APPENDIX 4
Memorandum by The Association for Improvements
in the Maternity Services (AIMS)
1. Introduction
1.1 The Association for Improvements in
the Maternity Services (AIMS) is a voluntary organisation, established
in 1960. Although we have received a small grant from the Community
Fund the AIMS Committee comprises entirely women who give their
time freely to help other women and their partners, to obtain
care that is appropriate to them. In order to do this we:
— Respond through our telephone help
line to enquires about how to access the kind of care appropriate
to each individual.
— Give information about obstetric
and midwifery practice.
— Give information and advice on how
to complain effectively about poor maternity care.
— Liaise with other organisations,
including similar groups overseas.
— Respond to requests for information
from health authorities and health professionals.
— Produce a quarterly Journal.
— Monitor obstetric and midwifery journals
and text books, and produce our own information leaflets and books.
— Support individuals throughout the
UK and Ireland who seek to improve maternity care.
1.2 The majority of the calls we receive
are from women who have had poor care, or who are unhappy with
the care they are receiving and are trying to find something better.
We also hear from women who have had satisfying and successful
births.
1.3 The accounts of women's experiences
enable us to identify potential problems and it also gives us
an insight into the huge importance a successful birth can achieve.
2. The Mirage of Choice
2.1 Unfortunately the word "choice"
when applied to maternity care, is frequently mis-used and misunderstood.
For the majority of women, choice in maternity care does not exist.
Choice is a word usually used to describe choices in the marketplace—choosing
one brand of washing powder rather than another. It is also used
to describe personal choices—choosing one activity rather
than another, or how or whether to pursue a relationship. When
a word with such a commonly understood meaning is used to describe
giving labour and birth, it can be not only misleading, it can
be positively dangerous.
2.2 "Choice" in pregnancy and
birth care often represents the expression of a deep and fundamental
instinct in the woman as to what is best for the safety of herself
and her child not just physical safety, but emotional safety.
Birth is not just a physical happening but a social and psychological
event. By listening to the signals from her body, her hormones,
and the child within her, she "knows" what is necessary.
For example many women tell us how unhappy they are at having
to lie flat on their backs in labour (a position which research
now shows reduces the blood supply to the baby), or give birth
lying on a bed when they knew they needed to be upright, to squat,
or to be on all fours.
2.3 Despite considerable evidence of the
risks to the mother and baby of labouring and birthing in a prone
position we are concerned at the numbers of maternity units where
a centralised labour ward bed is common and the majority of women
give birth on their backs. If women are encouraged and supported
to move about as they wish, those with babies in awkward positions
will automatically move in a way which reduces their level of
discomfort but also enables the baby to descend. A feeling of
emotional safety supports the production of oxytocin—the
natural hormone which creates and maintains labour. Respecting
the woman's "choices" affects the outcome of normal
labour and birth. It is not a decorative "extra"; it
is crucial for the process. Failure to respect these choices,
and imposing procedures on women, or manipulating them into agreeing,
can result in post traumatic stress disorder. (Robinson J.(2002))
2.4 Just as many animal studies have shown
that mammals usually seek quiet, dark places to give birth, and
that labour will stop if they are disturbed, so many women find
labour which has progressed normally at home, stops when they
enter hospital.
2.5 When having their first child in a developed
society, many women are not tuned in to what their bodies are
telling them, or do not have the confidence to challenge, and
they go along with what professionals tell them to do. Most often
it is after the first birth, when expecting a second baby or trying
to pluck up courage to have a second baby, that women approach
AIMS, telling us that they realise the care they had for their
first child did not meet their needs, and that it was not only
wrong but damaging. The wellspring of pressure groups like AIMS
and educational groups like the NCT, comes not from a few campaigners
but from a continual stream of women who have experienced the
standard maternity care offered in the UK today, and know that
they need something which is vastly different—care which
respects them and the ability of their bodies to give birth. For
the majority this kind of care is not available.
FACTORS THAT
INHIBIT CHOICE
3. Fewer Maternity Units
3.1 The first restriction on choice comes
with the concentration of maternity care into fewer and fewer,
and larger units. The Department of Health does not even have
statistics on how many maternity units there were, and how many
have been lost. Small (and even large) maternity units including
GP units have been closed, despite many hard-fought battles from
local communities, so that most women will in effect have no choice
but to enter their one large local unit.
3.2 As we know from 40 years' experience
of consumer comments, the culture of any individual maternity
unit is very long lasting and the statistics bear this out. High
intervention units remain high intervention units. Some units
are—and remain—more paternalistic and even authoritarian
in their attitudes towards their local populations than others.
Whatever the woman "chooses", her chances of getting
the care right for her, depend firstly on whatever the ethos of
her local unit may be—an ethos in which obstetricians, not
midwives, are dominant. As we know from the latest statistics,
only 45% of women in England give birth without intervention (Dept
of Health, 2003)—and many such births would still not rate
as "normal" by our definition, or that of the women
who experienced them. We believe that the statistics for Northern
Ireland are likely to be worse.
