The best place for women to give birth is among the most emotive debates in medicine. At home or in hospital? The argument has raged for decades.
Today, researchers attempt to settle the debate with a study of 65,000 low-risk women whose outcomes in childbirth were compared.
The results show that hospital obstetric units are safer than home births for first babies – but there is a higher rate of intervention with Caesareans, forceps and epidurals and a lower chance of a normal birth in hospital.
For second and subsequent babies, home births were as safe as hospital – and cheaper. The extra risk of a home birth applied only to first babies.
First-time mothers were nearly three times more likely to have an "adverse outcome" from death of the baby to injuries to the baby's arm or shoulder during delivery, if the birth was planned at home.
There was no increased risk for first babies whose birth was planned at a midwife-led unit.
All the women in the study were low risk – they were carrying a single baby, had no pre-existing medical conditions, there were no complications in pregnancy and they had not had a previous Caesarean. Overall, birth to these women was safe wherever they were delivered. Adverse outcomes were rare, numbering 250 in all among the 65,000 births.
Professor Peter Brocklehurst, of Oxford University's National Perinatal Epidemiology Unit, who led the Birthplace in England study, said: "While there is an increase in risk for first-time mothers planning the birth at home, that is an increase on something that is already very uncommon. Mothers will need to balance the increase in risk of uncommon outcomes for the baby... against the very much greater likelihood of having a 'normal' birth... than in a hospital".
The winners from the study are midwife-led units – the halfway house between home and hospital which tries to combine the best elements of both.
The findings, published in the British Medical Journal, show they are safer than home births but have lower rates of intervention – and are cheaper to run – than obstetric units.
Currently, 92 per cent of births are in hospital obstetric units in England compared with 3 per cent at home and 5 per cent in midwife units. Midwives said this must change. Cathy Warwick, general secretary of the Royal College of Midwives, said the research should influence planning. "There needs to be a seismic shift in the way maternity services are provided. The way services are delivered wastes taxpayers' money."
Campaigners said midwife units were under threat as NHS trusts sought savings – despite their lower running costs. Corbar Birth Centre in Buxton, Derbyshire, and Andover Birth Centre in Hampshire are among those facing closure according to the National Childbirth Trust.
Mary Newburn, head of research at the NCT said: "What is stunning is how positive the findings are for midwife-led units. There is no excuse for their not being made available in all trusts." Only about half of trusts have a midwife unit, despite offering cheaper care.
The cost of a birth in a midwife unit ranges from £1,435 to £1,461, compared with £1,631 in an obstetric unit and £1,067 at home. The researchers said it was unclear why home births were less safe for first-time mothers, or why hospital births led to more interventions.
Case study: Kate Morris
"William's arrival two years ago will be marked forever by the image of my husband sitting at the kitchen table, staring at shed designs on his laptop while I coped with my labour pains and texted the neighbours to apologise about the noise.
This picture explains why home births can be such a positive experience. You are in your comfort zone and, provided things go to plan, you can get on with labour in your own way.
It's a personal decision and I came to mine after examining the facts: my first birth in hospital was straightforward, and gave me confidence. And I knew I could go to the nearby Rosie Maternity Hospital at Addenbrooke's in Cambridge, at any time.
The actual birth could have taken place up the Eiffel Tower for all the attention I paid to my surroundings, but the difference was what happened after. My two midwives helped me upstairs, bathed me, chatted to me, and helped me to bed. They cleaned up downstairs and made me a cup of tea before they left. This is a level of after-care no NHS hospital could even aspire to."Reuse content