Birth at Home
27th September 2007

Chair: Beverley Beech (BB) of The Association for Improvements in the Maternity Services (AIMS)

The Chair: Since 1970 AIMS has campaigned for home birth. There has been no change since Magaret White's letter on the subject to The Midwife in 1974. Today we welcome the guidelines recommending the choice of home birth, and stating that birth at home is as safe as birth in hospital.

Research evidence of risk and safety.
Lesley Page (LP), Professor of Midwifery, Florence Nightingale School of Nursing and Midwifery, Kings College London

Early in my career I experienced home birth in a rural setting and realised how beneficial it was for the mothers to be the in the calm of their own homes. Later in my training I was exposed to the regimentation of the maternity hospital factory system of birth. The babies were taken away from their mothers, and only returned to them for four-hourly feeding. We hadn't met the women whose deliveries we were called to witness.

In most of the economically developed world close to 100% of women now give birth in hospital. The shift from home to hospital based birth was the largest uncontrolled social and medical experiment of the 20th century. Between 1954 and the 1980s the home birth rate in England fell from less than 35% to 1% without evaluation of the relative safety of birth in hospital and at home; in 2005-2006 593,400 of 609,000 women gave birth in hospital and 2.6% of births took place at home. In a few decades the birth of babies, the founding event of life and society, was lifted from everyday family and community life, with care mainly by midwives, and placed in hospital institutions, mainly under obstetrical care. The opportunity to evaluate this fundamental shift has been lost. However, a number of studies of home birth undertaken in different parts of the world indicate that home birth is no less safe than hospital birth for low risk women and their babies. Home birth is associated with a lower intervention rate and most women who have experienced home birth find it a positive experience.

Inequality of care in favour of the hospital was assumed, with hospital care compensating for poor social circumstances. But inequality of outcomes continues irrespective of social circumstances and place of birth, with the babies of mothers living in the most deprived areas twice as likely to be stillborn and twice as likely to die in the first month of life (CEMACH 2007). In fact there has been no reduction in the perinatal mortality rate since 1992. The maternal mortality rate increases 20 times where both partners are unemployed; it increases by 45% for women living in the most deprived areas, and by a factor of three for minority ethnic groups. The rate is seven times higher among black African women as compared with white women (Why Mothers Die 2000 - 2002).

The institutionalisation of birth has made it difficult for women to receive continuity of care, and care becomes dehumanised. It has resulted in an increase in the caesarean section (CS) rate in the developed world to an average 21.1%, increasing the risk of maternal morbidity and mortality, and the risks, including higher rates of stillbirth, of future pregnancies, in which rupture of the uterus and placenta praevia are dangers. In less developed parts of the world the CS rate is even higher, with areas where health care provision is virtually absent.

Why home birth? At home a woman is in her own surroundings where she may feel in charge of the situation. She can choose her birth companions, and the care we provide is likely to be more personal than that available in hospital. The study shows that there is greater satisfaction for the mother, who will rarely choose a hospital birth after having had a baby at home. The intervention rate for women booked and delivered at home is lower than in hospital, and I think this is at least in part due to a midwife's freedom from the distractions likely in a hospital or Birth Centre labour ward, where she may easily be called away for any of a number of reasons. There is paperwork, people coming in for equipment and other distractions from the focus of care on the mother. In the home I can concentrate on the woman and her family and feel relaxed.

There have been various types of studies of home birth. A very small randomised controlled trial (RCT) in 2005 was hardly more than a feasibility study (reference), but a large meta-analysis (Olsen 1997) arrived at valuable conclusions, in particular that hospital birth and home birth for women of low risk and for whom there is the back up of a hospital department are equally safe.It is my personal belief, taking hospital interventions into account, that home birth is safer. A large retrospective study carried out in the North of England between 1981 and 1994 showed a significant difference in the maternal mortality rate for booked and unbooked home births (reference). Professor Chamberlain gives a very good account of the experiences of women in the UK who had home births in 1994 (reference). Home birth had just been legalised in British Columbia when Jansen et al published a report to (reference); prior to that some births were conducted in the home by lay midwives. Despite their lack of experience the findings were very similar to those throughout the world. Their had been other studies are of dubious validity, and no more RCTs. However, all of these studies show a reduction in induced and augmented labour, the use of analgesia especially epidural, less use of episiotomy and a lower rate of instrumental deliveries including CS. Most studies show that low Apgar scores are fewer following home birth or there are no significant differences.

