Cathy Warwick on why women should be given a choice over where they give birth.
Readers may have seen a recent article in The Times, which was headlined ‘Women who think they can have a baby without 21st-century medicine are spoilt and complacent’. The author of the article, Melanie Reid, went on to express various opinions which, sadly, the RCM believes may be quite widely held - not only by the public, but also by some health service professionals. One of her more contentious comments held that ‘it is impossible to deny that homebirths are the preserve of homely, principled types who may then go on to breastfeed their child until it goes to secondary school’.
Midwives work in a climate in which they are asked to ensure that women can make an informed choice about where and how they give birth. It is fascinating that in such a climate journalists can write such factually inaccurate columns. I suppose the justification is that this was simply an ‘opinion’ piece - and everyone is entitled to express their opinion. But journalists are influential people, and their opinions could end up misleading women.
Let me, then, try to create a balance, first by providing some hard facts on the matter of homebirth and then by offering some opinions of my own as to why (as Ms Reid said) homebirths are not ‘mainstream’. This is despite policy documents that support the idea of women having the choice of home or hospital-birth having been published across the UK: Maternity Matters: Choice, Access and Continuity of Care in a Safe Service (England); Keeping Childbirth Natural and Dynamic Pathways for Maternity Care (Scotland); All Wales Clinical Pathway for Normal Labour (Wales).
Although at 2.8% (in 2007) the national homebirth rate remains low, it has risen by 54% since 2000. (Compared with only a 14% rise in the total number of births.) The rate increases in different areas range from 1% in parts of London to 10.7% in South Hams, Devon. Across England and Wales, seven local authorities have homebirth rates of more than 10%. Many of these higher homebirth rates are in areas where the population could hardly be called ‘spoilt and complacent’.
According to BirthChoiceUK, which quotes the Office of National Statistics’ data, in Bridgend, Wales, the health authority’s homebirth rate is 10.6%, while caseload midwives have a 24% homebirth rate. Torbay, Devon, meanwhile, has an 8.8% homebirth rate and Southwark, London, has a 6.2% rate. (www.birthchoice.com). None of these areas is affluent. Indeed, midwives in Peckham, which is in Southwark (one of the most socially deprived boroughs in England), deliver over 50% of their caseload of women at home.
‘It is extraordinary, at a time when hospitals are under serious pressure to manage capacity, that more maternity units are not introducing a viable homebirth service’
I think this shows that the homebirth issue has much less to do with class and much more to do with the services and support. In areas where homebirth services are properly resourced as part of total maternity services, and in areas where the availability and the benefits of having their baby at home are explained clearly, women from all walks of life may well make such a choice.
But is it a safe choice? Ms Reid claimed that ‘we wish to give birth safely and quietly in hospital with as little fuss as possible’, happily ignoring the recent evidence which supports the view of NICE that homebirth is a safe choice for appropriately selected women.
It is true, of course, that some women need all the benefits of the expertise and technology that our maternity hospitals can offer. But most women will be perfectly safe with a competent and confident midwife. She has the skill (and the equipment) to deliver most women who choose to do so at home - but she will also detect early on those women who may benefit from safe and simple transfer to a hospital. In those (extremely rare) cases in which a true emergency arises, the same midwife is also equipped to manage that emergency until further support can be accessed. Olsen and Jewell’s Cochrane review (1998) also demonstrates that appropriately selected women who plan to have their babies at home experience less medical intervention than those who have their babies in hospital. This would suggest there is less ‘fuss’ in the home environment.
It is extraordinary, at a time when our maternity policies advocate a reduction in unnecessary interventions, when the birthrate is rising and hospitals are under serious pressure to manage capacity, and when there is clear evidence that homebirth is the least costly model of birth, that more maternity services commissioners are not working with their local maternity units to introduce a viable homebirth service. Many commissioners, I fear, while happy enough for those asking for this service to receive it, are happy, too, not actively offering it to the appropriate population.
Lord Darzi is asking for health service personnel to suggest innovative funding ideas. I hope that the heads of midwifery in the UK, who have been instrumental in setting up successful homebirth services, will step forward so that others can learn from their example.
Meanwhile, Ms Reid should think again - and if she hasn’t done so already should read the plethora of emails her article triggered. It is a relief to me to see that on this issue many women have a rather different view from hers.
Cathy Warwick CBE is general secretary of the RCM