Our region’s homebirth services are in decline

Homebirth1

Homebirth is cheaper[1] than hospital birth, it’s proven to be the safest and best option for 2nd and 3rd time mothers[2], it’s satisfying for mothers, it’s crosses geographical boundaries, maternity care configurations, ethnicity and social class[3], and it’s satisfying for midwives[4].

So why is our region’s homebirth services declining?

Cambridgeshire was a county in love with homebirth

In 2010 the UK homebirth rate was 2.39%,  locally the homebirth rate for Cambridge City was a mighty 6.2%, South Cambridgeshire was 5% and East Cambridgeshire was 5.7%[5]. It was a time when women were actively encouraged and supported to birth at home if they wanted to. Women also had a caseloading community midwife, continuity of carer with a named midwife supporting them throughout pregnancy and postnatally. The homebirth service was provided by community midwives.

The birth of the Rosie Birth Centre

Birthplace choice in Cambridgeshire increased in 2012 when the glorious Rosie Birth Centre opened. It was also around this time that continuity of carer ceased, women were looked after by midwifery teams and it was common to see a different midwife at each antenatal appointment. The combined effect on homebirth was a gradual decline in numbers and by 2014 the homebirth rate at the Rosie Hospital had dropped to 1.69%[6].

Changes to the Cambridge homebirth service

In November 2015, two months after Addenbrooke’s and the Rosie Hospitals were put into special measures by the Care Quality Commission (CQC), a homebirth pilot started. Community midwives began working night shifts in the Rosie Hospital, called out to homebirths from there, if available. Initially letters were sent out to women who had booked a homebirth, as Ellie experienced.

Women, families and supporters of the Cambridge homebirth service believe this staffing change undermines women’s choice. It is not acceptable to run an NHS maternity service in this way; a homebirth service should be properly supported and resourced.

The Rosie Hospital place of birth webpage, now highlights:

TheRosieHospital_homebirthstatement

This paternalistic statement is at odds with the law protecting a woman’s legal right to choose where she gives birth.

“The legal principle of consent means that you cannot be compelled to give birth in any particular location or medical setting against your will, so long as you have mental capacity to make your own decisions.”[7]

It is also preventing midwives from doing their jobs properly:

“Local Supervising Authority midwifery officers, supervisors of midwives and midwifery managers have a professional duty to support midwives to provide home births.”[8]

Since January 2016, when the pilot ended, the change has continued without any input from the community it serves.

An internal audit measured the benefits for the hospital, staff preferences and financial savings.

It did not report women’s experiences of the homebirth service: how many have been ‘put off’ homebirth; how transfer rates and homebirth rates have been affected; how many women have been ‘facilitated into the hospital by ambulance’ after declining to attend; and importantly, where are women transferred to, the midwife-led unit or the obstetric-led unit.

How it affects women

During pregnancy women plan their labour and birth, visualising the experience. Uncertainty as to whether there will be a midwife available on the day introduces stress and worry.

“It wasn’t until I was 34 weeks pregnant that they mentioned that they might not be able to send a midwife due to staffing issues. I was crestfallen. I left the appointment in tears and spent the next few days not sleeping very well and in an anxious state…” Ellie, Cambridge, November 2015

“I finally got into the pool later that evening and made the call for the midwife to come out. I was told they had all been called into the maternity ward as it was so busy. This was my worst nightmare and I freaked out a bit on the phone and told them I couldn’t come in to hospital and broke down in tears. Katie [doula] then spoke to them and they agreed to send someone out when the shift changed…” Lora, Cambridge, July 2015

It’s difficult to know how many women have changed their homebirth plans and booked the Rosie Birth Centre instead, declining the number of homebirths further.

For the women who Cambridge VBAC Friends’ support, planning a birth after caesarean/s, and other “high-risk” groups, choice is already limited. The VBAC guidelines recommend birth in an obstetric-led unit with continuous fetal monitoring. It is possible for women to have a midwife-led VBAC in the Rosie Birth Centre, we know many women who have, but the option is not discussed unless the women asks directly.

