Women need to be more clearly warned about the potentially deadly dangers of giving birth at home and should only be assisted by an experienced midwife, experts say.
Maternity services around the world are faced with an increase in the number of women with more complex pregnancies. Many people prefer to give birth to a child in a familiar environment, in the comfort and privacy of their own home. Some choose a home birth because having their first child in a hospital was “deeply traumatic” and they don't want to repeat the experience.
But access to safe, reliable and unrestricted home birth services is patchy and varies greatly depending on where you live, experts say. Health services in many countries struggle to offer home birth services due to staff shortages, inconsistent training or local policy restrictions. Some have dedicated home birth teams, while others rely on overburdened community staff.
The Guardian spoke to leading doctors, scientists and pregnancy experts about home birth following the coroner's trial in Rochdale, England. ruled that mother and daughter died after home birth due to “gross failure to provide basic medical care.”
Jennifer Cahill, 34, died at North Manchester General Hospital hours after bleeding during childbirth at home in Prestwich on June 3, 2024. Her baby, Agnes Lily, was born not breathing, with the umbilical cord wrapped around her neck. She died a few days later in the same hospital as her mother.
Manchester University NHS Foundation Trust has apologized and admitted there were “serious failures” in the care of Cahill and Agnes.
IN England and Wales, approximately one in 50 births occurs at home. However, they are only recommended for low-risk pregnancies. Cahill's pregnancy was considered high-risk as she experienced postpartum hemorrhage after giving birth to her first child in 2021.
Because of this, she was advised to give birth to her second child in a hospital. But her husband Rob told the court the dangers of home birth had not yet been fully explained. Phrases such as “off-label” were preferred over “against medical advice” and the risk of death was not explicitly mentioned, the inquest was told.
Cahill's husband said his wife chose a home birth because she felt unsupported during her first birth, which she found “very stressful.” But she was not properly informed of the benefits of Agnes being in hospital and if she had been, it is likely she would not have given birth to her daughter at home, the court heard.
“This is an incredibly sad case of two deaths that could have been prevented,” said Kim Thomas, chief executive of the Birth Trauma Association, one of the world's first charities supporting women and families who have experienced traumatic births. “We often hear from women who, after a deeply traumatic first hospital birth, do not want to give birth in a hospital again. Some choose not to have another baby, while others choose a home birth.
“Unfortunately, for women like Jennifer Cahill, who have had numerous complications during previous births, home birth can be especially risky. It appears that several things went wrong in this case. It appears that staff were reluctant to explain the risks to Mrs. Cahill, so she was unable to make a fully informed decision.”
The inquest also heard from both community midwives who attended Cahill's home for reasons the court could not establish, did not see or were unaware of the careful birth plan the Cahills had put in place before Jennifer went into labour.
Both midwives worked 12-hour shifts before Agnes gave birth and were awake for more than 30 hours by the time labor ended. Each tried their best to help Cahill, but their effectiveness was affected by a “lack of understanding and confidence” in what she wanted due to a lack of communication with others. court heard.
Important notes such as Cahill's blood pressure readings and the baby's heart rate were not properly recorded, with the latter scribbled on a spare incontinence pad that was later thrown away.
“The midwives came straight to the birth after very long shifts and seemed to lack the knowledge and experience to cope with a complex home birth,” Thomas said. “While we support women's right to choose home birth, the risks need to be fully explained to them so they can make an informed decision.
“We also believe that it is unreasonable and unethical to expect midwives to attend a home birth after a 12-hour shift, when they must be feeling fatigued. Only very experienced midwives should attend a home birth if a woman is classified as high risk.”
One of two midwives who delivered babies at Cahill's home said there was “concern” in the office about requests for home births. Employees were “nervous about being on call” and some “would do anything not to be on call” court heard.
Dr Shubi Putassery, associate professor of maternal and child health at the University of Bedfordshire, agreed with Thomas that only midwives with extensive experience and advanced skills should be invited to attend home births.
“Home births should be supported by experienced midwives with improved midwifery skills who are officially recognized as competent and confident in caring for women in home births,” she said.
“While home birth is expanding women's choices and becoming increasingly popular, neither reckless promotion nor blanket bans is the way forward.
She said it was “absolutely important” that health professionals engage in “open and transparent” discussions with women considering home birth “about the possibility of worse outcomes” if something goes wrong during a home birth. Women should also be informed that in the event of an emergency, transport to hospital may take extra time, she said.
“The advice for women who have medical conditions, have previously had a difficult 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 specialized care,” Puthussery said.
Professor Asma Khalil, a consultant obstetrician in London, England, and a world-renowned expert in maternal-fetal medicine, said the evidence of the risks of home birth is clear.
“For healthy women with a low-risk pregnancy who have previously had an uncomplicated birth, a home birth may be appropriate, supported by a skilled team of midwives. However, evidence shows that home birth carries higher risks for babies, especially for first-time mothers or women with high-risk pregnancies.”
It is important that women understand the possibility of complications occurring during childbirth, and that any delay in seeking emergency medical care could put themselves or their baby at risk, Khalil added. “Events may occur during labor where quick access to medical care is critical, such as the baby getting stuck in the pelvic bone, uterine rupture, bleeding or umbilical cord problems.”
In Cahill's case, she bled and lost five pints of blood – almost half the blood in her body. On the way to the hospital, she suffered cardiac arrest and later died from multiple organ failure.
Khalil, vice-president of the Royal College of Obstetricians and Gynecologists, said recent data does not indicate an increase in home births and that they tend to make up a small percentage of births that occur.
However, she said maternity hospitals are seeing “an increasing number of women with more complex pregnancies” requiring more care and time with midwives. To ensure that every woman received the high-quality, personalized care she needed and deserved, governments “must ensure there are enough midwives and midwives to provide that care,” she added.
Khalil said she is also seeing changes in the way women give birth, including an increase in C-sections and inductions. Governments need to support maternity services “to adapt and ensure they have the necessary staff, training and capacity to manage increasingly complex births”, she added. “This is vital to ensuring that all children and women receive safe, personalized and compassionate care.”
Catherine Walker, Service Development Manager at National Childbirth The Trust, a UK charity that supports parents during 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 a high-risk pregnancy may also choose to give birth at home, although there are certain situations where this is not recommended. The decision must be informed, supported and respected.”
Even in low-risk pregnancies, Walker says it's important for women to discuss hospital transfer plans early and understand that they can change birth location at any time before or during labor.
There is also a postcode lottery when accessing secure services, she said. “Many families face unreliable or limited home birth services due to staffing shortages, inconsistent training, or local policy restrictions.” Some health services have dedicated home birth teams, while others “rely on overburdening local midwifery services”, she said.
“Pregnant women need a birthing system that provides safe, personalized and culturally competent care in all settings,” she added. “This means investing in midwives and protecting every woman’s right to make informed choices about where and how to give birth.”
