Home Birth

Booking a Home Birth

The decision whether or not to have a home birth rests with the mother, and no-one else. The decision is hers alone. Midwives, GPs or obstetricians have no authority to agree or deny anyone a home birth, they are there to ADVISE. Whether or not you accept their advice is entirely up to you. Some women have been told that it is 'illegal' to give birth at home. This is untrue.

In order to justify an attempt to refuse a woman a home birth some women are told that they are 'high-risk', for example, they may have had a previous caesarean section. If you are classed as 'high-risk' you can ask the doctor or midwife to put in writing precisely why s/he considers you to be so. It is not uncommon for women to be labelled as 'high-risk' as an excuse for urging a hospital birth and it is important to establish what the risks are perceived to be. However, even if a doctor has defined your pregnancy as 'high risk' you are still entitled to midwifery care and to have your baby at home if you wish.

You do not have to approach your GP in order to book your home birth, you can write directly to the Director of Midwifery Services at your nearest maternity unit along the following lines:

Dear

I am expecting a baby on the ... and intend to give birth at home. I have carefully considered the risks of home birth and compared them with the risks of hospital birth and I am not prepared to risk my, or my baby's health, by being delivered in hospital.

I would be grateful if you would arrange for my care to be provided by a midwife who is experienced and confident in assisting women to birth at home.

Yours sincerely

The Director of Midwifery has a responsibility to provide a midwife and if you have any problems making these arrangements do not battle alone, contact AIMS.

Home Birth Bullying

Many women expecting to give birth at home are subjected to a variety of tactics to persuade them into hospital, such as: 'we are short of midwives' or 'if you go into labour at the weekend/between 6pm and 8am' or 'midwife Bloggs will be on holiday' (and any number of similar alternatives). The following is not an unusual experience:

Dear AIMS,

I've planned a home birth with my midwife but I have just been told (at 37 weeks) that there are 5 other women due at the same time wanting home births and there is only one midwife on call. I've been told that if more than one of us goes into labour at the same time, it's on a "first come, first served" basis and there is a likelihood I will have to go into hospital.

I thought that I had a right to a home birth, and feel very upset to be told at this stage it may not be possible. They have suggested that I book an independent midwife but I really cannot afford this, and should I have to pay for this service?

I am really worried that if I go into labour I won't get the services of an NHS midwife anyway! What I can do?

This kind of tactic is very common. Women have a right to a home birth, the Government suppports a home birth service and the Trust has a responsibility to provide the service.

This is the only area in our consumer society where an increasing demand for a particular service is not met by increasing production (i.e. providing more midwives) but by telling the customers that they have to use a different service!

Your right to a home birth and the services of a midwife

Home birth midwives used to be employed by the local authority, which is under democratic control. We vote for local councillors, unlike members of health service Trusts, who are appointed. Under the NHS Acts of 1946 and 1949 there was a legal duty to provide a home birth service. When the health service was reorganized under the 1968 Act, the legal obligations were not clearly stated, and, as a result, NHS Trusts now only have a legal duty to provide a 'maternity service'.

Around 1995 the Trusts realised that they had no clear legal obligation to provide midwives when called by a woman in labour. The midwives' registration body, the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (now called the Nursing and Midwifery Council), despite considerable lobbying by AIMS and other concerned childbirth groups, gave contradictory advice on the subject. On the one hand it stated:

'While the employed midwife has a contractual duty to her employer, she also has a professional duty to provide midwifery care for women and would not wish to leave a woman in labour at home unattended, thus placing her at risk at a time when competent midwifery care is essential'.'

While, on the other hand, it also stated:

'The Council has been advised that it is the employed midwife's primary contractual duty to carry out the wishes of her employer, although the employer could not expect an employee to do anything illegal, including anything which contravenes the midwives rules. A midwife would not be in breach of her professional duty if unable to attend a woman requesting a home birth by reason of her employer's decision not to provide such a service. In an emergency, the midwife has a professional responsibility to provide midwifery care to the best of her ability.'(our emphasis) (UKCC, 2001) (Note: A woman telephoning the labour ward informing them that she is in labour at home IS AN EMERGENCY.

As a result of this lack of clarity it is not uncommon for Trusts to suggest that if they are short of midwives around the time the woman goes into labour she will have to come into hospital - and many women then abandon their decision to birth at home. Around 37 weeks is the most common time for telling women this, because from this time onwards women cannot face confrontation, and as a result the majority will accept what they are told and change their booking. With only a few weeks to go to the birth such information creates considerable stress for the woman and this can be very undermining. Furthermore, research has shown that stress in pregnancy can have a detrimental effect on the baby.

In AIMS' experience women who are determined to give birth at home, who make it absolutely clear (preferably in writing) that they have no intention of going into hospital to solve the Trust's staffing problems, are eventually provided with a midwife. To do otherwise, would leave the Trust in an indefensible position were a disaster to occur as a result of their failure to provide a midwife.

