"allowed" shouldn't be allowed"
lorna davies

This article was originally published in
MIDIRS Midwifery Digest, June 2004.
Republished with permission.


I recently attended a local NHS parent education session where the group, who were all 30+weeks gestation, were asked to consider their hopes and fears for their approaching births. One woman informed us that she was slightly disappointed at not being 'allowed' to have the home birth that she had really wanted. When questioned why she hadn't been able to secure such an arrangement, she explained that the midwife had expressed extreme reluctance when she had raised the issue during the booking interview. It transpired that her request had been 'declined' because she lived in a house that sits in between two railway level crossings. The midwife was concerned that in the event of an emergency, if both crossings were in operation simultaneously, then the ambulance would not be able to get to her and a catastrophe could ensue. The woman lived a maximum of 10-15 minutes drive from the local hospital unit. Another woman in the group, said that she had also raised the possibility of a home birth but was told by her midwife that she had an 'untested pelvis' and it would therefore be unsafe to even contemplate a home' confinement'. The subject was simply not up for discussion.

On reflection, several issues and resultant questions emerged from this discussion for me. The first was how ludicrous the 'level crossing' argument was, and how dated the 'untried pelvis' excuse was. I began to consider what other reasons women were possibly being given to deny them the opportunity to give birth at home. Secondly, I was appalled by the idea that midwives were telling women that they were not allowed to have home births on these spurious grounds. The women were not being informed that it would be unadvisable, but were being expressly forbidden from even considering home birth as an option. How commonplace is this? Thirdly, I was taken aback at the acceptance on the part of the women when they were informed that they were 'not allowed'. Oh informed choice where art thou? Is such acceptance without any challenge a regular occurrence?

In order to find some answers to my questions, I decided to contact the UK Midwifery List to ask the many midwives, students and women who access the list if they had been faced with or were familiar with any reasons offered by midwives to women to dissuade her from opting for a home birth. I was unprepared for the deluge of responses and the range of reasons given for when a home birth would not be 'allowed'.

In Table 1, I have attempted to organise a number of the responses into categories, as most could be loosely themed. Some of the reasons cited were recurrent so I have chosen to include them once only. The reasons generally centred around the current pregnancy, obstetric history, medical history, social factors, and staffing issues. There were a few which didn't fall into any of these camps and I have included those as miscellaneous.



Table 1. Reasons cited for not being allowed a homebirth


Current pregnancy
Baby is too small Baby is too big
Woman too old (37) Woman too young (16)
Too little amniotic fluid Too much amniotic fluid
Baby too early (36+6) Baby too late (1 week overdue)
Untried pelvis - maybe allowed next time Untested pelvis
Fourth pregnancy. "You've more than 3 children already, so might haemorrhage."
"I don't match the 'criteria' for being 'permitted' a home birth as I am having my 5th baby..." "You've had two babies already and your uterus is knackered."
Gestational diabetes Breech baby
Blood pressure too high, ("on one occassion after I had rushed from work to attend an antenatal appointment") "You have had high blood pressure, if you want to put your baby at risk go ahead!"

Obstetric History
Previous placental abruption (for woman who hadn't had one!) Previous section.
"You had a borderline test for gestational diabetes in your last pregnancy, so although there's no evidence of GD this time, you can't have a homebirth." How about "not with your history" when pregnant with baby no. 4 following 1 vaginal breech, 1 svd and 1 ventouse
They had had a 28 weeker previously. Previous ectopic pregnancy
1st baby died 29 days post birth, due to large tumour. 2nd baby born fine after normal pg and birth. Now pregnant again, and midwife phoned re: booking. Woman explains about 1st baby, and is wanting home birth. Midwife response is "one dead baby means no home birth".

Medical History
History of depression You are diabetic, if you want to kill your baby go ahead!
Heart murmur Partially sighted
Family history My mother has type II diabetes

Social Factors
Accommodation not spacious enough Terraced house (neighbours might hear)
Live in a council flat Husband with a history of depression,
BMI too great Husband too big
Woman who wanted to give birth on a houseboat was told that it was not possible because the midwife might fall off the towpath into the canal.

Staffing Issues
We don't have enough staff to cover a homebirth There are three other women due at the same time so you might have to come in (apparently in this particular area there are always *3* other homebirths booked)
If we don't have enough midwives on, you'll have to come in on the night' Had turned down any scans - so midwives would not feel happy being at the delivery as "they wouldn't know what they were dealing with"
'You can't have a home birth because we haven't delivered your home birth pack yet' You'd be taking two midwives away from the hospital
Labouring women in hospital their first priority The midwife said she couldn't because it takes 4 weeks to organize a birth pack (gas and air etc)
Multip was told she would have to come into labour ward when she had SROM as they did not want to wake the community midwife up Lots of midwives likely to be off sick with colds around that time (February)

Miscellaneous

No one trained to do waterbirth, "We don't do waterbirths (they are not natural).
Have to get an electrician out from hospital to check your wiring Worried I might sue if something went wrong at home
You can't have any pain relief at home Baby may be born "flat"
GP not delivered a baby in years I would have to find a GP who would agree to it.