3.3 Despite the Government's assurance that
there would be no more closures of small maternity units local
Trusts are still trying to close many small units, despite vigorous
opposition from local people. For example, Wiltshire Primary Care
Trust, in an attempt to reduce their multi-million pounds debt
propose closing a small midwifery unit in Devizes. The midwifery
unit is under-used, primarily because local GPs either do not
inform women of its existence or discourage women from going there.
If this unit were properly promoted many more women would use
it. Instead, the women will be denied the opportunity of giving
birth normally in small, local, low technology units and instead
will be channelled into the large, centralised, obstetric units
where normal birth in the majority of these units barely exists,
and huge amounts of money is wasted on unnecessary and avoidable
interventions which frequently lead to operative deliveries.
4. Midwifery Units
4.1 Although these are to be welcomed—at
last a token replacement of much that was swept away—there
is a difference between "stand alone" units and those
which are part of a centralised obstetric unit. With those attached
to hospitals, the obstetric culture "creeps under the door",
and although separate units often do better, many still have higher
transfer rates and higher exclusion rates than would be expected.
For example, women expecting a first baby may be excluded.
5. Choosing hospital birth
5.1 In theory, women have the right to decide
where to give birth, however, as the services have been centralised
and Trusts have drawn imaginary boundaries around themselves women's
choice of unit is severely restricted.
5.2 Those women who have had traumatic and
distressing first births often refuse to return to the same unit
for the birth of their next baby and often meet with considerable
resistance from their GPs when they are asked to refer them to
another unit. If they approach the hospitals directly they are
often told that as they are outside their area and they cannot
be admitted.
6. Choosing a Caesarean Operation
6.1 The majority of women contacting AIMS
do so because they wish to avoid a caesarean operation. We have,
however, been contacted by a minority of women who want to have
a caesarean operation because they are very afraid of giving birth,
usually as a result of previous birth experiences which ended
up with either a forceps or ventouse delivery or a caesarean operation.
They want an elective caesarean for the next child in order to
avoid the trauma. The propaganda about caesarean operations suggests
that it is an easy option and totally safe, so many women, made
fearful of birth by the constant portrayal of birth as a painful
and dangerous process see caesarean operations as a quick, pain
free and risk free option that can be conveniently fitted into
their busy diaries.
6.2 It is ironic that at a time when the
majority of caesarean operations are avoidable and in many cases
unnecessary those women who want a caesarean section often cannot
get one. The very obstetricians who have high rates of caesarean
operations appear very reluctant to carry out a caesarean when
it is the woman who is pressing for action. However, women who
request a caesarean seldom experience the hostility which is routinely
seen by those who want home/water/non-intervention births.
7. General Practitioners (GPs) as `gatekeepers"
for maternity care
7.1 Changing Childbirth recommended that
"Purchasers should ensure through their service specifications
that women can book with a midwife for their entire episode of
care and ensure that all women who become pregnant are informed
about this option". (Changing Childbirth, p18). This recommendation
has not been acted upon by the majority of Trusts. As a result,
women are still informed that once they become pregnant they should
book with their GP. GPs do not give women information about the
choice of place of birth and usually book the woman into the nearest
centralised obstetric unit. The woman is then subjected to "shared
care" and denied continuity of care that they could get from
midwifery-led care.
8. Referral to a consultant
8.1 Women are often referred to a consultant
obstetrician to "discuss" their decision and this discussion
is used as an opportunity to coerce the woman into accepting hospital
delivery.
`The consultant I saw stated I could have a vaginal
birth at the hospital as long as I delivered within 10 hours and
consented to continual monitoring. He then wrote in my notes that
I had agreed. I had not. I stated my intention to have a homebirth
at which point he shouted in my face and forbade me from birthing
at home, it was necessary that I remind him that I had a legal
right to birth at home. He was rude and intimidating and implied
that awful things would happen to me and my baby, I was stood
on the edge of a cliff about to jump off, and that I was a bad
person who was threatening my child.
He then required me to have a glucose tolerance
test and various scans (my first child, as with all babies in
my family was a healthy 10lb 7oz—he could not accept that
I had no glucose in my urine or that my broad pelvis could accommodate
a large baby). The scan was to scare me into believing the baby
would get stuck and to encourage a second caesarean.
Mrs A—7.4.03
9. Booking an independent midwife
9.1 AIMS often refers women to independent
midwives as these are the only midwives in the UK in whom we have
confidence that the woman will be the centre of care and the midwife
will listen to what she wants and will do her best to provide
appropriate care. While there are NHS midwives who have similar
philosophies their involvement in a woman's care cannot be guaranteed,
as they often work on shifts and do not carry their own case loads,
and as Nadine Edwards has shown in her PhD study (2002), NHS midwives
tread a difficult path between trying to provide what the mother
wants while also trying to satisfy the demands of the Trust and
senior managers.
9.2 While Trusts are not willing to give
Independent Midwives a contract to deliver babies in hospital
they are often more than willing to refer a woman, whom they consider
to be "high risk", to an independent midwife, rather
than send their midwives to attend her.
`The Trust policy regarding the progression of
labour in to the second and third stage, is that the mother will
leave the birthing pool. The Trust does not have a team of trained
and competent midwives to assist in the second or third stage
of delivery if the mother remains in the water . . . . . Of course,
you may wish to employ an independent midwife to assist with a
water pool delivery, but this would be at your own discretion.
