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As a pregnant woman looking forward to the birth of my first child, I am currently weighing up the options for the birth. I am nervous about hospital delivery, because I feel the atmosphere will be stressful to me, and because I do not appreciate the 'we know what's best for you' approach taken by doctors (my parents are both doctors and have influenced my opinion here), most notably by male doctors who can speak until they are blue in the face about medical history and statistics, but have no first hand experience of how it feels to be a labouring woman. I want control at the birth of my child, and I do not want the emergency C-Section, so prevalent nowadays, to be the back up for any problems, or when a doctor may feel a lawsuit is looming. I appreciate that the current low risk nature of my pregnancy may change, and that a hospital birth is preferable to risking my life or that of my baby, but I feel home birth is best for me, and that choice above all is what women need. Sarah Church, Colerne, Wiltshire

Let's start by discussing the points we more or less agree about.

I agree that the opinion of the patient is always important and it is as important in midwifery as it is in every other branch of medicine. Part of the art of good medicine is to make certain that the patient fully understands the intention of any course of action or treatment that is being planned. In order that she, or he in those disciplines of medicine that apply to both sexes, may be helped to come to a wise decision they must be fully informed. Decisions taken because "I feel this is right for me" and "only I know my own body" that could cause someone to reject hard facts in favour of a hunch or feeling are founded on weak ground. A conclusion based on research cannot be considered valid or relevant if it is formed only on the experience of a few people known to the patient. Even large scale trials have to be assessed for possible confounding factors and relevance to the patient in question. It is even more risky to base a conclusion on how any one person feels or felt about their own reaction to an experience they had had themselves without finding out how this compares with how the mass of people have fared under similar circumstances. Without any controls conclusions, although anecdotally interesting and of course always important, should be noted, but not necessarily acted upon, because statistically many of these statements are based on research in which N=1.

We both agree that the life of your baby, and your own, are the major consideration. I would also agree that the present strain on hospital facilities, both in terms of staff and equipment because of the cash starved nature of the NHS, means that the higher standards, as set in some other western countries (not necessarily richer than us in general terms), can't be guaranteed in our hospitals. Obviously the actual conduct of the delivery, for example the position you want to be delivered in, the presence of absence of other people such as husbands, mothers, friends, is something you need to enquire about so that you will be able to have a large measure of control, always provided that the birth proceeds satisfactorily and the expert intervention of a specialist obstetrician isn't needed.

I have, or had a secondary intention in any delivery in which I was involved that the baby should not only be alive, and thriving, after delivery, or even after the standard post natal checks, but should be still showing an intellectual performance that might have been expected from his, or her genetic inheritance during their later educational years. Many years ago I looked into the obstetric history, when obtainable, of children in our practice who were not performing intellectually as well as their parenthood might suggest would be likely. Even in a small and then static community it was not always possible to find the necessary details. When I could obtain this information this small and statistically unstructured research showed a quite appallingly close association between a difficult delivery and unexpected later intellectual problems for the baby. You will have seen the recent research, properly carried out, that showed the long term influence on academic performance of babies affected by various troubles in early life.

I would also say that there must be another intention and that is the woman must look back so far as is possible with pleasure on her deliveries and that they should be pain free.

Not all midwives have had children, so not all midwives can talk of personal experience of being delivered. I would hazard a guess that the proportion of women doctors working in a labour ward are just as likely to have had children as midwives. What matters is that the person conducting the delivery can empathise with the patient, know how they are feeling because they have seen so many other women in similar situations and will react to their difficulties in a kindly way. Gender is immaterial when assessing a particular patient's problems and needs and providing the necessary response. The idea that only women, because they are women, can understand what it is like to have a baby is similar to suggesting (without the slightly sexist tone of your comment) that only surgeons who have had, for example, cancer of the colon or appendicitis can recognise the problems of the treatment and will be competent to carry it out.

The available data shows that planned home births are in fact safer for women and babies, provided that no problems have been detected during pregnancy. Modern scanning allows the majority of complications to be detected early thus diverting women who need to be in hospital into hospital. Should problems arise in labour, women are swiftly transferred to hospital where medical care is available. Please stop being derogatory about home births. When carefully chosen and with good midwife support they are wonderful. I had two of my three children at home after a disastrous first experience in hospital where the standard of care was terrible. With the rise of superbugs and a continuing decline in hygiene standards it makes a great deal of sense for women to stay at home to give birth rather than bring their child into the world in germ-filled and unfamiliar environment.S Kilgour, Berkshire

All data needs to be examined carefully. It is essential to study the nature of selection of both patients and controls and to make certain that it was truly random and that the population that has been studied is representative of whatever population a particular patient is a member of. It is also essential to agree with the organisers of the trial that collected the data as to what they thought constituted a problem that could determine whether the delivery was classified as safe or unsafe. The condition of the baby in early childhood is not always a good guide as to the success of the delivery.

I quite agree that modern scanning has revolutionised obstetrics and made home midwifery safer. We should now know for example if there is a lesser degree of placenta praevia, pick it up before labour, but we still cannot prevent all emergencies. If the Queen's daughter-in-law and grand-daughter very nearly died from an unpredictable emergency, when her ant- natal care had been supervised by a supremely good obstetrician with the latest ancillary support, sudden disasters can also happen to less fortunate people.

I agree that the rise of the well-publicised resistant organisms, and of one or two infections that don't receive publicity, are points that favour the delivery of babies at home. They are less likely to suffer from an infection. Even in my day the difference in the minor infection rate was very striking between home and hospital deliveries. At that time, and I believe this is still so, the serious infection rate in the woman rose alarmingly if she was allowed to labour for too long. It was better to have an early Caesar if it appeared that one could well be necessary, rather than hanging on to see if all would go well.