A fair number of reasons given were directly linked to the current pregnancy and often based on poor supporting evidence. The grandmultiparous argument has been extensively critiqued by Page (1999) and would one consider a third or fourth or even fifth pregnancy to qualify the woman as a grandmultip in any case?

The obstetrical history of the woman was offered as another reason for 'refusal'. Sometimes the rationale was highly questionable, such as “You had a borderline test for gestational diabetes in your last pregnancy, so although there's no evidence of gestational diabetes this time, you can't have a homebirth" or, “They had had a 28 weeker previously” Why, I ask myself, would anyone present such reasoning and debatable clinical judgement?. Is the fear based, risk managed culture of the NHS mulching our brains, dissolving our ability to listen, assimilate and plan pathways of care that meet the needs of the women concerned? Where have the skills of negotiation and compromise gone, not to mention evidence informed practice?

I was under the misapprehension that the 'home birth visit' to check the domestic arrangements of planned homebirthers was an anachronistic practice, abandoned along with shaves and enemas. According to midwives in other areas of the country however, it would appear that the home birth visit is alive and well and being used, at times, as a stick to beat up women who are foolish enough to ask for support for a home birth. Women were told amongst other things that their accommodation was not spacious enough, that their neighbours may hear them in labour, and, most farcically of all, that the midwife might fall in the canal off the towpath, the response given when a woman requested a home birth on her house boat. I accept that ideally, there should be certain things in place in order to optimise safety in the home setting for birth. However, none of these women were asking to give birth in a yurt, without running water in the middle of a field in winter. Ironically, I know of such a woman who was fully supported when making such a request, by a wonderful midwife who spent the pregnancy building up a relationship based on trust which meant that such an environment became a less than fearful prospect by the time the woman went into labour.

Some excuses appear to be little less than manipulative attempts to win compliance. Sometimes guilt is used as leverage. Examples of this would include, “You have had high blood pressure, if you want to put your baby at risk go ahead!” However, the contender for the most cruel and insensitive refutation, has to be the case of the woman whose baby had died in the first month of life. As a result of this tragic experience the woman was told by her midwife, "one dead baby means no home birth".

Similarly, I have also heard of women who have an existing child with special needs being denied the opportunity to birth at home. Why, is it that if a woman is at some point in her childbearing life at some form of 'risk' is she labelled at risk for the remainder of her days, even when the risk cannot be directly attributed to any event in pregnancy or labour?

Many of the women in this list had very special reasons for wanting a home birth, and yet were cruelly challenged in their choice. The woman who had a history of depression possibly believed that a positive birthing experience in her own home may reduce the likelihood of postnatal depression.

Likewise, the woman who was partially sighted would have undeniably have benefited from being able to labour in her own familiar environment, where she knew that she would be able to find her way around and feel safe to labour and give birth freely.

It would be very difficult to establish how many women actually request a home birth, or are even asked their preference for place of birth during the antenatal period. The safety of homebirth for 'low risk women' is now widely accepted (Enkin, Keirse et al 2000, Olsen and Jewell 2000, Chamberlain et al 1997) and the list of proponents lining up to support the choice of 'low risk' women to a home birth is impressive including Heads of Midwifery (NCT 2001) In 1993 Changing Childbirth clearly stated,

“Women should receive clear unbiased advice and be able to choose where they would like their baby to be born. Their right to make that choice should be respected and every practical effort made to achieve the outcome that the woman believes is best for her baby and herself…………...”

and that maternity service purchasers should,

'ensure that home birth is a real option for women who may wish to have it'. Providers (ie NHS trusts) should 'review their current organisation and practices to ensure that real choice about place of birth is available'.

So eleven years on, why are women still being told that they cannot give birth at home for a diversity of reasons that range from the sublime to the ridiculous?

Midwives and midwifery managers would probably identify the issue of poor staffing levels as a primary cause and this concern also appeared in many different guises in the responses received. Sometimes the woman was directly and honestly informed, e.g. “We don't have enough staff to cover a homebirth”. Sometimes the guilt trip tactic was adopted “You'd be taking two midwives away from the hospital”. Sometimes the reason was preposterous such as “Lots of midwives likely to be off sick with colds around that time”.

