York’s Homebirth Guidelines: A Success for AIMS

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AIMS Journal, 2019, Vol 31, No 1

By Emma Ashworth

Back in 2018 I wrote about the horrific situation in York¹ where women were being told that they would be forced to accept interventions and tests in their home birth, including vaginal examinations, whether they wanted them or not, if they wanted their midwife to stay with them. York’s homebirth guidelines were clear:

“If you arrive at the home of a woman and she refuses to allow you to access her home or to provide care to her, you must explain that you will need to leave and explain this decision to her.”

Women were being told by their midwife that they would not be allowed to decline any “care” by their midwife, which meant that they would be coerced into vaginal examinations rather than giving their free, informed consent. This means that the midwives were, by these guidelines, being forced to assault women, as unless we give our informed consent for access to our vaginas, we are being assaulted. Furthermore, midwives who chose to follow the guideline and leave if the woman declined an intervention or test, could be liable, should there be injury or death to the woman or baby, as could the Trust.

Despite over a year of discussions with the senior midwives at the Trust, they refused to accept that the wording of their guideline was leading to serious risks for women, babies, midwives and the Trust itself. A change of tactic was needed.

I wrote a letter to the Chief Executive of the Trust, which included the following: 

“I am writing to make you aware of a guideline within the York Trust's midwifery service which forces midwives to undertake a criminal act if they follow it, or put themselves at risk of sanctions by the Trust if they do not.

[…]

 "The guideline states that women attended by a midwife at a home birth must allow the midwife to undertake interventions or tests, or the midwife should leave the woman's home. This means that women are being forced to concede to interventions such as vaginal examinations under duress, which is not giving consent in a way that the law requires. As I am sure you are aware, no one may put their fingers in a woman's vagina without her consent (and coerced consent is not, in law, consent, in the same way that, for instance, coercing a woman to have sex is rape). To do so without consent is the criminal act of Common Assault (there is also a chance that it might be considered to be Sexual Assault). The midwife is also at risk of being sanctioned by the NMC for assaulting a woman. Furthermore, if a woman declines this intervention and the midwife leaves, any adverse outcome could lead to the Trust being held liable."

The response from the CEO stated that women were not being forced into anything without their consent and that midwives were aware that they could not do this.

However, on the contrary, women had been reporting that they were in fact clearly told by their midwives that they would have no option but to consent to whatever the midwife wanted to do if they wanted them to stay. This is despite repeated reassurances from the Head of Midwifery that midwives were clear that the guidelines were not intended to mean this.

Despite his claim that there was no issue with the guidance, following my email to the Trust’s CEO, updates to the guidance were provided to me in January 2019, with the following amendment:

“ If you arrive at the home of a woman and she refuses to allow you to access her home or to provide any care for her, you must explain that you will need to leave and explain this decision to her. This does not include declining certain aspects of care such as vaginal examinations or auscultation of the fetal heart, which remains the woman’s informed choice; but in situations where a request that no communication between you and the woman be made, no clinical care is to be given and/or the request that you sit in another room or outside the home as she labours with no access to her, providing no care.” [Their emphasis]

Although I was delighted that the amendments now mean that women are safe from being coerced into vaginal examinations, the Trust is still treating women who are birthing at home differently to those in hospital. I asked the Head of Midwifery why it was that the normal physiological processes of birth were not being supported by allowing women space and peace from interference when they wish to labour without speaking, or to have privacy to allow her hormones to flow. She explained that women who desired this in hospital would be supported and that their wishes would be respected.

She also claimed that the professional role of the midwife would be compromised if the midwife could not be with the woman – despite the fact that women are sometimes left alone for hours in the hospital setting, which clearly invalidates this argument. She said that the NMC would take a dim view of a poor outcome if the midwife had not seen the woman during her labour. I have contacted the NMC and asked what their position would be on this, and of a midwife deserting a woman in labour, and they were not prepared to make a statement either way. They would only deal with a real-life scenario sent to them as a complaint. Therefore it is not reasonable for Trusts to suggest to their midwives that their registration is at risk if they do NOT leave as the opposite is just as likely. Any reassurances from Trusts to midwives that the NMC would take one view or another is simply speculation.

For some women, having a midwife close by is what she needs to birth in confidence, but to invite a midwife into her birthing space who may well be a complete stranger could interfere with her labour, perhaps (although not always) due to previous negative experiences with health care providers, or maybe due to an assault in her past. Having a midwife who respects her birth space but is there if needed is the safest option for these women and their babies. If women in this situation need to choose between having a stranger in the room or not having anyone at all, the stress this causes can seriously inhibit labour and cause injury to the woman and possibly her baby. For many women, knowing that the midwife will respect her wishes and not force her to choose between no midwife and someone she doesn’t yet know being in the room, leads them to, over the course of time, feel more confident in inviting them in.

If York were to implement a strong Continuity of Carer model as per the guidance from Better Births, this is likely to ensure that women are as comfortable as they can be having a midwife in their birth space. This will still not be right for everyone, but it would reduce the risk of harmful interference with the normal progress of birth. AIMS volunteer Katie Hickey’s experience summarises the issue perfectly.

“In my first labour the midwives were on top of me the entire time. It’s no wonder it ended in a c-section for ‘failure to progress’!”

For the time being, the York Trust is not recognising the needs of some women, and it continues to force them to choose between two very stressful options – but only if the woman decides to birth at home.

The campaign continues.

References:

1. https://www.aims.org.uk/journal/item/york-homebirt