Hi Anne, thank you for meeting with me to discuss homebirth in England.
How do your shifts as a midwife work?
I can either be doing visit days, or there are days when I’m on call for the day or the night. There’s two of us on call for homebirths. This weekend I’ve got a lady due for a homebirth any time now, but I haven’t heard from her yet.
I’m not on call for every single woman in the hospital, I’m on call as part of a team, so I will look after 3-4 women per month throughout pregnancy, and then as a team we do the labor care. I look after the women who go into labor when I’m on call within my team, and that can be at home or in the hospital birth setting. We then look after them postnatally as well for up to a month, depending on the situation.
Where in England do you work? Is homebirth an option in every area, or is it only available in specific locales?
Theoretically, every area should offer homebirth because it is what women want, and there should therefore be a provision for homebirths. But I suspect it doesn’t happen everywhere.
The national average for homebirths in the United Kingdom is around 2-3%, but within our team, we’ve got a much higher percentage than that. I think last year we had a 6% homebirth rate, but then I worked with a slightly different team. This year I’d say it’s sitting closer to 12%, so some weeks we can have 5 in a week, and then last week we had 2, so it varies.
Through my research it seemed that NHS, the National Health Service which is the national insurance every British citizen is on, was promoting homebirth as a good option for women, but when we emailed it seemed from your reply that it is not so common?
So if you look at the national homebirth rate of 2-3%, it’s not very common in comparison to giving birth in a hospital, or a midwifery led unit.
Homebirth took a downward turn when the NHS was set up, because then it said everyone should go to the hospital, and it was a lot safer to go in to hospital. Honestly at that time, yes everyone gave birth in hospitals then, as they were very nervous about birth at home, including GPs (General Practitioners).
So GPs are not supportive?
Some are and some aren’t. But again, if you talk to a doctor, they are probably far less supportive than any midwife.
In the UK, we are under the proviso that every single woman needs a midwife, and only some women will need a doctor. So it’s not like in the United States, Australia, or other parts of the world where you would predominantly see a doctor. Here, everyone sees a midwife. We’re trying to see women from around 10 weeks pregnant, so we’re actually seeing them super early, and then showing them what normal is, and only referring to a doctor if needs be. So we actually can go through place of birth, and where to give birth, and the evidence and the facts around them, and discuss this with them early on in their pregnancy.
So a woman who is pregnant will not see an obstetrician initially?
They won’t see an OB, because they won’t have access to them. Because in England, anything through the NHS, the GP (General Practitioner) is your first point of contact for doctors. So they would never see an OB right away, unless they want to see (and pay) privately.
If they are going through NHS they can self-refer, where they don’t even have to see their GP for the referral. They can self-refer to the hospital where they want to have their baby at, which is basically an online form they complete, and it comes to us and we organize the midwife appointment and scan. We then feed that form back to the GPs so they know that their patient is pregnant, and thereby obtain any other information that we might need to know that they might not have put on their form.
If a woman needs well woman care, and they are not pregnant, who would do that?
Their GP’s have practice nurses who will do that for them. The smear test (PAP) is done by the nurses at the GP’s health centre. They will also do any family planning and contraception they may need.
So there aren’t too many obstetricians, I’m assuming, because obstetricians in the United States do well women care. So they’re just there in case of an obstetrical emergency or pregnant with a pre-existing medical condition?
So midwives are basically running the maternity units at the hospitals?
At the hospital that I work in, we have a labor ward as you would know it, with an obstetric team, anesthesthetist, and 2 (operating) theaters. In addition, we have an alongside midwife led maternity unit. We call it “Home From Home”, so it’s effectively for anyone who’s low risk and can give birth at home but doesn’t want to.
So that’s the equivalent of a birthing center?
Yes. In my hospital, our labor ward is called Birth Center, which is a little confusing, as that is our actual hospital. Instead of calling it a ‘labor ward’, which is quite a negative connotation as labor is about hard work and pain and duration, we call it a ‘Birth Center’ because you’re going there to give birth. Aside from our labor ward, the other hospitals in the local area, call their maternity units “labor wards” or the name of a labor ward.
