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Home birth in a pandemic


A home birth is a much under used option for so many women. Falsely seen as a more riskier option for all, in reality a homebirth is not only a viable option for many women, but it is also statistically just as safe as giving birth in a midwife led unit for low risk pregnancies and second time mothers.

Home birth is an option that many women are now turning to amid concerns of increased risk of COVID-19 transmission in a hospital setting. It’s sad that it’s taken something as extreme as a viral pandemic for women to seriously assess their birthplace options, but perhaps this is the turning point for change. Previously, many women would dismiss the idea of a home birth as “too risky” but without fully understanding or researching the said risks of this option. So what does the medical research actually say on the matter?


In Autumn last year, a study was published which analysed 500,000 births. This is a much larger analysis than the birthplace cohort study of 2011 (which looked at almost 17,000 births), which found that risk of complications were the same for second time mums whether giving birth at home, in an obstetric unit or midwife led unit. They were marginally higher at home for first time mums (9.3 adverse outcomes out of 1000 births at home vs 5.3 out of 1000 in obstetric units).


The much larger study once again showed that home birth, when attended by a trained midwife, is not only AS SAFE as a hospital setting for low risk women, but has BETTER PERINATAL OUTCOMES. That’s right. A home birth if you’re low risk is BETTER than a hospital birth for many many women. Instead of asking if home birth is safe, maybe we need to be asking is hospital birth most appropriate? In a time where many NHS trusts are cancelling home birth as an option, perhaps we should be looking at if this is the most appropriate course of action. Women should be given the right to choose what is right and most safe for them and their babies, not backed in to an unattended free birth which may not be statistically as safe as a planned home birth. Removing choices from women may be ultimately causing more harm than good.


You can read the full opinion on this research in leading medical journal The Lancet, which includes links to the medical research.

https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(19)30142-7/fulltext


So why is a home birth more likely to give you the natural vaginal birth you may be hoping for? Well, in a nut shell, a home birth can enable you to have much more control of your environment, such as keeping the birth space quiet and dark, as well as familiar (promoting the production of vital oxytocin to progress labour naturally), and significantly reduces the instance of needing pain relief, interventions such as instrumental delivery or episiotomy, and Caesarean section. You have control over who is in attendance, and those that are present are entering YOUR space, automatically changing the balance of power. You are given dedicated care with two midwives in attendance, and many trusts will do your midwife appointments at home (although these may be reduced given social distancing measures currently in place). And you can change your mind at anytime if you decide you want to transfer to hospital.


With many trusts cancelling planned homebirths, the charity Birth Rights has provided the following guidance in response to a pregnant woman’s request for advice amid the coronavirus pandemic:

From Birth Rights:

"Thank you very much for contacting us. I am so sorry to hear that your local midwifery team has cancelled their home birth service. I can only imagine the stress and worry this is causing you. It is completely understandable that you wish to minimise your risk of infection, stay away from hospital and birth your baby at home. The unprecedented Covid-19 situation is placing additional stress on all NHS resources, and the situation is changing daily for each area and hospital Trust.
You have the legal right, under Article 8 of the European Convention of Human Rights to make choices about where to give birth, including birthing at home. Your right to make choices in childbirth is allowed to be limited by a hospital Trust but only if the limitation is lawful, necessary (such as protecting public health) and reasonable. When assessing whether a limitation is reasonable, the key consideration is whether or not the limitation is "proportionate". Sadly, the current public health situation, means that restrictive measures on maternity services that would not have been proportionate one month ago, now would be seen as more reasonable in many of the circumstances faced by the NHS.
You retain the ultimate right to make decisions about your own body and you cannot be compelled to attend hospital. However, the hospital Trust cannot be compelled to continue with their home birth service if they have a lawful and proportionate reason for limiting it at this time. Whether or not their decision is proportionate is going to depend on what is happening in the specific area that your hospital Trust covers, including local population numbers, numbers of confirmed covid-19 cases, staffing levels and resources.
We know that one London Trust, Chelsea and Westminster, have managed to continue their home birth service by finding the innovative solution of contracting with a private ambulance service to cover any transfers into hospital. South Warwickshire have also managed to continue their home birth service, despite facing very high levels of staff sickness (37% midwives and 50% of obstetricians). They have focussed on continuity of carer and staff wellbeing and have actively encouraged low risk women to consider home birth. A key part of their plan has been to work with the West Midlands Ambulance Service (WMAS) and create a standard operating procedure to reduce the need for an ambulance transfer. This has included identifying different levels of urgency for transfer with three categories. In the least urgent category, women will transfer in using their own car. I wonder if your Trust would be in a position to consider some similar, innovative solutions to resolving the issues of pressure on the ambulance service? It is certainly worth asking.
If your local health Trust have ended their home birth service due to staffing issues, the Independent Midwives UK association (IMUK) have offered a solution to help. Independent midwives are midwives who are usually paid privately and who have experience and skill to attend home births and births outside of guidelines. The private midwives who are part of IMUK have all offered to work for the NHS during this time, so long as individual health Trusts will give them a contract to do such work. The Government has passed legislation to say this is acceptable but the Government has left it up to individual health Trusts whether or not to offer such contracts to local independent midwives. The IMUK statement on this is here: independent-midwives-uk-covid-19-statement (https://imuk.org.uk/news/independent-midwives-uk-covid-19-statement/)
You might want to read through that and share it with your healthcare providers if you think it is an option that could work for you.
You can write and ask your Head/Director of midwifery and the Chief Executive of your Trust whether they will be taking steps to contract with an independent midwife who could then attend you at home during labour and birth. You could also explore whether they would consider taking steps to solve the issue of pressures on the ambulance service or transfer concerns in ways similar to Chelsea and Westminster or South Warwickshire.
Please do stay in touch with us and let us know how the Trust responds. I am so sorry that I can't give you a straightforward legal solution to the very abnormal situation at present. We really recognise your significant concerns about your birth choices in these worrying times and we are very willing to continue to give you as much support and information as we can."