The Trust is not obliged to employ an independent midwife to provide
the services you request. It would not be acceptable for the Trust
to agree to this, as the Trust would not be able to ensure competence
and professionalism of said midwife, at such short notice. Any
short fall in professionalism or services provided by such an
independent midwife would also be your own responsibility. You
may wish to contact: Thames Valley Independent Midwives (The midwives'
names, telephone numbers followed).
Mrs B—2003
10. Trust Lawyers
10.1 Whatever pressures may come from the
Department of Health at the top, or consumers (and many midwives
at the bottom) it seems impossible to get the leverage to bring
about changes at Trust and management level, and the re-allocation
of resources which would be required to enable women to give birth
in free standing midwifery units and make home birth a truly available
choice. We are getting an increasingly strong picture that policy
and attitudes of Trust officials are being over-influenced by
lawyers who have in fact become back-seat drivers—lawyers
who do not understand the literature, and misunderstand both safety
and clinical issues and are not, in fact even giving very good
legal advice. (We speak as an organization with considerable experience
in litigation, which has close contacts with Action for Victims
of Medical Accidents and which supports some clients throughout
legal actions)
11. Lack of information
11.1 Few women realise how ill-informed
they are about maternity care. Some of them will attend antenatal
classes at their local hospital or GP clinic and will invariably
be given information that the staff want them to have, invariably
limiting choice to what the hospital wishes to offer, some will
increase their knowledge by attending National Childbirth Trust
antenatal or Active Birth antenatal classes and some will not
attend any classes at all.
11.2 The amount of information leaflets,
booklets and books available from lay groups has increased enormously
since AIMS inception in 1960. It is a reflection on the failure
of the maternity services to provide information that enables
women to make informed decisions that lay groups felt the need
to produce their own material as they could not rely on local
information leaflets. Unfortunately, very little lay information
is advertised or available on NHS premises.
11.3 The Midwives Information and Research
Service (MIDIRS) has produced a series of research based information
leaflets for both the mother and the midwife. Few Trusts have
purchased these and research on the availability of these excellent
leaflets by Professor Mavis Kirkham (2002) revealed that they
resulted in "informed compliance" rather than the intended
"informed consent". Trust policies and views of local
professionals ensured that the leaflets were over-ridden, ignored,
or not given out at all.
11.4 The North West Lancs. Maternity Services
Liaison Committee produced a leaflet about the choices in maternity
care locally that was research-based, factual and readable. The
Health Authority was unable or unwilling to fund the costs so
the local Community Health Councils funded it. None of the PCTs
would support the leaflet and only one of the four local maternity
units agreed to supply a copy to every mother booking there. Local
GPs have refused to give it to local women on the grounds that
it mentions home birth and emphasised the role of the midwife.
Their opposition has ensured that local women are prevented from
exercising choice or even knowing that that had one.
12. Hospital Protocols
12.1 Women are unaware that care is provided
in a pattern dictated by a series of protocols. In many hospitals
these policies are not worked out in accordance with evidence-based
research but are based on the opinion of obstetricians and selective
research depending upon whether or not it fits with the obstetric
views. However, as those of us who read the research know, the
outcomes measured and by which a treatment is judged "successful",
seldom include emotional or psychological outcomes and we see
a different picture (e.g. on induction of labour).
12.2 Protocols also cause a pattern of rigidity
of response by staff, who feel safe if they "follow the protocol"—owever
unsuitable it may be for this woman at this time. Women are totally
unaware of this added barrier to their individual needs or choices
being met, which operates not only within the institution, but
also in community midwifery, which has also been institutionalised.
Women not only have to interact with an individual midwife, but
also with a set of invisible and unknown protocols, which provide
a shield of protection for the professional and can restrict not
only the midwife's flexibility but also her pattern of thought.
12.3 Faced with a client who is asking them
to go outside or beyond the protocol, the doctor or midwife can
feel threatened and the woman senses hostility even if it is not
expressed. In this situation, as we know from countless women,
they "comply" for fear of damaging their relationship
with those who may care for them in labour. Many have told us
they gave up and agreed to epidurals—not because they had
wanted them, but because they felt they had no hope of giving
birth as they wished to, and they might at least make it painless
and less stressful.
12.4 Many women are informed that they have
to comply with the hospital's procedures yet when they ask for
a copy of the hospital's protocols they are refused, or the staff
avoid sending them copies. Women are entitled to copies of the
protocols so that they can better understand what treatment is
available and appropriate, yet this is frequently denied them.
I requested a copy of the Hospital's Group B Strep
Protocol and I also asked for the Protocol for Premature Births.