Our birth center is adjacent to our obstetric unit, so we are all on the same floor. With other hospitals, they might be on different floors or a different building that is attached. So if labor is not progressing well or according to plan, we can transfer them easily to the obstetric unit, without needing an ambulance for transportation.
What’s your c-section rate like?
Our cesarean section rate at the hospital is quite high, it sits around 28-30%. But within the country, it’s sitting around 25%, which I find really high.
What is the name of your hospital?
St. Thomas’s Hospital.
We have a Level 3 Neonatal unit, and our hospital also covers the whole of the Southeast region for particular maternal cardiac problems and fetal cardiac problems. So we might have women coming up from Brighton, which is about an hour and a half away or so, to give birth at St. Thomas’s, because we have the facilities for their newborn baby. That’s probably why our c-section rates are higher than perhaps in places in other parts of the country.
When do obstetricians take over? When would they step in?
When I book the woman, starting when I see her at ten weeks pregnant, I’m always doing a risk assessment. So if there’s something during the booking (appointment) that I feel she needs to see the Obstetrician for, I would refer her then. So she well may see an obstetrician alongside a midwife throughout her pregnancy.
Let’s say she doesn’t. Let’s say she has a normal low-risk pregnancy, with nothing in her past medical history to indicate a problem, but she comes into labor and for whatever reason we have this lovely term ‘failure to progress’ or ‘labor dystocia’, however you want to call it. We would then call the obstetrician and say, ‘Look, this is what’s going on,’ and then they would come in and assess, and put their plan in place, and then obviously the midwives carry on the care. If everything is ok and they go on and have a normal birth, the midwives would do it. So they only really come in if instruments or cesarean section is needed. Otherwise midwives are still there in the room the whole entire time.
Are obstetricians on staff at the hospital?
And they’re on call at all times?
Yes. We cover our labor ward with permanent members of staff so I think we have about 11-12 midwives per shift and 13 at night. And then obviously an obstetric team, we have two theaters in our department which can run at the same time.
How does schooling work?
There’s two ways. There’s direct entry, where you can go straight from A-levels, which are our exams at age 18, to midwifery school, so you’re not a nurse first, you’re just a straight midwife. (you can also enter at any time of your life.) You would work for three years as a midwifery student, doing your shifts on the wards throughout the whole area, working with midwives, as well as attending lectures, taking exams, and everything else alongside that.
You can also go for nursing, and then take a midwifery course for 18 months studying and doing your shifts alongside midwives.
I happen to be a nurse and a midwife, but everyone on my team are direct-entry midwives.
As a nurse, are you considered a higher-level?
No. People have different opinions on whether this is an ok process or not. I personally think my nursing background has helped me in my midwifery, because I feel like I have a lot more knowledge about medical understanding and looking after sick patients. But in midwifery I feel it’s slightly different, so although it helps me, I found it very hard to learn everything I needed to learn as a midwife in 18 months. So I have great faith in my midwife colleagues who have studied for three years because actually although they might not have the same level of knowledge in other areas, actually their level of knowledge in terms of midwifery aspects was probably greater than mine when we qualified. So I’m not one of these people that say it should be only nurse then midwifery orientated, because I think they are very different. I think for my direct entry midwifery colleagues, their knowledge is amazing, so no, I don’t have any issues with it.
Can midwives work independently of NHS?
The main issue is getting malpractice insurance in order to practice.
So NHS provides malpractice insurance to their midwives?
Yes. The independent midwives have to get their own private insurance. There’s been some issues with that over the last couple of years. There’s been quite a push within the political field. From our point of view as midwives, it almost feels like they are trying to push independent midwives out of business, because of the demands on how they have to get their insurance and how much insurance they have to have in order to cover their practice. I think it’s made it very difficult for some independent midwives to be able to practice, so they may be able to do antenatal care and postnatal care, but it’s very difficult to get the insurance for labor care. Sometimes they do labor care, but if the woman chooses to go to the hospital say, they then can’t work when they are in the hospital environment unless they have an honorary contract with that hospital. If they get an honorary contract with the hospital, then they are saying they will go along with the hospital policies and protocols, but if they can’t get that, because you can’t always get that, they have to practice as a birth partner, and then the hospital midwife has to do the labor care.
