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From Cathy Warwick (CW), Director Women's Services, King's College Hospital (KCH), London

A graphical display showed an increasing home birth rate in the speaker's area, from 3% in 1994 to a projected 8% at the end of 2002; the national rate has remained static at 2%. It is a compact inner city area with a deprived population which figures in the home birth statistics in proportion to the total for the hospital.

The midwifery practice is intentionally mixed, with hospital based midwives, groups with caseloads, and a geographically based community service. That the medical model is prevalent is evidenced by the 27% CS rate. The Warwick philosophy is to facilitate any step which leads toward normality in birth, without worrying about where in resource terms these steps are leading; the service evolves to enable itself, with managers and supervisors ensuring that sudden and unpredictable surges in work load are met.

Midwives with enthusiasm for home birth are posted all round the service to spread the word; students are unlikely to miss being involved in home birth, and the doctors are being exposed to this positive attitude. Our consultant midwife encourages the groups with low rates to have the confidence to go for more births at home, often as in Torbay only decided when a mother is in labour. Importantly the word that home birth is positive, empowering, is spread by the women themselves.

In 1994 when the home birth service started with community based midwives its champions for development were identified: some enthusiastic midwives, an obstetrician, and the midwifery manager. The majority of local GPs opposed the service, and this was overcome by the obstetrician, who encouraged his colleagues to support it. This team worked to set up other teams with the same ethos.

Where the support of a second midwife at a birth is needed she attends; it is often unnecessary, and it is certainly not a legal requirement. This was a midwife concern, and the attitude of the managers has been to address those concerns rather than impose their own. However, the KCH Place of Birth Guidelines have been updated this year, and they identify a “grey” category of risk, where one risk factor exists early in the pregnancy; it may disappear, or other risk factors may emerge, making hospital birth advisable. Usually with a single risk factor the place of birth is probably not going to have a particular impact on the outcome of the pregnancy. The following passages are crucial: “There is no system currently available in the maternity services which helps elicit absolute risk or accurately predict adverse outcomes. In assessing where a woman is best advised to deliver, consideration has to be given to factors pertinent to an individual woman's unique situation. There is no justification for making the final decision for a particular place of birth early in pregnancy. The presence or absence of risk may change during pregnancy and labour and must be continuously assessed. Therefore the advice about the place of birth may also change.” And “Obstetricians and midwives should be offering home birth for women who are healthy, experiencing an uncomplicated pregnancy, expecting one baby, 37-42 weeks gestation, cephalic presentation and go into spontaneous labour.”

Discussion.

LL explained the low transfer to hospital rate for postmaturity in her service by (a) the relaxed attitude of the mothers and (b) the use of membrane sweep to encourage the onset of labour. She agreed that the assessment of fetal wellbeing may be adversely affected 14 days past the due date.

CW is encouraging the groups of midwives with high home birth figures to promote their practices among the other community (and even hospital based) groups, so instilling confidence throughout the service,

LL and CW agree in ignoring the E and F gradings of trainee midwives which rigidly prevent their getting experience in the community when they most need it. “We call midwives midwives. If when first appointed they lack necessary experience in a particular area of practice they are encouraged to get it, and to put themselves second on call for home births; this is welcomed by the teams”. A direct entry midwife criticized the required learning of the medical model in labour wards as an aberration. A KCH midwifery lecturer advises the placement of students where their preferences lie, rather than where the service wants them to go.

Wendy Savage recorded that the imposition of a fully integrated service in Tower Hamlets had been a failure because the midwives had not first been helped to have the necessary confidence to be wholeheartedly with home birth. The decisions on home birth made by a labour ward manager are likely to be informed by the culture of liability.

LL: When a mother has to be transferred in labour her midwife, being so focused on normality, may delay referring her for an instrumental vaginal delivery, to the point when an emergency CS is inevitable. CW reported the reservation of rooms in the KCH Birth Centre for normality, a move driven by the community midwives and the desirable shape of the future for such centres.

CW and LL have succeeded in making community midwifery, rather than the medical model in hospital, the gold standard, and this is what we must all aim for. With this model updating of skills can take place in the community setting, and the enthusiasm of direct entry midwives makes the time ripe for that.

Becky Read of the Albany Group described their setting up with CW's help in 1994 and their mode of working, which is to accept GP referrals of all risk levels, providing one-to-one care and deferring the place of birth decision until labour; the current home birth rate is 40%. She ascribed this success to the confidence of midwives in their working practice.

A late entrant to midwifery who had worked exclusively with home birth as an independent midwife reported gratefully the outstanding and essential support she had received from some supervisors.