The acknowledged chronic shortage of midwives in the UK is almost certainly instrumental in creating difficulties for women who feel that home is where they want to be to have their baby (RCM 2004), . I would however argue that if midwives were given greater autonomy and more flexible working practices, then they may be better placed to act as advocates for women and support them in their choice of birthing place. As a result midwives may be happier in their role which may even lead to a stem in the haemorrhage of practitioners currently abandoning the profession. (Kirkham 2003)

Where home birth rates are high, there is invariably a group practice system in evidence. For example the Albany Group Practice has a home birth rate of 43%, (Sandall 2001) quite an achievement in a country where the home birth rate nationally is only just approaching 2% (Chamberlain et al1997).

Independent midwives who are frequently employed by women considered to be too high risk for a home birth with an NHS midwife, have an overall home birth rate of 75%.(IMA 2004) The Netherlands where midwives are employed within group practices boasts a home birth rate of over 30%. (Weigers et al 1996)

Additionally, where group practices are found so is generally a more flexible service. Many of the women who are served by group practice midwives, do not make a decision about whether to go into hospital or stay at home until they are in labour, and feel that they can then judge how they are coping and how they feel about staying at home (Sandall 2001). What an eminently sensible thing to do. But it wouldn't fit in with the delivery of care where “it takes 4 weeks to organize a birth pack.”

Institutionalisation has a powerful effect on attitudes, beliefs and behaviours.(Haddikin & O'Driscoll 2000) If we could acknowledge that economy of scale doesn't always work, particularly in a humanistic context, we could be freed to embrace the notion of a partnership model of care and employ the support of women who use the service, instead of merely paying lip service by having an NCT representative on the odd committee or two.

As midwives and women, we could then begin the process of raising awareness of the benefits of home birth, such as the powerful economic truth that home birth has financial value. Statistically, a woman who opts to give birth at home is less likely to have any form of intervention and is therefore more likely to save the Health Service money. Each caesarean birth costs the NHS about £760 more than the cost of a normal delivery.  A 1% annual rise in caesarean births in England and Wales costs the NHS £5 million each year.(NCT 2002) How many more community based midwives could be funded? The softer less visible outcomes of successful homebirth cannot be overlooked either. In a health service busily promoting its public health agenda, it cannot be ignored that women who give birth at home are more likely to breastfeed for longer, they are less prone to postnatal depression. (Chamberlain et al 1997)

The spectre of fear has to be a major player in the showground of home birth request. In the early 1970's the Peel Report (DHSS 1970) decreed that hospital birth was incontrovertibly safer than home birth and that 100% hospital delivery was mandatory. This edict went largely unchallenged for almost two decades and home birth was all but outlawed throughout the 1970's and 80's. Many midwives who trained during this period were sold the myth and grew to feel afraid of home birth. The mind set of fear is a hard nut to crack and there is still a great deal of apprehension prevalent where home birth is concerned. The current blame and compensation culture does little to salve this situation and feeds into the illusion that constant monitoring, high technology and dubious intervention may help to prevent litigious claims. I feel that a lot of the excuses featured within the table, are manifestations of fear on the part of the practitioner. The six million dollar question is of course, how do we conquer that fear?

The relatively small number of homebirths in the UK, means that student midwives see them as something rare and frequently marginalised. Home births frequently bear little resemblance to the event in hospital which makes them different and paradoxically outside the parameters of what they perceive as normal. This serves to perpetuate the fear associated with home birth, leading them to feel that they do not have the skills or the confidence to attend women without the safety of the backup available in hospital. Ironically this may lead to a fairly newly qualified midwife with a philosophy that supports women's choice, looking for an opt out clause when the woman requests a home birth.

Home birth requires practitioners who are able to watch, wait and be patient. The quick fix stratagem adopted in hospital does not have a place in the domestic place of birth. In 1997 Jean Robinson wrote:-

“ What some of our women are getting is not a home birth, but a hospital birth at home…….the midwife who practices just in case interventions such as the breaking of the waters, or directed pushing, can create complications at home which there is no equipment to deal with.”

We can take the midwife out of the hospital, but can we take the hospital out of the midwife? For many midwives, the security of a hospital setting, with on-call obstetric and paediatric back-up is an essential comfort zone. We seriously need to look at how we are addressing the issues of confidence and skills at homebirth within education at both pre and post registration level. We need to start by normalising birth and ensuring that practitioners and learners have a strong grounding in birth physiology. Students must understand that homebirth is something that may have huge benefits, for the woman, her baby and her family. Just as student midwives are required to produce evidence of babies caught, antenatal examinations performed and breech deliveries observed, we could require that student midwives should attend a specified number of homebirths during their educational programmes. Midwife teachers could take on a small caseload of women booked for homebirth and involve student midwives in the total care of those women.

As far as qualified midwives are concerned, midwifery managers could make the first preceptorship placement for newly qualified staff, community based so that they are more likely to begin their qualified lives with a positive view of normality and attend some home births. Buddying schemes could be adopted, where midwives confident of their skills for homebirth could accompany those less confident. Also, there are now workshops available that explore dealing with emergency situations in the domestic setting. This model of workshop is one that should be considered by managers and practice development midwives along with ALSO and NALS courses.

