to do anything useful in the home setting [8].

One of the greatest worries for GPs contemplating home birth is that of the situation where they are faced with a neonate needing resuscitation. The anxiety is fired by the fear of the development of cerebral palsy in the baby, as a result of anoxia. The incidence of cerebral palsy is 0.2% and has not altered in four decades. Swedish evidence indicates that only one baby in 5000 full term normal deliveries needs intubation [9]. "What little evidence exists suggests that less than 2% of cerebral palsy could be attributed to sub optimal care" [10].

Changing childbirth is not about actively promoting one place of delivery above another one, but allowing the woman to make her own choices on balanced information given to her. Home birth should be one of the options presented. For women with uncomplicated pregnancies it is not a high risk option.

Dr Mary Keenan GP Advisor
Changing Childbirth Implementation Team

References:

  1. Department of Health. Changing Childbirth (Report Of The Expert Maternity Group). HMSO, London, 1993.
  2. R Campbell & A Macfarlane. Where to be born? The debate and the evidence. 2nd edition, 1994, p119, National Perinatal Epidemiology Unit, Oxford.
  3. Office for National Statistics, 1994.
  4. R Campbell, I Macdonald Davies, AJ Macfarlane, et al. Home births in England and Wales perinatal mortality according to intended place of delivery. British Medical Journal 1984 289: 721-4.
  5. T Dodswell, JG Thomson, J Hewison, G Young et al. Should there be a trial of home versus hospital delivery in the United Kingdom? British Medical Journal 1996 312: 753-7.
  6. JG Thornton, RG Lilford. The Caesarean section decision: patents choices are not determined by immediate emotional reactions. Journal of Obstetrics & Gynaecology 1989 9: 283-8.
  7. Report of the Northern Region Home Birth Survey 1993. Northern & Yorkshire Health Authority.
  8. AK Trehan, ILC Ferguson. The Flying Squad - an expensive and potentially dangerous practice in modern obstetrics. British Journal of Obstetrics & Gynaecology 1992 98: 1177-9.
  9. C Palme-Kilander. Methods of resuscitation in low-Apgar-score infants - a national survey. Acta Paediatrica, 1992 81: 739-744.
  10. Australian and New Zealand Perinatal Societies. The origins of cerebral palsy - a consensus statement. Medical Journal of Australia 1995 162: 85-9.



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