Choosing where to give birth 

Choosing where to give birth is a very personal decision. The pros and cons of each location are subjective depending on your health, whether your pregnancy is uncomplicated or not, and your baby’s health. On top of this, it will depend on which location you feel most secure and relaxed in! If you haven’t already, download our free ‘Choosing where to give birth tool’ to help you as you start exploring your options.

There are generally three options you can choose from when deciding where to give birth:

• Home.
• Midwife-led unit. 
• Obstetric unit.

The law allows you to give birth wherever you choose, as long as you have the mental capacity to make that choice. Your maternity team will do all they can to accommodate your preference. However, they will also consider which is the safest place to give birth depending on your health, your pregnancy and your baby’s health needs and advise you accordingly.

Let’s take a look at the options in a little more detail.

Choosing to give birth at home

A home birth is recommended for pregnant women who are healthy with a straightforward pregnancy.

Home birth: Understand your rights

There is no legal guarantee of a home birth service, although the Department for Health states that home birth services should be offered to women who want them. However, staff and skills shortages can mean these services are not always available in all NHS Trusts. Covid has definitely impacted homebirth services, for example. If this is the case in your local area, your NHS Trust should have a contingency plan that supports you and your birth preferences. 

Likewise, if you choose to birth at home against medical advice, your midwife and consultant should devise a plan that respects your choice, including having a midwife present at the birth. This may include speaking with the Head of Midwifery.

Things to think about with a home birth

The pros and cons of giving birth at home will vary from person to person. To help you decide whether you want a home birth, here are some of the things that may help you make an informed choice that best suits your individual needs.  

Your birth environment

Consider how you want your home set up for labour and childbirth. For example, which rooms have the most space, best access or are most comfortable?

Think about what specialist equipment you may want during labour, such as a birth ball or a birthing pool. You will need to buy or rent it and know how to set it up ahead of time.

Who will be with you during labour? 

Usually, you will be looked after by two midwives for the duration of your labour. 

As you are in your own home, you can choose to have as many birth partners and supporters as you want, including children and pets! Just think about who will be looking after them, so your birth partners can focus on supporting you. 

Medical considerations

You will have limited medical pain relief options at home – such as Entonox, also known as ‘gas and air’. Your midwife will encourage you to use natural pain relief methods and coping strategies you’ve been practising during pregnancy.

Whilst you are less likely to have medical interventions*, such as forceps, than someone giving birth in a hospital, your baby has a slightly higher likelihood of a negative outcome if it is your first birth. The Birthplace Cohort Study found that the possibility of adverse outcomes for babies increases from 5.3 per 1,000 in planned obstetric births to 9.3 per 1,000 in planned home births. Negative outcomes can include meconium aspiration, birth injury, stillbirth or early neonatal death. This doesn’t apply to second or subsequent births.

*If your pregnancy and labour are uncomplicated.

The other thing to consider is how you would feel if you or your baby needed to be transferred to the hospital during labour or after birth? The transfer would be via ambulance with your midwife. Your birth partner will be asked to follow in their own transport. 

The stats: Source, Birthplace 2011 (low risk women)

First time birth

• 794 in 1,000 women have a spontaneous vaginal birth.
• 450 in 1,000women transfer to an obstetric unit.
• 218 in 1,000 women have epidural and/or spinal analgesia.
• 165 in 1,000 women have an episiotomy.
• 80 in 1,000 women have a caesarean birth.
• 126 in 1,000 women have an instrumental birth..
• 12 in 1,000 women have a blood transfusion.
• 991 in 1,000 babies have no serious medical problems.
• 9 in 1,000 babies have serious medical problems.

Subsequent births

• 984 in 1,000 women have a spontaneous vaginal birth.
• 115 in 1,000 women transfer to an obstetric unit.
• 28 in 1,000 women have an epidural and/or spinal analgesia.
• 15 in 1,000 women have an episiotomy.
• 7 in 1,000 women have a caesarean birth.
• 9 in 1,000 women have an instrumental birth.
• 4 in 1,000 women have a blood transfusion.
• 997 in 1,000 babies have no serious medical problems.
• 3 in 1,000 babies have serious medical problems. 

Choosing to birth at a midwife-led unit (MLU)

An MLU is recommended for pregnant women who are healthy with a straightforward pregnancy. You may hear an MLU referred to as a birth centre. 

Midwife-led units: Understand your rights

Birth centres usually have admission guidelines based on safety considerations. These are not legal rules and should only be applied if clinical evidence suggests your care cannot be safely managed in a birth centre.

With this in mind, your maternity team should take an individualised approach to any risk factors you may have and consider making an exemption to the rules on your specific case. You can use the B.R.A.I.N. decision-making tool to help these discussions.

Things to think about

As with giving birth at home, there are things to think about which will help you decide whether you consider this the best place to give birth for you.

What’s on offer within your NHS Trust?

There are two types of MLU, but not all NHS Trusts provide them:

• An alongside MLU, located within the maternity hospital.
• A freestanding MLU, located away from the main hospital and maternity unit, often within a small community hospital.

