Homebirths suspended and under review

AIMS Journal, 2023, Vol 35, No 2

By Katherine Revell

During the covid pandemic home birth services were suspended in many Trusts and Boards throughout the UK. Some areas were more badly affected than others. As a consequence, the AIMS Helpline saw a big increase in enquiries from people who had just been told they couldn’t have a home birth. This was devastating news. It’s hard to gauge how many women were affected. We know that most people don’t contact AIMS - we only hear from a small fraction of the population.

For the people who did contact us our strategy was to support them to argue their case in advance for a homebirth, citing their particular needs and experiences, and to stick to their guns when the time came. Often Trusts went out of their way to provide a service, so for many this was a successful strategy. However, there were incidents when only an ambulance crew showed up, leaving birthing women in a difficult situation – should they go into hospital in the ambulance or stay home and give birth without a midwife?

Since the pandemic the situation has eased a little in terms of the number of enquiries, but now instead of homebirths being suspended, they’re “under review”, due to serious midwife shortages. This is even more unsettling for women planning a homebirth, as they cannot plan. It’s pot luck whether there’s a midwife available on the day. Over the past few months, the emphasis seems to have changed from “we’ll try our utmost to support you in your home birth” to “we can’t guarantee anything.”

This leaves women feeling angry, let down and scared. Most people will probably just give in and accept that they have to go to hospital. Other people will get their homebirth if they persevere and are lucky. Some will stay home, hoping for a midwife to show up and then give birth with just the ambulance crew in attendance, or not even that. A few will hire an Independent Midwife (if they can find one and if they can afford it) or a Doula. Some will actively choose to stay home and freebirth.

Here is a typical letter from the Helpline Inbox:

Dear AIMS Helpline Volunteers,

I am nearly 34 weeks pregnant and due on (____________). I have been planning to have a home birth but have just been told by my midwife that the home birth service is currently being reviewed daily due to staffing levels. Therefore, they can’t say for sure that they will be able to offer me a homebirth at the time I’m due. This has left me feeling distressed and anxious.

I know that legally I have a right to birth at home and cannot be compelled to go to hospital to give birth, yet these rights are being ignored.

Due to the impact of my previous traumatic hospital birth, I have found making plans for my home birth very reassuring. I have discussed the choice with my consultant and my midwife and I am optimistic that a calm approach at home will minimise the chances of a similar traumatic outcome.

I feel that I am being denied what should be a basic right to birth in the place where I will feel most safe. I cannot afford to pay for an Independent Midwife and I am now having to consider birthing at home without medical support. This is not an option I would normally choose but feel that if midwifery care continues to be declined, I will have no alternative.

Please can you help me to negotiate with the Trust. Are there any resources that you can recommend about birthing without medical support? I want to be as informed as possible so that I can make the best decisions and hopefully make my homebirth happen.

With kind regards

__________________________________________________

And here would be a typical AIMS reply:

Dear ___________________

Thank you for contacting AIMS and many congratulations on your pregnancy.

The homebirth situation is very much like this around the country, and the legal side of things is complex. While you have a legal and human right to decide where you give birth, a hospital Trust has no legal duty to provide a homebirth service. At the same time, midwives are still bound by their Code of Practice to attend you at home if you call them while in labour. However, they could be in trouble with their employers (the Trust) if they did so at a point when the Trust had suspended the service.

These fact sheets may be helpful: https://www.birthrights.org.uk/factsheets/choice-of-place-of-birth/,¹ and https://www.birthrights.org.uk/2018/03/07/home-birth-what-are-a-trusts-responsibilities-towards-midwives-and-women/² - and this article may feel relevant too: https://www.birthrights.org.uk/2022/11/03/home-birth-series-the-realities-of-planning-a-home-birth-in-autumn-2022/³

The suggestion we have made in the past and still offer is two-fold:

Firstly you can consider writing to the Head of Midwifery stating that you intend to give birth at home and that you expect a midwife to attend. This gives them fair warning and therefore enough time to make suitable staffing arrangements. We have a sample letter on this AIMS information page: https://www.aims.org.uk/information/item/booking-a-home-birth.⁴ Please feel free to copy AIMS into any written communications.

