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More choice - but what can women choose?


As someone who has always been of the opinion that trusting women to make choices for themselves, their babies (unborn and newborn) and their families is a good thing and results in fewer complaints about care, better outcomes (physical and mental) for mothers and babies and reduced stress on health services, I am naturally delighted that the NHS in England is to give each pregnant woman a ‘personal budget’ of £3,000 so that she can choose what kind of maternity care would suit her best.

Her choices will extend from hospital birth to midwife-led care in an alongside or free-standing birth centre, to home birth, with use of a birthing pool if she wants it. Pilot schemes will start later this year.

I don’t wish to be curmudgeonly, but a couple of things immediately worry me. Firstly, it’s hard to choose to have your baby in a midwife-led unit if there isn’t one anywhere near where you live (as is the case in certain parts of the country). And it’s not possible (or, at least, it’s difficult) to choose a home birth if your community midwives aren’t confident to provide one, and strive to put you off the idea (well documented – but I’m not blaming the midwives. If you haven’t been present at a home birth for years because they don’t happen in your neck of the woods, it’s understandable that you’re going to feel very nervous about taking one on). And a woman can’t choose to use a pool to labour in if the pool at her local hospital has been used as an extra storage cupboard for as long as anyone can recall.

So choice may be illusory, at least for the present and at least in some parts of the country.

And there is another important issue around choice – and that is: do women understand what their choices are? Do they know what a midwife-led birth centre is all about? What kind of support is available there? Which forms of medical pain relief can be accessed and which can’t? Do women have the chance to talk to someone who has had a joyous home birth and who can challenge the common myths that ‘there’s a lot of mess’ and that ‘there’ll be an ambulance waiting at the door throughout your labour’?

There’s also the pervasive assumption that home birth and birth centre birth are, self-evidently, risky, despite the strong evidence from a robustly executed trial (Birthplace) led by one of the country’s pre-eminent researchers showing that birth in a midwife-led unit is the safest form of birth for low-risk women, and that birth at home is the safest way to give birth if you’re a low-risk, second-time mom. I note that James Titcombe, who suffered the tragic death of his son at Morecambe Bay Hospital in 2008, has warned that, ‘Community births and home births are cheaper and …. a push to expand that needs to be done very, very carefully because the evidence about safety is questionable’. Given the authority he carries owing to his experience, this is a strong statement that will influence many women - and their partners perhaps even more. However, ‘the evidence about safety’ is not ‘questionable’; it’s good evidence when understood correctly.

So excellent news for women and for choice – but the profile of English maternity care and of women’s experiences of it won’t change overnight without better resources (Cathy Warwick is absolutely right to say we need more midwives), more place of birth options and better education for women during pregnancy to support them to make the best, evidence-based choices for each one individually.

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