Back to the Future: Will home births ever become the norm again?

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In 1948, around one in a 100 babies was delivered by caesarean section; in 2016/17, 32 per cent of infants (excluding twin, triplet and other multiple births) were born by C-section, largely driven by increases in obesity and infant birth-weight.

While increasing maternal age is also a factor - in 2017, four per cent of births in Scottish NHS hospitals were to mothers aged 40 or older - caesarean sections have been rising steadily across all age groups since the mid-1970s.

Meanwhile, incredible advances in medical technology mean that even extremely premature babies, such as those born at 23 weeks (weighing 1Ib on average), can now survive in around a fifth of cases.

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That would have been unthinkable in 1948, when records show that no baby weighing less 2lbs 3oz survived in the UK.

The expansion of special care baby units and incubators during the 1950s and 60s - spurred on by the creation of the NHS - began to change that.

However, Dr Daghni Rajasingam, a consultant obstetrician and spokesman for the Royal College of Obstetricians and Gynaecologists (RCOG), said the greatest breakthrough of all has been the use of ultrasound.

Prof Ian Donald at work

It was an innovation famously pioneered by Professor Ian Donald, the Regius Chair of Midwifery at Glasgow University in the 1950s.

Dr Rajasingam said: “The use of ultrasound in medicine began during the Second World War, and since Professor Donald first explored its use in obstetrics and gynaecology in the 1950s, it has become the single most important tool in monitoring foetal development and detecting foetal abnormalities during pregnancy.

"By the 1970s, ultrasound scanning had been taken up widely in hospitals across Britain. Technological advancements occurred at a rapid rate and in 1972 the first accurate detection of foetal cardiac action was reported.

"Ultrasound scanning is now routine in maternity clinics throughout the world and the technology has come a very long way.

"In the early days, clinicians could only detect the baby’s head. Now women are able to see 3D, real-time colour images of their baby.

"This vast improvement in image quality has led to a new brand of fetal medicine that has paved the way for diagnosis and treatment in pregnancy which were previously impossible.

"It has also revolutionised other aspects of women’s health, including the detection of gynaecological cancers. Although used in every speciality, ultrasound is arguably most intrinsic to obstetrics and gynaecology, and will continue to be used as a tool to improve women’s health in the next 70 years.”

Lindsay Inkster Reid, a retired midwife and researcher who was the first person to chart the history of midwifery in Scotland over the past century in her PhD, said that the arrival of the NHS "reinforced" a trend towards hospital, rather than home, births.

Graph by Dr Lindsay Inkster Reid

Dr Reid said: "Up until then, there was a trend toward hospital births. But even in the 1930s it was so accepted that mothers in Scotland would give birth at home that if a mother was running into trouble at home, the plan was to send out a hospital obstetrician and an anaesthetist to the house, along with a midwife and a doctor.

"They were quite ready to do that. Then the war intervened and this part of the plan was never implemented and the NHS reinforced the trend towards more hospital births.

"In the beginning of the 20th century, 95 per cent of babies in Scotland were born at home. By the end of the century, we were down to well under five per cent.

"The trend downwards starts gradually, then in the 1920s it begins to slide faster because better-off mothers were beginning to be offered something by doctors called 'twilight sleep' [use of morphine and scopolamine to induce pain relief and amnesia during childbirth].

"There was always new technology and eventually it became taken for granted that babies would be born in hospital. From the 1960s, it was expected. It was being fed to the mothers that 'you'll be safer in hospital'.

"I have long argued from a midwives point of you, that women were safer at home from the risk of being interfered with. As one doctor said to me - an eminent obstetrician - he said 'doctors itch to interfere'. Midwives are trained to wait."

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Dr Reid added that by the time she finished her own training as a midwife in 1979, intervention was becoming the norm.

"By then, so many mothers were being induced just because they were at their date or just past their date," she said. "For the slightest thing, they would induce them. To be induced if it's necessary is a great thing, but there came a point where the medicalisation of childbirth became 'we can do this so we will'. But is it always best? This became a real hot topic for a while."

In 1993, a policy review by the Scottish Office marked a shift in direction towards 'informed choice' and 'woman-centred care'. It was followed up a decade later by Keeping Childbirth Natural and Dynamic, Scotland's first major overhaul of maternal care post-devolution, which sought to encourage 'normal' births (that is non-caesarean, forceps or induced deliveries) and make midwife-led care the norm for healthy pregnant women.

To date, however, the former aims have yet to translate into practice. Between 2000 and 2017, the percentage of forceps deliveries in Scotland rose from 7.1 per cent to 9.1 per cent; induced labours increased from 27.4 per cent to 32 per cent; and caesarean sections - elective and emergency combined - rose from 20 per cent to 32 per cent.

The Scottish Government's latest ambition, set out in the 'Best Start' review in 2017, is to see a majority of mothers give birth at home or in midwife-led units. Only those with higher risk pregnancies or who develop complications during labour would be transferred to hospital.

Mothers with uncomplicated pregnancies and experience of a previous vaginal birth "should be encouraged to consider home birth as an option", said the review.

Dr Reid - who gave birth at home in the 1960s - welcomes this approach, but believes the rise of midwife-led units could ultimately act as a barrier to the return of home births as norm.

She said: "If the mother and baby appear to be okay and the mother wants a home birth, I cannot see why she shouldn't.

"But I think there is still a hesitation there because for a long time mothers who wanted a home birth were told by the doctors 'you are putting your baby's life at risk'. That's a very cruel thing to say to a mother. I was never told it personally, but I know it happened because mothers told me.

"And there was a reluctance on the part of midwives too, I must admit.

"Midwife-led units are marvellous. I think they are a good alternative to home births, I really do, and the mother can get home quite quickly. But I think they may be one reason why home births have stalled, to a certain extent. The numbers [of home births] are not what I would call good."