Autism Awareness Day: guest blog by Hayley

Birthrights research in 2013 and 2018 found disabled women reported poorer experiences of childbirth than other respondents. They told us they:

  • received inadequate information about their choices more often than other women;
  • were unhappier with the availability of pain relief; 
  • felt they had less choice and control over their birth experiences;
  • felt that their rights were poorly or very poorly respected;
  • only 19% of women (2018) thought reasonable adjustments had been made for them and some found birth rooms, postnatal wards, or their notes and scans “completely inaccessible”.

On World Autism Awareness Day, we’re really pleased to publish two guest blogs by Emma and Hayley, which shine a spotlight on the challenges faced by autistic women during pregnancy and childbirth. They show why listening to women, respecting them as experts in their own needs and enabling this through continuity of carer – underpinned by a human rights approach – is so vital.

The autistic birth experience is not necessarily an inherent part of public discourse around birth, disability and health care. Yet, despite evidence showing that autistic people have been part of society for millennia, there is a dangerous lack of awareness about how autistic people give birth.

To take advantage of all the useful narratives and information swirling around social media during Autism Awareness Month, bringing this much-needed topic to the public consciousness is long overdue. I have written personally for years about my experiences of birth and parenting as an autistic woman – my first birth as an undiagnosed woman was certainly a lesson in bad practice, my second birth was overwhelming empowering and positive. However, I hadn’t changed. I was born autistic. How could the same person experience pregnancy and birth so differently, even when the pregnancies themselves were very similar?

My first pregnancy was an unpredictable force of nature, a tornado of failed expectations and instability, created by a health service that had never (knowingly) cared for an autistic woman. But they weren’t alone, I was unaware of my own neurotype and struggled to identify why I wasn’t experiencing the blissful autonomy and self-confidence other new Mums had. From the moment I read my positive pregnancy test, my hands and arms flapping like a happy sparrow in a dust bath, my expectations were rooted in media depictions of pregnancy and birth. The intimate, reliable rapport with my midwife was something I had been told was my destiny, but this story was not to be. With no continuity in care, I never saw the same person twice, deeply exacerbating my problems with social communication and difficulty with changes to routine.

Once I developed Gestational Diabetes, the lack of autonomy over my body intensified. Where, like many autistic people, I relied on fact-sharing as a basis for my conversations, creating visible frictions in medical appointments that I couldn’t understand. What I could understand, however, was the numbers. Black-and-white, controllable blood sugar levels that were my anchor in a sea of discourse built for neurotypical mothers. These were tiny acts of sacrifice, where I tried to claw back my dignity as a Mum-to-be with no other way of expressing it.

This echoed along other symptom-reporting, too, particularly pain. As my recent systematic review of existing evidence showed, autistic people experience pain differently. In terms of touch, cold and heat we sense these things far sooner, whereas deep ‘true’ interoceptive pain is something we have a higher tolerance for. Further work suggests that if sensory preferences are taken into consideration, pain communication and reporting is improved.

However, my birth plan suggestion of ‘no lights, no music or shouting’ was ignored. Coupled with problems in initiating conversation, this gave an overall sense that I was lacking any choice, any dignity over my pregnancy and baby. “The NHS owns this pregnancy, not me” was something I remember telling my husband during the first precious days at home after birth.

What Emma and I want to work towards is that no autistic woman is at a disadvantage because of who she is. We do not want to blame autistic bodies, autistic brains for the problems. It’s a lack of education and awareness on female autism presentation and co-occurring conditions that would lead the way to improvements here. With examples of good practice models available with Mental Health Specialist Midwife roles, we intend to provide training to midwives and doulas across the UK. Autonomy over your birth experience is something we want to put back in the hands of autistic women, as a basic human right.