One of the midwives on the UK list sent me an email that summed up the total irrationality that is fostered by a number of health care practitioners (and who knows how many?) when the issue of home birth is raised. It précised an eight page account in a normal healthy woman's notes outlining the risks that she was at by requesting a home birth. These included:-

'PPH, shoulder dystocia, cord prolapse, retained placenta, may need complicated suturing, baby may have respiratory distress syndrome, may get an infection, maternal and neonatal death'.

One of the other midwives retorted that perhaps we ought to produce a criteria for a woman's eligibility for a hospital birth. It would then be necessary for a woman to consent ensuring that she had been given all the information required in order to make an informed choice. I have included a list of the suggested criteria produced by Laura Abbott (Table 2). It may seem comical, but if we stop to consider, is it really any more outrageous than many of the reasons cited in Table 1?


Table 2: Criteria for Eligibilty for Hospital Birth
Must not be scared of needles.
Must not be claustrophobic or uncomfortable in confined spaces.
Must be able to fast for long periods of time.
Must be happy to share one toilet with 30 others
Must accept that said toilet may be a considerable distance from the bed area.
Must enjoy sleeping on mattresses covered in plastic.
Must not have rebellious or questioning nature.
Must fully accept that may contract MRSA.
Must fully accept that may contract any infection: uterine or perineum
Must be happy to share one midwife with 3 other labouring women at same time.
Must also be happy that said midwife has been fasted for many hours.
Must like and trust in electrical equipment.
Must be happy that has a 1:4 chance of having major surgery for no good reason
This non exhaustive list has been included in your maternity records and must be discussed and signed by you (the mother), a registered midwife and a supervisor of midwives. If this has not been discussed or signed by all of the above staff you will not be allowed to have a hospital birth and will unfortunately have to stay at home to have your baby.



I appreciate that this article only scratches the surface of the issue and only really explores the subject from a midwifery perspective. What about our medical colleagues? How do we begin to make obstetricians and GP's see birth as a normal social event? The challenges are, I acknowledge, enormous.

In conclusion, it would appear that women are being denied access to a home birth for questionable reasons. Midwives for a variety of reasons feel that they are unable to provide women with a birth in the setting of their choice. This may be down to poor levels of staffing. It may be due to perceived lack of skills, confidence, knowledge, and support. It may boil down to rigid attitudes and an inflexible approach on the part of managers. I have not even begun to delve into the question about the acceptance on the part of women. That would take up a whole new article by itself.

The reflection has also led me to consider that there are ways forward that could prevent women from having to endure the ignominy of paternalistic attitudes that renounce their autonomy and render them passive recipients of care. We must expose this sort of behaviour for the nonsense that it is and strive to meet women in partnership as adult users of a 'service' that must be designed to meet their needs on their journey to motherhood.




References

Chamberlain G, Wraight A, Crowley P. (1997) Home Births. The report of the 1994 confidential enquiry by the National Birthday Trust Fund. New York: Parthenon Publishing Group.

Department of Health and Social Security (1970) Domicillary Midwifery and Maternity Bed Needs. The Report of the Standing Maternity and Midwifery Advisory Committee. London HMSO

Department of Health (1993) Changing Childbirth. Report of the Expert Maternity Group. London: HMSO.

Ruth Hadikin, Muriel O'Driscoll (2000) The Bullying Culture. Books for Midwives.

IMA (2004) A Solution to the Problem http://www.independentmidwives.org.uk/article155.html

Kirkham M (2003) Why do midwives leave? RCM

NCT (2001) Home Birth in the United Kingdom, London: National Childbirth Trust Olsen O, Jewell MD. (2000) Home versus hospital birth (Cochrane Review). The Cochrane Library, Issue 4. Oxford: Update

NCT (2002) Caesarean Section The Issues. http://www.nctpregnancyandbabycare.com/nct-online/caesarean2.htm

Page L (1999) The New Midwifery: Science and Sensitivity in Practice. Churchill Livingstone  

RCM (2004) Home birth pressures on hospitals - RCM Midwives Journal , vol 7, no 2, February 2004, p 54

Robinson J (1997) Complaints about Home births. AIMS Journal 8(4) 18-19

Sandall J (2001)Evaluation of the Albany Midwifery Practice Final Report March 2001 http://www.kcl.ac.uk/nmvc/external/project/moreinfo.php?id=4

UK Midwifery List http://health.groups.yahoo.com/group/ukmidwifery/

Wiegers TA, Keirse MJNC, van der Zee J, Berghs GAH. (1996) Outcome of planned home and hospital births in low-risk pregnancies: prospective study in midwifery practices in the Netherlands. British Medical Journal 313: 1309-13.

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