Home truths from the hospital: That women should have more choice in maternity care is admirable - up to a point, says Maggie Brown

DO LARGE numbers of women really want to revert to the traditions of their grandmothers and have their babies delivered at home, rather than in hospital? This is the question I keep returning to as I read and ponder the Changing Childbirth report published yesterday by the Department of Health.

This report should be taken seriously because it is so obviously concerned with the wishes of the users (ie, pregnant women), rather than the professionals. It is spot on when it says, 'Women have great confidence in the midwifery profession'. Its demand for the childbirth system to be regularly monitored so that women's views can be accommodated is surely correct. So is the call for national standards so that the best practices can be adopted for everyone. Since there are birthing stools in some hospitals, why not in every hospital?

But the key recommendation of this report is that women should be able to choose where to give birth: in hospital or at home. This means the facilities for home births - with two midwives in attendance - must be properly organised and accepted by the professionals to ensure there really is a choice. That will not be achieved without a battle. It implies a shift in power, with midwives gaining status, and the doctors - above all, obstetricians, and juniors below them - having much less say in how straightforward deliveries take place. Seen from the perspective of the labour ward, it often seems that doctors are intruding, while the woman is attended throughout what may be long hours of labour by midwives. There is a real sense of tension.

Greater choice must also mean that there will be a reduction in the 98 per cent of women who currently have their babies in hospital. The consultant obstetricians concerned with both safety and their professional territory are bound to question this. And to some extent, they're right. I wonder how many of the 22 per cent of women who told the survey they wanted home births would actually opt for one when the chips are down and labour pains intensify.

My view is that women would be wisest to err on the side of caution, especially with their first baby, when you do not know what you are about to endure. I have had four children in the past 10 years, a decade during which demands for more sensitivity and better treatment in hospitals have intensified. My particular grouses are mainly directed at the shambolic state of many antenatal clinics, where pregnant women are treated like cattle.

Lengthy waiting periods, overcrowded waiting rooms, never seeing the same midwife or doctor twice, these are dehumanising experiences. The system seems to assume that women have nothing better to do with their time than sit in hospital waiting rooms. One of the report's main recommendations, that women should be allocated one midwife who stays with them throughout the pregnancy, seems to me what most women want. They want a buddy.

All my children were born in a large London teaching hospital. The deliveries were normal. However, the first birth was an exceedingly lengthy affair that could easily have ended with forceps. After that experience, nothing would tempt me to give birth at home. It is unfashionable, but it needs to be said: I actually found the hi-tech apparatus provided by the hospital immensely comforting. In particular the system of foetal monitoring of the baby's heartbeat, which means you have to be strapped to a machine, assured me that although I was suffering in extremis at least the baby was fine.

A few tough things need to be acknowledged about giving birth. Queen Victoria described it as the dark side of womanhood. Perhaps it has something to do with our culture, but there is very little frank depiction of the process in our literary tradition. About the only really truthful account I have ever read is in an early Doris Lessing novel, Martha Quest.

CHILDBIRTH may be natural but it does not feel like that at the time. I regard it as a form of torture, except for its redeeming point: you get a baby at the end of it. We stem from a culture that largely manages to edit out pointless suffering - even the simplest dental filling is eased by an injection. One of the greatest recent advances has been the spread of the epidural, a spinal painkilling injection that takes away much of the agony of childbirth. But this requires a highly skilled anaesthetist based in a hospital and if the injection goes wrong, it can leave you paralysed. In my last visit to a labour ward, three months ago, I overheard a woman screaming wildly. She finally fell silent as an epidural was administered. Would she have suffered and screamed less at home? And would an epidural have been available there? The report does not deal with this aspect of pain relief.

On the other hand, the report does advise that low-risk pregnancies - those suitable for home births - will have to be defined very carefully indeed. It also says that women opting for home births will have to be told of the limits on resuscitation techniques for babies born outside of hospitals. Because there is no straightforward route out of the birth canal, the baby's head has to execute a turn. This makes childbirth a hazardous business, even now. The true irony is that while British hospitals deliver women and babies safely through this ordeal, eliminating the worst terrors of childbirth, the system is still held in very low esteem. Much of the pressure for a user-friendly system of childbirth has come from middle-class women who expect, rightly, high standards of care and treatment. Many of the best social reforms result from this sort of pressure. But home births, should they become widespread, runs risks similar to those of the Care in the Community programme. Is it appropriate for single mothers or for women who are poorly supported? Would you want to have a baby in a crowded house or flat with your other children inadequately shielded from what may seem to them frightening events? I know someone who wishes to give birth at home in a birthing pool. This has now been delivered. It would not fit into the bedroom so it dominates the open sitting room. Not everyone lives in a large home.

The pressure for home deliveries articulated in this report may, however, reflect something different from a simple desire to give birth at home. The key statistic that the Government should focus on is that 44 per cent of women favoured what professionals call the domino delivery, in which a midwife, already known to the woman, accompanies her to hospital when she is in the early stages of labour. She then returns home with her shortly after the delivery. However, women may be denied a more leisurely period of recovery in a hospital. If this system is introduced more widely, it is to be hoped that the Government does not use it as a reason to cut maternity beds and reduce the option for women to stay in for a period of recuperative nursing. Overall, however, the domino delivery system is perhaps a much better compromise than the route of home births. It could combine the best of both worlds for many women. The report itself seems to suggest that the cry for home births may well have become a slogan that conceals the true message, a longing for a more respectful, personalised and kind system.

So yes, there should be more choice, more consultation and more woman- centred maternity systems. But let us never forget that when childbirth goes wrong, as it can do rapidly and unexpectedly, there is not only one life at stake but two. With double the risk there should be twice the caution.

Report of the Expert Maternity Group, HMSO ( pounds 18.50).