Autism Awareness Day: guest blog by Emma

Birthrights research in 2013 and 2018 found disabled women reported poorer experiences of childbirth than other respondents. They told us they:

  • received inadequate information about their choices more often than other women;
  • were unhappier with the availability of pain relief; 
  • felt they had less choice and control over their birth experiences;
  • felt that their rights were poorly or very poorly respected;
  • only 19% of women (2018) thought reasonable adjustments had been made for them and some found birth rooms, postnatal wards, or their notes and scans “completely inaccessible”.

On World Autism Awareness Day, we’re really pleased to publish two guest blogs by Emma and Hayley, which shine a spotlight on the challenges faced by autistic women during pregnancy and childbirth. They show how listening to women, respecting them as experts in their own needs and enabling this through continuity of carer – underpinned by a human rights approach – is so vital.

My name is Emma Durman – I’m a late diagnosed Autistic woman with several co-occurring conditions. I’m also co-director of Autside, a training and consultancy company that specialises in Autism and neurodiversity, and a final year MSc student focusing my dissertation on the Autistic experience of pregnancy, birth and motherhood.

Disabled people have long been infantilised and desexualised and thus disabled women’s birth experiences have often been overlooked in research and support. Autistic women face the additional issues of disparity of diagnosis, meaning we – and those around us – often do not realise we have additional or differing needs in the maternity and birth process.

My birth experience was traumatic. On paper, it probably reads as uneventful. Normal vaginal birth, less than 24 hours. But internally, it has left scars that will never heal, stolen precious memories I can never regain.

I met my daughter on the worst day of life. It feels like a betrayal even to write such words – the birth of your child is meant to be the best day of your life, bar none, full of wonder and magic and overwhelming love, with the inconveniences of pain, fear and discomfort ushered away, forgettable, the moment you see your baby.

I am Autistic, and maybe it is my neurotype, or my nature, but I find it extremely hard not to be honest. And in honesty I did love my child. Of course. And there was wonder and amazement. But there was also unrelenting, overwhelming pain, anxiety, trauma and a thick layer of fog and disconnect that did not dissipate magically and completely. No, instead it stayed with me, as I tried to orient myself in a new and terrifying world, surrounded by people that did not understand me or respect my needs and wishes, that at best were dismissive and at worst openly hostile. It stayed and coloured the moments I laid eyes on my beautiful daughter, it stayed and infiltrated the days, weeks and months after her birth, sending me into a spiral of post traumatic stress and depression that made it difficult to function, to bond with my baby. That made me reliant on my partner to such an extent he had to refrain from returning to work for 9 months, and suffered his own mental health issues as a result.

I can never get that time back, those moments when time stands still, that stay with you forever. But I hope that my research, my work, the training for midwives and health professionals I am developing, along with that of my colleague Hayley, will make those moments safer, happier for other Autistic women. For my own daughter if she decides to have children of her own.

Autistic women have the same human rights as anyone else. But true equality is not about everyone getting the same treatment – is is about everyone getting the treatment they NEED.

Autistic women need their specific sensory, social profiles acknowledged and supported, recognising the enhanced anxiety we face daily in navigating a world that does not naturally accommodate our neurotype. We need our pain validated even if it does not look as expected. We need to feel safe and understood – and we need to be informed and included in decisions about our care.

Disparity in healthcare for women and disparity in healthcare for disabled people. The intersectionality of this combined with the complexities of the Autistic experience mean we are at a definitive disadvantage in healthcare, with research showing high mortality rates for those with Autism and/or Learning Disabilities. I am hopeful that Birthrights’ unique focus on human rights during maternity care can be applied to the Autistic experience to great benefit. It could mean improved outcomes for mothers, fathers, and children. It could mean the greatest gift of all – a birth that is safe and happy, a joy to remember.

Birthrights responds to the CQC’s national maternity survey

Commenting on the findings of the CQC’s national maternity survey, Amy Gibbs, Chief Executive of Birthrights, said:

“It’s positive that overall 88% of women surveyed felt they were ‘always’ treated with respect and dignity during labour and birth, but other findings highlight areas where maternity care is failing to respect women’s basic rights.