I have received a letter from the hospital saying that the consultant
will discuss at the next meeting which is to be held on Monday
4th March 2002. I then rang the consultant's secretary again requesting
that we have a copy of both protocols. She later rang me back
to say that the consultant could not let us have a copy as they
are intended for hospital staff only. Mrs C—27.2.03
13. Labelling women as "high risk"
13.1 Defining women as high or low risk
has political implications. The medical definition of high risk
does not take into account the woman's perceptions and her views,
and her views may be very different from those of the doctors
and midwives. For example, it is common for women whose iron levels
fall below 10 to be told that they are at increased risk of a
post partum haemorrhage and, therefore, cannot be "allowed"
to birth at home. The woman may balance this increased risk (which
is not numerically defined) against the risk of going into hospital
where she will have only a 1 in 6 chance of giving birth normally
and consider that the risk of haemorrhage is less than the risks
of hospital birth. This view is ignored by many professionals.
14. Birth Plans
14.1 Much has been written about birth plans.
Some of us naively thought this might enable women to obtain the
kind of care they wanted. Birth plans have often been mentioned
by obstetricians as an indication of their flexibility and willingness
to adapt to women's wishes. Our response to that is: do doctors
know of any other form of medical care where users of the service
have felt it necessary to arrive with a piece of paper listing
all the interventions they do NOT wish to have, because they do
not have enough confidence to believe that unnecessary procedures
will not be used?
14.2 Many hospitals have developed their
own birth plans and these plans restrict the choices available
and guide women to consider only the care that the hospital is
offering. Few hospital birth plans give women sufficient information
to enable them to consider the issues involved and the kind of
care they want and the likelihood of achieving their objectives.
14.3 We receive many, many letters from
women saying that their birth plans were ignored, and had no effect.
All of my simple requests in my birth plan were
totally ignored. I was given an overdose of pethidine which I
believe caused most of the problems. I was put in stirrups, given
a temporary catheter and they tried to give me an epidural—all
against my will—the m/wife even wrote in her notes "catheterised
with consent!", I'm still furious. The outcome was a kielands
forceps in theatre, baby rotated & removed, forehead badly
scarred. I was given a spinal anaesthetic and also scarred &
still aching from the episiotomy from my cervix to almost my leg!—against
my will! Mrs D 10.10.02
14.4 Worse, birth plans may have adverse
effects. A recent study at one unit showed that women who entered
with a birth plan ended up with more interventions than those
who did not, and the conclusion was that attitudes of staff towards
them may have been hostile.(Jones M, 1998 and Robinson J 1999)
15. Time Limits
15.1 The imposition of arbitrary time limits
for birth is one of the major reasons for the excessive amount
of intervention that takes place in our centralised maternity
units. Medically-based maternity systems over rely on time and
take little or no account of the woman's own birth rhythms. This
is not a good basis for decision making in a physiological process
as obstetrically imposed time limits usually over-ride both physiology
and women's carefully made decisions.
16. Labour and Birth in Water Birth
16.1 It is users of the service, rather
than professionals, who have led the demand for availability of
pools for labour and/or birth, although some midwives have also
supported this. Many hospitals and units now have a pool, and
it may be advertised as part of the "choices" they offer.
What we found was that in many units the pool was used so seldom
that its advertisement amounted to a con trick on pregnant women.
Those who asked to use it always found it was unavailable—being
cleaned, needing maintenance, needing sterilising, etc.
16.2 At considerable capital outlay, the
Trusts had gone through the motions of meeting consumer wishes,
with no intention of following through. In other units—with
a different ethos—the pool was frequently used. The crucial
piece of information for a pregnant woman to obtain, therefore,
was not whether the unit had a pool, but how many woman gave birth
in it during the previous year. To this day, the only way a woman
can ensure that a pool will be available and that she can use
it, is to hire her own pool and to give birth at home. Even so,
there may be problems
16.3 A further restriction of choice is
in whether women are "allowed" to labour in water but
"not allowed" to give birth in it. (Oddly enough for
decades, to our knowledge, labouring women were encouraged to
sit in warm water in the bath, both in hospital and at home, to
help with pain and relax them. It is only when women started asking
for pools, that the issue became contentious and a subject for
research). For both hospital and home births, women were told
they would have to get out of the water to give birth. When at
home, we informed them that they could stay in the water—it
was their water and their pool—and any physical attempt
by the midwife to remove them, whether in a pool in hospital or
at home, could be assault. We have even had midwives instructed
by their managers to empty the pool forcibly if the woman at home
would not get out!
16.4 We have seen two cases of severely
traumatised women who were told they were about to give birth
and must get out. Either the midwives miscalculated or the shock
of suddenly increased pain inhibited the labour, because in both
cases the labour became a nightmare, that continued in the long
term, the birth was delayed, and the women have not recovered.
16.5 The next hurdle—and the commonest
one we see now—is the frequent response from Midwifery Managers,
that their midwives are not trained to do water births—whether
for home or hospital birth, and they are making no apparent effort
to arrange that training. Although there can be some anxiety and
even hostility from midwives, the main cultural influence here
is the manager. In view of pressures on staff, they may give this
low priority, but the main problem we have seen is downright hostility
from some managers, who are in any case unsupportive of home births.
I met with the same negative response when I tried
to discuss the possibility of a water birth only to be told none
of the midwives were "trained and competent" so I'd
be expected to get out of the pool for the delivery. I would not
agree to this and I threatened to have the baby unassisted rather
that risk being "forced" to get out at the last minute.