The prime focus for our work in the next few years has to be this reduction in the rate of interventions. Very serious ethical questions must be asked when a hospital unit has a high rate of elective and emergency CSs but does not support home birth. It is quite possible that negative accounts of the results of home birth from Canada and Australia, where conditions are very different from those here in the UK, are due to differences in midwife training and hostility between the hospital and home sectors, leading to problems in arranging urgent transfer. Intrapartum perinatal mortality (IPPM) is defined as the deaths of babies at or around birth or within the first week of life. The national committee's report concluded that this was lower for completed home births but higher when a mother was transferred to hospital. No such differences were found in the Northern Region and Woodcock studies, but the Australian study by Bastian which included high risk women are found a higher rate of perinatal mortality. I suspect the methodology of the NICE Guidelines of 2007 , in which some figures were estimated, and transfer rates were based on low risk mothers; inclusion of high risk would have revealed more interventions in hospital, and these flaws in design introduced a bias against home birth which is unacceptable. There is a huge range of rates of transfers from home to hospital in these reports, and it is often unclear whether transfer took place during the pregnancy, during the labour or thereafter.

The studies have important limitations. Were booked and unbooked home births clearly differentiated? Was there a bias in the selection of women for home, especially when some women have an unreasonable determination to achieve it? It is my opinion that if there was a genuine choice far more women would choose home birth than do so at the moment. I believe the analysis to be skewed when there is a high proportion of transfers to hospital and much of a woman's time is spent there, away from the beneficial influences of the home environment. Perinatal and maternal mortality rates are too low to achieve significance, and the National Perinatal Epidemiology Unit at Oxford have recommended a national surveillance of women giving birth in midwifery-led birth centres and at home. Sub-group analysis, as used in the NICE guidelines, is suspect. It is hard to find appropriate comparison groups, and there is a difficulty when data are pooled, combining information sourced over long periods of time during which maternity care has changed, and that taken from countries with widely differing standards of care. Alison Macfarlane recommends systematic review in which individual studies are critiqued in preference to meta-analysis.

In The New Midwifery (Churchill & Livingstone), which I edited in 2006 with Rhona McCandlish, research in this field gives us data based on populations of women of sizes varying from a few to many thousands. As midwives and obstetricians we have to deal with one woman and her particular circumstances. My five sets of evidence based midwifery are, for this woman, finding out what it is important to her, the ability to critique the evidence, the ability to take the clinical background into account, talking it through with her - reflecting on the experience and the outcomes - and putting all this into the context of her values and the research.

How do we make home birth safer? Attention to clear and practical guidelines should prevent our overlooking things that are going wrong because we want a normal outcome. Good working relationships between midwives working in birth centres or the home and the hospital team ease transfer when it is required. And clinical expertise, coping promptly and appropriately with emergencies, is crucial.

It is important for us to remember that neither home birth nor hospital birth are safe for all babies.

How to encourage more home births.
Jane Sandall (JS), Professor of midwifery and women's health, Florence Nightingale School of Nursing and Midwifery, King's College London

At Guy's and St Thomas' Hospitals we are establishing a service innovation intended to increase the uptake of home birth; we expect continuity of care to be particularly important for this. The Department of Health has guaranteed that by the year 2009 women will have four choices:

Choice of how to access maternity care
Choice of the type of antenatal care
Choice of the place of birth
Choice of the place of postnatal care
Furthermore every woman will be supported by a midwife she knows and trusts throughout her pregnancy and after the birth.

We believe that women should be offered the choice of planning birth at home, in a midwife-led unit or in an obstetric unit.

They should be informed:

That giving birth is generally a very safe for both the woman and her baby.
That the presently available information on planning place of birth is not of good quality, but suggests that among women who plan to give birth at home or in a midwife-led unit there is a higher likelihood of a normal birth with less intervention. There is insufficient information about the possible risks to either the woman or her baby relating to planned place of birth.
That the obstetric unit provides direct access to obstetricians, anaesthetists, neonatologists and other specialist care including epidural analgesia.
Of the likelihood of being transferred into the obstetric unit and the time this may take.
That if a serious complication should occur during labour at home or in a midwife-led unit, the outcome for the woman and baby could be worse than if they were in the obstetric unit with immediate access to specialised care.
That if she has a pre-existing medical condition or has had a previous complicated birth it introduces a higher risk of developing complications during her labour and she should be advised to deliver in an obstetric unit.

Clinical governance structures and should be implemented for all births.