“Every woman has the right to choose where and how she gives birth, yet 15% said they were not offered any choices about where to have their baby and a quarter said they were not always involved enough in decisions about their care during labour and birth.

“Above all, the findings underline how vital continuity of carer is to improving women’s maternity experiences, giving them time and space to ask questions and make decisions that are right for them. We know that seeing the same midwife through pregnancy, birth and afterwards can make all the difference and help ensure safety goes hand in hand with dignity and respect. Yet only 15% of women reported that the midwives who cared for them during labour and birth had been involved in their antenatal care.

“It’s clear we need renewed commitment and drive at national and local levels, to ensure the vision of Better Births is achieved for most women to have continuity of carer by 2021.”

The full findings of the CQC’s maternity survey 2018 can be found here.

Reflections on 2018

Four weeks into being Birthrights’ new Chief Executive, I’m feeling very lucky to lead such a brilliant organisation and brimming with positivity and ideas for 2019. I’m blessed with a very talented team, engaged and expert Trustees, supportive funders, invaluable partners and a wider enthusiastic pool of people who share our mission to improve women’s experience of pregnancy and childbirth by promoting respect for human rights.

As 2018 draws to a close, we wanted to share our highlights from the year. And since it’s Christmas, here are our top 12. I’m so impressed by how much has been achieved by our small but perfectly formed team – showing why #smallbutvital charities are so important. Clearly, I can take no credit for these and my thanks goes to the team and my predecessor, Rebecca Schiller, who I’m delighted will be joining the Board of Trustees next year.

In 2018, we’re proud to have:

  1. Launched our biggest campaign yet on the right to maternal request caesarean section
  2. Responded to over 170 email requests for advice from women in need
  3. Seen our online factsheets visited over 7,000 times – a 7% increase on 2017
  4. Delivered 18 speaking engagements or training sessions to healthcare professionals
  5. Strengthened our links with NHS England, the Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, General Medical Council, Parliamentary and Health Service Ombudsman, Public Services Ombudsman for Wales
  6. Engaged with the Maternity Transformation Programme Stakeholder Council and numerous NICE consultations
  7. Secured a new grant from the Esmée Fairbairn Foundation to expand our team and impact
  8. Progressed our Baring Foundation and Trust for London funded work on women with complex needs
  9. Welcomed new team members, trustees, Associate Trainers and accountants on board
  10. Improved our financial systems and capacity to report on budgets and grants
  11. Deepened our partnership with Leigh Day and explored other corporate partnerships
  12. Continued our crucial collaborative relationships with Birth Companions and BPAS

And much more besides… Merry Christmas and thank you to all our funders, supporters and partners – I look forward to meeting and working with you in 2019!

New research: Disabled women need to be heard and respected as experts about their bodies

Research published today and commissioned by Birthrights shows that disabled women are generally not receiving the individualised care and support they that they need to make choices about their maternity care.

Today’s publication includes and builds on the survey research published in 2016 which found that more than a quarter of disabled women asked felt that their rights were poorly or very poorly respected.  A quarter felt they were treated less favourably because of their disability, and more than half (56%) felt that health care providers did not have appropriate attitudes to disability. Some found birth rooms, postnatal wards, or their notes and scans “completely inaccessible”.

The new report published today presents data from in-depth interviews with disabled women.  It highlights the need to treat disabled women – as all women – as individuals with their own specific needs.  It emphasises the need to recognise that disabled women are experts in their own conditions and what they mean for their bodies and choices in childbirth.  Participants described distressing scenarios of having to prove that their choices were suitable, undermining their dignity. In one very concerning case, one participant described not being given all the information she needed to make an informed decision about her care during labour, and being denied the choices she would have made as a result.  Respecting women’s dignity means respecting and trusting women’s individual needs and knowledge.