Mrs E—24.01.02
16.6 We see many cases where it is clear
that individual midwives are sympathetic, but they are prevented
by the ethos coming from the top, whatever the "officialspeak"
coming from the Trust may be.
17. Domino Births
17.1 Dominos (Domiciliary In and Out) where
a woman could go into the local unit accompanied, and delivered,
by her own midwife who would then return home with her and the
baby—have never been a reality in most areas, and now seem
to have disappeared entirely, almost without public comment. We
suspect that dominos originated at least partly as an official
sop to the public who were fighting the loss of home births, in
an attempt to provide an acceptable substitute. They never became
widespread, were provided for comparatively few women—usually
those who were in the know and otherwise would have insisted on
staying at home—and we have not heard of one for some years.
If available, they would be useful for some women, but a true
Domino means continuity of care by the same midwife which does
not exist anywhere outside the independent market.
18. Home Births
18.1 Research has shown that when women
are supported in their choice at least 10% would choose to give
birth at home. Examination of the home birth statistics in England
and Wales clearly reveals that in the majority of cases home birth
is not easily available, and in the majority of cases is vigorously
opposed, either overtly or covertly.
18.2 Factors which inhibit choice of birth at
home:
(a) The politics of applying a "risk"
status
(b) `Informing' women of the risks
(d) Hospital trained midwives
(e) Loss of apprenticeship-based training
19. The politics of applying a "risk"
status
19.1 Home birth has at last been proven
to be safe for "low risk" women—but a "low"
or "high" risk status is not based on firm clinical
diagnosis, but is often applied as a political weapon in the hands
of the professional, institutions, and individuals, and used in
effect to control women and as an excuse to opt out of meeting
unpopular requests.
20. Informing women of the risks
20.1 When a woman chooses a home birth she
will, invariably, be subjected to a lengthy and repeated discussion
of the `risks'. If she does not change her view this 'advice'
will be repeated constantly throughout her pregnancy. We have
yet to hear of a case where a woman was told of the risks of hospital
birth and some midwives have been taken aback when challenged
to detail those risks.
21. Medical antipathy
21.1 Although the safety of home birth has,
at last, been belatedly accepted—in the face of overwhelming
evidence—by government, the RCOG and the BMA, there is still
a time lag, particularly in general practice, in understanding
this, and in its true acceptance. What obstetricians "know"
from the literature, does not always govern practice when it conflicts
with their unscientific beliefs. Most obstetricians have never
seen, and therefore do not understand, normal birth.
22. Hospital trained midwives
22.1 The problem is compounded by the changes
that have taken place in midwifery. We now have a generation of
midwives who have trained in hospital, and have never seen normal
births. AIMS sometimes receives frustrated telephone calls from
midwifery students, nearing qualification, who have not yet seen
a normal labour and birth. Hemmed in by protocols, they are unaware,
for example, of the wide variation in length of labour which can
result in normal birth, or the "stop and start" labours
which enable the woman and the baby to rest before progress returns.
22.2 It is small wonder that they do not
have the confidence to go out and cope with supporting women at
home and helping to birth their babies. We have also seen a number
of cases where these midwives panicked unnecessarily and did not
know how to cope with normal aberrations. Experienced home birth
midwives (almost entirely independent, nowadays) have no problems
with these variations in the progression of labour, and are confident
in their judgment and their skills.
22.3 Every deviation—or alleged deviation—from
normality is seen as making a hospital birth necessary. We receive
a stream of calls from women, throughout their pregnancy, giving
spurious or exaggerated warnings of potential abnormality (on
which we obtain expert opinion whenever necessary). The pregnancy
becomes stressful and anxious as a result. It takes determination
to hang on to the hope of a home birth, and women feel they are
fighting the system, rather than being supported by it.
22.4 The commonest classic ploy is to inform
the woman towards the end of her pregnancy (usually around 36
weeks) that the staff cannot guarantee, or will not be able to
supply, a midwife because of staff shortages, with hints that
she would be "selfish" to try to take a midwife from
the labour ward. It now becomes a game of brinkmanship, with women
supported by us hanging on and informing the Trust that they will
give birth at home, come what may, and will hold them responsible
if they fail to supply care. We deal with at least one such case
a week, and often more. In the end a midwife is invariably supplied,
but by now she is seen by the woman as representing a domineering,
antagonistic system, which does not understand or support normal
birth, and it is difficult in those circumstances for the two
to create the intimate relationship which best supports birth.
`. . . I rang the hospital at 8.15pm (with contractions
approximately eight minutes apart),I was told that, although my
midwife was on duty, she and all other midwives on the labour
ward were too busy to com out to me, and I would have to go into
hospital if I wanted to see a midwife. I made the supervisor of
midwives on duty aware that my previous labour had been very fast—less
than two hours form start to finish . . . . The supervisor of
midwives informed me that it was possible that if I rang back
later, they might be less busy and able to send someone. I was
dealt with sympathetically, but the bottom line was clear—no
midwife was coming to my home. I rang again at 10.15pm (my contractions
were now four minutes apart) and, by chance, spoke to my team
midwife. She was very sympathetic, but still unable to come out
to me and asked if I would consider coming in either by ambulance
or car. I called the ambulance at 1030pm and left home at 10.50pm.