By our definition the continuity of care inherent in caseload midwifery evolves into a relationship between a woman and a midwife characterised by trust, loyalty, and a sense of responsibility. We have drawn on the experiences of the Albany Midwifery Practice but in a very different setting and in the NHS. The project started in July 2005 and ended 30th September 2006. Three community-based group practices of six midwives each, based in areas of deprivation, were established. There was a caseload of mixed risk women from an area defined by postcode, with a named midwife for each woman and a personal caseload of 36 births annually. Ours was a group structure and philosophy supporting continuity of care and carer, with partnership out of hours cover. 592 women were booked and 560 were delivered; in terms of age, parity and Index of Deprivation scores they compared well with the background group at St.Thomas' Hospital.

Our objectives were improved access, quality of care, maternal and neonatal outcomes and use of resources, while increasing women's choices and experience of care. 62% of the women were attended at the birth by their named midwife or her partner, 89% by the practice midwives. Some of the practices achieved higher levels of continuity by their arrangements such as out of hours cover. Over the year there was a 7% increase in the home birth rate recorded by the project, 13% for one of the practices. Does the intervention work? Does it have a positive effect on outcomes overall?

Of the groups studied the 20% who had caseload care expressed the highest degree of satisfaction in terms both of receiving care from the carer of their choice in labour and of being enabled to choose the form of postnatal care they wished. We interpret these findings to confirm the facilitating power of continuity. The confidence level of mothers in caseload care far exceeded that in standard care.

Factors which we found to be important in confirming the decision to proceed to birth at home were:

Discussion of anxieties with the birth partner
(At 36 weeks) What would happen and whom to call when labour begins
Importantly, assessment in early labour.

Mothers appreciated knowing their carer, knowing her by name, and being able to reach her by telephone directly.



Normal birth, magical birth.

That midwife practice can change rapidly when seen to be effective was shown when one group increased early labour assessment from 7 to 92% in one year. It reduces time in hospital for women booked to deliver there, and it enables a mother, midwife and birth partner to agree that all is well at this stage and that it is safe to stay at home and await the expected normal progress. Many of the women did not decide on the place of birth until they were in labour, which we believe to be an important factor in increasing the choice of home birth. Caseload audit shows that 62% of births were attended by a named midwife or partner and 89% by one of the practice midwives. For the partnership model these figures were respectively 74% and and 94%, and week on-week off call out including nights and weekends provided 24-hour labour cover. Alternating partnerships for different women may solve the loss of continuity caused by understaffing; it helps to develop a shared philosophy, and provides opportunities for learning and practice review.

This relationship model engenders trust and confidence for both families and midwives due to personalised contact with women, booking and antenatal appointments in the home (not wanted by all women), the 36-week birth talk in the home (for the benefit of the birth partner), and early labour assessment at home with the offer of birth at home for women at low risk. Continuity of the relationship through pregnancy, birth and postnatally, though vital for the development of trust over time, does not mean midwives being on call for 24 hours. It builds professional competence and confidence, as we see the results of our actions and advice, and the allegiance of midwives shifts from institutions to women.

Details of our project are here .

The NICE guidelines of 2007 make recommendations for research to compare places of birth, and prospectively to assess women's experiences of birth and outcomes including safety for all places of birth. The cost effectiveness and long term outcomes of caseload midwifery need study, and confirmation of the effectiveness of the 36-week birth talk and that continuity of care increases safety.

We have guidelines and policy, but will we be able to deliver on choice?

References.

R.Pawson, N.Tilley, (1997) Realistic Evaluation. SAGE Publications, London.

A framework for development and evaluation of RCTs for complex interventions to improve health. (2000) London, Medical Research Council.

Birthing Autonomy - negotiating a normal birth at home
Dr Nadine Edwards (NE), Sheffield Hallam University

It is assumed that women can plan home births if they want to; it is their right and the service exists to support them. It is also assumed that home birth equates with normal birth and that it means a mother being in control. But few babies are born at home in the UK, and mothers tell us that the degree of control they have there depends on the model of care. A woman feels the loss of control as soon she enters hospital, but the relationship with her carers is different there; at home her carers are her guests.

In practice planning a home birth might not be straightforward, and perceptions of the normality of birth vary. And perhaps an important part of what is called control consists in willingly submitting to supportive companionship, feeling that it is safe to let go. Finding themselves in a rigid structure of care in hospital women question much that is taken for granted. The numbers of busy people around them and the machines are confusing, and then women tend to fall back on survival mode. The constraints of the services are apparent to both mothers and midwives.