Participants also described having to explain themselves repeatedly to each new care provider; at times feeling as if the focus was on their impairment rather than their needs as a person: “You’re not a pregnant woman you’re just a body. Because if I was a person to them, if I was a pregnant woman they would have read my file”. Women who had experienced continuity of carer spoke very positively of their experiences and of experiencing more dignified care.

All women had some poor experiences of postnatal care.  In some cases participants did not see the point in raising issues when continuity of care was lacking and midwives were short of time; something the researchers suggest “must raise questions of safety of practice”.

Participants had mixed experiences of antenatal and parenting support: some women were provided tailored support early on but others felt that they were expected to take the lead in asking for what they wanted or found that activities or information were not offered in an accessible way.

Throughout the study, women felt that they had to be empowered, enabled, informed and supported to advocate for their rights.  They emphasised the need to be listened to and treated as individuals.  Not doing this has a long term impact: women who were not listened to and whose rights were not respected lost confidence and felt undermined long after the birth.

Birthrights’ Chair, Elizabeth Prochaska commented: “It is fundamentally important that disabled women – like all women – receive dignified maternity care that respects their human rights. The research published today highlights that much more work is needed by maternity services in order to provide high quality individualised care to all disabled women.  This must include ensuring that all women are given all the information they require to make decisions about their care, in a way that respects their own knowledge about their bodies.”

Professor Vanora Hundley said: “The National Maternity Review, Better Births, highlighted the importance of personalised maternity care that focuses on the needs of the woman and her family. Good communication is a key to achieving woman centred care, and our findings suggest that this remains a particular challenge for women who have a disability.”

Dr Bethan Collins added: “The findings highlight the importance of communication: service providers need to both respect women’s knowledge of their own bodies while also providing the expert support to enable women to make informed decisions about their care.

“Continuity of carer was so important to many of the women, but does not seem to be common practice. As a researcher and as a disabled parent myself, I empathise with the experiences of women in our study. There is a job to do to raise awareness of disability and enable women to have a dignified experience.”

The research suggests that maternity services need to adapt to provide high quality individualised care to all disabled women. This includes improving both attitudes and knowledge of disability and disabled women among maternity professionals, ensuring all disabled women receive continuity of carer, allowing additional time for disabled women to discuss their needs, preferences and choices, auditing access and ensuring that reasonable adjustments as required under the Equality Act 2010 are made available.

The research was conducted by Jenny Hall, Jillian Ireland and Professor Vanora Hundley at Bournemouth University and Dr Bethan Collins, Senior Lecturer in Occupational Therapy at the University of Liverpool.

With thanks to the Matrix Causes Fund for supporting this work.

Maternity Care Failing Some Disabled Women

Research published today (15/09/16) by Bournemouth University and commissioned by Birthrights highlights how maternity care may not be meeting the needs of some pregnant disabled women.

A survey of women with physical or sensory impairment or long term health conditions highlighted how  – despite most women rating the support they received from maternity health carers positively – only 19% of women thought that reasonable adjustments or accommodations had been made for them. Some found birth rooms, postnatal wards and their maternity notes and scans “completely inaccessible”,  while a quarter of women reported that they felt they were treated less favourably because of their disability. Most strikingly, more than half (56%) felt that health care providers did not have appropriate attitudes to disability.

Just over half of the participants expressed dissatisfaction with one or more care providers, particularly their awareness of the impact of disability and their perception that their choices in pregnancy and birth were being reduced or overruled. One participant with a physical impairment and a long-term health condition stated, “No one understood my disability. No one knew how to help or who to send me to for support.” Another added, “I didn’t have any control or any choice. Everything was decided for me.” And one woman said, “They did not listen to me. I advised them on the unique way my body works. They did not listen to my advocates.”

Speaking in advance of the publication of her book Why Human Rights in Childbirth Matter and the Birthrights #newchapter campaign linked to the launch, Rebecca Schiller, chief executive of Birthrights said, “this interim report suggests that there are significant human rights issues at stake for disabled pregnant women in the UK and Ireland. More than a quarter of women we surveyed felt that their rights were either poorly or very poorly respected. This is unacceptable and we will be working hard to address this over the coming years.