Charity AIMS has also prepared advice and a draft email template which women can use to send to their care provider. Please click on the link to read the full advice and your rights surrounding home birth and COVID-19:

https://www.aims.org.uk/information/item/booking-a-home-birth#post-heading-2


Dear
I am {x} weeks pregnant and due on {date}. I have been planning to have a homebirth but have just been told by my midwife that {name of local NHS Trust} is no longer providing midwifery support for homebirths due to the coronavirus pandemic.
I know that legally I have a right to birth at home and cannot be compelled to go to hospital to give birth, yet these rights are being ignored.
{Give details here if you wish of the reasons why you want a homebirth and/or why birthing in hospital would cause problems for you e.g. previous birth trauma, childcare issues, concern over coronavirus.}
I feel that I am being denied what should be a basic right to birth in the place where I will feel most safe. I cannot afford to pay for an Independent Midwife. {You may want to add: I am now having to consider birthing at home without medical support. This is not an option I would normally choose but feel that if midwifery care continues to be declined, I will have no alternative.}
RCM and RCOG have recognised in their “Guidance for provision of midwife-led settings and home birth in the evolving coronavirus (COVID-19) pandemic” that “Continuation of as near normal care for women should be supported, as it is recognised to prevent poor outcomes.” They also comment that “Emerging evidence from European settings supports continuing to strengthen community services in order to enable social distancing and minimise spread in healthcare settings.”
I appreciate the need to protect midwives at this time, but surely keeping midwives working in the community and attending homebirths where they are less likely to be caring for women with COVID-19 has to be safer for all? I know that some Trusts are actively encouraging low risk women to consider homebirth because this reduces the risk of exposure to coronavirus for women, their families and their midwives.
I would like to know whether the Trust is following an escalation/de-escalation plan as set out in the RCM/RCOG guidance, and what the current state of midwifery staffing shortage and ambulance provision is in this area.
I am aware that other NHS Trusts are continuing to offer support for homebirths, for example by having dedicated groups of midwives who only work outside the hospital or even giving contracts to independent midwives and/or a private ambulance service to cover any transfers into hospital. The Independent Midwives UK association (IMUK) has offered their services imuk.org.uk/news/independent-midwives-uk-covid-19-statement/ but have been informed by NHS England and the Chief Midwifery Officer that “it is to be left to local HOMs and DOMs to decide if they need Independent Midwifery support.” {If you know of local Independent Midwives who would be willing to offer their services to the NHS you may want to mention them too.} Have you explored this option?
RCM/RCOG say that homebirths should not be stopped just because of inability to provide two midwives. Rather, Trusts should consider using “senior student midwives, returning registered non-clinical midwives, returning recently retired midwives or appropriately prepared maternity support workers to attend as the second member of the team for low-risk home births”. Have you explored this option?
I urge {name of local NHS Trust} to explore whether there is a solution which could be implemented to enable myself and other mothers choosing a homebirth in this area to have the midwifery support we need.
I look forward to your reply.

Ultimately where you give birth is your choice, even in a pandemic. NHS trusts and healthcare professionals will have preferences and guidelines in place, but it’s important to know that you cannot be compelled to give birth in any one way or place, and it is still your choice. What IS important, is that that choice is made by weighing your options, based on research, information and facts, and not based on fear either of the unknown or projected fear by your healthcare providers. Do your research and make the decision that you feel is right for you and your baby. If you start from there, you’ll have a much more positive experience in the end.

References:

Birthplace cohort study: https://www.npeu.ox.ac.uk/birthplace/results


AIMS UK coronavirus and maternity services campaign https://www.aims.org.uk/campaigning/item/coronavirus

Birthrights official statement re maternity rights and COVID-19 https://www.birthrights.org.uk/2020/03/31/birthrights-calls-for-protection-of-uk-women-giving-birth-during-coronavirus/


The Lancet article: is it time to ask if facility based birth is safe for low risk women and their babies? https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(19)30142-7/fulltext

The Lancet: research paper - Perinatal or neonatal mortality among women who intend at the onset of labour to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analyses https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(19)30119-1/fulltext


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