The slow disappearance of homebirth services, the erosion of women’s choices and the need for respect and kindness.

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This week I received an invitation to a group called “save our homebirth team”.

It broke my heart, because this a campaign against the disappearance of the dedicated homebirth team in Peterborough.

Peterborough is one of the few trusts in the UK that still has a dedicated homebirth team.

This means that there is a group of midwives there who are not only confident and skilled at supporting homebirths, but when a couple books a homebirth, the team arranges for them to meet every single one of the midwives in the team. This ensures that they actually know the midwives who are going to come and support them during their birth. How awesome is that?

Nowadays in my antenatal classes, I mostly hear stories of women telling me that they rarely see the same midwife twice during their pregnancy. They say the appointments feel like box ticking exercises, and that they don’t trust the midwives they meet. Why would they? How do you trust someone you don’t know?

It didn’t used to be like this.

Ten years ago when I was pregnant with my son, Cambridge used to have a caseloading community midwifery team. During my pregnancy I saw the same midwife at every appointment (and the appointments were about 20 min long). She came to visit me at home a couple of times, and when I was in labour, as she was on call then, she came and supported me through the birth. I didn’t quite realise how lucky I had been to have this kind of continuity of care. My midwife was also very experienced, reassuring, and confident enough in her own practise to fully support my decision to refuse an induction (My son was born at home 16 days after his “due date”).

Three years later when I was pregnant with my second child, I had started my childbirth educator and doula journey and I felt I couldn’t take the risk of having a stranger turning up at my birth, so I hired independent midwives. It makes me so sad to think that not all the women who psychologically need this kind of care can afford independent midwives.

We know for a fact that continuity of care leads to better outcomes for mothers and babies. Beside the science backing this up, it makes sense, right? How on earth is a midwife going to know a pregnant mother is out of sorts, or more swollen than usual, or any other mental or physical signs are off, if she has never met her before?

We know that mothers prefer it, and that staff prefer it too, if they are adequately supported, with caseloads that are appropriately sized.

The trend towards team midwifery and lack of continuity of care is worrying enough, but I am now seeing a more worrying trend: the looming disappearance of homebirth services.

Kings Lynn’s hospital stopped providing a homebirth service a few years ago – this has been the object of a campaign called Birthplace Matters (the brainchild of doula Paula Cleary)  which has resulted in the Trust being criticised by the Ombudsman for its inadequate provision for choice of place of birth but has sadly not yet resulted in the reinstatement of services.

In Cambridge, where I live, we used to have a higher than average homebirth rate. When I started working as antenatal teacher in 2010 it was 6%, well above the 1% national average. In my antenatal classes, I used to have a homebirth couple in almost every class. Now it’s more like one or two per year (running monthly classes).

Since the local birth centre opened in 2012, the homebirth rate has steadily decreased to about 1%. This is partly due to the birth centre attracting potential homebirth couples, but I believe it’s also down to a lack of commitment to promoting homebirth from the local NHS trust.

Until last year we were lucky enough to have a fairly healthy homebirth service; whilst we heard stories of women being refused a homebirth in other parts of the country, it didn’t seem to happen here.

It all started to change last October, when a pilot was put in place at the local hospital. Instead of having two community midwives on call for homebirth at night, there is one, working an ordinary shift in the hospital.

Since then, several things have happened.

Couples planning homebirths have received letters telling them that the trust cannot guarantee a midwife will be available to support them at home. Whilst I understand that the hospital needs to be honest with women so they can make informed decisions, women booking hospital births are not being officially notified that the hospital may be short staffed or even closed when they go into labour.

The trust even has a statement about this on their website

The maternity service at the Rosie supports home births however it is acknowledged that at times this will not possible due to staffing and/or workload both within the hospital and/ or community. Should it not be possible to support a homebirth then a woman in labour will be asked to attend the Rosie(or if on divert to a neighbouring unit ) where there is a midwife available to care for her. In the event of a labouring woman being unable to make her way in or declining to attend and the unit is unable to attend the birth at home then an ambulance will be sent to facilitate transfer to a unit where a midwife is available to provide care.”

As you can imagine the recipients of this letter were very distressed, and the statement above doesn’t exactly inspire confidence to potential homebirth parents. You can read more about that here.

Since the change has happened, I have heard several stories of births for which a midwife wasn’t available and how distressing this was for the mother in labour.

In my antenatal classes, I have also heard stories of disgruntled couples who were in the birth centre, then their midwife told them she had to leave because she had to attend a homebirth. This gave parents the impression that a homebirth was more important than them.  I wish different language had been used. For example, the midwife could have explained that she was community based and if a call came from the community she may have to go.

I just do not understand the logic.