After Birthrights’ dignity in childbirth survey (2013) we became concerned that the needs of disabled women in the system were not being met. Though it’s heartening to see how overall most women were satisfied with their care and hear some positive stories of excellent practice there is clearly progress to be made. The women surveyed asked overwhelmingly to be listened to. It is crucial to listen to and trust women to ensure the system is genuinely meeting their requirements and that they are at the heart of decisions about their maternity care. The Equality Act 2010 places a duty on the public sector to provide services that meet the diverse needs of those who use them yet participants indicated worrying lack of attention to accessibility of maternity services and facilities for women with a range of disabilities.

The survey is indicative of a wider problem around women’s rights in childbirth that can impact on all women and often most forcefully on the most vulnerable . This month Birthrights is launching a campaign for a #newchapter in pregnancy and childbirth to ensure safe, quality, respectful care is available to all women. Pregnancy and childbirth are a vulnerable time and the physical and emotional impact on women and their babies of a negative journey through pregnancy and childbirth can be severe.”

Professor Vanora Hundley of Bournemouth University added, “while this is a small survey the findings echo the recommendations of the National Maternity Review published earlier this year, which highlighted the importance of personalised, woman-centred care with continuity of carer. It is clear that these are important considerations for all women, but particularly for those women who have a disability.”

Read the full interim report here. We expected the full report to be released in January 2017 when the qualitative research is completed. With thanks to the Matrix Causes Fund for supporting this work.

Maternity experience of women with physical disabilities

Birthrights are excited to be taking part in a joint research project with Bournemouth University looking at disabled women’s experiences in maternity care. The survey below is open now (deadline extended from 3rd June). If you are a mum with a physical disability, please fill in the survey. Otherwise please share the link. The more women we can reach the better!

Disability survey

This is an area that we want to work more on and are planning some qualitative research with Bournemouth University in the future. The survey results will be shared widely. We will also be using them to inform our training and resources.

With thanks to the Matrix Causes Fund for part-funding this project.

Three Years Defending Dignity

Three years ago this month, Birthrights burst onto the maternity scene. At our launch, we declared our intention to ensure that all women receive the dignity and respect they deserve during pregnancy and childbirth. Since then we’ve worked hard to do just that. Free, expert legal advice direct to women, respectful care training for midwives and doctors, research, campaigns and accurate, unbiased comment in the media…

Providing clear and objective information on women’s rights in childbirth has remained a priority. Our factsheets continue to be a popular resource for women and healthcare professionals. Our email advice has provided much needed assistance to hundreds of women and their families and with your help we hope to launch a telephone advice line.

We have published groundbreaking research – such as the 2013 Dignity Survey – to improve the evidence on the importance of respectful care. This year we will be focusing on the rights of vulnerable groups of pregnant women, including migrants and those with disabilities.

Birthrights reaches out to healthcare professionals through our own events, such as our Dignity Forum and Fighting the Fear study day. We speak at conferences and seminars across the country as part of our popular and expanding training programme designed to give practical tools to midwives and doctors.

We also know that it’s imperative that the maternity service is designed to understand and respect women. So we continue to work closely with maternity leaders, the Royal Colleges and offer our perspective in relevant government consultations, NICE Guidelines and the National Maternity Review.

We believe our legal expertise should be used to strengthen and uphold the protections offered to pregnant and birthing women. Working alongside the British Pregnancy Advisory Service, Birthrights intervened in a critical Court of Appeal case that questioned a woman’s legal status while pregnant and her rights to make our own decisions. We were pleased that the court upheld these rights in their judgement.

Through this work Birthrights has also been a consistent voice of reason on women’s rights in the media, with appearances on Women’s Hour, the Today Programme, major TV news, radio, broadsheet and tabloids.

