Editor's Blog

No progress towards home birth while the risk word reigns supreme

I attended two conferences last week, in Birmingham and Manchester, which examined choice around place of birth in the wake of the 2011 Birthplace study. If you recall, this study found that for low risk women having their second baby, the safest place to give birth was at home. For women expecting their first baby, the safest place was a freestanding midwife-led unit, or an alongside midwife-led unit.

However, as was pointed out by several speakers at both conferences, even a study as excellent as Birthplace, doesn’t appear to have been able to change the culture of fear around childbirth.

The discourse of risk is deeply embedded in midwives’ and obstetricians’ consciousness and practice, and permeates their engagements with women. Even giving a woman a label of ‘low-risk’ means that she, and those caring for her, will perceive that she’s ‘at risk’. If you ask someone to think of anything except a large blue elephant – they will immediately think of a large blue elephant. If you tell women that they are ‘low-risk’, they immediately think about their baby, and/or themselves, being in danger. And, of course, if they are described as being at ‘high-risk’, then they presume that they have no choices at all but to submit to every possible medical intervention (not, of course, true).

One obstetrician claimed that the UK demographic of childbearing women is increasingly a high risk population. I have heard this said before and I find it very hard to believe. By and large, women today have a higher standard of living than they did, say in the 1950s. There are fewer who are without the basic necessities of life in terms of having access to clean water, decent sanitation and a meal a day. (I am not naïve – I do know that there are women who do NOT benefit from these essentials of a civilised existence.) In the 1950s, surely conditions in many of our cities were far worse than they are today? And women had far larger families with childbearing starting very early in life and continuing across several decades with babies arriving every couple of years. The risks of PPH may well have been as serious as the risks posed by obesity.

Two obstetricians discussed the varying attitudes of their medical colleagues towards Birthplace. Some who have had personal experience of giving birth out of hospital find themselves in sympathy with the home birth movement. Others are prepared to fly in the face of the evidence and assert that the only safe place of birth for every woman is a consultant-led obstetric unit. Both these speakers felt that it was necessary to win the minds and hearts of doctors before any real progress can be made towards achieving higher rates of out-of-hospital birth.

For those of us who work with mothers and their partners in the antenatal period, it is difficult to know how to present the evidence that having your baby in hospital has been shown to be more dangerous for some groups of mothers than a home birth. It’s difficult because, in my experience, women tend to think either that you are a birth activist with left-wing views, or they simply think you’re lying. They may think that you are advocating a choice that is in sync with your political agenda but which you wouldn’t make yourself. None of this is unreasonable given the birth ‘climate’ over the last 40 or so years.

So where do we go from here? One midwife in Birmingham suggested that we get rid of the ‘r’ word entirely (risk) and replace it with ‘women who are having a normal pregnancy’ and ‘women with complex pregnancy’. She also felt that maternity services should move towards an ‘opt out’ system where women suitable for a home birth or to give birth in a midwife-led unit are booked for one or other, and are transferred to obstetric care only if they ‘opt out’ of out-of-hospital birth. This may help, but doesn’t seem likely to happen any time soon.

At present, maternity services may be contributing to what Michel Odent sees as women losing their ability to give birth, or as Ivan Illich puts it in his famous book, ‘Medical Nemesis’, a situation where we perceive our bodies as a foreign object. Are women’s bodies becoming a foreign object to them, little understood by the community of childbearing women, and controlled by others?



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