In 2006, following considerable lobbying and consultation, the Mid wifery Committee of the Nursing and Midwifery Council (NMC) updated guidance on the responsibility of a midwife to attend a homebirth (NMC, 2006). At the time, this circular was a powerful directive that asserted the rights of women to choose their ‘place of birth’ and set out the responsibilities of midwives to support women who opt for a homebirth.
Homebirth had long been a contentious subject, but in the intervening decade since the publication of this NMC circular, birth at home is well supported by the research evidence (Brocklehurst et al, 2011; Li et al, 2015) and is part of the Government's vision for the future of maternity care in the UK (National Maternity Review, 2016). So what has happened in the intervening 10 years?
A key statement in the 2006 document emphasised that (NMC, 2006: 4):
‘Should a conflict arise between service provision and a woman's choice for place of birth, a midwife has a duty of care to attend her. This is no different to a woman who has walked into a maternity unit to receive hospital care. Withdrawal of a home birth service is no less significant to women than withdrawal of services for a hospital birth.’
As a result, the Association for Improvements in the Maternity Services (AIMS) advised those women who were being told by Trusts that a midwife's attendance at a homebirth could not be guaranteed, to remind these Trusts of the midwife's duty to attend and to point out that, should there be problems during labour resulting from a midwife's failure to attend, the family would take appropriate action. Women were advised that, if possible, they should put this statement in writing to the chief executive of their NHS Trust. In the majority of cases, this ensured the attendance of a midwife. In one case reported to the AIMS helpline, three midwives turned up when called to a homebirth, suggesting that the service was not as hard-pressed as the Trust had initially claimed.
Nevertheless, many Trusts in the UK continued to give priority and preference to hospital-based services. This has been seen in the withdrawal of homebirth services and the use of community midwives to make up poor staffing levels in hospital maternity units, which has been reported to AIMS on a number of occasions.
The issue came to a head in 2014 when a woman, Jane Reeve, was told that King's Lynn had suspended its home-birth service and would not be sending a midwife. Mrs Reeve approached AIMS and Birthrights, and they assisted her in chal-lenging the clinical commissioning group (CCG) and the Trust. The CCG and Trust obfus cated and avoided any commitment to provide care. Mrs Reeve engaged an independent midwife and had a successful homebirth (AIMS, 2016a). Some women, in other areas, faced with similar intransigence, have been forced to birth without a midwife (AIMS, 2016b). Fortunately, in every reported case, the births went well.
Earlier this year, the Ombudsman awarded Mrs Reeve £1000 in recognition of the Queen Elizabeth Hospital King's Lynn NHS Trust's failure to provide appropriate care (AIMS, 2016c). Since this payment, it appears that the Trust's midwives have attended a number of homebirths, so the women have avoided stressful battles late in their pregnancies. When national policy is ignored, refusing support is a clear breach of a woman's human rights to birth at home, and the NMC no longer appears to see this as a ‘duty of care’, what hope has a midwife of using her or his clinical judgement and ensuring such women are supported to birth where they choose?
Increasingly, midwifery and lay organisations have become concerned by claims that a midwife, when called to attend a woman at home, no longer has the responsibility to do so. On behalf of the women who approached AIMS, the organisation checked the regulations with the NMC; the response was both disappointing and disturbing. It appears that the NMC (2006) circular had been withdrawn without any consultation or public notification. The NMC's Education and Standards team's email to AIMS, dated 19 July 2016, stated:
‘No specific announcement was made with regard to this particular circular. It was one of a number of circulars, guidance documents and other items, including the entirety of the “regulation in practice” advice pages, that were withdrawn when the NMC moved over to its new website in the wake of the publication of the revised Code on 31 March 2015.’
The need to revise the NMC's website was, it seems, used as a cover to withdraw the homebirth circular. When the question of a revised Code for midwives was being discussed on the NMC's Midwifery Com mittee, the AIMS member repeatedly asked for assurance that the duty of a midwife to attend a woman at home would be maintained. She was reassured that this would be so, but examination of the current Code (NMC, 2015) makes no mention of this. Indeed, the Code is so watered down, one could read just about anything into it.
Let us explore some of the NMC Code's statements. Midwives need to consider carefully the implications of these in terms of their use of clinical judgement, working to best available evidence and supporting women's choices of where to give birth.
The Code
‘Employer organisations should support their staff in upholding the standards in their professional Code as part of providing the quality and safety expected by service users and regulators.’
Can this Code, and the claim that the NMC is there to protect the public, stand when the decision to attend a woman at home rests with bureaucrats in an individual NHS Trust? The requirement is that organisations ‘should’—rather than ‘must’—support their staff in upholding the standards of their professional Code. How likely is that to happen?
‘For the many committed and expert practitioners on our register, this Code should be seen as a way of reinforcing their professionalism.’
This claim does not hold up; the Code does not reinforce midwifery practice, but undermines it. Midwives are now in a difficult position. In the past they had Midwives rules and standards (NMC, 2012) to protect their practice and enable them to challenge any Trust that tried to prevent them responding to a woman in labour who had called them. But now, midwives have no protection or authority to quote what is a clear professional duty of care. As a result, women may find themselves in a potentially dan gerous situation where they are forced to birth alone, or with unqualified assistance. It is ironic that NHS Trusts, ever sensitive to legal action, appear to be sanguine over the possibility of legal action should a disaster occur at home as a result of the Trust's failure to send a midwife.
‘The Code contains a series of statements that taken together signify what good nursing and midwifery practice looks like. It puts the interests of patients and service users first, is safe and effective, and promotes trust through professionalism.’
