Some mothers believe that the way to give themselves, and their babies, the best chance of a good and safe VBAC (vaginal birth after caesarean) is to plan a home birth. Home birth need not be dismissed as an option because a woman has had a previous caesarean birth, but it does need careful consideration.
Some health professionals will not even consider attending home VBACs, rejecting it as an unacceptable risk. Yet there are others who support home VBAC as a sensible choice, or who believe that a home VBAC (‘HBAC’) can sometimes be safer than a hospital VBAC.
What I hope to do in this section of the Home Birth Reference Site is to help you to consider the relative risks and benefits of home VBAC for your own circumstances. I will include references to all relevant research I find, whether the conclusions are what I would like to hear or not.
Your best chance of avoiding another caesarean?
We know from research on home birth in general that a woman who tries to have her baby at home has a greatly reduced chance of ending up with a caesarean, than if she had opted for hospital birth in the first place. For example, see the National Birthday Trust study.
There is not, as far as I know, any research which looks at the success rate for home VBACs compared to hospital VBACs. However, it seems reasonable to suppose that the factors which reduce the rate of caesareans in women planning home births generally, would also apply to women planning home VBACs. Women’s bodies generally labour better at home, which means that labour progresses more easily, and there is less need for pain-relieving drugs.
Women who plan home births after a prior caesarean often say that they felt they would be “set up to fail” in an attempt at a hospital VBAC. Overall we know that the vast majority of women who attempt a VBAC in hospital do in fact get one – but if your first caesarean was for slow progress, then perhaps your labour is more affected by the hospital environment than others. If this is the case, it may be that labouring at home is the best ‘treatment’ you could have.
One authority on vaginal birth after caesarean, Gina Lowdon, points out that women whose bodies do not labour well in hospital should recognise that their body is acting in a perfectly natural way – if you are anxious, then labour is inhibited. This is a mechanism which has evolved to help mammals prolong their labours until they can find a safe place to give birth. It works only too well for some women who plan hospital births, even if they consciously believe that hospital is the best place for them.
If your labour did not progress in hospital, it may not be the case that your body was “no good at labouring”; perhaps it was too good at the task of trying to give birth safely.
The National Birthday Trust’s 1994 study of home births in the UK detailed the final place of birth for women planning a home birth who had a previous caesarean section. Only 53 women in the study fell into this category, and of these 38 mothers (72%) gave birth to their babies at home. The remaining 15 (28%) transferred to hospital, before or during labour, where some (but certainly not all) had repeat caesareans – no further details are given, but some of these women probably gave birth in hospital without further intervention, while others will have had treatment ranging from augmentation of labour to assisted delivery or caesarean section.
No uterine ruptures were noted, but the sample is too small to allow any conclusions to be drawn about rupture risk at home births.
Although this study only covers 53 women planning HBAC, it is still valuable. The 72% of women with a caesarean scar who gave birth at home will have done so either with no intervention at all, or with minimal intervention. It would be an achievement in most hospitals for 72% of women to give birth without significant intervention, let alone 72% of women who were supposedly ‘high risk’.
How safe is home VBAC?
The simple answer is – we just don’t know. There have been many studies demonstrating that VBAC leads to better outcomes generally, for mother and baby, than planned repeat caesarean. However, these studies have so far all been conducted in hospitals where continuous electronic fetal monitoring is available, and where an emergency caesarean could be performed if necessary. On the other hand, these hospitals may also have used interventions which can increase the risk of rupture, such as inducing or augmenting labour, expecting women to labour on their backs or semi-recumbent (in order to make continuous monitoring easier), and performing ventouse deliveries.
There have also been many studies demonstrating that planned home birth for low or moderate-risk mothers is as safe, or safer, than planned hospital birth. However, these studies did not usually look at mothers with past caesareans. However much we support women who want home VBACs, even the most radical childbirth activist must acknowledge that a woman with a past caesarean is not low-risk. She has the known additional risk factor of uterine rupture, and this makes her medium-risk or high-risk in the eyes of most medical practitioners. Her first caesarean is a medical intervention which will affect all her subsequent births – she has already had intervention in each birth, before she even goes into labour.
But home birth is not just an option for low-risk women; it is up to each individual to make her own decision, rather than to have others dismiss her ambitions on the basis of broad statistics.
Remember that the VBAC mother’s chance of uterine rupture is less than 1 in 200. Overall, amongst mothers planning home births, 10-15% transfer to hospital for further observation or intervention not available at home. These transfers occur for slow progress, suspected fetal distress, maternal exhaustion, and so on.
If the transfer rate for mothers attempting home VBAC is similar, each woman is around 30 times more likely to transfer to hospital for any other reason, than she is for a uterine rupture. But the transfer rate for VBAC mums is likely to be higher, as midwives and mothers will probably be cautious and transfer at the first signs of trouble. The National Birthday Trust study found that 28% of its small sample of mothers planning home VBACs transferred, for instance . Bear in mind that intervention levels are generally far lower for women planning home births, than for women of an equivelent risk level planning hospital births, as that study shows. So we could guess that a mother planning home VBAC is perhaps 50 times more likely to transfer for any other reason, than for uterine rupture.
Now, we know that in general (ie not looking at VBACs specifically, but at home birth overall), outcomes for planned home births are on average as good as, or better than, planned hospital births for similar women, even after including the results for those women who planned home birth but ended up in hospital. So on average, the trade-off between the advantages of home birth and the disadvantages – the delay in getting to hospital if help is needed – seems to be worth it in safety terms.
The question is, does this apply to VBACs? We cannot say for certain one way or another. We know that the risks are higher once you have a scarred uterus, whether you plan a repeat section or a VBAC – what we do not know is how much being at home might benefit VBAC mothers and babies. All you can do is make an educated guess at which option would be, on balance, best for you and your baby.