Nadine Edwards challenges us to think about why it is still so difficult for women to choose to give birth at home.
When I joined AIMS in 1980, in my early twenties, it was after planning three home births and having two. I joined because I wanted women to have the opportunity to birth their babies peacefully, with minimum disturbance or intervention, at home or in hospital. I believed that birthing babies this way was the best way to protect the health and well-being of the woman and her baby and the best start to the mother-baby relationship, as well as the family's relationships. While we know that some women and babies need help, (and thank goodness it is there when we need it), we also now know that normal, unhurried, peaceful births wherever possible do indeed support optimal health and well-being1.
While it seemed easy to plan a hospital birth, it seemed extraordinarily difficult to plan a home birth and even more difficult actually to stay at home for the birth of one's baby. Thus, when I joined AIMS, I was keen to support the home birth campaign. I, like many AIMS members, believed in those days that women needed more information. What I have come to understand is that information is only one part of the equation. Of course women need information, but, without the support of skilled, confident midwives, they are unlikely to have their babies at home even if they plan home births. What I have also come to understand is that the culture around birth has a huge influence on how information is built up and presented, how skilled and confident midwives can be, and how knowledgeable and confident women and their families can be.
AIMS is not, and never has been, a home birth organisation. It supports normal birth but above all it supports individual women's needs. AIMS has supported women who plan caesarean sections and those who want epidurals to be available and remain free of charge. But one of its enduring and important campaigns is to promote the concept and practicality of home birth. This not only supports individual women and their families, who plan home births, it also keeps alive crucial debates about hotly contested beliefs and values about women's bodies, babies and birth. It prevents our technological society from completely having its way around where and how women give birth.
Does place of birth really matter as long as mother and baby survive the experience? If one or other is physically or emotionally scarred, it does matter. We know that some women have long-term health problems following birth where interventions have been used. Sometimes these interventions are necessary despite their potential disadvantages, but often this is not the case. Women also tell us in so many different ways that having a baby is a profoundly influential experience in their lives. It is a rite of passage, the time when formative relationships begin. It impacts deeply on their psyches. The way the birth unfolds can harm or enhance mental health: self esteem, confidence and the ability to parent their babies2, 3,4,5,6.
Some researchers and practitioners suggest that how a society manages birth not only reflects the beliefs of that society, but impacts on general behaviour patterns. For example, what could be described as aggressive and invasive birth practices, such as induction, caesarean section, and separation of mother and baby at birth, when used frequently, make for more aggressive, individualistic cultures, in which mental health problems are likely to be more prevalent7. Whether or not we believe this, there appears to be no good reason to discourage peaceful births at home or in hospital, and many good reasons for supporting more women to have their babies at home.
The safety of women and babies is not a reason for discouraging home births. The research that has been done on planned home births with midwives shows that outcomes are excellent. Not only do healthy mothers and babies survive as often, or even more often than they do in hospital, they tend to have fewer interventions, suffer less ill-health, and feel more satisfied. Even if they plan home births and end up transferring to hospital, they still have fewer interventions8 and are less likely to have a caesarean section (see NICE Caesarean Section Guideline 2004 at 8www.nice.org.uk/cg013).
Home birth is a hugely emotive and contested area throughout our culture. Many health professionals and parents accept the prevalent view that birth is inherently dangerous and that risk is minimised by more and more surveillance, that more rather than less technology is generally better, and thus home birth is unsafe. Home birth challenges the technological direction our culture is moving in. It questions its deeply held values based on particular thought processes, often called scientific9 which believe that technology can continually provide remedies for the problems it manufactures, in a drive to decrease the risks is has created in the first place10.
Is there any hope of changing direction? Perhaps there is. Research increasingly suggests that well-being around the time of birth is crucial for mother and baby and that normal birth, where possible, best supports this1. The Government, health managers, health practitioners, birth activists and parents are worried about the high interventions rates, which seem resistant to change. This is particularly true of caesarean sections rates. More people are questioning the efficacy, desirability and longterm sustainability of technology and are considering quality of life issues, such as spiritual and emotional well-being. Research is now giving us evidence that physical and emotional well-being cannot be separated and that emotional wellness improves physical well-being and vice versa. Encouraging home birth provides one way of addressing some of these concerns.