Speaker Debby Gould reported a 30 to 40% unplanned normal birth rate in the Birth Centre at Queen Charlotte's Hospital.

CW said that recruitment and retention of midwives now depended on the development of midwifery leadership to enable managers to cope confidently with uncertainty. LL praised the recognition of small acts of leadership, celebrated the resourcing, human and financial, of her service by midwives, close to the mothers, and the motivation to feel safe introducing new practice and challenging bureaucracy.

The educational and training imperative.

From Debby Gould (DG), Consultant midwife, Queen Charlotte's Hospital, London

This presentation began with a rallying cry: "Let us nurture nature, champion normality, and foster trust and respect for the birth process, for we are in peril of losing these".

What are the core values guiding midwives today? One, despite and in defiance of national guidelines, is the admission CTG, the first step on the cycle of intervention. Much has to be unlearned: the semi-recumbent birth position, the mother pushing with her legs on attendants' hips, giving Syntometrine with the anterior shoulder, two midwives attending a home birth, and all unwritten rules. The re-skilling required is fundamental: how to achieve a physiological first stage, how to support a woman in labour, what food may she eat should she need a general anaesthetic? Talking and being with have to be learned afresh, and one-to-one care in labour not only promotes these but reduces intervention because of the relationship which is built in that setting; the midwife's aspirations come to coincide with the mother's. (However, it must be recognised that the commitments and preferences of some midwives will not fit this model). Communication in all its forms make relationships; it will be verbal and non-verbal, coercive, and by deliberate or even inadvertent omission. A good birth experience depends largely on good communication, and the converse is too often true. Impersonal and medicalised language - 'patient', 'confinement' - is a bar to good communication, and terms which would have been acceptable years ago now stand out as blatantly racist. 'Love', 'darling', 'honey' patronise and diminish the women, and providing care for more than one mother at a time renders a feeling for the aspirations of each inaccessible.

Intelligent activity is the recommended approach in breaking down the medical model. "Is it necessary?", rather than "just in case", exemplified by blood transfusion policy, which now uses Hb. 7G%, or even patient symptoms as the point indicating transfusion rather than, as previously, Hb. 8G%. Multidisciplinary training workshops for midwives can be effective, for example with a physiotherapist supporting all-fours or standing birth positions by coaching midwives in back-sparing delivery postures. A workshop named "Better birthing" will be more popular than one named "Normal birth", since midwives suppose that they know all there is to know about that. The choice of appropriate mentor as role model for a student is very important in the context of fostering trust in and respect for the birth process.

The relationships we can and must foster are those between midwife and woman, midwife and other professionals, midwife and pupil, and midwife and the organisation which represents her (the Royal College of Midwives) or her views, where they coincide with the needs of mothers (AIMS). Our College is working hard to promote normality in birth and home birth with its publications; AIMS will inform and encourage the uncertain. One in need of support and respite from stress is the Consultant Midwife, who has daily to struggle against the common knowledge which is the error yet to be corrected, a lengthy task indeed.


From Mavis Kirkham (MK), Professor of Midwifery, Sheffield.

There is a constant tension between the individual and the bureaucracy and between the rhetoric and the practice. We work in a service which is about people processing, however fluent we may be in the language of woman-centred care and informed choice, and despite the well-meaning products of committees, such as Changing Childbirth. The trend toward centralisation throughout public services is apparent in my base, Sheffield, where there is now one monolithic maternity hospital and a much reduced home birth rate. "Politicians and administrators regularly discuss levels and amounts of care that will be provided, but rarely who will care and how they will express their caring" (Lipsky 1980, analysing the inevitable pressure on street-level bureaucrats to deal with people on a mass basis). A bureaucracy which sees the nation, given the present resources and values, as unable to afford care on an individual basis provides it in conveyor-belt form, as now in our antenatal clinics and labour wards. The focus is on control and the shortage of professional time, a system which blinds us to the fact that giving women control improves outcomes. Sadly women themselves collude in this: "I didn't like to ask; the midwife/doctor was so busy". The silence of women is compounded by the body language of the professionals, except where individual concern is expressed in the little time available, to benefit the more articulate to the cost of the silent majority.

Most midwives are shown in our Informed Choice research (2001) to conform in a world of rules and fixed guidelines where the "right" choices exclude home birth as a realistic possibility. Although policies and evidence from randomised controlled trials may be useful, they are designed to apply to the average woman; as soon as she speaks the rules become irrelevant, home birth being a case in point, something a woman wants.