If you are faced with this dilemma we recommend that you send a letter to the Chief Executive of the Maternity Unit along these lines:

Dear

I have been informed that you have a shortage of midwives and when I call in labour the Trust may not be able to send one and I shall, therefore, have to come into hospital. I understand that it is Government policy that the NHS should support women who intend to birth at home. In a House of Commons debate (20 Dec, 2000) Lord Hunt of King's Heath stated: 'The Government want (sic) to ensure that, where it is clinically appropriate, if a woman wishes to have a home birth she should receive the appropriate support from the health service. At the end of the day, it must be the woman's choice'.

Your midwives have been aware of my intention to give birth at home since ...(insert date). I have no intention of taking the additional risk of a hospital birth in order to alleviate your staff shortages, although I am prepared to transfer to hospital should a medical complication arise. I suggest that, if your hospital is short of midwives, you contact the Independent Midwives Association and arrange an extra-contractual referral.

I expect a midwife to attend when I call her in labour. Should a midwife not arrive and any untoward event occur that is related to your failure to respond to my needs and those of my baby, my family will take appropriate action and we shall hold you and the Director of Midwifery personally responsible for this failure.

If, when you ring for a midwife when you are in labour, you are still told that a midwife cannot attend because they are short staffed, we suggest that you, or your partner, responds as follows:

'What is your name and your status? (Make a note of who it is). 'I have no intention of putting myself or my baby at risk of travelling in labour to the hospital and exposing us to the additional risks of a hospital delivery. If you fail to send a midwife and any untoward event occurs which can be attributed to your failure to provide a midwife you can rest assured that my family will take appropriate action'.

So far, in every case to date that we know of, the Trust has provided a midwife. You may also wish to ensure that the authorities know that there are problems in your area so you could also send copies to the contacts listed below.

AIMS suggests the following action:

The usual time to be told that a midwife may not be available for your home birth is around 37 weeks. If this happens to you, take immediate action. Write to each of the contacts given at the end of this article, explaining your problem and ask them to help you - URGENTLY:

Tell each one of them the problem and ask them what they are going to do - URGENTLY. Do not telephone anyone (other than the press); you will be told a variety of things on the telephone that the authorities would not dream of putting in writing. They can then deny the conversation later, but they cannot deny what they have put in writing.

Every area has a Local Supervising Authority (LSA) Responsible Officer. She is a senior midwife who is responsible for midwifery practice in your area and we suggest contacting her; she can lean on the Trust. You can find out her address from the Director of Midwifery's secretary, or by telephoning the Nursing and Midwifery Council, or by accessing the web - see contact addresses below.

It is also very worthwhile contacting the local press, and if you want to give them the number of the AIMS Chair, Beverley Beech she will give them further information and quotes. Contacting the press will also alert other women in the area who are faced with the same problem.

As we have already suggested the parents should write a very strong letter to the Chief Executive at the local maternity unit informing him/her that the mother intends birthing at home, has no intention of going into hospital and when she calls for a midwife she expects one to attend and should there be any untoward event which occurs as a direct result of their failure to provide a midwife the family will take legal action. If the Trust has a midwifery shortage it can employ an independent midwife, as other Trusts have done.

What women do not realise is that the chance of getting a midwife to attend them depends on their determination and this tactic will only stop when sufficient numbers of parents make a fuss about it.

Response from a Reader:

Just wanted to say thanks for your site. I was told at 34 weeks that I might not be able to have my planned homebirth, as too many women wanted a homebirth around the same time as me.

My initial reaction was to just wait and hope for the best, but reading the AIMS site gave me inspiration to fight this.

I wrote a letter to my MP, to the Director of Midwifery, the Chief Executive Officer of the NHS Trust and also to the Dept of Health. Within 1 working day of posting these letters, I received a phone-call from the Director of Midwifery, assuring me that I would be supported in my decision to have a homebirth. I have now also received this promise in writing, and the Director came round to my house to write it into my green notes!

I'm really glad that I decided to argue my case. I may well have had a homebirth in the end anyway, but this way I know that I can prepare fully for a homebirth, without the fear of not knowing till the last minute where the birth would take place.

Thanks again

Rebecca - Coventry

Giving birth without a midwife or doctor

Some women feel so harassed or pressurised they lose confidence and trust in the midwife and feel they would actually be safer, and more likely to achieve a normal birth, if no local midwife was present.

Those women who have told the midwife that they are unhappy with their care and are considering giving birth without a midwife at all are often told that they are not 'allowed' to birth without a midwife and they will be prosecuted if they fail to call a midwife or come into hospital. This is untrue.

The woman herself cannot be prosecuted for birthing her own baby. There is no offence in law.

Confusion has been caused by a misunderstanding of the Article 45 of the Nursing and Midwifery Order 2001 which states that it is an offence for anyone who is not a registered midwife or doctor to 'attend a woman in childbirth'. This does not mean emergency help when a baby arrives too quickly, or unexpectedly and a husband or partner, taxi driver, shopkeeper or paramedic helps.