Negotiations start early: women often have to deal with the negative attitudes of their partners, who may have fears of the dangers of birth, particularly at home. They want to do what's best, but they lack information, unaware of the support system brought to the home by midwives, and assuming that there is safety in hospital. They feel unable to challenge doctors, and women don't like challenging partners. Unless they have experienced it before they are ignorant of the benefits of birth at home, and may be too ready to abandon the option. It is after the event that one hears expressions of elation, pride, confidence and freedom, all of which might be lifelong legacies.

Many women wrongly assume that they must book with a GP when pregnant, but there they may encounter a negative view of the process and a lack of confidence in the research which they may feel obliged to accept. We need midwives to be the first point of contact, and we need them to be unequivocally supportive, but all too many are unwilling to be involved in home birth, particularly for a first baby. Their issues include the balance between work and home life, varying degrees of knowledge and skill, restrictive polices in their employment and the opinions of colleagues; these have detrimental effects on their clients. Other objections are obstetric risk factors, full quotas, and short staffing. And worst of all 'Women don't have home births here'.

Women thinking about home birth know that they are doing something unusual, and pleased to know that there are midwives willing to support them but devastated when they meet with negative responses from them. The last thing that women need in the late stages of their pregnancies is battling with hostility, evasion and non-engagement, nor do they need a discussion about ideologies and resources.

Resource issues partly stem from the government's conflicting policies: on the one hand seeming to promote home birth and on the other, behind the scenes, dismantling the services. We must not evade our role in engaging with this political hurdle. Views around risk are many and various, but despite its own evidence the obstetric perspective remains that home birth is unsafe. We still hear obstetricians and midwives preferring to use fetal monitoring, even though they know that it does not change the outcome of birth. Women devoted to home birth find themselves challenging obstetric definitions of risk and negotiating with midwives who insist in advance on transfer to hospital if they say so. Wanting 'normal' or 'natural' is already a definition minefield; women don't realise that technocratic as opposed to social values and practices are entering their homes. "You have to know all the things that they're going to do as a matter of routine and put in your birth plan that you don't want Syntometrine, and you don't want her to hold the baby's head as it comes out". Midwives may not regard as interventions procedures such as active management of the second stage of labour, or the use of Syntometrine for the third stage and its permitted duration, and the use of vitamin K, while women may see them as not only interventions but routine and medical. Midwifery teams in the same area may have differing opinions and practices, as may the midwife members of a team. Fragmented care renders negotiation impossible, and the lack of time limits the possibilities.

When midwives find women are reluctant to agree to their proposals they may resort to persuasion, to fit with local or individual practice. If they adopt a wait-and-see approach this tends to cause the mothers anxiety, knowing as they do their vulnerability at this time, and negotiations become stacked against them. If they are successful in negotiating reductions in monitoring or vaginal examinations, they may feel that there are no necessary interventions. It may occur to them that interventions can be harmful; in the case of vaginal examinations:

"I could really picture myself just getting closed up."

"If the midwives can't observe women without physical examinations it interferes with me, slows me down."

"When I decided to get the pool there was a feeling of liberation from the midwives. I felt I could take a bit of power and that would give me confidence. I could remove myself physically to a place where they weren't going to follow me. My heart sank when a midwife told me that she had a Sonicaid which worked under water; now they're going to chase me in the pool. And there was measuring of the temperature of the water and my blood pressure and so on, and I thought, here comes the control issue again."


This sort of mistrust makes both mother and midwife feel unsafe. I believe that the relationships and the birth ideology have to be handled together to resolve this conflict, reducing the negative impact of the ideology and having a positive impact on the choice of place of birth. Good relationships promote confidence, the conversation in which mother and midwife get to know each other and and develop mutual trust; conflict and rigid positions in negotiations evaporate. The result is safe care, the midwife knowing when to act, with agreement on interventions and the need for transfer.

"I trust her and I trust her judgement. If she says everything's OK I'll believe her. Without such good communication the whole thing just wouldn't work."

Good relationships simplify negotiations around physical checks in labour, and the closer the relationship the better, one-to-one being the ideal.

"I didn't feel that I needed a birth plan anymore. I trust her opinion, and that way I don't have any fears."

Mechanical maternity services drive midwives away, and women don't like them. On the other hand, humane and well resourced services are known to provide safety and are popular with women. We need models which work for midwives and prevent stress and burnout, and by co-operation with women and the application of appropriate political pressure these can be achieved.

