In this blog, our Advice Line Co-ordinator Lorraine Pryce, also a doula, discusses the reality of planning a home birth against the backdrop of current challenges in maternity services.
“I don’t want to give birth in a hospital, I want to give birth at home or in a freestanding birth centre, but all of my options are being taken away from me and this is causing me stress”.
The above is something we are hearing a lot on the Birthrights advice service with women and birthing people being told by their Trust or Healthboard, that the home birth service has been withdrawn or suspended due to staffing shortages.
As a doula I am also seeing first hand the impact this is having on the emotional and physical wellbeing of families during their pregnancies, births and during their postpartum period. From births happening before midwives arrive leading to stress and anxiety during labour, to babies being born in the transition to labour wards; causing physical and emotional trauma that needs to be healed and processed during the precious postpartum period.
There is also a lot of frustration being felt by women and birthing people when they are being told that their choice to give birth at home is not being supported and that their rights to choose their place of birth are being restricted.
We are also becoming increasingly aware that their options are not being fully discussed with them so they are unable to make an informed decision ahead of time with the possibility of the support they deserve not being available.
Choice is an important aspect of an individual’s experience. Knowing all of your options for birth can ensure that you are able to make informed decisions about the events of your birth.
And the issue isn’t just one of choice, it is about effective communication and informed decision making. Many women and birthing people are being told late into their pregnancy journeys and sometimes even at the point of needing a midwife during their labour at home, that there is no one available. Here lies the problem.
We know that the NHS is suffering from record numbers of staff shortages, including in midwifery, with over half of RCM midwives surveyed in 2021, stating that they were thinking of leaving the profession.* There were 550 less midwives working in the NHS in May 2022 compared to May 2021 and we have seen a steady decrease of midwives working for the NHS since November 2021 with an overall decline of 3% year on year.**
The crisis in staffing is having a huge impact on Trusts being able to offer out of hospital birth support, which in turn is creating anxiety and worry for women and birthing people. So, what can you do when being faced with the issue and what are the options that the trusts should be discussing with you?
This is a question we often get asked…
“Where do I stand on getting a home birth? Is there anything I can say that will stop me from having to either give birth on a delivery suit or alone at home?”
Here is the legal position of what this means and the facts that you may want to know.
Your rights to choose where to give birth
The legal position is that you have the right under Article 8 of the European Convention on Human Rights and under the Human Rights Act, to a private and family life, which includes the right to choose where you give birth and who is present. However this is a qualified right which means that the rights can be restricted by a public body (i.e. a NHS Trust or NHS Wales Health Board) where there is a legitimate aim such as protecting the health of others, and where the restriction is “necessary”. In deciding what is meant by “necessary” the Courts consider the question of what is “proportionate” to the particular circumstances at that time.
What this means in reality is that you have a legal right to remain at home to give birth and you cannot be compelled to attend hospital. At the same time the Trust or Health Board can legally withdraw the service but only where they can show that the decision is properly made, properly under review, and the Health Board has explored all avenues to keep it going. The Royal College of Midwives and the Royal College of Obstetricians also published guidance during the pandemic which makes clear the benefits of home birth and sets out thresholds in terms of staff shortages for when withdrawing services might be appropriate. The threshold in that guidance is 20%.
So, what can you do if a Trust or Healthboard says no?
Constructively challenge the Trust or Health Board
Ask what they are doing to support your choice. Have they explored all avenues to support your right to remain at home including operating the service on a limited basis and/or offering bank contracts to local independent midwives who are available?
Contact your local Maternity Voices Partnership (MVP) or Maternity Services Liaison Committee (MSLC) (for Wales and Scotland). Part of their role is to collect the voices of service users and they may have more information about when the service will be running and/or when the most recent review has taken place. To find our details for your local MVP or MSLC, visit the National Maternity Voices website.
If you wish to contact and constructively challenge your trust or Health Board about their Home Birth service, please get in touch with us on the Birthrights Advice Service, where we can help you write a tailored letter to your Trust.
Consider your other options
If after contacting the Trust or Health Board, there is still no guaranteed support to birth at home you have other options that you may want to consider.
Changing Trust or Health Board
Is there a neighbouring Trust or Health Board who are still running a home birth service or who have an operational midwifery led unit? You can contact their maternity department or their Patient Liaison Services (often called PALS) and enquire about whether you can transfer your care. Do note that some Trusts and Health Boards will have capacity issues and they can legitimately decline your request if they cannot take on more people’s care for safety reasons.