One of the dictionary definitions of Care is "supervision and control, as in 'under the care of the doctor'"; the large units provide care as informed compliance. Home births are wanted by women who don't want standard processing, who are opting off the conveyor belt, yet the midwives who express their caring by satisfying this need are themselves trained in a people processing environment. As teachers we must equip students to understand these dilemmas of the modern world, so that they feel the contradictions rather than the comfort of the standard rhetoric of belonging. They need by observation to see the competing agendas and the differing stories, and to cultivate the questioning stranger in the back of the head, the stranger who asks "Why?", "Safe for whom?", "Risk of what?", "Expensive for whom?". This teaching is the necessary subversion of the complete occupational socialisation of student midwives, so that they can, having painfully experienced the contradictions, make choices away from the comfortable hiding places of doing the observations, reading the notes when unsure, and feeling useful. They will have found that the mothers give them a different and equally valid story.

When such students make the choice to equip themselves for home births we must ensure that there equipment is good: experience of home births, no easy matter where there are so few; the inspiration of being taken to these births by a strong role model; the stories of women. They need to be able to discuss better practice rather than how to justify what they have done; they need peer review, feedback, and the powerful support of women. Seeking professional security and "covering our backs" are incompatible activities.

References.

Lipsky M (1980) Street-level bureaucracy: Dilemmas of the individual in public services. Russell Sage Foundation, New York, p72

Kirkham M and Stapleton H (eds) (2001) Informed Choice in Maternity Care: An evaluation of evidence based leaflets. York, NHS Centre for Reviews and Dissemination.


Discussion.

Louise Silverton, RCM Deputy General Secretary. How is a midwife to be used? Allowing changing options during her career; full or part time, hospital shift work, self-rostering, by her own choice, not imposed. The home birth midwife and the high tech. midwife are of equal value, and women of whatever risk category have a right to their service.

Frances Day-Stirk, RCM Director of Midwifery Affairs. The Virtual Institute for Birth is being set up; it will bring together research, education, management, practitioners and women, focusing on normality with good guidelines. Other work addresses values and standards.

Beverley Beech of AIMS expressed disappointment with some midwives who are still unfamiliar with water birth and even one who was unable to use a Pinard stethescope. MK responded: An adequate knowledge of the physiology and anatomy equips a midwife to undertake unfamiliar procedures such as water birth or squatting birth without instruction.

Luke Zander made a plea for the inclusion of lay women in the teaching teams, citing a class in which they are submitting to vaginal examination while instructing the students in the right method, and the input of women in his own practice to inform trainees about home birth.

The value of consultant midwives (only 38 exist nationally), especially in units where the medical model holds sway; we need more, and they need our support. DG defined the consultant midwife's new multiple role as being primarily in practice, but also in research, strategic planning, and education, usually with a specific remit such as normality, public health or teenage pregnancy, while providing support and advice and acting as a role model.

Professor Wendy Savage inveighed against the TV model of birth, and made a plea for women to go into schools to talk about home birth and demonstrate breast feeding; she also described various effective teaching methods including home visits to discuss the issues which patients/mothers find important.

A plea for “real” learning of midwifery through story telling by and skill sharing with midwives and doctors experienced and enthusiastic about the normal. Midwife Becky Read has set up meetings in South London where this is happening.

A plea for a complete overhaul of midwife training to include apprenticeship, which will restore the respect for and practice of normality which is being lost. Perhaps the model is to be found abroad.

A former member of a self-help group of women having babies reported excellent outcomes. There was no recognition of postmaturity, and there were no inductions of labour in a setting in which mothers, without arrogance, taught midwives how to manage labour.

Male medical students suffer from rejection both by the middle class mothers (who want no student) and by Bengali women, who will not accept the males; it becomes difficult for them to get experience of birth as a result. A Scottish midwife reported no difficulty in this respect; additionally SHOs were required to attend normal labours and births.

A midwife teacher reported success when informing medical students about normal birth, and a need for tact when as a midwife she found it necessary to instruct even second year registrars in basic birth processes. Another gave her opinion that a changed curriculum without access to the stories of experienced midwives is likely to achieve little change.

Beverley Beech referred to Soo Downe's research showing how rare completely normal birth still is: 1 in 6 of first births, 1 in 3 of subsequent births, a serious indictment of current midwife training. A GP confirmed that some hospitals use an unrealistically broad definition of the normal, and is saddened by the fall in confidence and skills of midwives in recent years.

A midwife has found teenagers, mostly boys, very appreciative of her schools talks on birth - with explicit slides - and feels that this approach can make a strong and positive impression at the right age.

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