AIMS Journal, 2006, Vol 18 No 1
Beverley Beech recounts the long consumer battle to ensure that a woman in labour at home could expect a midwife to attend her when called.
In the 1950s the majority of women gave birth at home, attended by the local community midwife. It was accepted that when a midwife was called to a woman in labour she had to attend. The difficulty, at that time, was finding hospital beds for those women who really needed them. This changed in 1970 when the Peel Report (1) stated: 'We consider that the resources of modern medicine should be available to all mothers and babies, and we think that sufficient facilities should be provided to allow for 100% hospital delivery. The greater safety of hospital confinement for mother and child justifies this objective.' No-one asked the mothers if they would prefer to give birth in hospital and no evidence at all was presented to support the claim that hospitals were safer than women's own homes. From then on the numbers of women birthing at home declined dramatically to the present situation where fewer than 2% of women birth at home.
During the 1970s AIMS and other groups campaigned for the right to a home birth on the basis that the woman had a right to decide where to give birth, primarily because they had no research evidence to refute claims for hospital safety. In 1980, Marjorie Tew, a respected statistician, published her analysis of mortality rates at home and in hospital(2) and found that, even for women who had been considered high risk, home was a safer place to give birth. AIMS changed tactics and began campaigning on the grounds of safety, as well as choice. (Since that time other research has been undertaken, concluding that planned home birth is as safe as hospital birth(4). This research only considered mortality, it did not take into account the huge amount of morbidity following hospital births).
Despite protests from consumers the home birth statistics continued to fall. Midwives were being instructed by their Trusts to 'encourage' women into hospital. As a result, AIMS pressed the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC), the midwives' regulatory body, to publish guidelines to make it clear that a midwife was required to attend when called.
In June 2000, after a great deal of lobbying, the UKCC produced a Position Paper 'Supporting women who wish to have a home birth'(3). This document merely served to exacerbate the problems. While the advice to the midwife, faced with a woman determined to stay at home, was that 'the midwife should not withdraw care but should report the decision to her supervisor of midwives and seek her advice'. Unfortunately, it also said that 'it is the employed midwife's primary contractual duty to carry out the wishes of her employer, although the employer could not expect an employee to do anything illegal, including anything which contravenes the midwives rules. 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 put the midwife in an impossible position - support the woman and defy the Trust (and be disciplined or dismissed) or obey the Trust in the knowledge that disciplinary action would not be taken. Most midwives toed the Trust's line.
As a result of the UKCC's failure to support midwives who were trying to provide a home birth service, many women were faced with reluctant midwives and a lack of support. Some women decided to give birth alone because they lost confidence in their midwives or felt they had little option when faced with continuous negativity. Many women resolved to call the midwife at the eleventh hour and pretend that the baby arrived so quickly they were taken by surprise. While a minority deliberately chose to birth alone the majority did so because they saw no alternative.
In March 2002 the UKCC was disbanded and in April that year the Nursing and Midwifery Council (NMC) was established. This new Council has a Midwifery Committee responsible for all midwifery issues and the majority of its members are practising midwives. Once again, AIMS lobbied for a new Position Statement, pointing out that as a result of the UKCC's weasel words we were now facing a serious public health issue where women's and babies' lives were being put at risk by midwives' failure to act on their professional responsibilities and their Trust's wish to get every woman into hospital. All the lay members of the Midwifery Committee supported the call for new guidelines and, unlike the previous Committee's members, the majority of the midwives on this Committee recognised the need and resolved to address the issues.
On the 13th March 2006 the NMC published 'Midwives and Home Birth' a new circular advising midwives of their responsibilities when a woman decides to birth at home.
This circular is robust and makes the midwives' responsibilities crystal clear. Because of its importance in clarifying the rights and responsibilities of mothers and midwives we have published it in full and recommend that any woman deciding to birth at home should obtain a copy which can be downloaded from www.nmc-uk.org
This statement clarifies the rights of women, the responsibilities of midwives and the obligations of Local Supervising Authorities in a way that we trust will contribute significantly to the provision of safe and appropriate maternity services.
This circular explains the current regulatory framework within which midwives practise and replaces any previous guidance relating to home birth. It has become necessary to issue this circular, as the previous statement Supporting women who wish to have a home birth,1 needed clarifying as it touched on some employment issues that are not within the remit of the NMC.
The information in this circular is relevant to:
The core function of the NMC is to establish and improve standards of nursing and midwifery care in order to serve and protect the public. These standards for education and practice are required for registration or maintenance of registration as a nurse or midwife.
Midwives are required to work within the NMC Midwives Rules and Standards2 as well as the NMC Code of professional conduct: standards for conduct, performance and ethics.3 (the Code) As a member of a self-regulating profession, as well as being required to work within the law, a midwife is responsible for meeting the ethical standards set out in the Code and the Midwives Rules. This applies to all midwives whether in a clinical, managerial, education or statutory supervision related role. It is explicit in these standards that midwives should:
Government policy in all four countries of the UK is to promote choice for women in relation to their pregnancy care and place of birth. This includes being able to access midwifery care for birth at home. Nonetheless, the NMC continues to receive queries from women and midwives who are concerned that women are having difficulty in accessing home birth. The most common barriers identified to the NMC are
Midwives are experts in normal birth and the NMC's standards require them to be competent to support women to give birth normally in a variety of settings including in the home.
