A woman has a number of options when thinking about the place in which she wishes to give birth. For most women, pregnancy and birth is a healthy, exciting and special episode in her life. It is impor- tant that the woman makes the choice that is right for her and her family. Options need to be woman-centred and focused on meeting the needs of the individual rather than the service as a whole. An Audit Commission report (1997) on women’s opinions of maternity care found that although most were happy with the care they received, many wanted more information about their options for care and place of birth.
Hospital with a central delivery suite
A woman may choose to give birth in a hospital and indeed this is where the majority of babies in the UK are born (Birth Choice UK 2007). Women who have complicated or high-risk pregnancies are offered consultant-led care and the consultant obstetrician will be the lead carer. Examples of pregnancies deemed to be high risk are:
in women who develop high blood pressure and pre-eclampsia;
women with pre-existing medical conditions and women who are carrying more than one baby. However, for women who do develop complications, there needs to be a team approach, bringing together the skills of midwives, obstetricians, paediatricians and anaesthetists
to ensure seamless care for the woman. The Department of Health’s (2001) report Why Mothers Die, 1997–1999. Report of the Confi dential Enquiry into Maternal Deaths makes reference to the importance of teamwork in many areas where substandard care has been uncovered.
Healthy women who choose to give birth in hospital do so for a variety of reasons. The woman may feel safer there or wants the reassurance of knowing that an anaesthetist is on hand if she chooses to have an epidural. However, some women may be unaware that they have other options than to go to hospital. In a study about women’s choices undertaken by Lavender (2003), it was highlighted that women were reassured by the medical facilities a large consul- tant unit offered, especially in the event of an emergency. Lavender (2003) attributed this to women’s lack of knowledge of the choices available to them and the fact that a medically-oriented approach was perceived to be safer than midwifery-led care. Women should be given the opportunity to familiarise themselves with the delivery suite by having a guided tour with the midwives and midwifery assistants who work there. A woman whose baby is known to be likely to spend time in a Special Care Baby Unit should be offered the chance to visit it and meet members of the team.
Case Notes
My local hospital has a birth centre attached to it. Most of my friends have had their babies there. I must admit that I am petrifi ed of the pain and want to have an epidural as soon as I go into labour! The midwife has said that I should try the birth centre as it is very homely and has two birthing pools. I don’t care about the wallpaper, I just care that there is an anaesthetist on standby as soon as I have the fi rst contraction! I want every drug going!
Birth centres
Birth centres are also known as stand-alone birth centres, freestand- ing birth centres or midwifery led units. They are facilitated and managed by midwives and often have consumer involvement from women who may have used the birth centre previously and members of Maternity Services Liaison Committees (MSLCs) and the National Childbirth Trust (NCT). Staffi ng usually includes midwives, mid- wifery assistants and housekeepers. Birth centres often provide antenatal care and postnatal support, as well as facilitating
parenthood education. Being midwifery-led, birth centres take the focus away from the medical model and concentrate on the social model of care. With regard to medical facilities should intervention be required, birth centres are the same as what is expected from a homebirth – the woman would be transferred to a hospital just as if she was transferring from home. Birth centres have a wealth of benefi ts and these have been outlined by Walsh and Downe (2004):
• Increased normal birth rates
• Fewer assisted births using instruments such as forceps and ventouse
• Reduced caesarean section rate
• Fewer women using strong pain-relieving drugs, such as pethi- dine and diamorphine
• Fewer women using epidurals
• Reduced rates of induction of labour
• Fewer women needing episiotomies
• Fewer vaginal examinations
• Shorter labours
• Reduced incidence of shoulder dystocia (when the baby’s shoul- der becomes impacted behind the woman’s pubic bone)
• More intermittent fetal monitoring and less use of continuous electronic monitoring
• Higher maternal satisfaction
• Increased midwifery job satisfaction
• Increased breastfeeding success
• Cost-effective
Walsh (2005) defi nes a birth centre as a place that provides mid- wifery care in childbirth, with importance placed on relationships and the environment rather than on machinery and drama. Many birth centres offer birthing pools or large baths as pain relief and may have options for low lighting, birth balls, birth stools and music. The environment in a birth centre usually facilitates normal- ity. The birth environment is important to women and has been highlighted in the NSF (DH 2004). The NCT issues awards for mid- wifery-led units that facilitate the best birthing environments for women with the aim of celebrating innovations in practice that enhance women’s experience of labour and birth. Lavender (2003) found that many women believed that a midwifery-led unit on the same site as a consultant unit offered safety but with a more homely environment, and 51 per cent said that it was important to them to have a midwife help them to give birth naturally without medical intervention.
Midwifery case loading
Case loading teams of midwives provide total care for women and their babies throughout pregnancy until six weeks post-delivery. They offer hospital, community maternity unit and homebirths. Although this is predominantly primary maternity care, midwives will usually con- tinue caring for women whose pregnancies become complicated but in conjunction with the hospital obstetrician. Case loading midwives will often work in small teams and spend time getting to know a group of women, focusing on their individual needs and working in partnership with the women. Within NHS Trusts this can often be as many as 30 women a year depending on whether the midwife works full- or part- time. In one area of the UK, case loading exists in contract between a group of self-employed midwives and an acute Trust. Walsh (1999) explored case loading midwifery using an ethnographic approach and described the case-load midwife as a ‘professional friend’ to the woman.
