AIMS

A Nail in the Coffin for Home Birth

New UKCC guidelines fail to support mothers and midwives

AIMS Journal, Autumn 2000, Volume 12 No. 3

The United Kingdom Central Council for Nurses, Midwives and Health Visitors was established to maintain a register of qualified practitioners and in its information material it claims to have been established "to protect the Public".

AIMS, together with other childbirth and midwifery organisations, has been pressing the Council for some time to publish advice to midwives to guide them when they are faced with the dilemma of attending a woman who wants a home birth and an employer (the Trust) that is instructing them not to attend but to persuade the woman into hospital (usually on the grounds that they are short of midwives).

Such a document has now been produced, but the advice from the UKCC will help neither mothers nor midwives to provide a quality midwifery service which is responsive to women's needs, nor will it provide public protection as women are now being faced with giving birth at home unattended because of Trust's refusal to provide midwifery care.

AIMS Chair, Beverley Beech's initial comments on the position statement, and detailed response to it, are reproduced here.

AIMS' Initial Comments

On the 30th June 2000 the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (the body responsible for midwifery standards) issued a 'Position Statement - Supporting women who wish to have a home birth'. The following are some extracts:

'This position statement seeks to clarify the professional position of the midwife in respect of the provision of midwifery care for women who wish to have a home birth....

The Council fully supports the maternity service policies in the four countries of the United Kingdom which promote women-centred maternity services with the expectation that choice will be offered to women, and that the option of home birth should be available. .....

Women, midwives, and consumer groups have expressed concern to the Council's Midwifery committee about the issues which have arisen when there have been difficulties in arranging a home birth. The Council recognises its responsibility for enabling midwives to provide midwifery care and support for women in childbirth, whatever choice they make about the method and place of birth. ....

The Council acknowledges that the difficulties experienced by some women wishing to make arrangements for a home birth have given rise to conflict for some midwives. The competing demands of the employer who says that a home birth service cannot be provided, and the woman who wishes to remain at home for the birth, place the employed midwife in a difficult position. While the employed midwife has a contractual duty to her employer, she also has a professional duty to provide midwifery care for women and would not wish to leave a woman in labour at home unattended, thus placing her at risk at a time when a competent midwifery care is essential. .....

A midwife would not be in breach of her professional duty if unable to attend a woman requesting a home birth by reason of her employer's decision not to provide such a service. In an emergency situation, the midwife has a professional responsibility to provide midwifery care to the best of her ability. ....

In a situation where the woman's preference is for a home birth and there is no perceived significant risk, but the NHS trust says that it cannot provide a home birth service because of severe staff shortage, the facts of the situation should be clearly explained to the woman so that she can consider these when making the decision about the future management of her care. Again, if her decision is to continue with the planned home birth, the midwife should not withdraw care but should report the decision to her supervisor of midwives and seek her advice.' ....

AIMS Comment:

Many women approach AIMS stating that they have been told that a midwife will not attend should they go into labour. This position paper makes it clear that a midwife will attend "in an emergency" - and a woman in labour IS an emergency. Women, in labour, therefore can have confidence that a midwife will be provided.

AIMS' Response to the Position Statement on Home Birth

This is AIMS' letter to the UKCC's Chief Executive, Sue Norman:

Dear Ms Norman

"Supporting women who wish to have a home birth"

After consultation with our members I have the following comments on the above mentioned UKCC Position Statement:

1. At the joint meeting of lay representatives and professional groups the very first agreed comment on the draft UKCC Statement said: "a suggestion that in the title of the draft statement the words 'requesting home births' be replaced by 'intending to give birth at home". Women do not 'wish' to give birth home as they would wish for a holiday in Hawaii. They intend giving birth at home, and by diminishing this intention to a 'wish' the Statement implies that as it is a wish it is not necessarily achievable.

2. This underlying perception that a home birth is something within the gift of service providers continues throughout the statement and in paragraph 2 it states that: "The Council fully supports the maternity service policies in the four countries of the United Kingdom which promote women-centred maternity services". It then diminishes this strong statement with a proviso that: "with the expectation that choice will be offered to women, and that the option of home birth should be available." The implication is now that home birth is a choice to be offered, and if it is choice it can be refused. AIMS is dismayed that despite the strong representations made at the joint UKCC meeting the message has still not been understood. A woman has a common law right to give birth at home if she chooses to do so, and it is not dependent upon anyone's agreement.

3. The most alarming feature of this Statement is its misinterpretation of the law, and what the solicitors have advised the Council. The Statement says:

"It appears that many women believe that they have a legal right to have a home birth and that an NHS trust cannot refuse to support a woman who wishes to have her baby at home. Equally, many midwives believe that they have a professional responsibility to attend any woman in any circumstances if they are asked to do so by the woman. The specialist legal advice given to the Council's Midwifery Committee does not support either contention".