As well as checking what services are available with your community midwife, find out if there are different admittance criteria for the units, as this can sometimes be the case.

Your birth environment

Birth centre rooms are set up to encourage physiological vaginal birth. Not all will have a bed; for example, there may be a birthing couch instead. Find out what equipment is available in your local unit, including the number of birth pools.    

Birth centre rooms look more homely and have less clinical equipment. This can help some women to feel more relaxed. Visit your local units and see for yourself! It’s also worth asking what you can bring in from home.

Who will be with you during labour? 

The care is the same at alongside and freestanding birth centres. It is led by midwives, often with the help of maternity support workers. The only difference is that alongside MLUs have an obstetric team a few minutes away in the obstetric unit if needed. 

Depending on your NHS Trust, you may be allowed to bring more than one birth partner. Ask your community midwife what the local policy is. Remember, if you have other children, you will need to organise childcare for them as they will not be allowed into the MLU with you during labour.

Medical considerations

Most pain relief options, except an epidural, are available in an MLU. Your midwife will still encourage you to use natural pain relief methods and coping strategies. 

Two benefits of giving birth in an MLU are that you are less likely to have medical interventions*, such as forceps than someone giving birth in a hospital. And it is as safe for your baby as giving birth in the obstetric unit for your baby – even if it is your first birth.

Again, consider how you would feel if you needed to be transferred to the obstetric unit during labour or after your baby is born. The transfers are quite different. From an alongside unit you will be transferred by wheelchair or in your bed, whereas from a freestanding unit it would be by ambulance, with your partner following behind in their car or a taxi.

The stats: Source, Birthplace 2011 (low risk women)

Freestanding midwife-led unit: first time birth

• 813 in 1,000 women have spontaneous vaginal birth
• 363 in 1,000 women transfer to an obstetric unit
• 200 in 1,000 women have an epidural and/or spinal analgesia
• 165 in 1,000 women have an episiotomy
• 69 in 1,000 women have a caesarean birth
• 118 in 1,000 women have an instrumental birth
• 8 in 1,000 women have a blood transfusion
• 995 in 1,000 babies have no serious medical problems
• 5 in 1,000 babies have a serious medical problem

Alongside midwife-led unit: first time birth

• 785 in 1,000 women have spontaneous vaginal birth
• 402 in 1,000 women transfer to an obstetric unit
• 240 in 1,000 women have an epidural and/or spinal analgesia
• 216 in 1,000 women have an episiotomy
• 76 in 1,000 women have a caesarean birth
• 159 in 1,000 women have an instrumental birth
• 11 in 1,000 women have a blood transfusion
• 995 in 1,000 babies have no serious medical problems
• 5 in 1,000 babies have a serious medical problem

Freestanding midwife-led unit: subsequent births

• 980 in 1,000 women have spontaneous vaginal birth
• 94 in 1,000 women transfer to an obstetric unit
• 40 in 1,000 women have an epidural and/or spinal analgesia
• 23 in 1,000 women have an episiotomy
• 8 in 1,000 women have a caesarean birth
• 12 in 1,000 women have an instrumental birth
• 4 in 1,000 women have a blood transfusion
• 997 in 1,000 babies have no serious medical problems
• 3 in 1,000 babies have a serious medical problem

Alongside midwife-led unit: subsequent births

• 967 in 1,000 women have spontaneous vaginal birth
• 125 in 1,000 women transfer to an obstetric unit
• 60 in 1,000 women have an epidural and/or spinal analgesia
• 35 in 1,000 women have an episiotomy
• 10 in 1,000 women have a caesarean birth
• 23 in 1,000 women have an instrumental birth
• 5 in 1,000 women have a blood transfusion
• 998 in 1,000 babies have no serious medical problems
• 2 in 1,000 babies have a serious medical problem

Choosing to give birth in the obstetric unit

The obstetric unit is located in the hospital. It is the safest place for women with complicated pregnancies or pre-existing health conditions to give birth. The obstetric unit may be called the labour ward or central delivery suite. 

Obstetric unit: Understand your rights

For various reasons, your maternity team may recommend that the obstetric unit is the safest place for you to give birth. If you don’t want to do this, they will escalate your case to a more senior midwife or manager to discuss the options.  

Making an informed choice is essential if you go against medical advice. Before making any decisions, look at what the evidence says the benefits, risks, and alternatives are for your individual situation and listen to your maternity team’s recommendations. It’s absolutely e to get a second opinion! The following tools will help facilitate these discussions:

• B.R.A.I.N. decision-making tool
• Birth preferences research tool
• Communicating your birth preferences tool 

Things to think about

Just like home and the MLUs, there are some things to think about that will help you decide whether you consider this the best place to give birth.

Who will be with you during labour? 

Whilst your care is still led by midwives and supported by maternity support workers, specialists are on hand if you need their help and support during labour or after your baby is born – whether that’s the obstetricians, anaesthetists or neonatal doctors.

Depending on your NHS Trust, you may be allowed one or two birth partners. Ask your community midwife what the local policy is.

