Scotland's birth trends - from home deliveries to C-sections

Figures obtained by the Herald show that roughly 613 babies were born at home during 2021 - equivalent to 1.3 per cent of the live births that year.

In 2017, around one in 150 births in Scotland were home births.

Since the beginning of the pandemic in 2020, a total of 1,331 babies in Scotland have been born at home.

Lothian recorded the highest number of home births in 2021 - 121 - compared to 87 in Grampian, 77 in Greater Glasgow and Clyde, 69 in Tayside, and 18 in Highland.

NHS Ayrshire and Arran in particular has seen notable increase in home births, going from an average of 11 per year from 2012 to 2018, to 65 between January and November 2021 (data was unavailable for December).

This followed the introduction of the health board's home birth team in May 2019.

Jennifer Wilson, nurse director for NHS A&A, said: "Due to the restrictions during the Covid-19 pandemic, more women and their families opted to use the service at it was more inclusive and avoided admission to hospital.

"We are delighted that our home birth rates have continued to increase this year. We will continue to develop and expand our maternity services in line with the needs of our local women and their families as well as national recommendations."

Home births were once the norm in Scotland, and still accounted for 65% of all deliveries in 1937.

Hospital deliveries became increasingly popular with the arrival of the NHS, however, which enabled all women to have free access to midwives and obstetricians as well as pain relief.

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The Scottish Government has never set a target for home births but its 'Best Start' maternity agenda in 2017 said women "should be encouraged to consider home birth as an option" if they have had a previous vaginal birth without complications.

According to the National Childbirth Trust (NCT), even for an uncomplicated first-time pregnancy there is a "small increased risk" of adverse outcomes in relation to a home birth compared to a hospital delivery.

However, for a second or subsequent baby "having them at home is no less safe than having them in hospital" as long as the mother is healthy and prior labours were straightforward.

Home births are also associated with a lower risk of infection.

Dr Alastair Campbell, consultant obstetrician and spokesman for the Royal College of Obstetricians and Gynaecologists, said: "We encourage women who have not given birth before to deliver in a hospital setting and, if low risk, in an adjacent midwifery unit.

"This is due to evidence showing that first-time mothers wishing to deliver at home have a small increased risk of poor outcomes for their babies. Home births are safe for some women."

The proportion of mothers over 35 (purple) has been growing steadily, especially since the early 1990s (Image: PHS)

The rising frequency of home births contrasts with an increasing reliance on C-section deliveries.

A recent report by Public Health Scotland (PHS) shows that 37.6% of births were planned or emergency Caesareans in the year to March 2022, compared to 8.6% in 1976.

C-sections are at an all time high at the same time as the percentage of mothers who are overweight or obese - 56.9% - and over 35 (24.6%) are both also at record levels.

Being older and overweight both increase the risk of labour complications resulting in an emergency C-section.

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Separate monthly data from PHS shows that, as of August this year, 39.1% of births in Scotland were by Caesarean - with the upward trend seeming to accelerate from August 2020 onwards.

There is also considerable regional variation.

In Highland, 50% of births in June this year were C-sections, with Grampian exceeding 46% in July this year.

Meanwhile, in NHS Borders, just 25% of births in April this year were by Caesarean.

Percentage of births by C-section by month; orange colouring indicates above average compared to January 2018-February 2020 period (Image: PHS)

The World Health Organisation advises that a maximum of 15% of births should be by C-section, but such targets have become controversial in the wake of maternity scandals such as Shrewsbury and Telford Hospitals in England where hundreds of babies died.

The trust had a C-section rate well below the national average, but a damning report this year found that its overzealous pursuit of natural birth targets had led to fatal decisions not to perform Caesareans when necessary.

Dr Rosemary Townsend, a consultant obstetrician and senior clinical research fellow at Edinburgh University, said: "If we start chasing the numbers as a quality indicator then we run the risk of ending up at the other end of the spectrum where we're withholding Caesarean sections that actually are necessary and taking risks that are unacceptable.

"The general conversation now, rightly, is that we should be less concerned with the numerical value of the rates and more concerned with metrics of 'was the Caesarean appropriate?'"

She added that in parts of China and Brazil the C-section rate can be 80 to 100%.

It is unclear whether the pandemic has directly driven a faster increase in C-sections than would otherwise have occurred, but Dr Townsend said there was anecdotal evidence that some mothers had opted for planned Caesareans because Covid restrictions would have meant spending most of their time in labour without their partner.

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In addition, mothers who became seriously ill with Covid during pregnancy - especially those admitted to intensive care - were more likely to have had a C-section delivery, while Covid-related staff absences would also be associated with a higher probability of C-sections.

"Data shows that the fewer midwives and doctors you have around, the more likely you are to end up with a Caesarean section," said Dr Townsend.

She added that what deserves further investigation is the "massive variation between the different health board regions". 

"Grampian is interesting because they have recently moved towards being more flexible with their policy," said Dr Townsend. 

"It's always been the case that if you ask for a Caesarean you can have one, but historically that would have prompted quite a lot of long conversations about why and is there anything additional support wise that we can do to help people have a vaginal delivery. 

"One particularly difficult situation is if someone is in labour and they ask for a C section.

"Grampian have taken a policy in the last few years to do a section in labour where the woman is asking for it and to offer it as an alternative to other interventions in labour.

"They have been consciously moving in that direction so it's maybe not surprising with Grampian that they have a higher rate and I don't think that's Covid related."

A spokesman for NHS Grampian said it is "fully supportive of women making informed choices when it comes to planning how they would prefer to give birth", but that it does not currently have "robust data to help explain why high numbers of women are having C-sections".