Experts say women should be warned about the dangers of home birth and given access to skilled birth attendants NHS
Women should be given clearer warnings about the potentially fatal risks of home birth, and should only be assisted by experienced midwives, experts said.
Maternity services around the world are dealing with an increase in the number of women with more complex pregnancies. Many choose to have their children in a familiar environment, in the comfort and privacy of their own home. Some choose to give birth at home because giving birth to their first child in hospital was “too painful” and they are reluctant to repeat the experience.
But experts say access to safe, reliable, and unrestricted home birth services is patchy, and varies widely depending on where you live. Health care services in many countries struggle to provide home birth services due to staff shortages, inconsistent training, or local policy constraints. Some have dedicated home birth teams, while others rely on overworked community staff.
The Guardian spoke to leading doctors, academics and pregnancy experts about home births after a coroner’s court in Rochdale, England, ruled that a mother and daughter died after giving birth at home due to a “gross failure to provide basic medical care”.
Jennifer Cahill, 34, died at North Manchester General Hospital hours after she suffered a haemorrhage during home birth in Prestwich on June 3, 2024. Her baby, Agnes Lily, was born not breathing, with the umbilical cord wrapped around her neck. She died in the same hospital with her mother a few days later.
The University of Manchester NHS Foundation Trust has apologized and admitted there were “serious failings” in the care provided to Cahill and Agnes.
In England and Wales, about one in every 50 births takes place at home. However, it is only recommended for low-risk pregnancies. Cahill’s pregnancy was considered high-risk because she suffered postpartum hemorrhage after giving birth to her first child in 2021.
For this reason, she was advised to give birth to her second child in the hospital. But her husband Rob told the court the risks of home birth had not been fully explained. The inquest was told that phrases such as “beyond direction” were preferred, rather than “against medical advice”, and the risk of death was not explicitly raised.
Cahill’s husband said his wife chose to give birth at home because she did not feel supported during her first birth, which she found “very stressful”. But she had not been properly advised about the benefits of Agnes being in hospital, and if she had been, she likely would not have given birth to her daughter at home, the court heard.
“This is an unbearably sad case of two deaths that could have been avoided,” said Kim Thomas, chief executive of the Birth Trauma Society, one of the world’s first charities supporting women and families who have experienced traumatic births. “We often hear from women who have had a traumatic first birth in hospital, who are reluctant to give birth in hospital again. Some choose not to have another child, while others choose to give birth at home.
“Unfortunately, for women like Jennifer Cahill, who have had numerous complications in their previous births, home birth can be particularly risky. Many things appear to have gone wrong in this case. It appears that staff were reluctant to explain the risks to Ms. Cahill, so she was not able to make a fully informed decision.”
The inquest also heard community midwives who attended the Cahill home, for reasons the court could not ascertain, did not see or be aware of a comprehensive birth plan drawn up by the Cahill family before Jennifer went into labour.
Both midwives worked 12-hour shifts before Agnes was born, and were awake for more than 30 hours by the time the birth was over. They each did their best to help Cahill, but their effectiveness was affected by a “lack of understanding and confidence” in what she wanted due to a failure of communication from others, the court heard.
Vital notes, such as Cahill’s blood pressure readings and the baby’s heart rate, were not recorded properly, with the latter written on a spare incontinence pad, which was later discarded.
“Midwives attended directly to the birth from very long shifts and appeared to lack the expertise and experience needed to deal with complex home births,” Thomas said. “While we support a woman’s right to choose to give birth at home, she needs the risks to be fully explained to her so she can make an informed decision.
“We also believe it is unreasonable and unethical to expect midwives to attend home births after a 12-hour shift, when they are feeling exhausted. Only highly experienced midwives should be asked to attend home births where the woman is classed as high risk.”
One of the midwives at Cahill’s Birthing Home said there was “concern in the office” about requests for home births. The court heard that staff were “nervous about being on call” and some would “do anything to get away from being on call”.
Dr Shubi Pothusiri, associate professor in maternal and child health at the University of Bedfordshire, agreed with Thomas that only midwives with extensive experience and advanced skills should be asked to attend home births.
“Home births should be supported by experienced midwives with enhanced midwifery skills, who are formally assessed as competent and confident in providing care to women in a home birth setting,” she said.
“Although home births promote women’s choice and are increasingly popular, reckless promotions or blanket bans are not the way forward.
She said it was “extremely important” for health workers to engage in “open and transparent” discussions with women considering home birth “about the potential for worse outcomes” if things go wrong during a home birth. She said women should also be made aware of the additional time it may take to be transported to hospital in the event of an emergency.
“The advice for women who have medical conditions, have had a previous complicated birth, or are giving birth for the first time is to give birth in a hospital or health facility with immediate and direct access to specialist care,” Bottosseri said.
Professor Asma Khalil, a consultant obstetrician in London, England, and a world-renowned expert in maternal-fetal medicine, said the evidence about the risks of home birth is clear.
“For healthy women with low-risk pregnancies who have had a previous uncomplicated birth, home birth may be appropriate when supported by a qualified midwifery team. However, evidence suggests that home birth carries higher risks for babies, especially for first-time mothers or those with high-risk pregnancies.”
Khalil added that it is important for women to understand the possibility of complications during labor, and that any delay in obtaining urgent medical support may put her or her baby at risk. “Events can occur during labor where quick access to medical care is critical, such as when a baby becomes stuck in the pelvic bone, a uterine ruptures, bleeding, or problems with the umbilical cord.”
In Cahill’s case, she suffered a hemorrhage and lost five pints of blood, nearly half the blood in her body. She went into cardiac arrest while in the ambulance on the way to the hospital, and later died of multiple organ failure.
Khalil, vice-president of the Royal College of Obstetricians and Gynaecologists, said recent data did not indicate an increase in home births and they tended to represent a small proportion of births taking place.
However, she said maternity services were seeing “an increase in the number of women with more complex pregnancies” that required more care and time with midwives. To ensure that every woman receives the high-quality, personal service she needs and deserves, governments must “ensure there are enough midwives and obstetricians to provide this care,” she added.
Khalil said she is also seeing shifts in how women give birth, including an increasing number of C-sections and inductions. She added that governments need to support maternity services “to adapt and ensure they have the right staff, training and facilities needed to manage increasingly complex births”. “This is vital to ensure that all children and women receive safe, personal and compassionate care.”
Catherine Walker, director of service development at the National Maternity Trust, a British charity that supports parents through pregnancy, said everyone has the right to decide where to give birth.
Home birth can be a safe option for pregnant women with a low risk of complications, she said. “Those with high-risk pregnancies can also choose to give birth at home, although there are specific situations in which this is not recommended. The decision should be informed, supported and respected.”
Even for low-risk pregnancies, it’s important for women to discuss transportation plans to the hospital in advance and understand that they can change their birthplace at any time before or during labor, Walker said.
There is also a postcode lottery to access safe services, she said. “Many families face unreliable or limited home birth services due to staff shortages, inconsistent training, or local policy restrictions.” Some healthcare services have dedicated home birth teams, while others are “relying on overwhelmed community midwifery services”, she added.
“Pregnant women need a maternity system that provides safe, personalized, and culturally appropriate care everywhere,” she added. “This means investing in midwives and supporting every woman’s right to make informed choices about where and how to give birth.”