Like a doula?
Yes they will end up being like a doula, which is a bit odd, and it’s a bit odd for both midwives in the room where you’ve got a midwife who’s known that woman throughout, and then has to come in and leave the care to the hospital midwife who’s never met the woman.
Does NHS have a lot of regulations regulating midwives and what they’re allowed to do, for example delivering a breech baby at home? Are there specific guidelines to follow?
Yes. We have a Nursing and Midwifery Council that governs nurses and midwives. I work as a community caseload midwife, so I look after women throughout, so a bit like independent midwives I get to know my women quite well. From my point of view, if a woman chooses to have a homebirth, that is where I have to be. So regardless of whether we allow it, or don’t allow it, it’s irrelevant, because what we should be doing is offering support and advice and information. If you give women information in a way that they understand, and you go through the benefits, risks, and alternatives to the care you can offer, then women make the appropriate decisions that are right for them. They might not be right for everyone at the hospital, and while doctors may have issues with some of the decisions women make, my role is to support the woman and be a voice for her.
It’s difficult because you said that you know they wouldn’t be allowed a breech birth at home. As a midwife I want to offer appropriate care to women. If a woman is saying, ‘I want to stay at home and this is what I’m going to do.’ As a midwife, my professional responsibility is to be with that woman. So unless she is freebirthing, where she never calls the midwife and she goes off and gives birth on her own, if she’s calls us for support while she’s in labor, I have to be there for her. So if she’s having a breech birth at home, or she’s had two previous cesarean sections and she wants a baby at home, anything, that is where I have to be.
As far as regulations for our profession, there is a revalidation process we have to complete in order to continue to practice. We have training hours and extra study, as well as feedback we have to obtain from families we look after to prove we’re still competent to be midwives.
What if you were at a homebirth and things were not going in the right direction and you felt like you might need to head over to the hospital. How would you present that to her?
It kind of depends on what’s going on doesn’t it, because I’ll always talk to them about homebirth prior to them having a homebirth. I always talk to them about the benefits, the risks, what we might do, and transfer rates to hospital.
We had a study done in 2011, called the Birthplace Study, and this was set in the U.K., which looked at 65,000 low risk women and where they planned to give birth and where they gave birth. One of the findings out of the whole thing firstly was that homebirth is very, very safe. It is so safe for everyone, whether it’s your first time, second time, or third time, for low risk women. The second thing they found out was that actually there was a higher transfer rate for first time mums. So I think it’s 45% for first time mums as a transfer rate to hospital, and for second time mums sitting around 12%.
Do you personally recommend first time mums give birth in the hospital?
No. If they want to give birth in the home, I will support them to do that. Absolutely. I feel like a woman needs to be relaxed and comfortable wherever she gives birth, so if for her, hospital just frightens her completely because she doesn’t like the noise, the lights, the people, the smells, whatever it might be, that is not the place she’s going to give birth. So I just go through it with the women what they want to do. I always go through the Birth Place Study with them, because I feel like a lot of women are very appreciative that it was a study done in the U.K., it’s not that long ago, and it looked at thousands of women. 65,000 women was a really big study.
I always talk to them about the risk factors, the transfer rates, why they might need to transfer to the hospital, and how we would transfer. Generally a transfer to the hospital would be via an ambulance. I explain why it might not be rush, rush, rush, and why it might just be depending on what’s going on; I would let them know at the time as there’s lots of reasons why people might transfer in from a homebirth, in terms of something might not be going according to plan, or she might want extra pain relief like an epidural, or she doesn’t have a pool at home and she wants to use the hospital’s pool.
Are women generally receptive when you tell them, ‘Ok, I think we need to head over to the hospital now?
Yes, most of the time. It depends what it is. I can tell you recently I’ve had all sorts of homebirths with risk factors so I’ve had one who’s baby’s abdominal circumference was on the 97th percentile so she was expecting a large baby. I had to speak to her about the risk of shoulder dystocia and what that meant having the baby at home, what that would mean in terms of a transfer, the detrimental issues, she also has polyhydramnios, which is extra fluid around the baby, and what that would mean in terms of cord prolapse, I had many frank conversations with her. And for her, her homebirth went absolutely fine. She gave birth in the comfort of her own home and had a beautiful 4.3kg baby boy without any complications.
