APPENDIX 36
Memorandum by the Haringey and Enfield
Home Birth Campaign (MS 45)
INTRODUCTION
The Haringey and Enfield Home Birth Campaign
is a group of concerned parents who oppose plans by the North
Middlesex University Hospital (NMUH) to disband its team of specialised
home-birth midwives. The group is supported by the local National
Childbirth Trust, local MPs and numerous national maternity figureheads.
Tessa Thomas, a health journalist and mother of three children
born at home, is the campaign manager.
1. HISTORY OF
NMUH HOME-BIRTH
SERVICE
1.1 The home birth team run from the NMUH
was set up in 1993. An innovative flagship service, it provided
total midwifery care to any woman requesting a home birth or hospital
water-birth. It increased home birth rates, decreased intervention
rates, guaranteed continuity of carer and extended the choice
of a home birth to all parents; it became highly valued by the
local community.
1.2 In 2000, with a home-birth rate of three
times the national average, the NMUH announced plans to integrate
the Home Birth Team into the core community midwifery service.
Reasons given for this policy included cost, safety and equity.
Each of these reasons was withdrawn when evidence was provided
that the service was cost-effective, had "an exemplary safety
record" (according to the Director of Public Health) and
had increased the rate of home birth in the boroughs' most deprived
areas.
1.3 More than 2,000 parents, 40 GPs (out
of 46 GPs questioned) and 97% of all the NMUH midwives registered
their opposition to the integration plan. Implementation was delayed
three times over the next two years but went ahead in December
2002.
1.4 Between the announcement of the plans
and their implementation the team was cut back: Midwives who left
were not replaced and the team's services were not publicised.
Home birth rates fell from their peak of 8% to 3%.
1.5 The integrated system that is replacing
the Home Birth Team is set to accelerate this decline. Early indications
are that fewer midwives are offering home births and some are
even advising women to book elsewhere.
2. STAFFING
2.1 A shortage of midwives means that many
are not offering the option of a home birth. To do so would mean
they may be required to work at night on home births and still
run clinics the following day. Further, they could not rely on
the attendance and support of an experienced home-birth midwife,
as these home-birth midwives have lost their flexible working
arrangements and have to be on call to their own geographically-restricted
team at specified times. The number of community midwives was
halved in 1999 from 64 to 30.
2.2 There are now areas not covered for
home birth care for a 16 hours a day; this period includes the
night, when most home birth occur. Each of the six community teams
was due to start up by January 2003. But two of these teams are
still not in operation. Because the experienced home-birth midwives
have lost their relative autonomy, they cannot commit to cover
these two areas as they would otherwise wish. Both of these (N15
and N17) are underprivileged communities, which the hospital committed
itself to target in order to safeguard equity.
2.3 There have been problems recruiting
and retaining heads of midwifery, resulting in frequent changes
and subsequent unrest among midwives. The current head of midwifery
was appointed internally because both external candidates withdrew
late in the selection process.
2.4 Continuity of carer has been lost. The
hospital management had assured concerned parents that although
the Home Birth Team was being disbanded, the new community teams
would still be able to offer women continuity of carer through
a system of "caseload midwifery". However, this has
been diluted and "group caseload midwifery" is operating,
meaning that women will not have a named midwife during their
pregnancy or delivery.
2.5 Overtime costs are set to increase:
midwives inexperienced in home birth are likely to attend mothers
earlier and to call a second midwife earlier in labour.
3. PROVISION
OF TRAINING
3.1 Training in home birth has been minimal
despite a real perceived need for it. Despite objections by midwives,
management had removed the on-call system which gave the community
midwives regular hands-on experience at births. The community
midwives had not been on-call since 1999 so had assisted at relatively
few births in recent years. In the run-up to integration, some
of the midwives joined the Home Birth Team for a fortnight but
few births occurred in that time. Others had two weeks' training
in natural delivery at the Edgware Birth Centre. Very few had
any hands-on home-birth experience before being on call for domiciliary
deliveries from December 2002.
3.2 The training provided has not enabled
community midwives to book any woman requesting a home birth.
They are only taking on women who constitute a very low risk under
new restrictive criteria. The Home Birth Team midwives offered
home births to all women.
3.3 If midwives were fully trained in home
birth and confident in their skills they would now be advising
low-risk mothers-to-be to book for a home birth. But many women
say they have not been offered the option of a home birth or have
been advised instead to book with the Edgware Birth Centre for
a home-like birth. The Edgware Birth Centre is a low-tech birthing
unit. But it is not a local service and has a significantly higher
rate of transfer to hospital and lower rate of spontaneous vaginal
delivery than the NMUH Home Birth Team was providing.
4. CAESAREAN
SECTION RATES
4.1 Caesarean section rates among mothers
booked for a home birth are now very likely to rise. Rates under
the Home Birth Team over the past nine years have been consistently
low, at an average of 4%. (This is despite the fact they cared
for high as well as low-risk women.) The caesarean section rate
on the NMUH labour ward is 20%. Research suggests that the average
caesarean rate on integrated teams is more than 10%. A concordant
increase in the NMUH home-birth caesarean rate will not only remove
the mothers' choice regarding place of birth but increase the
cost of its home-birth service.
5. COLLECTION
OF DATA
5.1 Record-keeping in respect of home births
has been poor. A revised calculation of home births direct from
the hospital's birth register (requested by the Home Birth Campaign
and carried out by the home-birth midwives) has shown that the
hospital's own data were flawed. They underestimated the number
of home births and overestimated the number of transfers to hospital,
suggesting a lower level of performance than was the case.
RECOMMENDATIONS
1. Set a national target for home births
of no less than 10%. [The NCT estimates 16% of women would like
a home birth. The Welsh assembly recently set a target of 10%.
Baroness Noakes said in a recent Lord's debate that the unmet
demand for home birth is "at least 10%".]
2. Provide full training for all midwives
interested in home births that enables them to feel both confident
and competent.
3. Require all hospitals considering integrating
or otherwise reconfiguring services to provide the Primary Care
Trust with forecasts of the impact on home birth rates, based
on empirical evidence.
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