Place of Birth – How much choice do we have?

We are a fly on the wall at the first appointment a pregnant mother is having with their midwife or obstetrician, their LMC (Lead Maternity Carer). Among other things, we watch the expectant mother given a pamphlet or other information that explains her three main choices for the place they would like to give birth, to take away and consider. We hear the LMC explaining that they can choose between birthing at home, in a primary birthing unit, or in a hospital, an overview of the pros and cons of each location. We hear the LMC recommend that they take some time to think about the different options, perhaps do some research of their own, and to come back and ask any questions they need to to clarify things. And we hear the mother told that when they reach 28 weeks, they can let the LMC know their preference, but that they are free to change their mind anytime before baby actually arrives.

If you have already become a mother, did it happen that way for you? If you can ask other mothers you know, was that their experience? Or did you, and they, walk away from the first appointment with the forms already filled in for a hospital? Were you told that this is the hospital that your LMC works out of, and it’s easier to get the paperwork out of the way right from the start so we don’t have to worry about it later? Do you live in an area with more than one hospital option, like Auckland, and so it was more a comment like “I work out of either Auckland or North Shore, which would you prefer?”

Let me ask you another question: If you were a mother told at your first appointment “I work out of either Auckland or North Shore, which would you prefer?”, what does that leave you concluding? A number of women would hear that and conclude that those are her ONLY two options, Hospital A or Hospital B, and that that was it. Others would hear that and conclude that they must need medical support if that’s their only two choices, so their pregnancy must have some difficulties ahead that the midwife isn’t telling her about yet. Or for a one hospital location, how many people would have filled in the forms and taken that to mean that they were now booked into the hospital, and that was that? How many people would hear what the should have heard, that if a hospital is required, then this LMC can come with them to this hospital or these hospitals, but that these forms are only a precaution. How many expectant mothers hear that they can choose to birth at home, or in a birthing unit and quite likely never need to go anywhere near a hospital….? And while we are at it, how many people are getting the feeling that they NEED to be pre-booked into a hospital? As if hospitals would turn you away if you hadn’t already sent in the appropriate forms…

The HDC Code of Rights* actually requires that we are given full, unbiased information before we make our own decisions. (It also says that we aren’t required to give any reasons to anyone for what we choose to do, which some medical professionals seem to forget if they don’t like your decision.) And informed consent actually requires ALL the options clearly explained to you, with the pros and cons given so that you are in possession of all the facts, and then you are given time to digest and consider and come to your own decision without any pressure (or manipulation) by the medical professionals involved with your care. Think back to the last few times you were being helped by a medical professional, particularly in a hospital setting, but also at your GP’s office. Were you given choices, or were you just told the course of action your health professional had chosen for you? Did you get the pros and cons explained to you? Did you hear what possible side effects were known for this treatment plan? Were you given information about what was the expected outcome if nothing was done? And were you then left alone to take time to choose, with no pressure or coercion, and then your decision accepted with no issues whatsoever?  Hmmmmm…..

Back to our focus for this article, a pregnant mother and their decision where to birth their baby. This falls squarely under the Code’s Right 7: It’s Your Decision. This means a) It is up to you to decide; and b) You can say no or change your mind at any time. And it dovetails nicely with Right 6: Information. This means a) You have the right to have your condition explained and to be told what your choices are. This includes likely benefits and side effects; and b) You can ask any questions to help you to be fully informed. Our opening paragraph illustrated this happening perfectly, however for the majority of expectant mothers in Aotearoa New Zealand, what they get is not even close. More often than not, mothers receive something along the lines of the second example, the one where the filling out of hospital paperwork is often interpreted by the mother as the only option they have available to them. LMCs may feel that they are offering their new clients full choice, but their actions and words, or lack of them, are giving their clients a message of little or no choice on their place of birth options. Other LMCs are actually actively ensuring their clients will birth in hospital by not explaining the three key options, only discussing the option or options that the LMC prefers. And still others do offer all three choices, but sabotage their client’s choice by finding a reason (consciously or subconsciously) later in the pregnancy that “requires” a hospital setting. So the client feels that they did get to choose, but that the choice later was no longer available to them. Which might or might not actually have been the case. And while in some cases the hospital setting and medical support is 100% necessary, what is very worrying is the fact that too often those reasons given by the midwife or obstetrician for needing a hospital actually do not NEED a hospital at all. They are things that are still within the scope of a physiological birth outside of a hospital if any LMC who has the skills, knowledge and the confidence in their skills and abilities to provide that assistance (Note: Right Four is about Proper Standards – You have the right to be treated with care and skill, and to receive services that reflect your needs, and all those involved in your care should work together for you. So a midwife or obstetrician that is not up to scratch with supporting physiological birth, without the need for the back up of a bunch of interventions and a building full of medical professionals just outside the door, actually isn’t holding up to their side of the Code of Rights requirements. Just sayin’).