The skills which women want their midwives to acquire can be difficult for them to develop within a technocratic model. These are the skills of the mind and body, the emotional intelligence which leads to a knowledge of women's concerns around birth, gives confidence and inspires courage. It is vital to reduce damaging negotiations between midwives and mothers. Aside from reducing midwives' stress it enables women to protect their babies, themselves and their families from unnecessary physical, emotional and spiritual harm. It also enables the safe experiences that protect wellbeing and set parents up for parenthood. It may even heal past wounds and avoid new traumas during the heightened state of awareness in which labouring mothers exist, and which can have a considerable impact, possibly long term.

(Here Nadine showed a DVD, a work in progress, focusing on women's words, why birth matters to them, how environment modifies their experiences, and the importance of the birth companion and what she brings to the experience.)

Discussion.

Chris Naylor, obstetrician: In 1971 the caesarean section (CS) rate was only 7%, despite which we were erroneously advised that fetal blood sampling and fetal monitoring would reduce it. If the home birth rate increases now, will midwives receive the drills and skills to enable them to deal (for example) with postpartum haemorrhage and shoulder dystocia? Also I believe that we should resist the suspension of staff, often prolonged, against whom claims of negligence, frequently unsubstantiated, are made. Professor Wendy Savage (WS): We await the results of a study recommending doing without routine and intrusive vaginal examinations in labour; simple observation will usually tell us that progress is satisfactory. LP: I believe that most staff are taking the courses in drills and skills now available. However there is a crisis of confidence among midwives who have had little or no experience of home births, and this requires midwives to attend them in pairs. Extended litigation, often over years, is now common, and good note keeping, especially of discussions held between staff and mothers and their families is crucial. I am the Midwifery Adviser to the Health Ombudsman, and in my long experience one-to-one care of women in labour has invariably avoided litigation.

A doula: It seems that mothers expecting their first babies prefer birth in hospital. Women who delay their first pregnancies and are delivered by CS often opt for subsequent repeat CS after too short an interval. How can we persuade them to be patient before they conceive again and then to consider VBAC (vaginal birth after CS) at home? LP: It is important to encourage women to have their first babies at home, to protect them from unnecessary interventions, particularly CS.

A student delegate expressed anxiety because the tenor of the meeting seemed to run counter to the current obstetric mantra. JS: We have been speaking within the present NICE guidelines, that no woman should undergo an intervention which is unsupported by evidence and a clinical indication. For example there is no evidence that fetal monitoring benefits the babies of women of low risk. We should be offering women the choice of place of birth. My role is to look at the evidence, and to generate new evidence where there is none; proceeding with practice which is unsupported by evidence introduces risk.

Despite the guidelines and the National Framework and the utopian expressions of confidence made here today, the reality is that we are constrained by management who are constrained from above, and women who make contact to say they are in labour at home are being told to come into the hospital for lack of community midwives, who are being ordered into the operating theatre to catch the babies from CS. JS: There are questions in the recent Health Care Commission Survey about provision of services; some of those items will become benchmark indicators and we can only await their publication. LP: Most helpful is for midwives to speak to their Heads of Midwifery and the managers about their wanting to support home birth, and in doing so to convince them that they believe in its safety. NE: What you're saying is very political; it is about our values and beliefs, and in support of these we need to mobilise the public. There is supposed to be lay representation on Maternity Services Liaison Committees (MSLCs), and it is they who should be pressing for Birth Centres in their area, for a reduction in the CS rate, and for more home births. JS: I have concluded from my study of this problem that the key to change is for women's groups and midwives' groups to work together at both local and national levels. WS: In other words, knock on the doors of the hospitals and the Primary Care Trusts (PCTs). The government contradicts itself by saying that maternity matters and at the same time midwives can't get jobs and PCTs are not commissioning and so hospitals are laying off staff. Please go on line to keepourNHSpublic.com and donate money to enable us to put effective pressure on the government for this and other reasons and for their waste of money on Private Finance Initiatives (PFI).

