By Beverley Lawrence Beech
'The choice of home birth should be offered to all mothers'. Maternity Matters, Department of Health, 2007
'Choice', 'should' and 'offered' are interesting words. First of all, let us be clear, there is no such thing as 'choice' in most maternity care,1 it has become the most over-used and misleading word in the English language. And when choice is offered, far too many staff believe that the woman will choose what they decide she should have.
Few people today understand that the idea of choice has been bandied about as if women were choosing different brands of washing powder in a supermarket; when in reality it is making decisions based on individual beliefs, values and experiences that are extremely important to individual women. Unfortunately, in our NHS provided care, there is an assumption that the Service will provide the care, but that they will also decide who will or who will not avail themselves of it. For the majority of women the first question they are asked after they have confirmed that they are pregnant is: 'Which hospital do you want to go to?' or 'I will book you into St. Elsewhere's. It is only the informed woman who states that she does not want to go to any hospital and instead intends to birth at home.
In 2007 the Department of Health produced Maternity Matters in which it guaranteed that by 2009 women in England would have choice of place of birth. On the 26th October the National Childbirth Trust published its report 2 which found that '95% of women in the UK are not able to choose where to give birth.' Most women are booked into their local consultant unit and, if they are lucky, they might be able to give birth in a freestanding midwifery unit but very few will achieve a home birth (unless you live in a particular part of South London where 44% of women booked with the Albany Practice midwives birth at home). This service, however, has become so threatening to the medical profession that despite excellent outcomes King's management cherry picked some cases with poor outcomes and then employed the Centre for Maternal and Child Enquiries to investigate, produced a secret report, gagged the midwives and then closed down the service, so the choice of a home birth in South London is now even fur ther restricted.
Those women formerly cared for by the Albany midwives will now be required to join the ranks of all the other women around the country who do not find it easy to book a home birth.
Numerous tactics are used to dissuade those judged to be 'unsuitable'. One of the most common is for the midwife to appear supportive until the woman nears term,
'up until about 34 weeks she seemed to be very pro-home birth'
During the pregnancy any discussion of the home birth arrangements are avoided until the last couple of weeks. It is at this point that the women often find that there is some reason why they cannot have their home birth:
'Your baby is very large/very small'
'Your baby is 2cm over the average fundal height'
'Your iron count is too low'
'Your BMI (body mass index) is too high'
'You had a previous caesarean section'
'You are in labour at 37 weeks'
'You are a strep B carrier'
'You are overdue'
'You are expecting baby no 3, or even baby no 1'
'You are not in our catchment area for a home birth so you have to approach xxx'
Or the latest, most priceless one, 'we are stopping the home birth service because too many women want it.'
'They also moaned about my BMI being 1 over the average - and that my father who is now deceased had diabetes'
In some Trusts women have even been told that they cannot have a home birth but they can contact an Independent Midwife who might be willing and able to attend them. The Trusts do not, however, offer to pay for the midwife.
The latest excuse is that the Trust is expecting a swine flu epidemic so it has decided to suspend the home birth service. Over the last 20 years, at least, Trusts have been telling women that they have a staff shortage and the women have to come in, particularly over Christmas, Easter or any other bank holiday. If that fails then women can be told that they have to come into hospital because:
'We have three home births booked and if you go into labour at the same time we will not have the staff'
'We have exceeded our home birth quota for this month'
'You might go into labour when Nellie is on leave, or sick'
'The maternity unit is closed (in which case you have to go to a distant maternity unit).'
For many Trusts a reason for dissuading women from booking a home birth is money. The Trusts are paid £2,579 for each caesarean section (and £3,626 for a caesarean with complications) compared with £1,174 for a normal vaginal birth (a definition that includes interventions that would not match our definition of normal birth). So encouraging more home births where the risks of a caesarean section are very much lower is not in the Trust's financial interests.
While the Trusts only have an obligation under the NHS Act 'to provide a maternity service' many Trusts will claim that they do that by providing an obstetric unit. The Midwives Rules and Code of Conduct3 require that when a woman calls in labour the midwife has to attend (and if she cannot do so then she has to find a midwife who can.) Few women (and surprisingly few midwives) realise this and when told that there are no staff available and that they 'have to' come in most women give up and obey. In these situations, it is only the informed and stroppy ones who stand their ground and refuse who get their home births.
While the Nursing and Midwifery Council expects that every midwife on the register is competent and adequately trained, the reality is that many of those midwives who have worked in hospitals for most of their careers are not necessarily competent to attend a woman at home. The skills required to be still and observe and support the woman to birth successfully at home are very different from the skills required to break the waters, set up a drip, interpret an electronic fetal monitor printout and top up the almost inevitable epidural. It is unfair and dangerous to expect a midwife accustomed to such medicalised births to go out and attend a woman at home without being offered any re-training. Yet that is what so many Trusts expect of their midwives, and few Trusts have put in place a structured re-training programme to re-skill the midwives for this role.
A woman is also faced with trying to assess whether the midwife is telling her, often repeatedly, of the 'risks' of home births because she really does not want to attend a home birth or whether she is doing it because that is the Trust's policy. Yet not a single Trust informs women who book into the consultant unit of the risks of doing that.
'For some women, it is possible but not proven that the iatrogenic risk associated with institutional delivery may be greater than any benefits conferred'.4
Furthermore, while student midwives can qualify without ever having seen a normal birth those who have realised the shortcomings of the training and who have searched for placements with experienced community midwives are not enabled to develop these skills. Until we have separate community based midwifery practices and free-standing midwifery units, in every district, which will enable midwives to gain experience in attending normal births, we will continue to put women's and babies lives at risk. It is unacceptable that far too many Trusts persist reluctantly in sending obstetric nurses out to attend births in women's homes; and women will have to continue the battle to get the kind of care they want with the skilled midwives that are needed.
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