I went to another homebirth, I don’t know what was going on, she was probably quite frightened, there had been a shift change, and I was coming on at 8pm, after her midwife left. I think her midwife had told her she wanted to do another vaginal examination to see what was going on, and had told her we’ll probably have to break your waters. She was hypnobirthing and wasn’t receptive to this at all, and then of course there was a change of shift, and I came to the house and took over from this other midwife, and I could just see it: She was petrified. She was on the toilet, and I just said, ‘Listen, I’m not going to anything, go back to the zone you were in, keep your music on, do your affirmations, let’s just see what happens.’ She declined everything I offered her, from catheter to vaginal examination, to breaking of the waters, to everything.
Were you able to listen to the baby with a fetoscope?
Yes I listened in, mum and baby were absolutely fine. She was happy for me to listen to the baby, she was happy for me to take her pulse and blood pressure, and all those kind of things, none of that was a problem. She just felt any interventions were unnecessary. She had a very long pushing stage; It was probably a good three and a half hours. I know that my colleagues, particularly at the hospital, and particularly the obstetric team, would be very horrified by this, but she ended up having a normal birth in the pool at home finally, in the early hours of the morning. But she got the birth that she wanted and the experience that she wanted, and I had to respect her wishes. Now I can’t do anything to her without her consent, because as far as I’m concerned, that is called ‘assault’, so I’m not doing it. I can only give her the benefits and the risks, and what we might do instead, and for her, I do need to respect her wishes.
I love that you said it’s considered assault, because that’s really what it is. In the hospital, when they ignore the woman’s wishes, when they do a vaginal exam or an episiotomy without obtaining consent, that’s assault.
Well, I think that’s why I like where I work because you’ll have a midwife standing there going, ‘No, stop.’ And we will do that if need be.
I find they’re quite respectful, to be totally honest. Especially with our muslim ladies, or with our ladies that have been sexually assaulted and raped in the past and we know about it, the team is very respectful.
But as far as explaining risks, obviously if there’s a massive problem, and we’re really concerned for the baby, talking about a proper life and death situation, most people will accept what someone is saying. I think the issue sometimes in maternity and obstetrics, is your time frame may be very short. If you’re caring for a woman who’s in pain, having contractions every two minutes, and you’re going to give her really succinct information very quickly, and you need to go to theater, the way you say it might not appear to be a choice, and I think that’s sometimes very difficult for women to understand. Your benefits are your baby’s going to live, the risks are your baby’s might die. Well, that’s never a choice to a woman. There’s no choice, is there?
Well, the women need to trust that you’re telling the truth. Not all c-sections are absolutely necessary.
Basically in the NHS, there is a lot of pressure to bring down our cesarean section rate, because actually we don’t know what it’s going to do in the future. Doing a cesarean section when a woman’s fully dilated, we don’t know whether that’s actually impacting on their future pregnancies and causing premature births. As the uterus grows and the cervix opens, the way you cut into the uterus may be much closer to the cervix than it would have been if the cervix was not that dilated. We’re starting to wonder if we’re affecting women for future babies and for the future getting pregnant, as we know it sometimes can reduce their fertility.
There’s a big drive in the UK to drive our cesarean sections rates down, so whenever a cesarean section is done, every morning the doctors all discuss it with the consultants as well. There’s a discussion about the section and why it was done, and discuss the CTG (Cardiotography, known in the US as Electronic Fetal Monitoring, which monitors contractions and baby’s heart rate). They’re always trying to look and see, could we have done something else, could we have waited. We’re doing a lot of work with how we read CTGs at the moment, and we’re trying really hard to go to a more physiological reading of them. So there’s a lot of training going on in the hospital around reading the CTG.
Does every woman who comes into the hospital in labor get a CTG?
Absolutely not. Only the ones that need it. If you’re low risk, no, you would never have one. Let’s say you’re low risk but you decide you want an epidural. Fine, that’s totally up to you. We would ideally have the CTG on for 30 minutes before the epidural, 30 minutes after the epidural, and then we don’t put it on again unless they have a top up.