Professor Jacqueline Dunkley-Bent: A London PCT is planning to discontinue financial support for CS undertaken solely on maternal demand while clearly recognising there there may be a genuine indication for the procedure where there has been previous birth trauma. I hope that their agenda is quality of care rather than financial stringency. A delegate expressed her deeply felt objection to this. She knows of women who have so little confidence in the service they will receive in hospital, expecting intolerable interventions, that for them CS is the only solution preventing feared psychological damage. BB: I agree with Gill Gyte of the NCT that maternal requests for CS are few. But I have become aware of situations in which an obstetrician has recommended CS for a specious clinical indication and who then recorded CS on demand in the patient's notes. It is reliably reported that the rate of 'normal' intervention-free birth in our hospitals is one in six, and this includes the 30% CS rate; such are your expectations if you book birth in hospital today. And many regard their definition of normality as unacceptable.

JS: The case for home birth has been made across the social classes; the acceptability of home birth for women depends on the way in which it is offered. The essential moment of decision, when the offer is confirmed or otherwise, comes with the risk assessment of the women in labour at home.

A midwife with experience of the Domino scheme identified its major benefit to be continuity of care; whether transfer to hospital was chosen by the mother or advised by the midwife it was seamless; the women's confidence in their midwives was unaffected, and the midwives continued their care of their clients whether a labour became complicated or not. Some of our present problems have followed the abandonment of that scheme.

A delegate: The prospect of a substantial increase in home births will be fought tooth and nail by the obstetricians; the matter is political. However a senior midwife was able to report good support from obstetricians for the 30% home birth rate in her hospital area. Dunkley-Bent: We are promoting more groups of midwives practising one-to-one caseload care, and while the Trust has a financial interest in such change, they are all also impressed by the quality aspects. Eugene Oteng-Ntim, President of the Forum: Clinical directors who see home birth caseload audits can then inform the executive of the cost effectiveness of home birth in terms of the reduction in premature birth and intra-uterine growth retardation. JS: This will be all the more effective when good research on these improvements has been completed.

A delegate complained of the removal of funding from midwife training by government at a time when we need to recruit more midwives.

LP: The effects of anxiety mediated by the autonomic nervous system on pregnancy and labour are greatly underestimated. A doula commented that a doula can provide the continuity of care in hospital that busy midwives are unable to do. LP: Earlier reviews of continuous care looked at and approved doula support; the continuity, the trust, must reduce anxiety.

WS: Although admitting defective research design, we found a lower rate of pre-clamptic toxaemia in women whose care was community based when compared with hospital based care, probably because they were familiar and so comfortable with their midwives and GPs. The response of the College of Obstetricians (RCOG) to Maternity Matters was disappointing, despite Professor Chamberlain's conversion to home birth after he conducted his own research, in which the conclusion was that home birth is a good option for healthy women. And still an influential obstetrician stated that hospital birth is safe. We face opposition from so many quarters: funding, politics, the long-standing differences between midwives and doctors, and midwives who lack the confidence to recommend mothers to consider home birth.

The author of this report, a retired GP: 20 years ago Marjorie Tew, a statistician in an orthopaedic department and a well respected member of this Forum, produced retrospective evidence for the safety of home birth in all categories of risk. LP: Her research was not flawed, although others attempted to pick holes in it. The RCOG were reluctant to release their own data, which included risk assessments numbered 1 to 5, but Marjorie paid for it herself and included it in her research, with the same results. Subsequently the College has avoided publishing those risk categories.

Gill Gyte agreed with a delegate that confusion among the mothers could be avoided if antenatal teaching by midwives and the NCT could be integrated; but this is at present a rarity.

BB, responding to a delegate enquiring whether a shortage of resources excused a midwife from her duty of care to a woman who had booked birth at home, said that could properly inform her Trust that the duty is laid upon her by the Nursing and Midwifery Council. Although the law is imprecise in such a matter NHS Trusts would be held liable for culpable negligence if they refused to to provide the care which was the mother's due. And such negligence would be publicised widely by AIMS. If community midwives are overstretched by lack of numbers, they should put pressure on their Trust by pointing out the litigation the Trust risks if they employ too few midwives to cover the needs of the community. They can appeal to the Chief Executive or even to the commissioning Strategic Health Authority, where they can demand why they commission from a Trust which is not providing a service. JS: Trusts should also be asked whether they are misapplying funds on, for example, unevaluated technologies. Also they should be challenged if they claim that home birth is too expensive. A representative from a Birthing Centre complained that Trusts are unwilling to use their services although they are cost effective. LP: Refer them to the NICE guidelines, which say that women must have the choice of home birth and which also recommend midwifery-led care. BB: Professor Sandall's book and the reports from the Albany Project are also available. PCTs are targeting maternity for the next five years, and we need good negotiating to drive this forward. They are the commissioners of services, and they are wanting to talk to us about Maternity Matters.