Within 10minutes, my contractions were three minutes apart and,
five minutes later, I was bearing down. Ten minutes after that,
the baby was born—on a petrol-station forecourt in the back
of an ambulance'. Mrs F, 2002.
22.5 Increasingly commonly we find that
the midwives supplied are either lacking in confidence and experience
to cope with home birth, or rigidly imposing a hospital pattern
of care (vaginal examinations to a timetable, rupturing membranes
to speed things up, despite the risks etc) and they simply do
not understand the ethos of supporting women. The gap between
the kind of care they provide, and that provided by true midwives
(who have had to migrate to the field of independent practice)
is almost unbridgeable. We have even had two cases of post traumatic
stress disorder after home birth care given by rigid hospital
midwives
23. The loss of apprenticeship based training
23.1 The fact that training became increasingly
academic and less apprenticeship based, has greatly contributed
to this lack of skill and confidence. Compared with the old domiciliary
midwives, much of the current cohort has in fact been de-skilled,
and it will take time and determination to recoup the knowledge
and confidence their predecessors had.
24. The Post Code Lottery
24.1 The result is that the woman who "chooses"
a home birth is likely to face difficulties—unless she can
afford £2,500 upwards for total care from a independent midwife.
This is a huge sum for most women—some have taken out loans,
or pay on instalments. Every woman we know who has experienced
this care has thought it worth every penny. It is very much a
postcode lottery. If a woman lives in Torbay, for example, she
will be welcomed and cared for by NHS midwives with enough experience
to be skilled and supportive, supported by a manager who believes
in home birth., In most areas she will be formally accepted—though
sometimes after a battle—but cared for by a team of possibly
8 midwives, so that she has no continuity, and has the added stress
of not knowing who will attend the birth.
25. Women with Risk Factors
25.1 Women have a legal right to give birth
at home, whatever their risk factors. We are often contacted by
women who are at some degree of possible risk (e.g. from a previous
caesarean or a baby presenting by the breech or low haemoglobin
levels) who want a home birth. This is usually for one of two
reasons—either they were so traumatised by their previous
birth that nothing will induce them to enter a hospital again,
or because they know their best chance of achieving a normal vaginal
delivery is to labour undisturbed at home.
25.2 The only people who will provide the
care they want are the independent midwives. Money gives the power
of choice. We find that they care successfully for women with
two or three caesarean scars, women expecting twins, women with
a breech baby. There are some transfers, but most achieve successful,
safe vaginal births at home. Statistics are shortly to be published
by this group.
25.3 The NHS, unfortunately, insists on
entry to hospital. As a result we have some very high risk women,
labouring and giving birth alone at home. Sometimes they cannot
even have their partner present, for fear that he will be threatened
with prosecution, even though the law does not allow them to do
that.
25.4 Women carrying breech babies are now
told in hospital that they must have a caesarean (after an international
trial (Hannah, 2000), the conclusions of which we strongly dispute).
I wonder if you can help me please. Although it
is early days (15-16 wks)
into my 3rd pregnancy my midwife took great pleasure
in forming me that xxx Hospital has a Caesarean only policy for
Breech Birth. Mrs F—4.3.03
I am a midwife too and my colleague has been diagnosed
with a breech presentation at 40 weeks of pregnancy. She is desperate
to avoid an elective caesarean section and wants to attempt a
vaginal breech birth. She has no support from the obstetric team
and has been told to transfer her care to another hospital! I
can't help but think that if a midwife cannot get the opportunity
to experience childbirth, what hope is there for other women?
The situation has been so frustrating to work and now its all
coming to a head. I would love to communicate with you over this
issue and attempt to change the situation for other women as I
fear that it is too late for my colleague. Mrs G.—24.1.03
25.5 Since almost all diagnosed breeches
are given a caesarean, young doctors are unable to acquire the
skills of vaginal delivery of a breech baby, so choice is further
restricted. Whereas once midwives in the home routinely delivered
breeches, this has been taken over by the doctors, so they too
have lost their skills. Once again, the remaining pool of knowledge
remains largely with the independent midwives.
25.6 Those women who are expecting twins
will also find considerable difficulty in arranging for a normal
birth and midwives are losing the skills of delivering twins.
With little or no evidence of benefit, women expecting twins,
if they are not told they have to have a caesarean operation,
will be required to labour on their backs, have an epidural in
situ 'just in case', be required to suffer continuous electronic
fetal monitoring. Not infrequently, the first baby will be born
vaginally but the second will be delivered by caesarean.
25.7 Hospitals often refuse to support a
woman's wish for a normal birth at home on the grounds that the
woman is 'high risk'. As a result, some women book independent
midwives so that they can be sure the midwives will respect their
wishes. The Trusts will inform the mothers that they are taking
a considerable risk in giving birth at home, and are prepared
to leave them unattended by refusing to send any midwives. Having
told the mother that they are abandoning her some are, nonetheless,
prepared to advise her to employ independent midwives.
