Changing a birthing culture

AIMS Journal, 2015, Vol 27 No 4

Becky Reed explores why so many women with the Albany Midwifery Practice had home births

In our Midwifery Practice (The Albany in Peckham, London) between the years 1997 and 2009, we achieved an overall home birth rate of 43.4%. This is especially impressive as we were working in a deprived inner-city area with what is known as an 'all-risk' caseload - this included all the women referred to us by the local GPs, regardless of their obstetric, medical or social risk. So why was it that so many of the women we looked after ended up choosing to give birth to their babies at home?

None of the midwives in the Practice would have recommended home birth in a situation where it was clear that mother or baby (or both) would be safer in hospital. There are a few situations where immediate access to medical support that is only available in hospital is definitely recommended, but these are rare. Place of birth for all women should be their decision, based on good sound information and their own feelings about what is right for them. Ideally added to this should be continuity of support with a known and trusted midwife, and importantly also the support of partners, family and friends. In our practice we discovered that when all these things came together, many more women than might be expected chose to have their babies at home.

It might be useful to unpick some of this. After all, with such a high home birth rate amongst a population not usually seen as home birthers, questions are often asked about how we achieved this.

Midwifery support with a known midwife This has to be one of the key factors that enables women to make the right decisions for themselves. When the woman, and her family, can get to know the midwife, and the midwife can get to know them, a relationship can develop that fosters mutual trust and respect. In this environment the woman can fully explore the options available, knowing what feels safe for her, and knowing that no choice that she makes is cast in stone. Reassuring a woman that it's (almost) never too late to decide where to have her baby takes the pressure off any decision making and lets her relax and enjoy her pregnancy and grow a healthy baby. We visited every woman at home in labour, with a full set of equipment, and offered her the option of staying at home if that felt right. And of course for very many women it did, even if they had previously thought they would prefer to go to hospital - we are mammals after all, and moving away from our 'nest' in labour doesn't come naturally and is known to be unsettling for women and disruptive to the normal labour process.

Sabina had her first baby in hospital at 36 weeks. This is how she described her second birth at home:

'In my first labour I needed drugs and hospital support... so when it came to having my son Charlie I was not so sure about a home birth in case I needed to go to hospital, and I was worried about the space and the mess.

'My midwife arrived and I felt at ease. I was made to feel comfortable. I did not feel frightened or scared. She told me I was doing good and I can do it. Not only was it explained to me previously about home birth but as I was going through it I was given reassurance all the time.

'After, I was so happy to experience a home birth. I was comfortable in my own bed/home. My family came over for the birth... they all helped me with after the birth, with baby, cleaning the house, making food. We all were much more relaxed than in a hospital environment. It's defo something I would recommend to any pregnant woman even to experience once. I am so glad it happened this way...'

Sound information

With very little factually correct information in the media about the safety of home birth, and with hospital birth consistently presented as the norm, it's little wonder that women often think they have no choice. Midwives, backed up by the evidence from the birthplace study,¹ are now hopefully correcting this, and explaining the study findings to women. But this has to be done with the back-up of a strong supportive system of care. And in my experience women benefit from the information being repeated and discussed at each antenatal visit.

In our practice every woman had continuity of carer with two named midwives, who she was able to get to know and trust, and most importantly, who would be there at her birth. We were able to discuss - and actively promote - birth at home throughout her pregnancy, supporting our discussions with good information and examples in order to make this a real option for each woman. We were careful with our language, always talking positively about the options. 'Would you like to have your baby at home?' opens up different possibilities from 'Which hospital do you prefer?' (this was London, with more than one potential maternity unit to consider).

Above all we made the idea of birth at home real and normal, explaining that home birth as a default position makes sense in all births where a pregnancy has been straightforward, where the baby is well grown and in a good position, and where the woman goes into labour by herself. It is always possible to transfer to hospital, but it's virtually impossible to extricate yourself from a labour ward if you are in labour and wishing you were at home!

Women's feelings about what is right for them As midwives we can never know enough about each woman's individual circumstances to make decisions for her, nor indeed should we. But by booking her in her own home, getting to know her throughout her pregnancy, guaranteeing (as far as possible) to be with her when she has her baby, we can help her to explore what feels right for her when it comes to her birth. A Vietnamese woman I looked after knew instantly how continuity of carer would work for her. She had previously had two 'normal' births in hospital, and in both labours had had an epidural. When I told her at her booking visit that I would be there when she had her baby, her immediate response was 'I won't need an epidural then, will I?' She eventually had a beautiful water birth at home, so very different from her previous experiences.

The support of partners, family and friends When partners, and/or family, are an integral part of the woman's preparation for her birth, discussions can be had and choices can be made that feel safe and right. Women on their own can feel lonely in their decision making, and partners who are not involved, and therefore don't necessarily have sound information, may feel too ignorant or scared to support a woman's decision. Friends, neighbours, acquaintances with positive stories to share can all help. There's nothing as powerful as another woman's positive birth story - in a twist on that famous When Harry Met Sally moment: 'I want what she had'! Our well-known antenatal groups, woman-led but facilitated by a midwife, held the answer to this. Women (and their partners) learnt from other women, as nearly everyone returned to the groups to tell their story. I have observed such wonderful sharing of information, woman to woman, in these groups - I will never forget 15-year-old Linda 'teaching' 42-year-old Sheila how a baby is born!

This I think is the key to the 'cultural norm' of birth at home that we were able to develop in Peckham over the twelve and a half years that we worked there. Women saw other women doing it and enjoying it. Rather than seeing it as a slightly odd and rather unsafe option, women (and their partners and families) began to see staying at home to give birth as a normal, safe, satisfying and joyful thing to do. Often we were able to point to another woman in their block or down their street who had had a baby at home and who was happy to share her story. Friendships were forged and birth became normal again, rather than something to be feared.

Sabina and baby Charlie

I remain bewildered about why the UK home birth rate remains stubbornly below three per cent. My oldest daughter had her first baby at home eleven years ago, and she was the only one in her antenatal class to do so. My youngest daughter had her first baby at home in August of this year, and the story remains the same - when the classes started she was the only one planning a home birth. We have the information, but even apparently wellinformed women are still choosing what almost feels like the path of least resistance, and we know from the evidence that this often comes at a cost.

More midwifery group practices working in a similar way to the Albany midwifery Practice could make such a difference to women, babies, families and midwives. We changed the story in Peckham, and with the National Maternity Review well under way in England we now have the opportunity to get involved and improve women's experience nationwide.

Becky Reed is an ex-Albany midwife, grandmother, doula, writer and birth activist.

References

1. Brocklehurst P, Hardy P, Hollowell J, Linsell L, Macfarlane A, McCourt C, Marlow N, Miller A, Newburn M, Petrou S, Puddicombe D, Redshaw M, Rowe R, Sandall J, Silverton L, and Stewart M (2011) Perinatal and maternal outcomes by planned place of birth for healthy women with low-risk pregnancies: the birthplace in England national prospective cohort study. BMJ, vol. 343, p. d7400, Jan. 2011.

To read about the achievements of the Albany midwifery Practice and its unexpected and unwelcome closure see thealbanymodel.com