This is untrue. Women's belief that they have a right to a home birth is absolutely correct. A woman has a common law right to give birth at home if she decides to do so, and that right is not dependent upon a lack of "perceived significant risk". The Council has confused, deliberately or incompetently, this common law right with the right of the woman to be attended by a qualified midwife, and the lawyers' advice that the Trusts have no obligation to provide a midwife.

A supervisor of midwives in discussion with me this week about providing a midwife clearly stated that: "the UKCC's home birth statement says that a woman does not have a legal right to a home birth". If a supervisor of midwives responsible for a health region has been misled into believing this statement it will not be long before this lie becomes an accepted "truth".

4. Perhaps it is worth reflecting on the history of birth in the UK. When employment of domiciliary midwives was transferred from local authorities to the National Health Service (the midwives were previously employed by local councils) it was understood that a community midwifery service would be maintained, so that when a woman in labour called for a midwife the midwife would attend. This understanding persisted until recently.

In the last four years the Trusts have realised that the 1977 Act merely required that the Secretary of State should provide "facilities for the care of expectant and nursing mothers as he considers necessary" so they could vigorously curtail home birth by claiming that they were providing a service in the local hospital, and, for a variety of reasons, they could no longer provide a midwife for a home birth.

5. In paragraph 4 it states that the Committee is "mindful of the Council's remit for public protection". It is unfortunate that this Statement fails, miserably, to achieve this. Most of the statements which could offer the public some protection are countered by statements which undermine that remit, and offer no assistance whatsoever for the midwife torn between her concern for a woman intending to birth at home and her instructions from her employer not to attend. For example:

While the employed midwife has a contractual duty to her employer, she also has a professional duty to provide midwifery care for women and would not wish to leave a woman in labour at home unattended, thus placing her at risk at a time when competent midwifery care is essential.

A midwife would not be in breach of her professional duty if unable to attend a woman requesting a home birth by reason of her employer's decision not to provide such a service, in an emergency situation, the midwife has a professional responsibility to provide midwifery care to the best of her ability.

This leaves the midwife torn between her ethical concerns for the woman and the risk of losing her job if she responds to the woman's needs.

6. We are now receiving calls daily from women who are being bullied, intimidated and stressed late in their pregnancy by midwives who are seeking to coerce them into hospital. We believe this is a direct result of the UKCC's advice. For example,

"In a situation where the woman's preference is for a home birth and there is no perceived significant risk, but the NHS trust says that it cannot provide a home birth service because of a severe staff shortage, the facts of the situation should be clearly explained to the woman so that she can consider these when making the decision about the future management of her care. Again, if her decision is to continue with the planned borne birth, the midwife should not withdraw care but should report the decision to her supervisor of midwives and seek her advice."

7. A few supervisors see their role as repeating the "risks" and many have difficulty in understanding that most women who decide to birth at home have very carefully considered the 'risks' and have decided that the risks of being delivered in hospital far outweigh the risks of birthing at home. There are supervisors who wish to support the woman totally, but they too have to consider their employment status and they are not assisted in any debate with their Trusts by weak and pusillanimous statements such as this. We are also concerned to note the increase in the numbers of midwives and supervisors who appear to have lost the ability to listen to what the women are saying, and this document does hale to change that.

8. The UKCC claims that it has a role in protecting the public but it is failing to protect the public and, indeed, by circulating this Statement it is putting the public at risk. I received another call yesterday from a woman in the west country who informed me that she is so dismayed with the sub standard midwifery care she is receiving she is going to birth at home unattended. She has spent the last few months battling with local midwives who are trying to get her to comply with their wishes. We know of a number of women who have deliberately birthed at home unattended and others who intend to do so. Another woman, in the north-east of England, has been informed that unless she gives birth between 9.OOam and 500pm the midwives will not respond to her call. A third woman has been told that she cannot have a home birth unless she has an ultrasound examination to verify her dates.

9. In another case earlier this month a woman expecting her second baby with a breech presentation was told by her Trust's Chief Executive that "a home delivery of a breech presentation baby is outside the scope of practice for our midwives and providing sub-optimal obstetric care at home is simply not an option for us". When it was suggested that the Trust should give a temporary contract to an independent midwife who was skilled in attending breech births the Chief Executive refused to do so. When the mother said that she was determined to stay at home he announced that in that case the hospital's on-call midwives would attend (despite having previously acknowledged that they did not have the skills to assist with a breech birth!). The situation resolved itself when the baby fortuitously turned to a cephalic position.

10. The Council's failure to address the provision of a midwife for a home birth has ramifications far beyond the experience of a single woman. The Statement says that: "It is expected that the programs (of midwifery education) will provide student midwives with a wide range of experience, including the provision of midwifery care in the domiciliary setting".