So why is this happening? Why are pregnant mothers often encouraged, passively or actively, into going to birth in hospital? All LMCs are supposed to be able to support normal birth in low risk pregnancies (and the majority of pregnancies ARE low risk). And we have New Zealand research using New Zealand data showing that your chances of interventions and issues for mother and baby are significantly increased if a low risk mother births their baby in a hospital. Hospitals are emergency care facilities, and do that wonderfully well. But this does not transfer to non-emergency situations. Hospital staff are trained to look for problems, and as well, have time pressures on their resources. Also, they are used to using interventions, and often having forgotten what a normal, physiological birth looks like, and how best to support that. Which most of the time is very little to nothing. Sitting back and doing nothing, and waiting for as long as mother and baby need, is difficult to achieve in a hospital setting. Hospital staff are used to taking action, doing things, and clearing beds as soon as possible for the next intake. A clash of cultures, so to speak. We even see the caesarean section rates increase when the staffing numbers go down, as that is the quicker option. So when extra medical support is required, transferring into hospital is a fabulous facility to have, but labouring and birthing in a hospital if you aren’t requiring medical support is actually increasing your risks of problems occurring. Seems counter-intuitive, but it’s true.

So why are LMCs taking their clients to hospitals to deliver? Surely it’s because they, in their professional judgement, feel that that’s the best place for that client to deliver? This is the widely held assumption the general public makes, but actually there are usually a number of factors that trump what’s best for mother and baby. I can’t speak for every LMC and every situation, but here are a number of issues that can often be part of the mix, most particularly for independent midwives:

• Confidence – in a hospital, outside that door is a collection of experts and equipment, to consult or to hand responsibility over to. A midwife can rely more on the skills and opinions of others, and needs less to rely on their own skills or those of their back up midwife.
• Protection – if there are any unexpected, traumatic outcomes, then blame is less likely to fall on the golden institution of a hospital, and if it does, it can be shifted to guidelines and protocols and not the individuals involved. The media spotlight is less likely to fall, rightly or wrongly, on the health professional concerned and their career is less likely to be put on hold (or destroyed) while enquiries take place into whether they did everything right or not. Even midwives that have carried out their duties perfectly can have their reputation damaged by the media before the details are available, however once their exemplary care has been confirmed by the enquiry, there is no public confirmation or celebration of how well they had performed by the same media who did the damage. The media have a lot to answer for…
• Convenience – in a hospital, the LMC does not need to have a second midwife arranged and available to provide back up, whereas in a home birth they have to arrange that themselves. Also, if two mothers are labouring at the same time, in the same hospital, the LMC can bounce back and forward between the two, with the hospital midwives covering the gaps. If this was a home situation, the houses could be quite far apart, plus there is no automatic extra back up. The LMC would probably only be able to be there for one birth, and not the other. And so they will be paid less for the work they have done with this client… which leads onto the next point.
• Finances – Are there any other professions where the ONLY way to make more money is to take on more clients? Usually we can also choose to raise our prices or go for a promotion. LMCs can not do either of those things. The payment plan is set by the government, and if a client changes to another midwife, or if something occurs and the LMC is not present at the birth, they lose income. This can mean that LMCs often have to accept a caseload that is too large to give the quality and amount of care they would like to, or that is recommended, for each client. And they have to because they can’t pay their mortgage if they cap their numbers at the level that would be best for all concerned. So one way to help support a larger number of clients is to have them all birthing at the same hospital, so the LMC can work between several clients who are labouring or recovering from giving birth in the same building. And as we said above, with the hospital midwives filling in the gaps. Also, this can mean that LMCs can be quite aggressive in either obtaining clients, or in trying to discouraging them from leaving for another LMC. One tactic I have heard of a number of times is an LMC telling a new client that they definitely support a home birth, but as the time approaches, reasons are found to “prevent” home being a safe choice according to the LMC and so another hospital birth ensues. Sometimes an LMC who lists home as one of the locations they support hasn’t actually been present at a home birth in several years, and their physiological skills are out of practice.

