The debate: Should home births be made more freely available? An obstetrician and a doula discuss

Peter Boylan: No. Home births can be safe in many cases – but not for first-time mothers

Home birth can be a safe option for low-risk healthy women, with one critical exception – their first birth. This is my firm conclusion based on attendance at thousands of births over more than 40 years as an obstetrician in Ireland, the UK and the USA. This view is supported by extensive clinical data including the landmark Birthplace in England study of 2011, which followed nearly 65,000 women who had healthy pregnancies and began labour with no known risk factors. The study found that while birth overall is safe wherever it happens, the rates of complications for home births, including stillbirth and brain damage to the baby, were three times higher than for births in hospitals.

First births take longer than subsequent births and require higher rates of intervention such as Caesarean section. During home births, about half of first-time mothers require emergency transfer to hospital for reasons including slow progress of labour, pain relief or concerns about the health of the mother or baby.

If a woman’s first birth goes smoothly, however, subsequent births are likely to be unproblematic. Home birth can therefore be an attractive option for some women for second or subsequent deliveries.

The safest option for first-time mothers – if available in their area – that gives the closest alternative to a home birth is the community-based and midwife-led Domino scheme, in which a woman gives birth in hospital but goes home as soon as six to 12 hours after birth.

The 2024 data on Domino births at the National Maternity Hospital shows how well the scheme works. First-time mothers had low rates of intervention, with a Caesarean section rate of 5.7 per cent for women who entered labour spontaneously at term, and just 0.7 per cent in women who had previously given birth vaginally. These outcomes are particularly impressive given the overall Irish Caesarean rate of 36.6 per cent in 2023.

Of the nearly 6,600 pregnant women who attended the NMH in 2024, 35 (0.53 per cent) opted for a home birth. Seven were first-time mothers and five (70 per cent) required transfer to hospital. Twelve of the 28 women, 43 per cent, who had previously given birth also required hospital transfer.

Childbirth in Ireland is safer than ever before, for both mothers and babies. Nine mothers died of causes directly related to the pregnancy in the last three-year period analysed (2020-2022). This represents a rate of 5.3 per 100,000 pregnancies and is among the lowest in the EU. The national perinatal mortality rate in 2022 was four per 1000 births, when corrected for death due to congenital malformation.

There are many reasons for the improvement in safety over the years, including better maternal health, improved diet, vaccination and smaller family size. One of the most important reasons, however, was the steady transition from home to hospital birth. In the 1930s, the national maternal mortality rate was 444 per 100,000 births. In Dublin, however, the rate was a whole 80 per cent lower at 86 per 100,000 births. This was because Dublin women had access to the three maternity hospitals while in the rest of the country most births took place at home.

Giving birth is safer than ever, but doctors and midwives are always vigilant because we never underestimate the potential for catastrophe in childbirth, often sudden and unpredictable.

A recent HSE audit found there is “no national governance structure in place” for home births due to reorganisation of the HSE and that there is “risk to patient safety where there is no agreed standard maximum safe travel time or distance from the mother’s residence to the self-employed community midwives and nearest maternity unit”.

In the right circumstances, home births can be a safe and welcome option for some women. It is imperative however that the inadequate governance system is urgently addressed by the HSE.

Dr Peter Boylan is former master of the National Maternity Hospital and former chairman of the Institute of Obstetricians and Gynaecologists

Krysia Lynch: Yes. The most important birth for a woman to have at home is her first

The National Maternity Strategy (2016 – 2026) clearly laid out the importance of offering choice in maternity care. The strategy also identified the need to ensure equity of access to maternity services irrespective of geographic location. In 2016, Ireland had neither the same range nor geographic spread of choices as our nearest neighbours. Nearly ten years on, very little has changed. Unlike most European countries, we have no birth centres.

The only option for an out-of-hospital birth in Ireland is home birth. To remove this choice from women would leave us with only centralised, obstetric, medicalised, interventionist care. We can already see the outcomes of this approach in the monthly maternity patient safety reports. These reveal first-time mother C-section rates approaching 50 per cent, and rates of medical induction of labour exceeding 70 per cent in some units. Furthermore, we know that perinatal mental health services are struggling to cope with the number of women suffering from birth trauma, which may be caused by nonconsensual interactions in hospital settings.

The majority of pregnant women are not sick. Being pregnant and giving birth are normal physiological events in the life of a human being. This makes maternity care services unique in medicine – as they deal with a cohort of well people, who are perfectly entitled to choose how, where and with whom they give birth.

Birthing at home with professional midwifery care is a valid, safe and acceptable choice. The safety statistics from our home-birth service speak for themselves. They include breastfeeding rates of more than 96 per cent. This is partly due to the continuity of care women receive and also to the extra time home-birth midwives spend with women.

The most important birth for a woman to have at home is her first. First births take longer, and progress more slowly, and the home setting is more likely to allow this.

Our home-birth service is provided by highly skilled midwives, with all the appropriate emergency training. They are supported by their hospital colleagues, to whom they refer women when there is a potential risk status change, or when it is more appropriate to transfer women into hospital care. This is why people who choose a home birth must also register with an obstetric unit. The HSE has a long list of exclusion criteria for its home-birth service, and it is certainly not an option that is available to everyone. Women are screened and rescreened all the way through pregnancy and also during labour.

The 2025 HSE audit of home birth governance recommended that no person who lived more than a 30-minute blue-light distance from a maternity unit should be “allowed” to have a HSE home birth. This blanket rule was already proposed in 2022 and resulted in wide-scale protests from birth activists, pointing out that it was non-evidence based and not substantiated by any research. The idea was dropped, so it’s surprising to see it appear again. Effecting such a blanket rule would remove home birth as a choice from rural Ireland, therefore reducing equity in service provision. It also begs a question about the safety of women who are not planning a home birth, and who will undertake part of their labour at home without any professional support – but who live well beyond a 30-minute drive to hospital.

And therein lies the true problem with our maternity services. They are too centralised and too medicalised – not just for women wanting home births, but for anyone seeking a more physiological experience in a setting other than home, and in particular for rural women.

Krysia Lynch PhD is a doula and chair of Association for Improvements in the Maternity Services (Aims) Ireland