Lone Birth - Ethical Dilemmas

AIMS Journal, 2001, Vol 13 No 3

As AIMS members know, ethical standards in research are always in our minds when we look at the latest studies and summarise them for our readers. Jean Robinson shares with you some of the ethical problems we have ourselves.

We are getting more and more requests for help from women who want their next baby at home and are being told that they are not "allowed" to do so, either because they have risk factors, or because the Trust cannot guarantee to have a midwife available.

Many simply want a home birth because they feel that a straightforward normal birth is right for them, and they believe - with good reason - that staying at home is the best way of getting it. Other women are determined they will never give birth in hospital again. They are still traumatised by the care they had and some cannot bear even to go near the building.

Women are telling us that they are getting continuous pressure - some subtle, some overt - to give in, but this makes many of them more determined. They also realise that they do not want the midwives who behave like this to come anywhere near them in labour, because they believe their chance of giving birth normally at home will be reduced and they no longer trust these midwives to tell the truth. They recognise that the midwives, in turn, are being pressurised from above.

Some of them then tell us that they will give birth without professional help, because in their estimate it is the safest thing for them to do. They have compared the risks of different actions and made a thoughtful choice - the only one they think possible.

What do we do? Firstly we assure them they have a legal right to stay at home, come what may, and they cannot be forced into hospital (a piece of basic information some midwives seem reluctant to mention).

Secondly we find out what they have been told and what they understand about risks. Quite often "risk" is a term waved about like a phantom over their heads but which is not described or quantified. One woman, recently, with two previous caesareans and a post traumatic stress disorder (PTSD) which has affected her ever since, had been told she was at risk of the scar rupturing, but no-one had mentioned her increased risk of placenta praevia or placenta accreta, (see note 1) or recognised the risk of the PTSD being reinforced and intensified.

We talked about these risks, but in a low-key, factual way and talked about how each risk might be dealt with. Thirdly we try every way we can to find them care - suggesting an independent midwife to those who can afford it, when all NHS sources have failed, but with only 60 of these in the country there are not enough to go round, even for the rich.

Finally we have to warn them that if their husband, partner or someone else who is unqualified is present and helps them with the birth, they could be prosecuted (although the mother herself cannot). Some then react to this by saying "OK, I'll send him out and give birth alone."

A surprising number of these babies end up as "BBAs" (born before arrival of the midwife) - and we do not probe as to exactly what happened if the parents do not share the whole story. So far, all these stories have had a happy ending, but it is a nail-biting time both for the parents and for the support group involved. We are all well aware that we could find ourselves giving evidence at a coroner's inquest about the attempts the mother had made to obtain professional help, and how this had not been forthcoming.

We fear that a mother could haemorrhage and there might be no one in the house to see and call an ambulance. We were so worried about one woman that we debated whether one of us should go and be with her just to ensure she was not alone if an emergency arose. That might put the helper at risk of prosecution, since "attending" a woman in labour is the offence - one does not even have to deliver the baby - but it seemed more important to ensure basic safety than worry about a court case. Fortunately the baby arrived - safely - before we had to decide.

Some committee members were worried in case AIMS was thought to be advocating birth without professionals present. Of course we have talked about this - and we do not advocate such actions. We simply support women's right to choose. Sadly, many feel they have to make choices that they know are not ideal, but are the best they can make when acceptable help has been denied them.

If midwives and the health service do not meet their legitimate needs, we are not going to abandon them too just because it might be interpreted as AIMS acting "irresponsibly". We provide facts as far as we can, try to locate acceptable care, but if it cannot be found, we let the woman know she has our support, whatever choice she makes.

Views from our members would be welcome.

Note

1. Both placenta praevia (the placenta growing low down in the uterus and partially or totally obstructing the baby's exit from the womb) and placenta accreta (the placenta being morbidly attached to the wall of the uterus so that it does not come away after the birth) are more common after a woman has had a previous caesarean section. With every additional caesarean section, the risk increases.