`When my twin pregnancy was first confirmed I
was told I would not be allowed to have a home birth. On querying
this I was told that there would not be enough available staff
for a home birth away from the xxx hospital (3 midwives for a
twin labour). When I queried this again I was subsequently told
that the midwifery staff at the xxx had no experience of twin
births at home (and very little of hospital twin births either,
most taken on by obstetricians and medical staff) and would not
want to attend a situation for which they felt unprepared. I found
this a very disappointing situation, and I felt put in the position
of being unable to insist on attendance at home by qualified and
experienced staff. I wrote to the xxx to request that suitably
qualified staff were found from the NHS trust region to enable
me to have the birth I required, or an independent midwife, qualified
in twin home birth deliveries, be employed on my behalf. I received
no help on either of these matters and it was confirmed to me
that no suitably qualified staff could be found to attend a twin
home birth. I therefore had no alternative but to seek the assistance
of an independent midwife myself'. Mrs H—1999).
26. Social Services
26.1 Social Services were developed to assist
members of the community who had difficulties with their every-day
lives. In many areas they provide an invaluable service but they
have been subjected to considerable criticism of late for their
failure to act in cases of gross child abuse.
26.2 In recent years we have been contacted
by women who have either been threatened with Social Services
if they did not comply with what the staff wanted to do, or have
been reported to Social Services in order to pre-empt a potential
complaint about the quality of care they received.
The community midwife came to visit me today,
with her supervisor, and informed me that if I decide to go ahead
and have a home birth without a midwife or a doctor present I
would be breaking the law and face prosecution and prison, and
the baby would be removed by social services . . . the reason
I am writing is to find out if they can do this to me . . . I
mean all I want is to have a home birth-a wish that is being denied
to me. Mrs H—20.10.02
26.3 As we have said in our submission to
the Climbie Enquiry 'What we have seen of the quality of social
work in child care intervention, the way the system is run, and
the devastating and long lasting impact of such intervention on
families, has been deeply shocking' . . . . `The impression the
public gets from the understandably horrifying reports such as
those on the Climbie case is that social workers should be removing
more children, more quickly. The lesson we learn from such cases,
however, is that the same errors—failure to investigate,
failure to use commonsense judgment, failure to coordinate evidence
and evaluate it—are being made when there is unnecessary,
clumsy, or over-prolonged intervention—and the resulting
damage is enormous'. (Beech and Robinson, 2002)
27. Obtaining the case notes
27.1 Those families who challenge the allegations
made against them are advised to obtain their case notes. This
can be difficult enough in the NHS, and Trusts, increasingly,
are attempting to charge £50 for each set of case notes.
If the mother requires her own case notes, the GP's notes, the
baby's case notes and perhaps the psychiatrist's case notes the
costs can be prohibitive and discourage her from obtaining them.
Where applications are made to Social Services the problems are
greater. Social Service departments appear not to understand that
they have a legal obligation to send copies of the case notes
within 40 days. In one case we are assisting the mother applied
for her notes in November last year and needs them in order adequately
to challenge the reports that have been made to the Court. She
is still trying to get Social Services to send her the notes.
28. Maternity Staffing
28.1 No one would dispute the value obstetricians
offer in caring for women and babies with problems, and many women
and babies are alive today who would not have survived without
the care and attention of obstetricians. Unfortunately, over the
last 40 years obstetricians have extended their influence over
the care of all women and babies and as a result birth has become
a medical event, where women are no longer given individualised
care, but are expected to comply with restricted protocols, partograms
and produce their babies within a very limited time frame. As
a result, fit and healthy women and babies pay a very heavy price
for the illusion of safety that is, allegedly, provided by a centralised
medicalised service.
28.2 Research into interventions in birth
in a range of obstetric units (Downe et al, 2001) revealed that
only one in six first time mothers had a normal birth, i.e. a
birth that did not involve, artificial rupture of membranes, induction
or acceleration of labour, epidural anaesthesia or an episiotomy.
28.3 Because obstetricians are involved
in all births, instead of concentrating on the 10% of women and
babies with problems there are constant claims that there are
insufficient obstetricians available. On the contrary, there are
far too many obstetricians involved in maternity care and were
they to focus on those women who really need their services there
would be more than enough available.
28.4 On the other hand, there is a serious
and acute crisis in midwifery. The majority of maternity units
are short staffed, and we receive a constant stream of complaints
from women who have been left on their own (and leaving a women
with her partner counts as leaving them alone) without a professional
attendant. This serious problem has become commonplace, and little
or no attention is paid to the damaging affect this has on the
quality of care. When midwives have to look after three or four
women in labour at the same time it is not uncommon for a developing
problem to be missed, and the staff have to rescue the woman or
baby from the problems that arose as a result of their failure
to provide adequate midwifery staffing.
28.5 The medicalisation of birth has been
disastrous for midwifery practice, it has led to a generation
of obstetric nurses who are most comfortable complying with protocols,
putting up drips and viewing birth as a mechanical event to be
monitored and recorded. Those women who want a normal birth fail
to realise, and are not informed, that their chances of achieving
this objective in the majority of centralised obstetric units
are minimal.