One practice in South London (the Albany Practice) was evaluated by Sandall et al. (2001). They describe how the normal birth rate, the home- birth rate and breastfeeding rates all increased for women being case loaded by the midwives at that practice.
Homebirth
Case Notes
I was the 100th mum to give birth in the Hemmingway birth centre. It is such a great environment to give birth. The midwives and staff are so calm and professional and just let you get on with the business of labour.
I spent my early labour in the ‘sensory room’ where it was dark and relaxing with gentle music and aromatherapy oil burning. I had bean bags to lean on and a birth ball to sit on. When I got to 8 cm dilated (with no drugs!) I transferred into the dolphin room (aptly named because of the deep pool). The warm water was just what I needed as I was really howling the place down by then! It wasn’t long before my baby boy was born into the water and into my and Lynda’s (the midwife) hands. He looked into my eyes and I fell in love instantly and all the pain of labour just melted away. I was on cloud nine. I did it!
Midwifery wisdom
At a homebirth, you are the guest. This puts the woman in control.
Homebirth truly empowers the woman and enables the midwife to be
‘with woman’ without interruption.
There is a large body of evidence that suggests that homebirth is at least as safe as hospital birth for healthy pregnant women (Chamberlain et al. 1997; Ackermann-Liebrich et al. 1996; Olsen and Jewell 2005). Tew (1985), a research statistician, describes how mor- bidity is higher among women who have babies in an institution- alised setting such as large consultant-led units and a large majority of women who experienced both hospital and home delivery pre- ferred the homebirth. Chamberlain et al. (1994) revealed that there was no evidence to suggest that the safest place for healthy low-risk women to give birth is the hospital, and a Cochrane review by Olsen and Jewell (2005) found no compelling evidence to suggest that hospital birth was safer than homebirth for low-risk women.
Case Notes
I was pregnant with my fi rst baby and really keen to plan a homebirth.
However, when I went to see the midwife, she told me that I couldn’t have a homebirth with my fi rst child as I had an ‘untried pelvis’. She was quite adamant about this. I had really wanted my midwife’s support.
My partner was nervous about the idea of homebirth and I was hoping that the midwife would put his mind at rest. After the midwife implied it was dangerous, my partner said there was no way he would let me have the baby at home. I ended up in hospital with a ventouse and a third degree tear. I wish I had stayed at home. I wish my midwife had supported my choice. Instead, I felt cajoled into doing something I didn’t want to do. I must admit, I felt a bit powerless I am sure my postnatal depression has something to do with feeling as though I had no control over my decisions.
Having a homebirth usually results in fewer unnecessary inter- ventions such as episiotomy or assisted birth, and being in familiar surroundings the woman is more likely to feel relaxed, enabling labour to progress effectively. The National Service Framework (DH 2004) standard 11 states that women should be able to choose their place of birth and that normal childbirth should be facilitated wher- ever possible. This includes being offered the choice of homebirth.
NICE states: ‘During their discussions about options for birth, healthy pregnant women should be informed that delivering at home reduces the likelihood for caesarean section’ (NICE 2003).
The NMC (2003) says that midwives have a duty to respect women’s choices when choosing homebirth. If there is a perceived confl ict between risk and a woman’s choice, midwives should seek guidance from a Supervisor of Midwives. (The role and function of Supervisor of Midwives is discussed in more detail in Chapter 18.)
Women having their babies in a birth centre or at home may choose to labour and/or give birth in water. The Royal College of Midwives (2000) states that ‘women experiencing normal pregnancy, who choose to labour or deliver in water should be given every opportunity and assistance to do so’. Birth in water is considered a normal birth and just like homebirth it gives midwives a chance to practise autonomously, using their ‘with woman’ skills. Women have said that water birth has given a greater sense of control and movement as well as providing good pain relief (Garland and Jones 2000). Researchers such as Burns and Kitzinger (2001) have found water birth to be a safe option. Midwives have a responsibility to ensure they are competent and accountable for their actions and omissions, and all units should be developing guidelines for water birth. Midwives have a responsibility to refl ect on rules and ensure accountability for their own practice. One of the roles of the Super- visor of Midwives should be to help other midwives acquire and sustain their skills in water birth.
Table 3.1 provides a list for parents from Independent Midwifery records in order to be prepared for a homebirth.
Table 3.2 describes the contents of a hospital bag.
Midwifery wisdom
Remember to pack some food or drink. The midwife needs to be cared for too!
Midwifery wisdom
Remember, it is the woman’s choice to make. Count to ten before you ever hear yourself saying to her ‘you can’t’ or ‘you’re not allowed’.
Case Notes
Giving birth to my third child at home was an amazing experience for all of us. My older children were there to witness their little sister being born and my midwife was fantastic and so supportive. However, the best part was having a relaxing bath afterwards in my own bath and then snug- gling down into my own bed with my gorgeous new daughter!