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Home Birth Rhetoric and Reality - a dilemma for professionals.
From Trish Morris-Thompson (TM-T), Executive Director of Nursing and Midwifery, Birmingham.

The Peel Report of 1970 had the effect of reducing the total of home births over the following decade. In 1984 the Maternity Services Advisory Committee emphasised that any labour can become complicated, and recommended the hospital as the safest place for delivery. 1992 saw the House of Commons Select Committee (Winterton) and 1993 Changing Childbirth (the Cumberledge Report) supporting home birth as a safe and reasonable option for appropriately screened women. The NHS Management Executive Planning Priorities of 1994 provided guidance for health authorities in the use of their resources, but did not translate this into a recommendation for home birth as an option for all maternity care providers when a change of government led to a change in priorities.

The much welcomed NHS Plan recognises patients' preferences for health care. Shifting the Balance of Power (the Department of Health's programme of change brought about to empower frontline staff and patients in the NHS) placed 70% of resources in the hands of Primary Care Trusts (PCTs). We should use our influence on these to highlight the importance of maternity care. At the RCM conference in 2001 Alan Milburn said that we should work together to end the lottery in childbirth choices, offering women in all parts of the country equal access. The 1995 joint statement from the RCM and the RCOG sensibly proposed that GPs need not take responsibility for the maternity care of their own patients, but could ask partners or other GPs in their areas to undertake this. The same bodies, with the National Childbirth Trust, produced the document Modernising Maternity Services, a toolkit for PCT purchasers on setting up performance measures. This fell short of providing targets, but recommended that home birth should be an option, and we should now be asking all PCTs what their priorities for the next 5 years are.
The RCM publication The Home Birth Handbook should be required reading for all midwives, GPs and obstetricians; evidence based, it highlights where the support for women should be, and where the responsibility lies. Management must respond to the wide variation in the attitudes of midwives to home birth, some of it negative. Is this due to lack of confidence in skills, apathy, or fatigue? The same differences in opinion and in the interpretation of data exist within the medical profession, as highlighted in Where to be Born (Chamberlain and Zander) and in a subsequent BMJ correspondence. Is our ambition to include attention to public health measures such as improving breast feeding, involvement in mental health, domestic violence, and smoking cessation, expecting too much from our midwives, who are in any case inadequately resourced? We can rule out a significant difference between rural and city practice. Negative gatekeeper influence at the point of booking, for which all the professions including midwives share responsibility, clearly has an important effect. Changing consumer opinion in favour of technology doubtless operates, as does a lack of sufficient information to allow women informed choice. Performance targets such as waiting lists, waiting times, and surgical procedures throughput may be pushing the maternity services down the priority ladder. This is hardly surprising when one considers the overwhelming pressure from Whitehall on managers in PCTs and acute Trusts. We make a rod to beat our own backs by insisting on a 2 to 1 midwife ratio for home births, so sapping resources. The strategic impetus must now lie in putting pressure on the PCT providers.

The apparent advantages of Birth Centres within hospitals were outlined; these may or may not have a negative impact on the demand for home birth. Future plans could include contracting for independent midwives to service home births, and the increased employment of community workers across maternity services to relieve midwives of some of their workload.

References.

Peel, Sir J. Domiciliary Midwifery and Maternity Bed Needs, HMSO, 1970.

The Second Report of the House of Commons Heatlh Committee - Maternity Services. HMSO 1992. (Committee Chairman - Nicholas Winterton MP)

Changing Childbirth - Report of the Expert Maternity Group, Department of Health. HMSO 1993. (Group chaired by Baroness Cumberlege)

The NHS Plan. Department of Health July 2000. HMSO Command Paper 4818-1

Chamberlain G, Zander L in: Campbell R; Macfarlane A. Where to be born? The debate and the evidence. Oxford: National Perinatal Epidemiology Unit , 1994. 2nd ed. 176p.

Junor V, Monaco M. (2002) The Home Birth Handbook. Royal College of Midwives, London

Discussion

A former biologist, now midwife, made a plea for patience when assessing progress in labour, with the help of her scoring system which is to be published soon.

A suggestion that for marketing purposes a video be made of women obstetricians who have had their babies at home; there are a number.

A researcher (who has reported that the cost of home birth is less than birth in a Birth Centre, with hospitals the most expensive) was forbidden by her GP to deliver at home; the baby was born in a taxi.

