Home birth, the normal option

AIMS Journal, 2008, Vol 20 No 3

AIMS Vice Chair Nadine Edwards looks at what helps and hinders normal birth

Sally Willington, AIMS's Founder and President sadly died on 6th September 2008. She founded AIMS in 1960 following her experiences of being isolated and uncared for during her pregnancy and birth in hospital. She felt so strongly about this that she initially named the organisation The Association for the Prevention of Cruelty to Pregnant Women. What a stroke of genius, and what foresight and courage, to found a lay organisation to campaign for better maternity services, based on women's actual experiences, at a time when lay involvement was considered a kind of insubordination, and when professionals definitely 'knew best' and pregnant women apparently knew nothing at all.

When Sally first founded AIMS, one of its campaigns was for more hospital maternity beds, as there were too few beds for those women who needed to give birth in hospital because of complications. As we know now, those were complications related to ill health from extreme poverty, a lack of safe contraception and overcrowded living situations. Hospital birth became the norm in the 1960s and 1970s. This trend intensified after the Peel Report in 1980 which recommended beds for all birthing women and medicalised birth became the norm. As women shared their experiences with AIMS and other organisations about the impact on them of the use of routine medical procedures and drugs during labour, and as AIMS members listened to their stories and read the research, the focus changed from getting some women into hospital to getting healthy women out of hospital, and campaigning to reduce the use of the often poorly researched and unresearched medical interventions and drugs in childbirth.

While campaigns have changed, what Sally initiated lives on. AIMS continues to listen to women, and to base its work on their experiences, because women themselves know best of all how maternity services impact on childbearing and ongoing family life. This is clear from many of the following articles, especially Melanie Hughes's, on page 20.

It is perhaps a reflection and critique of both rhetorical change and the reality of the challenging struggle over birth issues, that many of the articles focus on home birth. There are many political strands to this issue that are woven through the words of our contributors. One of these strands is to do with the dismantling and fragmentation of health services. As readers will know from previous AIMS Journals, and from their own experiences of local services, health care and other forms of social care are under increasing financial pressure which has led to greater rationalisation, standardisation and centralisation, despite government and health service rhetoric to the contrary. These influences shaped the recent report, 'Safe Births: Everybody's business' which focuses on technological safety rather than holistic safety (see page 18.)

We see how the rationalisation of health services impacts on maternity care very directly though our AIMS calls. At our helpline, we answer questions from the public, and over the last months, many of these calls have come from women planning home bir ths who are facing obstacles to their plans. The interweaving of older paternalistic and patriarchal influences with recent 'modernising reforms' of hospital and primary care trusts, and how this impacts on how birth is seen and 'managed' is highlighted in the articles in this Journal. They explain how difficult it is for women to retain autonomy around birth, and why it is so important that women are supported to make decisions they believe are right for them, and have access to good quality holistic midwifery care, and appropriate, sensitively used technology, if it becomes necessary.

The patriarchal attitudes and practices described by Gina Lowdon in the last edition of the AIMS Journal and the reduction of health care that impact negatively on birthing women, impact just as negatively on midwifery and midwives. They can be divisive, creating fear among midwives that women will not comply with their local policies and protocols, and will make demands on them that they are unable to meet because of the stress and burnout caused by midwifery shortages, as our first article describes. So while shortages are very real indeed it can become a standard reason for discouraging women from planning home births without understanding that the problem is not the 'stroppy women' referred to by Mavis Kirkham on page 14 but the way in which maternity services are resourced and provided. This might also mask other issues to do with the control of women during childbearing, as illustrated by the quote on page 9. We can see from the articles included in this Journal, that when birth is medically dominated, midwifery practice is medically dominated. When midwives are also over-stretched and unable to provide the kind of care many would like to provide, they lose, or are unable to develop the midwifery knowledge and skills they need to attend women skillfully and confidently out of hospital, knowing they will be supported by colleagues. This is surely one of the key issues to safe birth, as Sarah Davies's article makes clear.

In women's and midwives' discussions about birth, trust and relationships usually feature prominently.² As Sarah Davies's, Ruth Weston's and my articles suggest,standardisation of practices and fragmented care are not only deeply unsatisfactory for all, but do not lead to safe, holistic care or increased skill to promote and protect straight forward births. We must continue to gather up and share the knowledge and skills needed for midwives to practice competently and supportively. Home birth conferences, such as the Sheffield one (report on page 12) do just this. This conference, organised by Michelle Barnes and Olivia Lester, and books such as those by Anne Frye and Mary Stewart reviewed on page 24 provide a great deal of theoretical and practical tools, which, if we can integrate, provide both women and midwives with solid ground to work from, in their campaigns to improve maternity services. We will continue to develop and build on all of this work, as we know that midwifery care improves outcomes for women and babies as Melanie Hughes so poignantly tells us.

All of the issues raised highlight how crucial it is for women and midwives to work together politically in the ways suggested by Ruth Weston. Indeed, the current collapse of the free market economy may work in some ways to our advantage and give us more leverage to persuade Governments to be more accountable to the public. Over the last years we have seen a developing situation whereby, on the one hand the Government and its various worthy reports have accepted that women should have the choice of where they give birth and that for healthy women, home birth and births in free-standing midwifery units are safer than being 'delivered' in large centralised obstetric units. On the other hand it has been reducing resources available to Trusts, encouraging rationalisation and privatisation and then distancing itself from decisions made by Trusts faced with too few resources. This has led to a gap between the rhetoric of the Government and the reality of maternity services.

Finally, in 2010 AIMS will have been campaigning to improve maternity care for 50 years and, perhaps, by then we will be able to celebrate a real change in maternity care, and a significant return to birth at home or in small, free standing, midwifery units. If this occurs then those women with medical complications who really need high technology obstetric care will be better able to receive it. Our sadness will be that Sally Willington died before she could celebrate with us. But her foresight, determination and energy will continue as the banner is continually taken up by other women who recognise the importance of a good birth experience for the mother, the baby, the rest of the family and our whole culture.

References

1. Lowdon, G (2008) Culture Clash, AIMS Journal,Vol 20, No1, p3-6.
2. McCourt C, Stevens T (2009) Relationship and Reciprocity in Caseload Midwifery. In B Hunter, R Deery (Eds). Emotions in Midwifery and Reproduction. Basingstoke, Palgrave Macmillan pp 17-35