To practise competently in caring for women who wish to receive midwifery care, regardless of setting, a midwife must possess the knowledge, skills and abilities for lawful, safe and effective practice without direct supervision. This will include competent care throughout the antenatal, intranatal and postnatal periods.
As a member of a self-regulating profession, each midwife is responsible for maintaining her own competence. This includes any professional updating in relation to provision of care at a home birth. Whilst a midwife must not provide care that she is not competent to give, it is not acceptable to refuse to care for a woman on this basis and take no further action.
Birth at home is physiologically no different from birth in hospital. It is true that if there is a deviation from normality, it may demand a different approach from that on a hospital site where assistance may be immediately available from a number of sources.
It may be that a midwife does not have the experience required to care for a particular woman at home. In order to fulfil her duty of care she may:
A midwife providing care to women, regardless of the setting, must take care to identify possible risk and pre plan to mitigate those risks through her approach to care, knowledge of local help systems and communication with colleagues and the woman and her family.
Research over the last couple of decades suggests that home birth is at least as safe as hospital-based birth for healthy women with normal pregnancies4.5 6 7 8 There are some very clear categories of women for whom obstetricians and midwives would be positively recommending a hospital birth. There is also an 'intermediate' category of women who have factors associated with their pregnancies or with themselves or their baby, which potentially increase the risk of an adverse outcome.
Women can make the choice for a particular place of birth at any stage in pregnancy. The presence or absence of risk may change during pregnancy and labour and the midwife must continuously assess the advice she gives to women about the place of birth. Conflict sometimes arises over whether or not the woman is making a choice that places her or her unborn child at risk. Risk is a complex issue; however there is no system currently available in the maternity services, which helps elicit absolute risk or accurately predicts adverse outcome9. In assessing where a woman is best advised to give birth, the midwife should give consideration to factors pertinent to the woman's individual and unique situation. Midwives may have some anxieties if there is a clash of a woman's choice versus the perceived risks of caring for women in a home setting. If there is a clash then the midwife must continue to give care but can seek support by discussing her anxiety with her supervisor of midwives.
The supervisor of midwives will discuss how the midwife may reduce any risks inherent in a woman's choice of home birth. It is good practice for the midwife and the woman to agree a plan of care and the action that will be taken should problems arise. It is a midwife's duty to make all options and choices clear and to respect the choices a woman makes if she is legally competent to make that choice. The midwife should document the advice she has given to the woman in the maternity record.
The NMC recognises that it can be diffi cult for midwives to balance the regulatory requirements, needs of women and the demands of service provision. Where there is time, most problems that relate to resources can be avoided by good planning.
If a midwife is concerned that a woman is making a choice that is not readily available, she should make her concerns known to the manager of the services in the fi rst instance. If this is not successful in resolving the problem, the midwife should also make this known to her supervisor of midwives who has a duty to assist midwives in supporting women's choices.
Whilst an employed midwife has a contractual duty to their employer, she also has a professional duty to provide midwifery care for women. A midwife would be professionally accountable for any decision to leave a woman in labour at home unattended, thus placing her at risk at a time when competent midwifery care is essential. It would be good practice for every local supervising authority (LSA) to have a plan of action in place to support home birth. This can be included in the standards for annual auditing of supervision of midwifery and midwifery practice in local areas. If a woman seeks advice in relation to her wish to choose a home birth, she may obtain advice from the LSA midwifery officer and seek help from the LSA. LSA midwifery officers, supervisors of midwives, and managers who are registrants on the NMC Register have a duty to support midwives to work within their professional standards for practice and to promote the Code. This includes offering choice of home birth to women.
Should a conflict arise between service provision and a woman's choice for place of birth, a midwife has a duty of care to attend her. This is no different to a woman who has walked into a maternity unit to receive hospital care. Withdrawal of a home birth service is no less signifi cant to women than withdrawal of services for a hospital birth.
In summary, all midwives have a responsibility to ensure that all women receive care that is based on partnership with women and which respects the individuality of a woman and her family. Women have the right to make their own decisions on these issues if they are competent to do so and midwives have a duty of care to respect a woman's choice. The standards confi rm that women using midwifery services have the right to expect safe and competent care from any midwife who holds registration in the UK, and that midwives will provide them with evidence based information so women can make choices for care including place of birth. The standards therefore protect women and, at the same time, protect midwives by providing a sound framework for their practice. Enquiries about the contents of this NMC Circular should be directed to the Midwifery Department on 020 7333 6545 or e-mail midwifery@nmc-uk.org.
Sarah Thewlis
Chief Executive and Registrar
AIMS sent the following official comment to the NMC For the attention of Jonathan Ashbridge, President, Nursing and Midwifery Council
The AIMS Committee would like to express their support and agreement with the NMC Circular 8-2006, 'Midwives and home birth' that was issued in March 2006. This statement clarifies the rights of women, the responsibilities of midwives and the obligations of Local Supervising Authorities in a way that we trust will contribute significantly to the provision of safe and appropriate maternity services. Gina Lowdon, AIMS Hon Secretary
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