Sounds bleak, doesn’t it? It doesn’t have to be. You as a consumer, if you understand the situation, understand your choices, and vote with your feet, you can help yourself and your baby by finding midwives who are amazing at what they do, and support both your choices and your right to choose. You can ask the right questions of LMCs, and then explain to those that don’t fit your needs, gently and respectfully, what you were needing that took you elsewhere. If it is a reason that they would do better to address, then perhaps hearing it voiced as an issue might give them reason to consider looking at how they currently practice….

But there is more you can do that will benefit midwives, all of them.

• Talk about the great experiences you have had, wherever they were. Share how valuable the skills and services are that a midwife provides. Those who have never experienced the services of a good midwife or any midwife have no idea how important it is, and that it’s more than just catching the baby.
• Don’t put up with poor service. Write a letter to someone, or contact your local support services, and find someone that will help you pass on your concerns in an anonymous way if that feels more comfortable for you. If people don’t know there’s a problem, they won’t know they need to change. And the more people speak up, the more impact it will make. You don’t just speak up for yourself, but you also speak up to make it better for others who come after you….
• Speak up for midwives’ pay conditions, any chance you get. If you know anyone in a position of influence, don’t be afraid to say that midwives can’t do their job well because the pay is woefully inadequate, and that consequently we haven’t enough midwives across the country… and that has to change. Mothers suffer because of this… babies suffer because of this…..
• Don’t encourage media witch hunts of anybody, health professionals or otherwise. Media continue to have that power because we click on that story that sounds juicy about someone. Often those stories are part fact and part speculation and all it does is damage good people. And definitely don’t share or talk more about those stories. Let the proper processes work it all out, as they are supposed to.
• If you feel that “normal”, physiological birth is something that appeals to you, do something to help you learn more, and to help others learn more. Find great resources to read or watch, check out your local home birth or positive birth organisations, and be part of what they do. You will also find you help strengthen your own knowledge, help others find out more, and you usually get to make great friends among like-minded people. And you do not have to have had a home birth yourself or even be pregnant to be involved. Myself, I am very involved in my local home birth group, and have made some amazing friends among the people there, but not only have I never had a home birth or will never have one (no more children in our future), my personal experience was an induction-caesarean in hospital. All I have is an interest in what could be, should be normal birth, and a wish for more people to understand their choices and options better than they do now. And for people to choose what they know is the birth they want, wherever that is, rather than go along with whatever their LMC says, or what they see everyone else do, or what happens on TV…..

I hope that this article has given you some things to think about, and that it helps you to make a decision that you feel confident in. That’s the best outcome for everyone.

– SANDY MCGIVERN-BUTLER, Chairperson, Auckland HomeBirth Community

• Right 1: the right to be treated with respect
• Right 2: the right to freedom from discrimination, coercion, harassment, and exploitation
• Right 3: the right to dignity and independence
• Right 4: the right to services of an appropriate standard
• Right 5: the right to effective communication
• Right 6: the right to be fully informed
• Right 7: the right to make an informed choice and give informed consent
• Right 8: the right to support
• Right 9: rights in respect of teaching or research
• Right 10: the right to complain