Homebirth services around our region – Peterborough

The Save Peterborough’s Homebirth Service campaign hit social media last week. Peterborough’s pioneering homebirth service opened in May 2015. Its lead midwife did a talk the Royal College of Midwives giving an insight into the work which went into setting up the service.

(Peterborough is not in Cambridgeshire however the hospital is run by the same Clinical Commissioning Group (CCG) as Addenbrookes and the Rosie hospitals.)

King’s Lynn

Serving families in the north of Cambridgeshire is Queen Elizabeth’s Hospital in King’s Lynn which closed its homebirth service nearly three years ago. A complaint was made to the ombudsman which ruled that:

“The length of time the Trust’s homebirth service had been suspended without any alternative homebirth service being offered or explored amounts to maladministration.”[9]

A group of dedicated women have been campaigning for its reinstatement and progress is moving forward slowly with the planned recruitment of a team of community midwives. In the meantime, the ombudsman recommendations that a contingency plan be implemented has not happened.

NICE Guidelines

In the NICE Guidelines CG190 Information for the public, choosing where to have my baby, says:

“All options should be available to you. Wherever you choose to have your baby, you should be supported in your choice.”[10]

The NHS Constitution

All NHS bodies in England, including CCGs and NHS trusts, are required by law to take account of the NHS Constitution in their decisions and actions. The Constitution contains high level principles that are ‘rules’ governing how the NHS operates and seeks to achieve its purpose.

“Working together for patients. The value of ‘working together for patients’ is a central tenet guiding service provision in the NHS and other organisations providing health services. Patients must come first in everything the NHS does. All parts of the NHS system should act and collaborate in the interests of patients, always putting patient interest before institutional interest, even when that involves admitting mistakes. As well as working with each other, health service organisations and providers should also involve staff, patients, carers, local communities to ensure they are providing services tailored to local needs.”[11]

The National Maternity Review

Better Births, the National Maternity Review published in February 2016 sets out a promising vision for safe and efficient models of maternity care: safer care, joined up across disciplines, reflecting women’s choices and offering continuity of care along the pathway. The Maternity Transformation Programme seeks to achieve the vision set out in Better Births, work began In July 2016.

You may have read in the national media about the £3k maternity allowance; pilots have already begun with nine Trusts around the UK. Broadly speaking the idea is that the money follows the women, rather than, as is happening in Cambridgeshire, the women follows the money (i.e. some important people decide that homebirth isn’t a priority and the money is focused elsewhere, the service declines, a reduction in the homebirth rate follows and it then continues to be a low priority).

Homebirth demand

An NCT survey in 2009 suggested that the demand for homebirth was greater than its supply and that more women would choose it if it was offered more proactively.[12]

Perhaps Cambridgeshire’s homebirth rates will never be what they were before the Rosie Birth Centre opened? Research in the National Maternity Review[13] suggests the opposite; more women would prefer a homebirth, and more women would prefer MLUs than are actually able to access those services:

  • 10% of women would prefer a homebirth (UK homebirth rate in 2012 was 2%)
  • 6% of women would prefer a Freestanding Midwifery Units (2% 2012)
  • 49% of women would prefer an Alongside Midwifery Unit (9% 2012)
  • 25% of women would prefer an Obstetric-led Unit (87% 2012)

This was certainly the experience of Brighton and Sussex Hospital which turned around a falling homebirth rate and struggling service, tripling its homebirth rate to 9.1%[14]

What do you think?

“I urge you to play your part in creating the maternity services you want for your family and your community. Voice your opinions, just as you have during this review, and challenge those providing the services to meet your expectations.” Baroness Julia Cumberlege, National Maternity Review

What’s your opinion? If you have personal experience of Cambridge’s homebirth service, whether it was a good or not so good, please post a comment on this blog.

If you would prefer to comment anonymously, you can email or contact Healthwatch Cambridgeshire. (Healthwatch can challenge local health and social care commissioners and providers if care isn’t working in the way it should or if a decision has been made where people have not been able to contribute.) 