Going to a birth centre
Is there a local birth centre close to you, even if it is run by a neighbouring Trust or Health Board? A birth centre can be considered as a home away from home environment where care is often led by midwives and the birthing rooms are often set up to have less of a clinical feel to them with no or reduced immediate access to obstetric, neonatal or anaesthetic care.
If you would like to consider a birth centre, this information on the NHS website might help you to understand more about the differences of a birth centre compared to a hospital or obstetrics ward and what is available in your area.
Going into hospital
Consider how you can make the hospital environment more like home. Who will be there to support you? Communicate to your care team about your desire to birth at home and what that meant for you and why that was your choice. What is it about the hospital environment that was not right for you? Ask your care team to explore how they can support you to have the birth you want. You may wish to take your own music and choose to have the lights dimmed and to have minimal people in the room with you (who should always introduce themselves to you properly). Remember that you always have the right to decline any medical treatment or procedure which is offered, even if that is going against a recommendation from a healthcare professional. You can read more on your rights in relation to consent, in our factsheet: consent – the key facts.
If you are concerned about how your informed decisions will be supported and respected in a hospital environment, especially if they are choices outside of the usual Trust guidelines, you could consider having a doula or second birth partner. Doulas and second birth partners will offer additional support to you and to any birth partner to create and maintain the right environment during your birth.They can give you emotional support and be your advocate during labour. Being an advocate means that they can help you to communicate your wishes during labour. Almost all Trusts and Healthboards have relaxed any covid restrictions on second birth partners. You should usually be able to have a professional birth partner (doula) as well as your chosen birth partner from your family or friends.
If you would like to understand more about what a doula does and how they may be able to support you, you may find this information on the Doula Uk website helpful. You can also search for a doula close to you, using the Nurturing Birth or Abuela Doula directories.
Also known as free birth which is birthing without the presence of a healthcare professional. Some women and pregnant people feel very confident that this could be an option for them if they want to remain at home. They are fully informed, aware and accepting of any events that may arise during their birth, whilst knowing that a midwife will not be available. You have a legal right to birth unassisted and you do not have to accept any medical or midwifery care or treatment during childbirth.
If the service suspensions have been made following a proper, demonstrable risk assessment and are a proportionate restriction, the Trust are not obliged to attend if they are called on the day and do not have sufficient staff to release a midwife to attend. This would be a proportionate restriction of Article 8 as they are making the choice based on the risk of harm coming to greater numbers of women/birthing people in the unit by sending a midwife out to the homebirth. Although it shouldn’t be the case, sometimes midwives are looking after more women than they should be in the unit meaning they have capacity to care for a greater number of women/birthing people in the same place.
If they are aware of the homebirth plans ahead of time they should do everything they can to put a plan in place to support that individual, however with the staffing crisis, sadly this restriction appears to be a proportionate in many instances as they are simply not able to rapidly boost the numbers of midwives available in time.
In this circumstance they would be obliged to offer to send a paramedic ambulance to support the family and this is something the family could choose to accept or decline.
You have the right to give birth where it feels safest for you and to have enough information to make an informed choice about where that place is. There is no such thing as “not being allowed” a home birth due to restrictions on home birth services. Instead you should be supported to know what your options are. Trusts and Health Boards who are running an operational home birth service are obligated to attend you when you are in labour no matter where that is. It is important that they do all they can to meet that obligation, even during times where there are reasonably predictable staffing shortages (such as several staff away for planned leave). However, where Trusts and Health Boards have suspended their Home Birth Service, there must be discussions about how your right to choose a home birth can be respected and supported.
“I hope you know how much I’ve appreciated our correspondence. It may not have gone my way but standing up for myself with your support has been important to me and I’ve really valued the time and advice you have shared with me”.
Need advice about your maternity care?
Knowing your rights and the law in pregnancy and childbirth is important. If you have are pregnant or recently given birth and need advice on any aspect of your care, please contact our advice team.
Our free factsheets provide you with the latest information on your rights, where they come from in law, and how they are backed up in guidance.
Birthrights is the UK charity that champions respectful maternity care by protecting human rights. We provide advice and legal information to women and birthing people, train healthcare professionals to deliver rights-respecting care and campaign to change maternity policy and systems.