What Happens in Normal Birth?
In the last month of pregnancy, the cervix softens and ripens like a piece of fruit. Contractions of the uterus become noticeable, and the baby settles into the pelvis. The contractions become stronger, the cervix stretches and opens, and the baby moves lower and rotates, eventually moving down the birth canal. With each contraction, pain sends a signal to the brain and oxytocin is released. With the release of oxytocin, the contractions increase in intensity. As the pain of contractions increases, more oxytocin is released and the contractions become harder.
The pain of labor is what most women worry about. It is important to understand that the pain of the contractions in labor is valuable. It is an important way in which nature actually helps women find their own ways of facilitating birth. In a very real sense, the pain of each contraction becomes a guide for the laboring woman. The positions and activities she chooses in response to what she feels actually help labor progress by increasing the strength and efficiency of the contractions and encouraging the baby to settle in and move down the birth canal. When the pain is entirely removed, the feedback system is disrupted and labor is likely to slow down and become less efficient. As labor progresses and pain increases, endorphins (much more potent than morphine) are released in increasing amounts. The result is a decrease in pain perception, quite naturally. Nature's narcotic! The rising level of endorphins also contributes to a shift from a thinking, rational mind-set to a more instinctive one. Endorphins create a dream-like state, which actually helps women manage the tasks of birthing. Inner experiences become more important than the external environment. As labor progresses and the pain of labor increases, women “go into themselves,” become much less aware and, at the same time, much more focused on the work of labor, and are able to tap into an inner wisdom.
A woman surrounded by family, friends, and health care providers who remind her of the power of labor and encourage her quietly and patiently is a woman who is not afraid. Her support team is totally present and comforts her as she does the hard work of labor. She eats and drinks and, even if labor lasts a long time, she has the energy she needs to persevere. She rests between contractions. No one looks at the clock. Everyone trusts the process of birth and believes that she has the strength and the wisdom to give birth.
The woman moves in response to what she feels. Whether she gives birth in a hospital, birthing center, or at home, she is able to use a wide variety of comfort measures; for example, moving freely, listening to music, taking a shower or bath, and having her feet and hands massaged. She is able to create an environment that is just what she needs as she does the hard work of labor and birth. She pushes her baby down the birth canal, responding now to the pressure of contractions and the baby as he rotates through the pelvis and moves down the birth canal. She moves, changes position, and grunts, sometimes holding her breath—all in response to what she is feeling. In this way, she not only protects the muscles of the birth canal and perineum but also protects her baby as he is born. A great surge of adrenaline insures that the mother is alert, even if her labor has been long. She is totally focused on her baby, ready and eager to embrace him. Baby is eager and alert, too. The stimulation of his journey has primed him for the transition to life outside the womb.
With her baby in her arms, the mother is engrossed, excited, at peace, proud, and astounded at the miracle she has produced. No one tells her what to do. They know that she knows what to do—not because she and her baby have read the books or attended Lamaze class, but because their journey has physically and emotionally prepared them both for this moment. The weight of her baby on her belly helps her uterus contract and expel the placenta. Baby stays warm in his mother's arms. Baby knows just what to do to survive in the world he has entered. He is awake and looks around. Within seconds or minutes, he has his hands in his mouth and is smacking his lips. Unpressured, he slowly but methodically crawls to his mother's breast and self-attaches. As he nurses, his mother's uterus contracts, insuring that bleeding will not be excessive. The two greet each other unhurried, confident, and unpressured. Together, over the next hours and days, they will get to know each other and fall in love.
Source: Lothian JA. Why natural childbirth? J Perinat Educ. 2000 Fall;9(4):44-6. Retrieved from Why Natural Childbirth? - PMC (nih.gov).
“Birth for women and their families is a major life event and a rite of passage that should be respected and facilitated. Women have a right to decide where they wish to give birth to their baby.” (Australian College of Midwives, 2019).
"There is now clear evidence that homebirth leads to better outcomes for women compared to hospital birth.” (Hannah Dahlen, 2019).
Why do women choose to birth at home? It is important to understand that most women are not sick during pregnancy and birthing. Pregnancy and birth are normal bodily functions that we’ve perfectly evolved to carry out over hundreds of thousands of years. If we are not sick then why do we need to attend a hospital?
Birth is a human rights issue. Women have the right to choose where and how they want to birth, and who they want to be with them during this time. For some this may mean choosing a hospital birth, or choosing a caesarean section; for others it may be choosing a home birth. It is every woman’s right to make this important decision about herself and her body. Nobody has the right to take this choice away from her.
Birth is a very intimate event in a woman’s life. Being at home means she can control exactly who is and isn’t with her in the room during this time, or she can choose to hide away in a quiet corner during moments of vulnerability. Women can choose who will be part of their birth team, including partners, children, family, friends, pets, a photographer, a doula or anyone else they like.