And join other passionate parents, birth workers and midwives in these grassroots campaigns, to bring about positive change to our region’s homebirth services:

Written by Rachel James

Rachel is a local volunteer, she co-runs Cambridge VBAC Friends, is a user rep at the Cambridge MSLC and Cambridge NCT’s caesarean birth & VBAC contact. She is a director of Caesarean in Focus (unpaid), a community interest company which aims to improve caesarean birth for women and families. Rachel is a mother to two small people born in 2011 and 2013. She also works as a freelance marketer.


References
1- 4 sourced from RCM Midwives publication, Issue 5, 2014
  1. The economic case for home birth is also convincing. It has been shown that the NHS saves over £600 per case, compared with obstetric unit birth (Schroeder et al, 2012).
  2. The Birthplace study revealed interesting findings on home birth. The headlines may have been the poorer perinatal outcome for first babies born at home, but there was little said on the finding that home birth was the safest and best option for women having their second and third baby. For these women, it provided the lowest rates for CS, assisted vaginal birth, episiotomy and drug use in labour. Home birth also resulted in the highest normal birth rate, with high levels of water immersion and physiological third stage. There were low transfer rates too (Brocklehurst et al, 2011).
  3. Home birth experiences also tend to demonstrate high levels of satisfaction (Borquez and Weigers, 2006) with an enhanced feeling of control and Redressing balance empowerment (Lindgren and Erlandsson, 2010). These positive evaluations cross geographical boundaries, maternity care configurations, ethnicity and social class (Cheyney, 2008; Parratt and Fahy, 2004; Chamberlain et al, 1997) and have been under-recognised by maternity care stakeholders to date.
  4. Home birth is highly rated by midwives (Vedam et al, 2009) and can assist in recruitment and retention while institutional models often struggle (Sandall, 1997).
  5. 2010 homebirth rates from: http://www.birthchoiceuk.com/
  6. The Rosie Hospital website, 2014 facts and figures
  7. Birthrights Factsheet place of birth
  8. NMC Circular supporting women in their choice of homebirth 
  9. Ombudsman report following QEH homebirth complaint
  10. NICE Guidelines CG190
  11. p13 of the NHS Consitution Handbook
  12. Dodwell and Gibson, 2009
  13. NWIW research National Maternity Review, page 20
  14. Brighton and Sussex midwives scoop top prize at RCM awards
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10 thoughts on “Our region’s homebirth services are in decline

  1. The community midwives were very supportive of my choice to have a homebirth. I don’t remember who told me I would have to go in to the birth centre if no midwives were available – but I don’t remember it being one of the community midwives. I discussed at a Cambridge Birth Choices meeting what the plan would be if this were to happen – and independent midwife Siobhan reassured me that it had happened very few times , was unlikely to happen to us, and put my mind at rest.
    Unfortunately, on the night when we called, I was told the midwives were attending another home birth. They requested I come in to the birth centre. I had been coached (by Cambridge Birth Choices to be awkward and demand they send someone (as is their duty of care) – so I did. Actually I think someone said ‘you’ll have to come in’ and I just (incredibly rudely) shouted ‘No I won’t!’.
    My doula then spoke to them and told them we’d talk about it and ring them back. It was a quick discussion as I wanted a midwife present , so we obviously were going to have to hop in the car. But the labour gods (and adrenaline) intervened and as my husband went to collect our hospital bag I started pushing. With no midwife on their way my doula rang for an ambulance and my baby was born 5 or 10 minutes after the paramedics arrived.

    About half an hour afterwards a lovely community midwife arrived (in time for the 3rd stage). We assumed the ambulance service had arranged this – they hadnt. Apparently the birth centre had been trying to call us back to find out if we were coming in, but because the 999 people stay on the line the birth centre couldn’t get through. We were told there was a hurried middle-of-the-night telephone conference with the supervisor of midwives to decide what to do (I presume they thought we were opting to freebirth rather than go in to hospital since I guess that is what I had implied on the phone (in an effort to have a midwife sent out)? – and they ended up turning one of the midwives back from the other birth to come to us. She said she sat in a layby on the A14 for half an hour while they decided what she should do… clearly they didnt have protocol for that scenario. I hear they then sent a midwife from the delivery ward out to be 2nd midwife at the other homebirth.

