Making choices

AIMS Journal, 2012, Vol 24 No 4

Beverley Beech highlights some key issues

In the United Kingdom women have the legal right to birth at home if they so choose. This is protected by Article 8 of the European Convention on Human Rights.

‘In countries and areas where it is possible to establish a home birth service backed up by a modern hospital system, all low risk pregnant women should be offered the possibility of considering a planned home birth and should be informed about the quality of the available evidence to guide their choice.’ Olsen & Jewell 1998

In 2006 the Nursing and Midwifery Council published further advice to midwives which made it clear that ‘Should a conflict arise between service provision and a woman’s choice for place of birth, a midwife has a duty of care to attend her’.

Despite the NMC advice to midwives, it is clear from those who contact AIMS that women are commonly still vigorously dissuaded from birthing at home. There is a common belief that anyone deciding to birth at home has to obtain the consent of an obstetrician or senior midwife. This is untrue, as a woman has the right to decide where she gives birth and a midwife has a responsibility to attend. If she is unable to do so, she is required by her Midwifery Rules to seek support from her Supervisor of Midwives and arrange for another midwife to attend.

It is common for women to be told that the home birth service has been cancelled, suspended or scaled back due to staff shortages and that, in the event no midwife is available, women have no choice but to go to hospital. In reality women who stand their ground and insist on remaining at home are likely to get care, although some Trusts have threatened to send an ambulance, and only sent a midwife when the woman made it very clear she would not get in it.

When a woman states she wishes to stay at home regardless, or plans not to call for a midwife, it is common for her to be told that a home birth without a midwife is illegal, either because the midwife or doctor is ignorant of what the Nursing and Midwifery Order 2001 actually says or because it is the easiest way of gaining compliance. The Order, Part 9 Article 44, actually states that it ‘is illegal for an unqualified person to undertake the role of a registered midwife.’ Article 45 further explains that ‘no person other than a registered midwife or a registered medical practitioner shall attend a woman in childbirth (assume responsibility) unless in an emergency or in supported recognised training.' It goes on: ‘An unqualified person is an individual who gives medical or midwifery care but may not lawfully do so.’ This does not mean that a midwife or doctor must be present, it means that you can’t work as one when you are not registered. It does not prevent a woman either birthing on her own or birthing with her husband, partner, other relative or friend present, but they ‘must not assume responsibility, assist or assume the role of the medical practitioner or registered midwife or give midwifery or medical care in childbirth.’ Sometimes women, choose to telephone for a midwife at the last minute, thereby increasing their chances of giving birth before a midwife arrives.

Women who want a home birth are often accused of being selfish and of putting their babies at risk, without any evidence to support these claims. Research evidence indicates that the health outcomes of planned home birth, such as Apgar scores or need for resuscitation, are as good as or better than those for hospital birth, and that many women experience a range of emotional and practical benefits from giving birth at home.

It was commonly accepted that birth in hospital was safer than home birth until Marjorie Tew published her analysis of the risks of home birth in 1977. This analysis has never been refuted and further research continues to support her findings.

‘There is ample evidence that planning a home birth improves overall outcomes for mothers and babies … For women with normal pregnancies labouring at home increases the chances of a birth that is both satisfying and safe.’ Royal College of Midwives 2002

The iatrogenic risks of birth are still poorly researched and the risks of hospital deliveries are underplayed. However, it should be noted that the 2004 Confidential Enquiry into Maternal and Child Health stated that ‘suicide was in fact the leading cause of Indirect or Late Indirect maternal death over the whole year following delivery.’ This might even be more likely after a hospital birth, as medical interventions and a lack of personalised care and support are known to increase psychological trauma.

It is important to understand differences between the government’s, obstetricians’ and paediatricians’, and mothers’ definitions, and assessments, of ‘risk’. Often officials and doctors see it as having facilities and staff available immediately to deal with emergencies, or intervening in a situation that might become an emergency. Provided the mother takes home a live baby they are not concerned about, or even aware of, the mental and physical damage that may have been done in the process. Mothers include the whole family outcome – their mental health, bonding with the baby, bonding of the father with mother and baby, bonding of siblings, and their postnatal physical state (stitches, infection, postnatal depression, post traumatic stress). It is not just about health of the child, but the creation of a family, with a mother who has the ability to care for them and joy in doing it. The accounts of women who have experienced both kinds of birth have convinced many doubters.

‘Over the last 50 years of medicalised, centralised birth, women’s hopes and desires have been remarkably consistent. They want to come through the experience physically and mentally whole and in a fit state to start life as a parent with a live and healthy baby. Parents who will not benefit from medical intervention have been misled into believing that the best way to achieve their hopes for the birth is by an operative or obstetric delivery. As a result, the medical resources of the health service are spread thinly across too many births and poor care may be provided both for those who only need non-medical support to have a normal birth and for the minority who need medical intervention to preserve the life or well-being of mother and baby.’ Beech & Phipps 2008