Luke Zander reflected that GP obstetricians, a diminishing resource largely due to their own preference, are in the exclusive position to see the lifetime effects of birth on a woman, her family, and her relationships. Beverley Beech of AIMS echoed this, while commenting on the reported difference - calmness - in personality of children born at home, and the harm done not only to mothers but to their babies when they are placed under the stress in pregnancy of professionals who persistently advise birth in hospital against the preference of their clients.

There is no such thing as zero risk, and this has to be put into perspective by reference to the science.

We have to be able to guarantee that there will always be sufficient staff to support births at home.

A complete costing of a home birth with two midwives: £1200. The service must be properly funded. (But see Lynne Leyshon below).

45% of UK midwives become eligible for retirement within the next 5 years. Midwives in training are being inducted into a scientific system; they need to be taken out of that and to home birth, where they can develop enthusiasm, and receive knowledge which they will take forward in their careers. Only then will grass roots pressure on providers remain a force.

The establishment of Birthing Centres within District General Hospitals, however desirable in themselves, threatens the existence of small outlying midwife-led units in the same districts.

Is the attendance of two qualified midwives at a home birth an appropriate use of resources? An independent midwife reports attending her last 50 such births alone with no problems; the Dutch system has, and the British system once had one qualified midwife, with a care assistant or equivalent. We seem ourselves to be advancing the argument that it is unsafe to have only one midwife present.

Risk is information, not proscription. Who is risk analysis for, the client, the service, or ourselves the midwives, to cover our backs? The mother's perception of risk may not be mine; it is my duty to give her the information on which she can base her own choice. It is her right to weigh the risks of hospital versus home birth and make her decision.

Dutch mothers have begun to trust technology rather than the continuity of care which we expect to engender trust; they depend now on ultrasound to tell them their babies live, rather than on fetal movements. Should we be looking at society for an answer to the question of the adherence to hospital birth?

The emotional and the spiritual are essential components of risk assessment, to be combined with all other observations, and perhaps only available to an independent midwife who can spend time again and again with a mother and the family in their home. Science is not all.

A GP reflected that a generation of GPs who might have supported home birth has been lost, having been trained on the hospital model. Today's GPs are loath to visit homes for a variety of reasons, and thus miss the opportunity to learn more about the lives of the families they serve than could be uncovered in a lengthy consultation.

Mavis Kirkham: Young newly trained midwives are leaving the profession in frightening numbers, chiefly because they are unhappy with the present state of midwifery and the training for it. A change is urgent.

A consultant midwife reported the distress of a midwife, enthusiastic for home birth, who is accused of selfishness by her managers and colleagues for pursuing her chosen role. Her obstetrician husband has attended the home birth of twins with a successful outcome (or two). He had seen the mother throughout the pregnancy and had been through all the possible scenarios with the couple. However he later commented: “I and the midwives would have been vilified if anything had gone wrong”. On the contrary: the result was good, not by luck, but as always with normal birth outcomes by careful planning, relationships, and the positive influence of midwives.

JM-L quoted Melissa Benn (1999): “Society is unable to understand the full work of mothering”. We have seen the retreat of the State bodies which once would have wanted to support mothering. They have retreated from providing the safety which they formerly wished to provide, eroding the task of the public servant, midwife or GP. It is a political struggle to place women's agency foremost, and to challenge the State's response to us as professionals.

TM-T registered a vote of confidence in today's midwifery students, who more and more support normality. She urged any with influence to use it on the movers of the new NHS Framework. Birth Centres are one of the options, not an alternative to home birth.

BP made a plea for all involved in the promotion of home birth to sing from the same song book and so successfully “market” their product, the message that home birth is a mainstream option.

Luke Zander stressed the need to consider risk and benefit, rather than risk and safety. He reported a study (1997) comparing the feelings of women who delivered in hospital (positive about the service) and those of women who delivered at home (positive about their own confidence and relationships). He too made the case for looking at birth from the qualitative standpoint.

References.

Melissa Benn (1999). Madonna and Child: Towards a New Politics of Motherhood. Cape and Vintage (paperback)
Zander L (personal communication 1997). In: Ogden J, Shaw A, Zander L. Women's memories of home birth. British Journal of Midwifery. 5: 208-216.

