Positive Health Online

For expectant mothers, the prospect of the baby's birth can be both exciting and daunting. It is the culmination of nine months of waiting and the start of a new role for the woman and her partner, although many also worry about how they will cope with labour and the responsibility of becoming a mother. Most women do not realize that they are entitled to choose where they wish to give birth, the majority being referred to their local maternity hospitals; in some areas a midwife-led birthing centre is offered if there are no medical or pregnancy problems. However, all women have the option of home birth on the NHS, even though many doctors and some midwives use emotional blackmail to paint an alarming picture of the dangers of giving birth outside a hospital equipped to deal with emergencies. The home birth rate in the UK has declined since the 1970s and remains low at between 2% and 5%, with just 2.7% of women giving birth at home in 2009.[1]

Women's Right to Insist on Home Birth

Women are entitled to insist on home birth, even when there are medical complications. Midwives are legally responsible for the care of women from conception to the end of the postnatal period, usually about four weeks. Importantly, unlike doctors, midwives may not decline to care for a woman who insists on home birth,[2] even if her medical, pregnancy or social circumstances are gravely compromised. I know of one woman who insisted on home birth even though she was expecting triplets, all breech (bottom first). She was attended by a wonderful midwife, who helped her to achieve three normal vaginal breech births without any problems. This was despite that fact that the doctors and hospital midwives were on tenterhooks until after the event, expecting problems which never materialized. 

Sadly, most women are not made aware of their options, and major shortages of midwives in the UK,[3] most notably in London and the southeast, often means there is limited time available to prepare women to approach birth with confidence. Whist there is a genuine desire to provide care which is as holistic as possible, in reality the demands of NHS maternity services lead to an emphasis on the physiopathological, with the psycho-emotional and social aspects of childbirth coming a rather poor second.

Shortage of Insurance for Maternity Care

Some women opt for obstetric care in a private maternity hospital, although it is not common, especially as most private health insurance packages do not cover maternity care. Unfortunately, private medical care does not necessarily mean that the birth will be normal because doctors consider birth to be "only normal in retrospect", and pregnancy care focuses on being alert to physical complications. Since birth is seen as the most "dangerous" time for mother and baby, most obstetricians plan a "managed birth", which does not always take account of the mother's wishes. Interventions such as induction of labour, episiotomy (cut to enlarge the birth opening), forceps delivery or Caesarean section feature more prominently than when care is overseen by a midwife. Private obstetric care costs around £5000 and may be more if complications ensue; home birth is not an option.

Indemnity Insurance Unaffordable for Independent Private Midwives

Other mothers appoint an independent (private) midwife to provide care from early pregnancy until the baby is about four weeks old. This virtually guarantees that the mother will receive all her care from one, or perhaps two, midwives whom she comes to know, and who support her throughout the whole experience, focusing not only on the physiological, but also on the psycho-emotional and social aspects of pregnancy, birth and becoming a mother. If the condition of the mother and baby and the progress of pregnancy are normal, the mother does not need to see a doctor at all, as the midwife is legally entitled to take responsibility for her care. Employing an independent midwife costs between £2000 and £4500.

However, there are threats to even these limited options for mothers wanting home birth. The shortage of NHS midwives is increasing, particularly as there is a large proportion of the workforce approaching retirement, and limited numbers of younger midwives being trained. Local shortages often force managers and budget holders to restrict NHS home birth provision, and mothers who are adamant about having a home birth have to fight the system to achieve their aim. In addition, newly qualified midwives do not gain adequate experience in working with women who want home birth, and lack the confidence (and often the competence) to provide this service, although all midwives are trained to be able to assist with births, both in hospital and community.

Furthermore, there is a real risk to independent midwifery in relation to the issue of indemnity insurance. Whilst midwives employed by the NHS have insurance cover through their Trusts which belong to the Clinical Negligence Scheme for Trusts (CNST), and midwives in private maternity hospitals are covered by their employing authority, there is no such insurance cover for independent midwives. A court case involving an independent midwife in 1994, caused insurers providing cover to Royal College of Midwives (RCM) members to threaten to raise their premiums substantially to cover the risk of payouts to midwives working independently. This led the RCM to stop providing cover for midwives in private practice, in order to keep insurance premiums down to manageable levels for the majority of its members who are employed by the NHS. The only commercial insurance cover available to independent midwives meant that annual premiums rose to almost £20,000, more than most earned! Many independent midwives discontinued their practice, and those who remained were forced to work without insurance cover.

Currently, there are about 350 independent midwives, all working without indemnity insurance cover. They are entitled to do so, on condition that they discuss this with their clients fully. The expectant parents must decide whether they are happy to proceed, in the knowledge that, should a major complication result in a situation for which they may seek redress, the midwife has no access to indemnity insurance and is therefore personally liable for any costs incurred. In practice, the close and trusting relationships which independent midwives develop with their clients usually changes the dynamics of the situation. The partnership which evolves is less likely to result in parents wanting to sue for negligence in order to obtain compensation. If something goes wrong in hospital, it is often related to inadequate communication, impersonal care or lack of continuity; most parents only want an apology and a de-briefing, but often the only course of action open to them is to take the case to court for a financial acknowledgement of culpability. If current plans become law, requiring all healthcare providers to be in possession of personal professional indemnity insurance cover by 2012, midwives will no longer be able to work independently, as it will be impossible for them to find adequate insurance cover at a price they can afford. This effectively removes one of the choices for women who wish to birth their babies at home.

A small, but growing, minority of women choose 'unassisted birth' at home, also called 'freebirthing'. It is against the law for anyone who is not a midwife or doctor to take sole responsibility for the mother and baby, except in an emergency (Nursing and Midwifery Order 2001), and there have actually been court cases where partners have been prosecuted for attending the birth without midwifery or medical support. However, it is not illegal for a mother to labour and give birth alone, although the lack of a professional to monitor the progress of labour and the condition of mother and baby does increase the risks of undiagnosed complications occurring.

Is this the way we are destined to go, with women unable to obtain the types of birth they would like, possibly resorting to courses of action which put themselves and their babies in jeopardy? Of course, there are many factors which impact on this situation, not least the shortage of midwives and the dire state of the health service, particularly in the recession. Changes of government also affect attitudes to healthcare choices, including home birth, and it remains to be seen whether the current government will advocate a wider home birth service on the NHS. However, it seems certain that a requirement for all healthcare professionals to be in possession of indemnity insurance cover will be mandatory by 2012 and this will have a dramatic, negative effect on the right of women to choose a private home birth, and of course, on the right of midwives to choose to work independently of the NHS.

References

1. Briggs H. Home birth fall "disappointing". BBC News Health 9 November 2010.  Viewed online at www.bbc.co.uk/news/health-11717595. 9 November 2010.
2. Her Majesty's Stationery Office 2002 no. 253 The Nursing and Midwifery Order 2001 Viewed online at www.legislation.gov.uk/uksi/2002/253/contents/made  2002.
3. Nursing and Midwifery Council. Supervision, Support and Safety: an analysis of the 2008-2009 local supervising authorities' annual reports to the Nursing and Midwifery Council Viewed online at www.nmc-org.uk  2010.