28.6 Those midwives who want to provide
supportive, holistic, midwifery care are regularly driven out
of midwifery or are browbeaten into complying with the medicalised
model. Following the `Short Report' in 1980 the Government of
the day provided a considerable amount of money to `improve' maternity
care following widespread criticism of increasing medicalisation
and routine induction and acceleration of labour. The money was
used, primarily to decorate the walls and put up pretty curtains.
The ethos of the maternity units did not change and we do not
believe that further tinkering with maternity care will achieve
the changes that are desperately needed in maternity care.
29. Summary
29.1 Superficial changes in maternity care
have been proposed and sometimes implemented over the last forty
years but little has changed in the quality of care. Indeed, in
comparison with women giving birth in the 1960s the levels of
intervention have increased and the caesarean operation rates
have soared.
29.2 Little will change until the care of
fit and healthy women is removed from the bailiwick of the obstetrician
and firmly placed in the hands of the midwives. This will not
be easy, we now have a generation of midwives who have been turned
into obstetric nurses and many of those will fight as vigorously
as the obstetricians to block change.
29.3 If real change is to be affected in
maternity care and the recommendations made in the Winterton Report
(which was based on scientific evidence) and echoed, to some extent,
in Changing Childbirth, are to be implemented there has to be
fundamental change.
29.4 Midwifery education has to be underpinned
with an apprenticeship system that enables midwives to learn the
clinical skills they need to attend safely a woman who wants a
normal birth. This can only be achieved by ensuring that a substantial
number of women give birth at home or in small, free standing,
midwifery units away from the influence of obstetricians and their
medicalised view of birth. The present system that requires midwifery
training to take place in hospital destroys midwifery practice
and ensures the continuation of a generation of obstetric nurses
whose midwifery skills are knocked out of them.
29.5 By establishing a community midwifery
service that is totally separate from acute, high risk, obstetric
care midwifery will be able to flourish and develop the skills
that midwives practising in the 1940s and 1950s had. It is ironic
that women expecting their first babies were expected to give
birth at home and the first birth a newly qualified midwife attended
alone was a home birth. Midwives knew that should there be a problem
a first time mother would give plenty of notice. As obstetricians
took over maternity care, and as midwives were brought into hospitals,
home birth for first time mothers was re-defined as 'high risk'
on the grounds that the obstetricians were unable to forecast
the outcome.
29.6 Centralised, obstetric, maternity care
has been a disaster for the majority of fit and healthy women
and babies, they have paid a heavy price in unnecessary inductions
and accelerations; high levels of pharmacological drugs to deal
with the pain; serious physical postnatal problems caused by episiotomies
or tears; unacceptably high levels of post natal depression and
post traumatic stress; worryingly high levels of maternal suicide;
and for the babies the long term risk of heroin addiction as a
result of the drugs the mothers were given during their labours
(Jacobson, 1990).
29.7 The present system of medically controlled,
centralised, obstetric care has got to change, and it needs foresight
to `think out of the box' and the courage to implement real change
rather than tinker, yet again, with an dysfunctional system.
30. Recommendations:
1. A separate community midwifery service
should be established in every area.
2. Every area should have a free-standing
midwifery unit which is part of the community midwifery service.
3. Every woman should be able to book her
care with a professional of her choice, either a midwife, general
practitioner or obstetrician.
4. All midwives should have the right to book a woman
into hospital for the birth if that is what the woman wants.
5. All Trusts should be required to reach
a target of 10% home births by the year 2005.
6. All midwives, during their training, should
be required to attend at least three home births.
7. Women should have the right to copies
of their case notes immediately.
8. Failure to provide case notes within 40
days should carry financial penalties.
9. Independent midwives should be enabled
to deliver babies in hospital if that is the woman's wish and
provide a home birth service in every area for those women who
want to birth at home. Women who cannot afford an independent
midwife should be enabled to obtain this service too.
10. Obstetricians should be restricted to
providing care for high risk women and those women who are referred
with possible problems, or who choose to have their care provided
by an obstetrician.
June 2003
REFERENCES
Beech, BAL and Robinson J. Effects of Child
Protection Investigations on maternity care and subsequent effects
on families, AIMS, February 2002.
Department of Health. NHS Maternity Statistics:
England 2001-02. Statistical Bulletin, Department of Health, May
2003.
Downe S, McCormick C and Beech BAL. Labour interventions
associated with normal birth, British Journal of Midwifery, October
2001.
Edwards N. Women's experiences of planning home
births in Scotland—Birthing Autonomy. PhD Thesis, University
of Sheffield, December 2001.
Hannah M et al. Planned caesarean section versus
planned vaginal birth for breech presentation at term: a randomised
multicentre trial, The Lancet, 2000, 356, p1375-1383.
Jones M H et al (1998) Do birth plans adversely
affect the outcome of labour? Br J Midwifery, Vol 6, No1, p 38-41
Kirkham M (2002). British Medical Journal, Vol
324, p639-43.
Robinson J (1999) The birth plan game, British
Journal of Midwifery Vol 7, No 10, p642.
Robinson J.(2002) A Consumer View of Post Traumatic
Stress Disorder in Drife J and Lewis C (eds) Maternal Mortality
and Morbidity, RCOG London.
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