Sessions 2 and 3. Chair Dr. Gavin Young , General Practitioner

Lessons to be learned from units with high home birth rates
From Lynne Leyshon (LL), Director of Midwifery, Torbay Hospital

Our service covers a large rural area, with social deprivation and a transient population, drug problems, and regrettably a lot of abuse. There are since 1992, stemming from Changing Childbirth, two models of care in our totally integrated service: team midwifery and midwifery group practice; there is a very small core team in the hospital. Our success is reflected in the fact that we have a waiting list of midwives applying to join us; for those working with us this integrated scheme is now their preferred way. Most of our student midwives grow with home birth and have little understanding of the practice which is otherwise prevalent in the UK. This is the result of planning, effort, and persistence in the boardroom. GP resistance was overcome by writing practice-based agreements for every practice, defining the skill of a GP at a home birth as simply making a 999 call.

At around 11% of the service's annual total of 2,200 deliveries, ours is the highest home birth rate in the country; between 1st and 12th November this year we delivered thirteen babies at home. Our midwives are confident and competent, and they see home birth as part of their normal work, not as an extension of it; the way we encourage women to choose home birth is by ensuring that they are very well informed, as the midwives themselves are, using an approach in marketing copied from big business practice. Because any reference to hospital is not made until 20 minutes into the first visit discussion women can begin to see home birth as a reality. The midwives can address risk by reference to evidence derived locally and nationally; women with high risk criteria are not led to expect home birth, but given a sense of normality while expecting hospital delivery. There is direct access for opinions to consultant obstetricians who actively support home birth. When a midwife new to our unit is building her confidence more experienced midwives or the supervisor herself will “buddy up” with her, shadowing her and supporting her as second midwife.

The low risk group are not asked to decide the place of birth on booking, but only told that they are suitable for birth in hospital or at home; we then put a positive gloss on the birth experience throughout the pregnancy. The concept is planning a birth, not a place. Our home birth handbook is updated regularly, and will be the first to publish an annual review of results where home births are not planned. Risk is calculated as an ongoing process without raising anxiety in the mother, best achieved by providing continuity of carer in the antenatal period when a relationship is built and information shared. She emphatically does not want to see someone different at her antenatal visits, but we have found that she does not mind who delivers her baby, as long as she can feel confident in that midwife. By educating the wider family and including them in the care we avoid their influencing women as they formulate their decisions.

Our midwives are acutely aware of fetal wellbeing at all times, without a sense of panic if for example there is diminished movement over a 12-hour period; nor do we regard postmaturity with alarm, but we pay close attention to the baby and avoid causing a mother the anxiety which leads to hospital admission, an anxious baby, and the all too well known cycle of interventions. We await the fetal response to labour; all mothers are visited for about two hours when in early labour at home, when she, her partner and the baby are most at ease, and it is then that we can all agree together on the place of birth. There is no question of denying a home birth because it was not planned; the culture of our service is for the visiting midwife then to continue at the home through to delivery and after, if that is what is agreed. Our midwives are all fully equipped for this, both with the necessary equipment and by training; in particular they are trained and confident in neonatal resuscitation, with twice-yearly workshops in the technique. As Unit Directorate Manager I have been able to upgrade the complete equipment carried by the midwives continuously, so that they have the confidence of knowing that they need never call for an item they lack. We see a role for maternity support workers in the community, enabling midwives to attend most of a home labour single-handed, but we still place importance on there being two midwives present at the birth itself, in the interests of both mother and baby. The risks which midwives may themselves face in terms of health and safety or in the occasional abusive situation are not overlooked. A written evaluation of the accessibility of homes to emergency transport is placed on file.

With the knowledge that two thirds of maternity units have sufficient midwife strength, but wrongly distributed, we now staff women, not wards; now the midwives are where they are needed, thanks to our integrated service. This is a necessity which all Trusts should be addressing. Heads of Midwifery should be given responsibility for their budgets; it results in much improved resourcing. The Reference Cost for an uncomplicated home birth in Torbay is £423; an uncomplicated hospital delivery, including one bed night, is costed at £828, and £250 per extra bed night is added. Caesarian section (CS) is costed locally at £1700. Our 217 home births last year saved the Trust £92000, sufficient to fund three midwives; it will be more this year. This is the data with which to influence Trusts and Government. The cost of “Category X” admissions with one bed night in pregnancy - no intervention, sometimes just anxiety, but 25% of 3000 births - would fully staff a unit with midwives. A 1% reduction in CS rate would save £51000. Consider the cost benefits of mainstreaming home birth.

After detailing the satisfactory outcome statistics of her service Ms. Leyshon quoted one of her midwives: “Every time I deliver a baby at home it feels like Christmas”.

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