Not all midwives do this though, so you’ll find a CTG is on for epidural only.
So it’s not continuous epidural.
We have a patient controlled epidural, so it’s not a continuous dose all the time. It’s called a mobile epidural. The women press the button, and they have control when they want pain relief. It will only give a drug every 20 minutes, so theoretically, if they can get away with pressing the button maybe once or twice an hour, they can then get up to use the toilet and then would not need an indwelling catheter placed in their bladder.
In Holland the homebirth rate is around 30%, and you just think, well the women in America, or the UK, or anywhere else, are no different. The variation in Europe is fascinating. Absolutely fascinating. The Scandinavian countries: Holland, Denmark, Sweden, Norway, Finland are definitely far above the rest of Europe in terms of midwifery care and homebirth rates. Their reduction of obstetric anal sphincter injuries, the third and fourth degree tears, they lead Europe. They’ve got some really good ideas and ways of working, and again, a lot of it is about midwifery care; The premise is everyone needs a midwife, only some people need a doctor.
Then you’ll go to France, Spain, Portugal, Italy, and you will have women flat on their backs in lithotomy (position), everyone with an epidural, everyone’s got their waters broken. So as a pregnant woman, you don’t expect anything else; You expect to go to hospital, almost give up your body, and have your waters broken, have a drip, and everything, because it’s the norm.
We have people come to our hospital from all around the world and you’ve got to understand that wherever you’ve come from in the world, that will be your normal. Whereas when Americans come over to the system in the UK, or Brazilians, where the c-section rate in Brazil is probably the highest in the world. When people from these countries come in for prenatal visits, sometimes they are quite alarmed, ‘Why aren’t I seeing the doctor? Why am I only seeing a midwife?’ and it’s almost having to explain what’s normal in the country. Sometimes you just have to respect that. If I’ve got a woman from America who thinks I don’t understand why they’re not seeing a doctor, well if seeing a doctor is what will calm them down and relax them for whatever reason, so just book the appointment. It’s no skin off my back. I would rather they were happy and relaxed with the care they were given.
If you come from Finland, and the expectation is you’re going to give birth at home and put your baby in a box. Have you seen those birth boxes? They were designed in Finland years ago, a cardboard box for babies to sleep in. In Finland, all pregnant women are eligible to have access to this sleep box and they’re filled with all sorts of things you would need for when you have a baby, such as nappies (diapers), clothes, blankets. it’s not for the birth, it’s more about for the baby for the first days and weeks.
So the baby sleeps in there?
Yes, but it doesn’t have a lid, obviously.
This has come from Finland, and this year Scotland has funded this for all their first time mums. Partly this has come to reduce SIDS rates.
How does it reduce SIDs?
I think it’s partly to try and encourage the baby to sleep in the box, rather than in the bed or on the sofa with the parents.
So if that’s your normal, and then you go over to Brazil, you’re going to be shocked that you then have to see an OB that’s going to examine you every month. I had someone tell me that recently. One of my Brazilian ladies, she said the doctor would do a vaginal examination every month in pregnancy, to assess how well the cervix will be in labor. I kind of thought, ‘Yeah, but why would I bother? Why don’t I just wait and see in labor? And also, why wouldn’t it open?’ We’d be a very poor human race if we couldn’t have babies.
I know doctors who do routine ultrasounds at every visit.
We have two scans in pregnancy. We have the nuchal scan, which people can decline, so that’s for the down syndromes screening. If they decline the nuchal, that’s fine. We advise them to have the scan if they’re ok with that, and just not have the nuchal part of it if they don’t want to. The second scan would be around 20 weeks pregnant, and that’s really to assess that the baby’s growing normally, where the placenta is. And then they wouldn’t have any scans after that. So unless there was a problem, or there was a scan needed, at St. Thomas’s we only do the two. The hospital down the road does a third trimester scan as a routine, but in all honesty you’re looking at 2-3 scans in the UK, and that’s it.
I still have my trusty Pinard which I use to listen to the baby’s heartbeat. It looks like a trumpet, and it’s a non-invasive way to assess the baby’s heart rate.