Beverley Beech, Nadine Edwards and Debbie Chippington Derrick look at birth place choices
A significant nail in the coffin of home birth was driven home when the Peel Report1 recommended that provision should be made for all women to have a hospital 'delivery'. No evidence was sought to support this view and no women were asked if they wanted to be 'delivered' in hospital. The announcement, however, gave the green light to hospital birth for everyone and what Professor Wendy Savage later called the largest unevaluated medical experiment of all time.
When women began complaining about the care in hospital, the response was to improve the décor, put up pretty curtains and paint the walls, but the quality of care did not necessarily improve in any setting; hospital or community, as attitudes remained largely unchanged.
In 1992 the Winterton Report2 was published and parents, midwives and others celebrated what they thought was, finally, an acceptance of what women were saying. The Government's response was to suggest that choice was of primary importance, but little changed in practice.
In the meantime, the home birth rates declined further in some areas, and have remained extremely low in most. Where home birth rates are high, then, as now, it is because a dedicated group of midwives are skilled and positive, offer choice, and support women to have them. Midwives who were enthusiastic to provide women centred care developed midwifery teams in the community, but adequate resources to maintain these were (and are) often not forthcoming, leaving midwives overworked, with caseloads that were far too large and, on top of that, were also required to work in the hospital; as a result, teams came and went and exhausted midwives too often gave up midwifery, leaving many midwives believing that continuity of care was untenable.
Women, however, despite being told that home birth was dangerous, persisted in birthing at home, and some (if they were lucky enough to have a free-standing midwifery unit in the vicinity) birthed in Birth Centres. Although new Birth Centres have opened, they, and even long standing ones are continually under threat of closure by cash strapped Trusts and Health Boards. Two of our main articles on why birth centres fail (see the article on page 14) and choosing out of hospital birth (on page 11) explain why these can be difficult to establish and what is needed for them to succeed. Our book reviews and reports also provide clues to the obstacles and enablers for out of hospital birth. An article highlighting the importance of doulas remaining independent provide insight into the different ways in which birth might be demedicalised, and the potential impact on women can be clearly seen in the personal and moving account by Lisa Sykes on page 22.
Independent midwives, one of the last bastions of gold standard midwifery care, are also under threat. An EU ruling that all health professionals must have insurance comes into effect in October 2013 and if the midwives fail to obtain insurance they will no longer be able to practice legally, as discussed on page 18. At the moment, they are often the last resort for women who want to have a vaginal breech birth, or twins born vaginally, or who decide to birth at home when they have been labelled 'high risk'. This growing group of women will have nowhere to turn, and AIMS has been pressing the Government to acknowledge the fact that many of these women will decide that they have no option but to birth at home without anyone in attendance, even though they would have preferred to have a midwife of their choice to support them.
So what of the future? The Birth Place Study, reported and examined on pages 4 and 11, has shown that healthy women and babies are safer birthing at home or in small midwifery units than going to an obstetric unit. The Halcyon Free-standing Birth Centre (described on page 8), along with other Birth Centres and other midwifery initiatives are beacons of light for real midwifery practice and independent midwives are vigorously negotiating a means of contracting their skills to the NHS.
We now have the evidence that for better outcomes for women and their babies, healthy women who are 'low risk' should be birthing at home or in a midwifery led unit (MLU). Trusts which continue to fail to provide access to free-standing birth centres and home birth for these women are not providing the best care, and are wasting NHS monies. All women should have access to free-standing birth centres and home births in order to make informed decisions about their births. Women need to have a real option other than a consultant led unit (CLU) if they are to make informed decisions about what is best for them and their baby.
After the Winterton Report2 there was a great opportunity to promote real midwifery, but it seems that ball was dropped. The results of the birth place study and reorganisation in provision of care needs to be seen as an opportunity to pick up that ball. We need midwives to come together and to work with women to make sure that we hold onto the ball this time and run with it.
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