Research shows that homebirth is as safe as hospital birth for women who are low risk and attended by professional midwives who, in turn, are well networked into a responsive health system. It can be less safe for the baby when women with significant risk factors choose homebirth, or when they give birth without regulated health providers in attendance. (Hannah Dahlen, 2019).
Finally, and in my opinion most importantly, birthing at home can provide an environment and a level of support and undisturbed quiet that allows a woman to enter a place of personal power, without fear, and to birth her baby faster, more calmly, with less pain, and with more connection to her own body and her baby. Interventions are minimal, and there is little opportunity for the ‘cascade of intervention’.
Having witnessed a number of home births in my lifetime, and having birthed one of my own babes at home, I believe that the true joy and wonder of birth is witnessed in this environment at almost every birth, rather than it being on rare occasions, as it is in the hospital environment.
"As a midwife there's something magical about looking after a woman in her own home. You are a guest in her space and as such the woman is in control of her own labour and birth. She eats when she likes, she drinks when she likes, she moves around freely. She can labour in the bath, on the couch, in the shower, in the kitchen." (Hilary Rorison, 2019).
So what do leading health organisations around the world think? In 2014, following a series of recent research results, the UK’s National Institute for Health and Care Excellence (NICE) reviewed its guidance on intrapartum care. They specifically outlined the need to focus more on out-of-hospital birth as an appropriate option for at least 45% of all mothers (this includes birth centres and home as place of birth). NICE advocate for the evidence that homebirth is better for mothers and as safe for babies. They outline the importance of offering women the option to birth at home with a known midwife. They state it is as safe, if not safer, for low-risk women who already have a child to birth at home; and that homebirths result in lower intervention rates, which in turn reduce the financial cost of birth to the State. While NICE did recognise that there were increased risks to the baby if choosing to birth at home for a first baby, subsequent meta-analysis of global research by Hutton et. al (2019) found this to be untrue – finding homebirth is as safe for babies, and safer for low-risk mothers. Hutton et. al summarized their research by stating “There is now clear evidence that home birth leads to better outcomes for women compared to hospital birth and it is time this was given more attention”.
In 2019 Australia’s biggest ever birthing study analysed 1.25 million births and found that planned homebirths had the highest rate of “normal” no-intervention births (95.1%). Home birthing mothers had the lowest rate of third and fourth degree perineal tears. Lead researcher, Caroline Homer, said the findings supported mounting evidence that “homebirth is a safe option for low-risk, healthy women”.
A recent (2014) UK National Maternity Review concluded that “Women should be able to make decisions about the support they need during birth and where they would prefer to give birth, whether this is at home, in a midwifery unit or in an obstetric unit, after full discussion of the benefits and risks associated with each option.” Major studies throughout the leading countries of the world are reminding us that childbirth choices are enshrined within the Human Rights of every woman. Choice is imperative within maternity care to meet the rights of these women, and yet in many areas the choice quite simply is not there.
Maralyn Foureur has done a lot of work with various other researchers and has identified that two key components optimise the physiology of birth: relationship based maternity care (one-to-one care such as a caseload model), and an optimal birth space. Maralyn refers to the ‘birth sanctum’, that space where you can feel completely safe and at ease. So, a birth sanctum combined with one-to-one care creates a positive physiological impact on a woman’s brain that enables her to release the right amount of oxytocin, at the correct times, to help lower her BP, lower her heart rate, and increase her pain threshold, whilst remaining calmer because adrenaline isn’t being produced. These elements all combine to make the likelihood of achieving a normal physiological birth far more likely.
So based on the above information we can be reassured that homebirth is safer than hospital birth for women, and as safe as hospital birthing for babies. Homebirth also increases opportunities for a normal physiological birth, reduces caesarean rate (and therefore physical costs to the woman), and reduces mental and emotional trauma caused by previous traumatic birthing experiences.
Key Benefits of Homebirth
Increased vaginal birth rate (90% v 63%)
High waterbirth rate (52% of homebirths)
Reduced intervention rates (episiotomy, instrumental birth and caesarean section)
Reduced third and fourth degree perineal tear rates (1.1% v 2.3%)
Reduced postpartum haemorrhage rates (1.8% v 5.0%)
89% success rate for VBAC (vaginal birth after caesarean)
Comparable rates of neonatal death and stillbirth
17% of homebirths transfer to hospital (majority are non-emergency transfers)
High risk pregnancies are safer when birthing in a hospital environment with the additional resources that may be required close at hand. High-risk pregnancies include:
Multiple births (twins or triplets)
Post-term pregnancy (after 42 weeks gestation)
Obesity (BMI over 35)
More than 5 previous babies
Significant maternal medical conditions eg. Diabetes (incl. gestational diabetes on insulin), high blood pressure, cardiac issues.