Your birth environment

Whist the rooms in the obstetric unit are generally more clinical and noisy with more medical equipment, many delivery suites still have access to many of the same birth equipment used in MLUs, such as birth balls and even birth pools. Ask your community midwife what’s available locally. 

Consider what you could take into the hospital to make your room more appealing? You can do many things to make it a less clinical environment. Whether it’s bringing in your favourite pillow (avoid a white pillowcase!), setting up fairy lights or playing music. Your midwife can also help by keeping the lights low and moving the bed to suit your needs.

Medical considerations

All pharmaceutical pain relief options, including epidurals, are available in the obstetric ward. Your midwife will still encourage you to use natural pain relief methods and the coping strategies you’ve practised during pregnancy. 

If there is a clinical need, your baby’s wellbeing can be continuously monitored in the obstetric unit using a Cardiotocograph (CTG). For example, if you have pregnancy complications, health conditions, or there are concerns about your baby’s wellbeing, such as signs of meconium when your waters break. The NICE guidelines recommend women are offered telemetry monitoring, which is wireless and, in some cases, enables women to still use the birth pool. Telemetry monitoring is unavailable in all units – check with your maternity team about what’s on offer in your local area.

If your pregnancy is uncomplicated, the NICE guidelines recommend that your baby’s heart rate be listened to intermittently to see how they cope with labour. For this reason, the CTG is not usually available outside the obstetric unit.

The doctors, medical equipment and operating theatre, are on hand should you or your baby need them – you won’t have to transfer for specialist care. It’s worth considering that women with uncomplicated pregnancies who choose to give birth in the obstetric unit are more likely to have an instrumental birth and epidural than if they gave birth in a midwife-led unit or at home. 

However, the good news is that the labour ward is as safe as the birth centre for the baby. 

The stats: Source, Birthplace 2011 (low risk women)

First time birth 

• 668 in 1,000 women have a spontaneous vaginal birth.
• 10 in 1,000 women transfer to a different obstetric unit due to lack of capacity or expertise.
• 349 in 1,000 women have epidural and/or spinal analgesia.
• 242 in 1,000 women have an episiotomy.
• 121 in 1,000 women have a caesarean birth.
• 191 in 1,000 women have an instrumental birth..
• 16 in 1,000 women have a blood transfusion.
• 995 in 1,000 babies have no serious medical problems.
• 5 in 1,000 babies have serious medical problems.

Subsequent births

• 927 in 1,000 women have a spontaneous vaginal birth.
• 10 in 1,000 women transfer to a different obstetric unit due to lack of capacity or expertise.
• 121 in 1,000 women have an epidural and/or spinal analgesia.
• 56 in 1,000 women have an episiotomy.
• 35 in 1,000 women have a caesarean birth.
• 38 in 1,000 women have an instrumental birth.
• 8 in 1,000 women have a blood transfusion.
• 997 in 1,000 babies have no serious medical problems.
• 3 in 1,000 babies have serious medical problems. 

In conclusion

Hopefully, this article has given you some food for thought as you consider where you’d like to give birth. Look at the pros and cons for each location regarding your pregnancy, your safety and that of your baby and the rate of medical interventions. As mentioned at the beginning, the choice is a very personal one.

Also, consider your preferences should anything arise, making your first choice unavailable. For example, if you wanted a home birth but the home birth service was cancelled due to staff shortages. Or if the birth centre is full when you go into labour. Having a backup plan can alleviate a lot of stress. Remember, many elements of the birth environment you create can be transferred between units. 

Content Disclaimer

The information contained above is provided for information purposes only. The contents of this article are not intended to amount to advice, and you should not rely on any of the contents of this article. Professional advice should be obtained before taking or refraining from taking any action as a result of the contents of this article. New Life Classes disclaims all liability and responsibility arising from any reliance placed on any of the contents of this article.

References

Birthplace in England Collaborative Group: Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ. 2011, 343: d7400-

Hollowell J, Rowe R, Townend J, Knight M, Li Y, Linsell L, Redshaw M, Brocklehurst P, Macfarlane A, Marlow N, McCourt C, Newburn M, Sandall J, Silverton L. The Birthplace in England national prospective cohort study: further analyses to enhance policy and service delivery decision-making for planned place of birth. Southampton (UK): NIHR Journals Library; 2015 Aug. PMID: 26334076.

NICE Clinical guideline [CG190] Intrapartum care for healthy women and babies. Published December 2014. Updated February 2017.

NICE Clinical guideline [CG138] Patient experience in adult NHS services: improving the experience of care for people using adult NHS services. Published February 2012. Updated June 2021.

NICE Guideline [NG179] Shared decision making. Published June 2021.

NPEU, Birthplace in England Research programme.

NPEU, Birthplace in England Research Programme: further analyses to enhance policy and service delivery decision-making for planned place of birth.

Rowe, R.E., Townend, J., Brocklehurst, P. et al. Duration and urgency of transfer in births planned at home and in freestanding midwifery units in England: secondary analysis of the Birthplace national prospective cohort study. BMC Pregnancy Childbirth 13, 224 (2013). https://doi.org/10.1186/1471-2393-13-224