It’s been a busy three years and we’re proud of what we have achieved. We have big plans going forward: expanding our training, commissioning vital research and expanding our advice service so that we can ensure that dignity in childbirth is universally understood and respected.

But we can only continue this work with your help. As we celebrate our birthday please consider making a regular monthly donation to Birthrights as we defend the dignity of pregnant and birthing women. We ask you to continue to stand beside us for years to come.

 

Elizabeth Prochaska (Chair) and Rebecca Schiller (Director)

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‘Captured womb’: feminism, childbirth and motherhood

Deborah Talbot explores the relationship between birthing experiences and the transition to motherhood.

Ann Oakley wrote in her seminal work on childbirth and motherhood, Women Confined, that ‘the medicalisation of childbirth has changed the subjective experience of reproduction altogether, making dependence on others instead of dependence on self a condition of the achievement of motherhood’ (1980, p.98). For Oakley, a core part of the feminist project was control over one’s own body; childbirth, in the context of increasing medical intervWomen Confinedentions, no matter how well-meaning, was a critical moment in the social control of women’s bodies.  The core question of ‘who owns my body, myself or the state’ is answered in Oakley’s work.

Yet since then there has been a resounding silence on the relationship between the feminist project, birthing and motherhood. Of course birth doulas and midwives talk about these matters, and the natural birth movement through organisations such as the National Childbirth Trust have highlighted some core concerns (albeit with their own strictures), and there has been specialised research done, but it has thus far remained on the margins of debate. Of course, rape, contraception, work and childcare are important aspects of women’s equality; although arguably the equation of work with equality – a capitalist hijacking of oppression – unravels when children arrive, and is perhaps more to do with the lack of flexible work and work/life balance for all, than the lack of childcare as successive governments have claimed.  The embodiments involved with being pregnant, giving birth, being a mother, seem to sit uncomfortably and messily with recent feminist demands for equality and inclusion, precisely because it is a condition of difference and, in our work obsessed and micromanaged society, deviance.

These issues were all raised in the first seminar of a new seminar series organised by Birthrights and myself, and sponsored by Centre for Citizenship, Identity and Governance at The Open University.

Elizabeth Prochaska presented a range of perspectives around dignity in birth, including highlighting the importance of rethinking the feminist project to be inclusive of birthing and motherhood. So she argued that ‘there is a need to match up feminist discourse with women’s experiences of their bodily integrity through pregnancy and childbirth…feminism is quite uncomfortable with the concept of motherhood. It doesn’t know what to say about it or construct it in any positive way’. She cited the case in 2013 in Essex of a women who had her baby removed from her by forced caesarian section because of a breakdown; this underlies the increasing lack of control women have over their own bodies and when, in the words of an article of the Lancet (2010) ‘Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk.’

Nicky McGuinness presented research around midwives’ perspectives, touching on issues of consent and control even for the most committed midwives. Her research showed that her sample thought and cared deeply about how women were treated during labour, but that ‘there was a feeling that sometimes biased presentation and/or coercion was used to manipulate women to make certain choices that were in line with recommendations and guidelines‘. The subsequent discussion focused on the surveillance and control of women’s bodies through the dominance of risk management in the NHS, where women’s compliance is expected and delivered, and midwives use of guidelines secured, through the threat of likely harm or risk particularly to the baby. The discussion was very lively and demonstrated an appetite not just for thinking about birthing and motherhood, but how we might begin to articulate a narrative of resistance.

I will present the next seminar on the 26th February, and will be taking forward these themes by examining research I conducted in 2013 exploring the relationship between birthing experiences and the transition to motherhood.

For further information on the seminar series and to register for future events follow this link.

 

Reflecting on the National Maternity Survey

The Care Quality Commission published the National Maternity Survey in December. We tweeted about it at the time and various press stories highlighted the main findings (see here for the Guardian, BBC, Independent), but we thought it was worth taking a more considered look at the results and comparing them to what we found in our own Dignity Survey, undertaken in October.

