by Nadine Edwards
Joint meeting of the Forum on Maternity and the Newborn of the Royal Society of Medicine, Royal College of Midwives (RCM) and Association of Community-Based Maternity Care (ACBMC) at the Royal Society of Medicine, London, 13 November 2002
Luke Zander, former secretary of the ACBMC and long-time supporter of choice of birth place opened the day. Luke explained some of the history behind the conference and the organisations taking part.
The Forum on Maternity and the Newborn arose from a multidisciplinary conference on Pregnancy Care in the 1980s, and the ACBMC was formed some years later. There have always been strong links between the ACBMC and the RCM as community care and home birth depends on midwives.
The day was well-attended by midwives, childbirth-group representatives, researchers, doctors and others, and divided into four sessions, each with two or three speakers and 45 minutes for debate. This format facilitated fascinating and important discussions among all of those present.
Jo Murphy-Lawless, of the Department of Social Policy and Social Work, University College Dublin, raised some crucial questions on the assumed certainties of science and medicine, and suggested that, while the scientific paradigm provides some information, it cannot capture the social complexity of birth. Only women can weigh up the risks and benefits of home birth for themselves. Therefore, debates over home birth are about women's agency, rather than scientific evidence alone.
Belinda Phipps, Chief Executive of the National Childbirth Trust, gave an overview of women's experiences of home birth, the Trust's Home Birth Survey and the campaign to promote home births. Women's quotations on home birth showed how positive and healing the experience can be, but the survey revealed that information and support for home birth remains inconsistent throughout the country. It identified a need to target different groups of stakeholders in different ways. The campaign is attempting to address the miseducation and concerns of GPs, midwives, Health Service managers, obstetricians, and women and their families to create a more positive image of home birth.
Trish Morris Thompson, Executive Director of Nursing and Midwifery in Birmingham, suggested using primary care trusts to highlight the importance of maternity care. While the option of home birth has had parliamentary support, the professional bodies involved in maternity services have not consistently supported the option. The RCM has produced a home birth handbook, but the Nursing and Midwifery Council (formerly the UKCC) remains uncertain about its support for home birth, and few obstetricians positively support it. Trish called for retaining a range of alternatives, including home births and birth centres, contracting in independent midwives, increasing the use of community workers and reviewing the home birth booking system.
Lyn Leyshon, Director of Midwifery at Torbay Hospital, opened the second session on 'Lessons to be learnt from units with high home birth rates'. Lyn explained how a home birth rate of 11 per cent and rising, in a part-rural and part-urban setting, had been achieved in the last few years. Home birth is presented as a positive option to women and their families, but women book with midwives to provide for their care wherever they decide to give birth. So, decisions about place of birth can be left open until the woman is in labour. (This has been shown to increase numbers of home births in other areas). She attributed the success of home births to confident and competent midwives, informed women, continuous risk assessment instead of it being decided at the beginning of the pregnancy, good equipment, leaving decisions about place of birth open, visiting women in early labour at home, integrated midwifery services so that midwives can follow the women and appropriate use of resources.
Cathy Warwick, Director of Women's Services at Kings College Hospital in London, described how the hospital serves a diverse population, provides a diverse range of services, has a caesarean section rate of 27 per cent and a home-birth rate of just over 8 per cent. Women planning home births come from a variety of backgrounds and reflect the childbearing population as a whole. Cathy suggested identifying 'champions' of home birth and encouraging enthusiasts, who tend to overcome obstacles and encourage others. She also addressed the need to recognise uncertainty and to develop a dynamic, rather than restrictive, approach to risk, and the need to provide a supportive system in which midwives are encouraged to identify their own concerns and find their own solutions.
The afternoon session, 'The educational and training imperative', began with consultant midwife Debbie Gould, from Queen Charlotte's and Chelsea Hospital in London, who explained the change-making role of the consultant midwife, and the tenacity and energy required to reassert trust in the birth process lost through risk management. Like Cathy, Debbie stressed the need for 'champions': those who can challenge dogma and inappropriate practices, and introduce practices that facilitate birth, such as nurturance. Debbie maintained that the essence of good care is the quality of relationships.
Mavis Kirkham, Professor of Midwifery in Sheffield, examined tensions between bureaucracy and individuals, and rhetoric and practice. While current rhetoric focuses on individual choices, in reality, centralised services control the process. Women are directed towards 'right' choices - among which home birth is not. Thus, choice becomes informed compliance.
Home birth is an act of resistance on the part of women and midwives, but most conform to the norms of the system, as resistance makes them targets of hostility. Mavis suggested that student midwives gain awareness of these dilemmas by being taught to observe and question like social anthropologists. Unless these inherent contradictions in education and practice are understood, students will fail to subvert their own socialisation and develop autonomy.
I (who?) spoke next on 'The ethical and legal dimension', drawing on the research carried out for my qualitative PhD on women's experiences of home birth. My focus was on choice: the limits to choice when it is defined through medicalised beliefs about birth, how it has been divorced from ethics, and how it is based on libertarian assumptions that don't truly reflect how women make decisions.
For choice to equate with autonomy and be a reality, we need strong theoretical and practical alternatives to medicalised birth practices; women's different concerns and vulnerabilities to be acknowledged; ways of relating through relationships that facilitate women's and midwives' autonomy; and skilled midwives.
Finally, Rick Porter, consultant obstetrician in Bath and Chair of ACBMC, examined how ethics and legalities around birth relate, and how practitioners may consider balancing these often conflicting entities in the current climate and systems of maternity care. Bath has a 10 per cent home-birth rate, and Rick suggested that women choose home births for different reasons and that there is no reason to suppose this diverse group is more or less litigious than other childbearing women. His main messages to practitioners were that: there are few 'absolute' reasons for not planning a home birth; it is an ethical obligation to provide a safe and responsive home-birth service; and we need good information on the potential benefits and risks, and to accept women's decisions. Rick identified some of the barriers to professional support for home birth: intellectual atrophy; a desire to exercise power; and fear for oneself and one's organisation.
The participants' views and experiences were as much a part of the conference as those of the speakers. One of the comments that I found particularly resonant was made by Luke Zander, who suggested that we could begin to think about linking safety with benefit rather than only with risk.
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