The Big Question: What are the risks of home births, and are they greater than in hospital?

(Independent Graphics)

Why are we asking this now?

A large study has for the first time calculated the national death rate for home births. The results show that they are safe, unless things go wrong in which case they are risky.

Isn't that blindingly obvious?

It is, but for the first time researchers have been able to quantify the risks. Home was the usual place for birth until a century ago, and even in the 1950s a third of babies were born at home. Over the last half century, place of birth has switched to hospital, and today of the 660,000 births a year, only around 17,000 (2.5 per cent) occur at home, of which roughly half are planned.

Obstetricians say hospital is safer but organisations such as the National Childbirth Trust say the switch to hospital has led to the over-medicalisation of what should be a natural, joyful process. Campaigners say that too often women are left feeling powerless, without control and in some cases traumatised.

What did the study involve?

The 10-year study covered all births in England and Wales from 1994 to 2003, totalling 6.3m, of which 130,000 took place at home. Of these slightly more than half (75,000) were booked to take place at home – the remainder being the "accidental" home births referred to above. The findings, by the National Collaborating Centre for Women and Children's Health, London, are published in the British Journal of Obstetrics and Gynaecology (BJOG).

And what did it find?

It showed that the death rate during labour or after delivery (called the intra-partum perinatal mortality, which includes stillbirths) is one in 2,000 (0.48 per 1,000) for those who planned a home birth that was successfully completed at home. This is nearly half the average death rate for all births of 0.79 per 1,000.

Does that make home births safer than hospital births?

Yes – but not if things go wrong. The researchers also found that for parents who planned a home birth and then got into difficulties and ended up in hospital, the risks were much higher, with a death rate in this group of 6.05 per 1,000. That is 12 times more risky than for birth completed at home and over six times more risky than the average for all births.

How likely were home births to end up as hospital births?

In round figures, they faced a one in seven chance of being taken to hospital. Of the 75,000 women who booked a home birth, 10,750 (14 per cent) ended up being transferred – an emergency in which every second counts. The death rate among the babies of these women is correspondingly higher.

Is the risk of ending up in hospital the same for all women?

No. For women having their first baby the risks are much higher – about one in four will end up being transferred and having their baby in hospital. For women having a second or subsequent baby, where the previous birth went well, the risks are much lower – one in 20 have to be transferred. In other words, experienced mothers who have already delivered successfully have a much better chance of enjoying the natural birth in a familiar home environment surrounded by loved ones that many mothers crave.

So which option should an expectant mother choose?

The bottom line is that home births are mostly safe, especially for mothers having second or subsequent children, but improvements in the safety of hospital births over the last few decades have left them looking riskier than they were. As perinatal mortality has fallen overall, the risks of home births have become more obvious.

Philip Steer, editor of the BJOG, puts it like this: "When perinatal mortality was higher, perhaps we did not worry about home births. But as the tide goes out, we see the rocks poking out of the sand. That is the central dilemma of home births. It is a perfectly reasonable choice but women need to be aware of the risks. They are mixing the very best with almost the worst. Women who choose a hospital birth are in effect hedging their bets – it may be not as nice an experience but it is safer when things go wrong."

Can women hedge their bets if they live close to a hospital?

How close is close? Women in Scotland voted overwhelmingly in a recent survey against the idea of home births – because of the distances to the nearest hospital. But even Londoners, where hospitals are plentiful, can run into trouble – for example if they go into labour when the local football team are playing at home. An ambulance with a blue light flashing cannot shift a traffic jam.

What does the Government say about home births?

It gives tacit approval. A year ago, Patricia Hewitt, then health secretary, published "Maternity Matters", setting out a vision of a woman-focused maternity service with "a full range of birthing choices" and more emphasis on home births, to be implemented by 2009.

And the view of obstetricians and midwives?

They think the plans are bunkum. It takes two midwives to supervise a home birth – one to see to the mother and one to see to the baby – and there are currently not enough to provide the promised one-to-one care in hospitals. The Royal College of Midwives says that thousands of extra midwives will be required. The Royal College of Obstetricians says it has "concerns" about encouraging more home births.

What do childbirth campaigners say?

Sheila Kitzinger, the author of Birth Crisis, says: "Our medicalised culture is one reason why it is important that there is a home birth alternative. Home birth offers a model on which hospitals should base practice, and that enables midwives to learn how to keep birth normal."

The debate about where is the best place to give birth – at home or in hospital – has raged for many years and shows no sign of abating.

Should home births be encouraged?

Yes...

* They are mostly safe, especially for second and subsequent babies, and are often a happier experience for mother and baby

* Women should be offered a choice about where they give birth, provided they are properly informed about the risks

* Home births help midwives understand how best to provide the service in a hospital maternity unit

No...

* As hospital births have grown safer, home births have been left looking riskier

* When home births go wrong, the delay in transferring the mother to hospital can put the baby's life at risk

* The NHS does not have sufficient midwives to provide an increased home birth service