CQC Trust scoresThe National Maternity Survey obtained responses from over 23,000 women who had given birth in English NHS Trusts in February 2013. It is the only large-scale maternity survey of its kind in England. The Scottish government also conducted a similar survey last year and results are expected on 28 January. The survey matters because it informs both consumer perspectives on maternity care – the CQC ‘scores’ for individual NHS Trusts are intended to help inform women about where they might choose to have their baby – and because it sets an agenda for improvements in maternity care over the next three years.

The media focused on the fact that 25% of women reported being left alone during labour (an increase from 22% in 2010). This depressing finding reveals the impact of persistent NHS staffing shortages and adds yet more support, if it were needed, to the call for an increase in the number of midwives. What was not picked up in the media reports was the potential impact of being left alone on the outcome of women’s births. The survey found that significantly more women who reported being worried about being left alone went on to have an assisted birth or a c-section. We can conclude that being left alone contributes to poor birth outcomes, with associated mental and physical trauma for the woman. Any savings achieved by cutting the numbers of midwives are very likely to be lost in the financial consequences of bad births for the NHS.

Birthrights is particularly interested in the survey findings that related to respectful care. In common with the finding in our Dignity Survey, overall a substantial majority of women surveyed by the CQC said that they felt treated with respect and dignity (85% in the CQC survey, 82% in the Birthrights survey). However, 19% of women surveyed felt that staff did not listen to them when they raised a concern during labour. This accords with our finding that 18% of women felt that staff did not listen to them. When asked whether staff introduced themselves, 16% of women surveyed by the CQC reported that only some did and 2% that few or no staff did. Similarly, we found that 20% of women did not know the names of all the staff caring for them. These results suggest worrying failures in communication that can lead to women feeling degraded and disrespected. No doubt good communication is harder when staff are overstretched, but it ought to be possible to maintain basic standards of kindness and politeness whatever the staffing situation.

The CQC has not provided a breakdown of its results by type of birth (other than those relating to being left alone in labour). We found that women who experienced an assisted birth reported significantly poorer care than those who had a spontaneous vaginal delivery or a c-section. In particular, our findings showed that a quarter of women who had an assisted birth believed that their consent had not been sought for procedures during labour. It would be useful if the CQC were to provide results by type of birth in the future, so that maternity providers are made aware of serious issues that can arise during assisted deliveries.

When it came to choices in childbirth, the survey painted a depressing picture. As the CQC concluded, ‘Information needed to make choices was not consistently provided and the choices themselves were not universally offered to women.’ 18% of women said they were not offered any choice about where they gave birth, only 38% were offered the choice of home birth, 35% were offered the choice of a birth centre and 60% a choice between hospitals. The respondents to our Dignity Survey reported similar lack of choice – 26% said they did not have a choice about where to give birth and 21% said they were not given adequate information to make choices about their birth.

The government’s maternity policy, enshrined in ‘Maternity Matters‘, expects NHS commissioners to implement a ‘national choice guarantee’ of the full-range of places of birth – home, birth centre and hospital. The NHS Choice Framework, written for patients, entitles women to ‘self-refer’ into a midwifery service of their choice. The difference between the choices that are promised and the choices that are being delivered is stark. It is all the more depressing in light of what we know about the outcomes for women who are given choices about where they give birth. Our Dignity Survey repeatedly highlighted that women who give birth in birth centres and at home have dramatically more positive experiences that those who birth in hospital. Just one example – 45% of women who gave birth in hospital felt it had a negative effect on their self-esteem, compared with only 11% of those who gave birth in a birth centre.

The survey underscores a systemic failure to introduce real choice into maternity services that must be addressed by the Department of Health, NHS England and Monitor. If NHS Trusts are not going to provide services to meet women’s needs, private maternity providers that take advantage of the new NHS commissioning arrangements will grow to fill the gap.