I know the NHS finances are in a terrible state, but when the Birthplace study shows us that homebirths are significantly cheaper than hospital births, (and also that homebirth is very nearly as safe for healthy first time mothers at home than in hospital, and safer for second time mothers), that homebirth are less likely to result in costly interventions, when the NICE guidelines were changed last year to reflect this, surely there should be a concerted effort to INCREASE the homebirth service and to actively promote it rather than trying to scrap it?

Yet it seems that the opposite is happening.

I am by no means trying to say that everybody should birth at home by the way. I have been in the birth field for long enough to know individual perceived safety is, and that women should birth where they feel the safest. For some it’s at home, for some in a birth centre, for others in an obstetric unit. I have no issues with that.

What I have issues with, however, is that women appear to be having their choices restricted.  It is paramount that these choices are respected, not just because many women prefer to birth outside the hospital but because for many women, it really is the only psychologically healthy option for them.

Asking some women to go to hospital is like asking a soldier to return to the battlefield that caused his shellshock.

I believe that women cannot make fully informed choices when they aren’t informed of all the options, their pros and cons (teaching antenatal classes for the last 5 years have showed me how many misconceptions people have about the safety of homebirth), and also being confident that the option they choose will be available.

For homebirth to become normal like it is in some countries like Holland, or even some parts of the UK where the homebirth rate is closer to 10%, there needs to be a concerted effort from the NHS to promote it as a valid choice.

Legally, where we choose to give birth in the UK doesn’t fall under the remit of maternity care, it falls under the remit of human rights.

Some countries in Europe, in particular Hungary, have banned homebirth. In 2010, a Hungarian homebirthing woman called Anna Ternovsky challenged her country in the European court of human rights, and won the case. The court ruled that meaningful choice in childbirth is a human rights issue, and that birthing women are the ultimate decision-makers regarding the circumstances in which they birth their babies. You can read more about women’s rights in childbirth on the Birthrights website.

Beside the decrease of women’s birthing options, I am also seeing a worrying trend towards disrespect of women’s choices within the health system in general. I see a lot of coercion. I hear a lot of “do as you’re told, or else”. This week I was told of a new mother who was threatened with a report to social services when she tried to discharge herself from the hospital against medical advice. Earlier this year a client of mine chose to go home to wait for labour to start on its own rather than consenting to induction, and was told by the midwife as she left “I hope you don’t have a stillbirth during the night”. Another one wanted to wait for labour too and was also told “your baby might die”.

Health professionals, I just don’t get it.

I know you want what you think is the best for the mother, but do you think for one second that the mother doesn’t have the best interests of her unborn child at heart?

Do you think there is any mother in the world who is going to put her unborn baby willingly at risk of injury or death?

Do you realise you are in breach of your own code of conduct?

The code of conduct of doctors and midwives in this country is very clear on consent. The GMC guidance states that:

” You must respect a patient’s decision to refuse an investigation or treatment, even if you think their decision is wrong or irrational. You should explain your concerns clearly to the patient and outline the possible consequences of their decision. You must not, however, put pressure on a patient to accept your advice.”

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Very clear right? Only I wish I witnessed it more often. From time to time I meet a refreshing doctor or midwife who really gets it. But they are a minority. It’s so unusual that I am in awe of them. I always mention it to the person in question how impressed I am by their bedside manner. What I see, most of the time, are various shades of coercion. Sometimes it’s gentle and well meaning, but it’s still coercion. What I believe happens is that most patients are compliant with medical advice and do not question things. Therefore I assume that medical professionals are used to this behaviour, and few get to hone and practise informed decision making on a regular basis. I also believe that the fear of judgement from peers and the fear of litigation, has a lot to answer for.

The other problem is that clinical guidelines and hospital policies are based on a population. They have to be. But you, an individual pregnant mother, are not the population. You are an individual, and as such you deserve an individualised plan of care.

I appreciate the words above are potentially upsetting. I am not writing this to cause upset.

I am writing this because I hope expectant and new mothers read this  and that it helps them make more informed decisions.

I am writing this because I hope more expectant and new mothers can receive nurturing, individualised care.

I am writing this because I want to see more respect and kindness within maternity services.

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I do not believe the system will change through people like me. I have been trying to make positive change happen for the last 5 years, by being a lay member of my local maternity liaison service committee and bending the ear of every health professional who will listen, with little results.

What I have seen however, is system changes happening when the people who use it (pregnant and new mothers) demanded it.

If you are pregnant, attend antenatal education, inform yourself about your birth and postnatal options, reach out to other mothers and to birthworkers and build up your knowledge so you can make the truly informed decisions that are right for YOU.

If you work with expectant parents, help them feel empowered enough to challenge the decisions that don’t feel right for them.

The more people challenge things, the faster it will change.

 

 

 

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