A mother's right to make choices: They said it wasn't safe, but it's safer. Wendy Savage on giving birth at home

Many of us who work in maternity care felt a sense of shame last week on reading the Department of Health's report Changing Childbirth because it had to point out that the woman is at the centre of childbirth. Of course she is, and should be treated that way.

Giving birth is an exciting, emotional, creative and unique experience for a woman and her family, and she should decide how she wants to do it. She must have good information so that she can make an informed choice. Yet, in recent years, she has not been given this information, while obstetrics has been dominated by the conviction that 'no birth is normal except in retrospect' so every woman must have her baby in hospital 'in case something goes wrong'.

The report cites a Mori poll which suggests one woman in five would like to have her baby at home - and this is after a quarter century of being told it is not safe. If women knew that there was no evidence to support the theory that hospital birth is safer for healthy women, would the number choosing home birth rise even higher?

Home births in this country have declined from about one-third of women in the late 1950s to 1 per cent in the 1980s, half of which were unplanned emergencies. In 1981 the Government accepted a select committee conclusion that hospital birth was now safer than home birth. This was erroneous, because it forgot that unplanned home births were likely to be unexpected premature labours, or women who had concealed their pregnancies. These women were 50 times as likely to lose their babies as women who had planned home births.

Obstetricians feel anxious at the idea of change. When I was born, one woman in 250 died giving birth. Now, the risk of dying in a car accident is higher than the risk of dying in childbirth. Women with high blood pressure, bleeding before birth or thrombosis are not the ones who are likely to choose to have their babies at home. These are the women that obstetricians see, the ones they should be looking after, not those who are healthy. As the report says, 'birth is not an illness'. But because of their experience, many obstetricians have lost faith in the power of women to give birth mostly without difficulty.

Ante-natal care today is usually shared between a hospital consultant-led team and GP with or without a midwife. The birth takes place in hospital, assisted by hospital midwives who have never seen the woman before. This means that women may see as many as 30 different professionals during pregnancy, labour and delivery, and that midwives rarely have a chance to use their skills to look after normal healthy women throughout their pregnancy.

For almost 25 years the role of the midwife has been eroded so that she may feel like an obstetric nurse rather than an autonomous professional. GPs have been trained in hospital by obstetricians, know little about birth outside an institution, and are badly paid for care at the time of birth. It is a poor and inefficient way of caring for women.

So can these professionals rise to the challenge of providing the care women want in the community? Although some midwives work part- time, there are the equivalent of about 23,500 full-time posts, about one midwife to about every 30 births. Organised into teams of three or four, even with holidays, the workload does not seem excessive. But what has to be changed are attitudes and policies about on-call payments, child care, and maternity leave cover. Most midwives have families who need to be cared for when they are called away to a birth. If hospitals have no subsidised creches, and on-call payments are too low, then midwives will not be able to afford to work in the way they, and women, want them to.

GPs are paid only pounds 35 for attending a woman in labour, which could mean many hours on duty. This needs to be improved. The report recognises that the training of GPs has to be changed, and that some of their work can be covered by using midwives properly. Can GPs who have spent six months of their training being called to births that go wrong in hospital, hardly ever seeing a safe, midwife-assisted delivery, be persuaded to change their views?

A survey done in east London by Rosie Burton and myself in 1991-92 suggests that they can. Forty per cent of GPs were prepared to help a woman who wanted a home birth. More than 10 per cent agreed that for a healthy woman, the best place was at home. I am hopeful that my own branch of the profession, the obstetricians, will not obstruct the progress that Changing Childbirth proposes. Let us stop arguing about safety and let women decide how they want to give birth. It's her body, her birth and her right to choose how and where to have her baby.

The author is Honorary Consultant in Obstetrics and Gynaecology at the Royal London Hospital, and Visiting Professor, Middlesex University.

(Photograph omitted)