Since so many doctors and midwives misquote this Order you might like to know what it really says in section 16:

  1. A person other than a registered midwife or a registered medical practitioner shall not attend a woman in childbirth.
  2. Subsection (1) does not apply -
    1. where the attention is given in a case of sudden or urgent necessity; or
    2. in the case of a person who, while undergoing training with a view to becoming a medical practitioner or to becoming a midwife, attends a woman in childbirth as part of a course of practical instruction in midwifery recognised by the General Medical Council or one of the National Boards.

A person who contravenes paragraph (1) shall be liable on summary conviction to a fine not exceeding level 5 on the standard scale. (5,000 to you and me)

The Order is intended to prevent people pretending that they have midwifery qualifications when they do not. It is not designed to prosecute those who are present at a home birth when a woman decides that she is not going to call a midwife or a doctor. As a result of this confusion AIMS lobbied the Department of Health asking for clarification. In September 2002 Jacqui Smith MP, the Minister of State at the Department of Health wrote to Julia Drown MP as follows:

'Attending a woman in childbirth, as opposed to general support given by partners and relatives, has been an offence against the protected function of midwifery since the Midwives Act 1902 and the fines are set at a level to reflect the seriousness of the offence. By 'attend' we mean, 'assume responsibility for care' and this is not intended to outlaw husbands, partners and relatives whose presence and support during childbirth are extremely important'.

Using this Order to threaten women in order to force them to comply with what the midwives or doctors want has had the unfortunate effect of increasing risks. Some women have sent their husbands or partners away while they gave birth, and truly birthed alone, to avoid what they understood to be the risk of the child's father, or their friends, being prosecuted.

Some women choose to avoid this scenario by employing an independent midwife to ensure home birth care they can rely on; or they decide not to call the NHS community midwife until labour is well advanced so the baby arrives before the midwife is able to arrive.

Britain used to have a superb domiciliary midwifery service. It is a sad reflection of the maternity services today that we have come to this. The service is very patchy, some areas still do provide excellent community care, others appear to have a policy of jollying the women along until 37 weeks and then begin to pressurise the woman into changing her booking and transfer to hospital. In Glasgow women are told that they have an 'allocation of two home births a month' and once they have exceeded that figure the remaining women will have to be delivered in hospital.

AIMS is concerned that so many women are refused the maternity care of their choice, contrary to the Department of Health's policy. Women are entitled to birth at home, indeed the latest Government report on caesarean section points out that 'healthy pregnant women with anticipated uncomplicated pregnancies should be informed that delivering at home reduces the likelihood of caesarean section'1

We are very worried by the numbers of women who have problems getting a home birth to the point that some women feel they have little alternative but to birth alone

AIMS will support any woman who is finding it difficult to get appropriate care for a home birth and we have often successfully challenged Trusts to provide an adequate service. If you are attended by a midwife in whom you have little confidence you have the right to dismiss her and the Trust has a responsibility to provide another, but do not battle on alone, contact AIMS and we will do our best to help you get the kind of care you want.

Contact addresses

The Chair, Association for Improvements in the Maternity Services, 5 Ann's Court, Grove Road, Surbiton, Surrey, KT6 4BE, chair@aims.org.uk

Dr Stephen Ladyman, Under Secretary of State for Health, Department of Health, Richmond House, 79 Whitehall, London, SW1A 2NS

John Reid, Secretary of State for Health, Department of Health, Richmond House, 79 Whitehall, London, SW1A 2NS.

Catherine McCormick, Midwifery Officer, Department of Health, Room 519, Wellington House, 134-155 Waterloo Road, London, SE1 8UG

Julia Drown MP, Chair, All-Party Parliamentary Group on Maternity, House of Commons, London, SW1A 0AA.

David Hinchliffe, The Chair, Health Committee, Committee Office, House of Commons, London, SW1A OAA.

Your local MP. If you can access the Web, you can contact you MP directly using www.writetothem.com. It costs nothing, all you do is put in your postcode and type your message, and it will go directly to your MP.

The Local Supervisory Authority Officer, who is responsible for midwifery practise in each region. Lists of all the LSA officers are available from http://www.nmc-uk.org/Nurses-and-midwives/Midwifery/Supervisor-of-midwives/Contact-a-LSAMO/ You can also contact the Nursing and Midwifery Council, 23 Portland Place, London W1B 1PZ tel: 020 7637 7171 and ask for a list, or the name of the LSA officer covering your area.

References

  1. National Collaborating Centre for Women's and Children's Health. Caesarean Section, Clinical Guideline, Royal College of Obstetricians and Gynaecologists Press, London, 2004. ISBN 1 904752 02 0 (Available online from www.nice.org.uk
See also:

UKCC Position Statement on Home Birth, and AIMS' response.

Choosing a Home Birth: excerpt from the AIMS booklet by Pat Thomas.

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