You could also call the hospital to make an appointment to speak to the consultant midwife. A consultant midwife has more authority to tailor care to the individual and to advocate for you. It may be a good idea to keep a record of every written communication and to ask for any verbal guidance or information you are given to be confirmed in writing. This request often helps people to focus on their legal duties more clearly.

Secondly, we used to suggest that the mother (if she wishes) holds tight to her homebirth plan and, when she is in labour, has someone else call for a midwife. If they are told that no one is available, this other person can simply repeat that the mother does not intend to leave the house and that she is expecting a midwife to attend. There is no need for them to be drawn into a debate; it is a matter of just calmly repeating the request.

We used to find that those two things almost always resulted in a midwife attending. This is still worth trying. Unfortunately, though, Trusts are getting wise to this tactic and sometimes women are told that they have a right to give birth at home without a midwife (free birth), and to call an ambulance if they are worried. They are correct in saying that free birth is your legal right, but it should not be something you feel forced to do.

In terms of resources about freebirthing, these fact sheets may be of interest: AIMS: https://www.aims.org.uk/information/item/freebirth,⁵ and Birthrights: https://www.birthrights.org.uk/factsheets/unassisted-birth/⁶

Some women are handling this uncertainty by having a contingency plan. They may hire an experienced doula to be with them at home so that if a midwife does not arrive promptly, they feel supported (https://doula.org.uk/).⁷ They may also read up about free birth and talk with others who have chosen this option (https://caerphillydoula.co.uk/exploring-freebirth/).⁸ And there is also Anita Evensen's book, “The Unassisted Baby”,⁹ which is useful for anyone planning a homebirth - midwife attended or not.

With any birth there is the possibility of the baby arriving before the midwife, or even before there is time to get in the car to travel to the hospital. Therefore, it is always useful to feel ready and relaxed to welcome your baby without the help of a midwife or doctor - whatever the plan.

We hope this is useful to you. Please let us know how you get on and if we can be of any further help.

With kind regards,

________________________________________

So where does all this leave us and where are we heading? The situation of midwife shortages looks set to continue, if not to deteriorate. For us on the AIMS Helpline it’s no longer possible to reassure people that they will probably get their homebirth if they stick to their plans. It feels expedient to suggest they explore all of their options, including having plans to either go to hospital on their own terms, or to freebirth in a fully informed and prepared way. Then, if a midwife does not appear, the woman is still at the helm and her personal contingency plans can fall into place. However, this could be experienced by the mother as capitulation¹⁰ and, in the bigger picture of things, not serve well in reinforcing women’s rights to decide on the place of birth.

As staffing levels are always the reason given for not being able to guarantee that a midwife will attend a homebirth, how do we retain our current midwives and recruit new ones? Is this a question of money, investment, or job satisfaction? The RCM (Royal College of Midwives) is looking closely at this situation.¹¹ If money is the issue, homebirth is much cheaper than birth in hospital and could pay for itself in terms of increasing the number of midwives.¹² If job satisfaction is an issue in midwife retention, then changing models of practice, greater autonomy, more midwives and smaller caseloads seem to be the answer,¹³ and worked well for midwives and mothers in New Zealand.¹⁴

How do we transform the system and how do we change the accepted view that a hospital is the normal place in which to give birth? In my mind these two things fit together: if homebirths were the norm, there would be more midwives; if there were more midwives, homebirths would be the norm.

Author Bio: Katherine Revell became passionate about childbirth when pregnant for the first time, back in 1994. Her first homebirth was a deeply empowering experience, and led her to train and work as an active birth teacher and doula, which she did for over twenty years. She no longer works in the birthing world, but keeps her passion alive by working as a Helpline Volunteer for AIMS. Please visit ninjagranny.org to find out more about Katherine's work as a Tai chi, Qigong and Somatics teacher.