By attending a home birth a student midwife will understand normal birth, and giving birth at home is almost the only place in the UK where a woman can have some assurance that she will be supported and enabled to give birth normally. A student midwife recently informed us that she was within a few months of qualifying and as she had trained in one of London's large, centralised, obstetric units, she has yet to see a normal birth; over 80% of the women in the unit laboured with an epidural.

In the reports we have received from women who have been traumatised by their birth experiences, some of them have described how the midwives simply stood and watched them during the labour and did not do anything to assist them. We could not understand how a midwife could behave in this way until we realised tha, by attending women with epidurals in place, there is little for the midwife to do other than observe the woman and the monitors. As a result, they have little or no understanding of how to support a woman in normal labour. They were not being unkind, merely ignorant. But the effects on the women can be devastating.

11. Midwives who have already attended home births need continual practice to maintain their confidence and skills so that they can pass these on to the next generation. The ability to help and support normal labour and birth is not a midwifery "extra" it is the fundamental core of midwifery. Unfortunately, the home, nowadays, is one of the very few places where a midwife can learn and practice this skill. The future educational base of the profession depends on the existence of home births, and the quality of hospital care also benefits from having confident and experienced practitioners who are used to taking this responsibility. The UKCC is not playing its part to ensure the profession is being properly educated.

12. Increasingly, we receive reports from women who tell us of a whole range of tactics midwives use to persuade a woman to deliver in hospital. It is quite clear that many of those midwives are extremely anxious about attending a woman who is not surrounded by a bank of medical equipment and who does not have a doctor down the corridor to rescue them from the iatrogenia many hospital practices cause.

The Statement says that: "it is the Council's expectation that a practising midwife will be competent to provide midwifery care in any setting and that women who wish to have their baby at home can be supported to achieve this by a midwife who is able to practise with in the home environment". Because there is no separate community midwifery service available the numbers of midwives who can fulfil the Council's expectations are considerably diminished, and Trusts that have difficulty persuading midwives to work in their centralised units have been using the community midwives to top up their staffing complements.

13. It is clear from the national home birth statistics that Trusts and midwifery managers are deliberately suppressing requests for home births If South London's Albany Midwifery Practice can provide around 35% home births for high risk mothers in their area, with better outcomes than the focal hospitals, why do the vast majority of Trusts barely achieve 2% home births?

14. It is understood that there are over 50,000 qualified midwives who are not practlslng midwifery. A well qualified and respected midwife recently told me that she was giving up midwifery because she was no longer prepared to continue abusing women in hospital.

15. The current home birth battles mask a national problem of seriously understaffed maternity units and an over-medicalised service which does not address the needs of fit and healthy women - the majority of the population. The midwifery services have been cut back to such an extent that women are not getting adequate care in hospital. The rising caesarean and litigation rates are a reflection of the current sub-standard care on offer. Informed women are well aware of the risks to which they will be subjecting themselves and their babies should they go into hospital, and they are voting with their feet. AIMS has a list of large, centralised, obstetric units it would like to see closed immediately as they offer a substantial risk to any woman going into them. Interestingly, a woman does not have the right to a hospital birth, but no-one is arguing to deny her that!

16. The UKCC, by failing to produce a strong statement enabling midwives to support a woman who intends giving birth at home, has worsened an already difficult situation. Women are now faced with the choice of being forced into hospital or giving birth at home unattended. Where is the public protection in these circumstances or do we have to wait for a woman or baby to die at home unattended before the UKCC grasps this particular nettle?

17. Finally, in view of the incorrect statement about the legality of a home birth we expect that this Position Statement will be withdrawn and we trust that, this time, we will be consulted before the final version is released.

Beverley Beech
Hon. Chair, AIMS

Update:

The UKCC responded to this letter by stating that the contents had been noted and it would be put before the Midwifery Committee for them "to note".

A copy of the letter was also sent to the Chair of the National Boards of Scotland, Northern Ireland and Wales. Only the Scottish Board has responded:

"I note your comments about services and education and I assume you have had a response from the UKCC in connection with this. My understanding is that now that the statement has been issued the consultation period is over." - Beatrice Grant, Professional Officer (Midwifery)

One wonders whether Miss Grant even read the letter. If so, she appears to have no concern whatsoever about the misinformation promulgated by the UKCC!

No response has been received from the Welsh or Northern Ireland National Boards, and in the meantime women are being given a variety of excuses for denying them a home birth.

If you have been told that you are not "allowed" to have a home birth, do let us know what reasons you were given, and what part of the country you live in.

Update 31 March 2001

AIMS has received a brief response from the UKCC, and has replied to them. Read it here.

See also 'Home birth alert', and Choosing a Home Birth: Excerpts from the AIMS booklet by Pat Thomas.

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