But so far, all this is rather theoretical. While a cultural shift in values is needed for home birth to seem more of a possibility, more acceptable, this will only happen if there are skilled, confident midwives who can make this a realistic option: an option that women can choose with confidence, in the knowledge that this is a safe choice.
The NMC has made a vitally important contribution to this process of change, by issuing clear guidance to midwives that they can and must support women, if they decide to plan and have home births (see page 6). Knowing that their regulatory body will support them to support women is crucial for midwives, who have been extremely vulnerable. Caught between women, employers, protocols, and policies, they have been right at the nub of the contested meanings of birth: the social approach and the medical model.
These groundbreaking NMC Guidelines need to be followed up in every midwifery school and birth establishment in Britain: we need better training for student midwives so that they have a deep grasp of physiology and the skills they need, tutors and lecturers who can teach these skills, mentors who can support midwives to use these skills and finally senior midwives who understand and promote midwifery and who support and protect those midwives who already practice these skills, and who embrace the concept of normal birth in hospital or at home.
Developing skills and promoting normal birth where possible includes challenging the notion of time. As long as clock time dominates birth practices, the level of interference and intervention will remain high11,12. But moving towards normal birth, embracing women's time requires different and additional midwifery skills to those currently learnt in most large obstetric units. Midwives need carefully honed skills and knowledge to know when labour is taking its time and when it needs help. They need skills not only to keep birth as normal as possible, but to bring low tech midwifery skills to developing or existing complications. Some midwives already use nutrition to address pregnancy related problems; manual skills to turn babies in awkward positions during birth; counselling skills to address emotional blocks during labour; herbal and homeopathic remedies and so on. It is the ability to see the woman and her birth as a whole, in the context of her life that best enables the midwife to develop the skills she needs. One of the best places to see this is in women's homes13.
We know that changing the culture of birth is difficult but possible. Developing positive attitudes among a population of women towards normality and birth at home with the midwifery skills to enable this is certainly possible. We know this because the Albany Practice midwives in London14, the midwives at the Montrose Birth Centre in Scotland15, the midwives in other free standing birth centres16, those in NHS community teams17, and independent midwives are doing just this, with outstanding results, regardless of the areas that they are working in (see for example birth stories in the AIMS Quarterly Journal, Midwifery Matters and The Mother).
While midwives cannot work miracles and eradicate the impacts of poverty, abuse and/or exclusion, what they and women can do around birth is truly stunning, when given a chance. We need to keep the momentum going. We can do this in many ways: supporting the One Mother One Midwife Campaign (see www.onemotheronemidwife.org.uk) , the Community Midwifery Model (see www.independentmidwives.org.uk/?node=725) and the Birth Centres campaign (groups.yahoo.com/neo/groups/birthcentres/info) are good places to start (see the AIMS website for suggestions as to how to press for these initiatives to be brought in at www.aims.org.uk/ActionNow.htm). These initiatives contribute to changing the negative, risk-based culture around birth, to one that is based on a more optimistic, positive view of birth, that nonetheless accepts the value of interventions when needed. Communitybased birth along with continuity develops trust between women and midwives. It provides a more holistic approach to women and their families and promotes well being more systematically. It encourages thoughtfulness among midwives so that they can develop midwifery skills to reduce and sometimes treat pregnancy and birth complications, without necessarily resorting to invasive interventions, thus reducing mortality and morbidity overall(18). Home birth and other out-of-hospital birth settings are places where women and midwives can take their time. This helps them develop deeper insights and understandings about the physiology of birth and how body-mind connections work. Promoting good health at the beginning of a baby's life, as well as that of its family is a commonly stated aim. Home birth is one obvious way of contributing to this. It seems the Government thinks so too.16
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