    Im very grateful they decided to send someone to me, it was just unfortunate my baby was born so quickly she missed the birth! I do hope it made them consider the need for capacity for more than one homebirth at a time.

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  2. I’m planning my home birth through the Bedfordshire community midwives and getting THE letter saying they might not be able to send a midwives is my biggest fear about the whole thing.
    When they say send paramedics I always think of two burley men who are kind but don’t get privacy and calm birth turning up at my birth making it all feel emergency not a normal event (last time I was in an ambulance my son had stopped breathing due to a febrile convulsion – so not great for the oxytocin)!
    I also think it’s awful that they haven’t taken into account how women feel about the service in anything!

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    1. Yes, I don’t think the people making these decisions necessarily realise how stressful the added uncertainty can be, for all involved. As Sophie wrote on her blog http://sophiemessager.com/slow-disappearance-homebirth-services-erosion-womens-choices-need-respect-kindness/ women planning hospital birth wouldn’t get this level of warning about staffing difficulties and potential hospital closures.
      Thank you for your comment and have an awesome homebirth! X

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  3. I had 2 home births in Cambridge 2010 and 2014. I loved them the midwives I had were brilliant and the event was what I had hoped for. I have been recommending home births to everyone and was quite shocked to see how many women were telling me that they were told they couldn’t have one. I now can see the politics used to coerce women into what suits the system and not the patient. Terrible

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  4. I had a homebirth in Cambridge 2 months ago – I honestly can’t fault any member of the NHS team; the community midwives prepared me brilliantly for it (and in fact encouraged me to go for it over the birth centre option) and the midwife who came out from the Rosie was great too. Only slight problem was that the baby arrived before either she or the ambulance did but that wasn’t something she could have predicted – my contractions went from 10 minutes to 2 minutes apart in just half an hour! In an ideal world, I would have preferred to have the same midwife throughout my antenatal and birth experience but that’s my only slight negative; everything else was really wonderful. I will remember the laidback, gentle care from my birth midwife forever; the total opposite to previous hospital experiences.

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    1. Wow that’s great care Anna! The community midwives are brilliant. When the system doesn’t work properly it fails pregnant women and midwives, hope that comes across in the blog. Thank you for sharing your lovely homebirth memory.

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  5. I had a home birth with my second child in May 2016. I have to say that fortunately my experience does not correlate with your post and my community midwife was very supportive of my decision. The only time she ever mentioned me not being able to have a home birth were for all the routine medical reasons (blood loss/heart rate/meconium etc) which would probably be reasons that I would be happy to transfer to hospital for. When the time came we called Hinchingbrooke and a midwife was sent out to us. She didn’t actually make it for the birth but this was possibly due to a very rapid labour (1 hour start to finish!) but arrived within 5 minutes of baby being born. Along with two paramedics who are dispatched routinely for any unattended birth. My minor gripes are that whilst the midwife who did attend was lovely, it would have been really nice to have known the midwife I’d seen all the way through my pregnancy was coming to see me. Secondly that I still had to go to Hinchingbrooke the day after he was born for another midwife to do the newborn checks. Didn’t understand why midwife who attended birth couldn’t have done that. One of my reasons for home birth was being at home and able to relax/recuperate, not sit waiting around on a labour ward. Even the GP at the 6 week check said he could have done a home visit to sort that for us. I was under the St Ives midwifery team. They were brilliant.

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    1. Thank you for commenting. Good to hear about Hinchingbrooke’s homebirth service. I will pass your comments to their maternity forum (The Parks Maternity Voices); perhaps homebirthing parents could be informed they could attend their GP instead? And continuity of care for all; yes please!

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