When a Trust refuses to send a midwife to a woman in labour at home, it is not putting ‘the interests of patients and service users first’. Nor is it safe and effective, as it undermines trust in the midwifery profession; midwives' hands are effectively tied by their contract of employment and the abrogation of the NMC's duty to protect the public.
It would be interesting to see whether any NHS Trust's past refusal to send a midwife to a homebirth has coincided with the closure of the hospital because of staff shortages, or whether it has been used as a convenient excuse to close down a service. The Code clearly states that a midwife or a nurse must
‘put the interests of people using or needing nursing or midwifery services first. You make their care and safety your main concern and make sure that their dignity is preserved and their needs are recognised, assessed and responded to. You make sure that those receiving care are treated with respect, that their rights are upheld.
Midwives have a duty to ‘respect and uphold people's human rights’ (NMC, 2015: 4). Women have, under Article 8 of the Human Rights Act 1998, the right to family life. Demanding that a woman transfers to an obstetric unit for birth does not respect her rights, and may increase the risks to her and her baby.
‘You assess need and deliver or advise on treatment, or give help (including preventative or rehabilitative care) without too much delay and to the best of your abilities, on the basis of the best evidence available and best practice.’
The best evidence available demonstrates that fit and healthy women are safer giving birth at home than attending an obstetric unit (Brocklehurst et al, 2011; Li et al, 2015).
Midwives have a duty to ‘tell any employers you work for if you have had your practice restricted or had any other conditions imposed on you by us or any other relevant body’ (NMC, 2015: 17). But who does one tell when it is the employers who are restricting one's practice by failing to enable attendance at a homebirth?
‘The Nursing and Midwifery Council exists to protect the public.’
How can the NMC possibly protect the public when it has allowed NHS Trusts to determine whether or not a midwife attends a woman birthing at home? In an email exchange with the NMC Education and Standards Team (dated 18 July 2016), the response to a question about midwives attending a homebirth was:
‘Maternity care providers will have local commissioning requirements and policies in place with regard to women's choice. Information should be available to women to inform them as to whether home births can be supported at all times. Decisions regarding the safe and effective care of women and their babies must be undertaken locally.’
If the decisions regarding safe and effective care of women and their babies are undertaken locally, what is the role of the NMC in ensuring public protection? It would seem that the NMC has a responsibility to punish midwives when things go wrong, but little obligation to uphold the standards of practice, the rights of women and the responsibilities of midwives.
It seems the NMC has relinquished its role in protecting the public and has, equally, ignored the rights of women, clinical evidence, and the long-held belief and obligation that, as one of only two professions (midwifery and medicine) legally entitled to attend women giving birth, midwives hold a duty of care to attend and support women whenever and wherever they choose to give birth. This is probably not surprising given that the NMC Education and Standards Team has no midwifery members (NMC, 2016). Also, the pre-registration education and training standards make no mention of homebirth as an educational requirement, a serious omission that helps to explain why some midwives are at best uncertain, and at worst fearful, of attending women who choose to give birth at home. So exactly what advice is given, and what confidence do midwives have that this helps them to direct their professional practice and support women and their families?
Rules and standards
Rule 5—Scope of Practice (NMC, 2012: 15) states:
‘You must make sure the needs of the woman and her baby are the primary focus of your practice and you should work in partnership with the woman and her family, providing safe, responsive, compassionate care in an appropriate environment to facilitate her physical and emotional care throughout childbirth… Except in an emergency, you must not provide any care, or undertake any treatment, that you have not been trained to give.’
Surely a woman in labour at home requires—and is entitled within the rules of the NHS—to be attended by a registered midwife? Problems do arise, although rare in multiparous women (Brocklehurst et al, 2011). In women giving birth at home, transfer rates to obstetric units are 36–45% for first-time mothers and 9–13% for multiparous women, and poorer neonatal outcomes do occur, although the risk remains low (Brocklehurst et al, 2011). Without a midwife present, devi ations from the norm can go unchecked, problems may escalate, and emergencies requiring professional support and intervention may go unrecognised and unheeded. So where does the NMC sit in protecting the public?
NHS Trusts that fail to support the right of a woman to give birth at home, and forbid their employed midwives to attend such women, are surely acting contrary to the Human Rights Act 1998 and the aspirations of national policy. They, and the NMC, are equally at odds with the Code and standards set out by the regulator, which appears to use its own rules when taking action against midwives for mistakes and misdemeanours, but seems unwilling or incapable of using them to support and uphold practice standards and the imperative of ‘public protection’.
The National Institute for Health and Care Excellence (2016)A states that practitioners should:
‘Advise low-risk multiparous women that planning to give birth at home or in a midwifery-led unit (freestanding or alongside) is partic ularly suitable for them because the rate of inter ventions is lower and the outcome for the baby is no different compared with an obstetric unit.’
Why, then, are the NMC and the Department of Health permitting Trusts to continue forcing women to accept care that they do not want, and which the research clearly shows puts them and their infants at greater risk of interventions and complications by coming into hospital?
Legal role of the midwife
‘Both the title “midwife” and the function of a midwife are protected in law. You must not, or permit anyone else to, arrange for anyone to act as a substitute for you, other than another practising midwife or a registered medical practitioner.’ (NMC 2012: 15)
As attendance at birth is restricted in law to a midwife or doctor, it is only right that when called, the midwife must attend (or find another midwife who can). If this is not so, then it must follow that anyone can attend a woman at home, regardless of whether they have a midwifery qualification. We cannot have it both ways.
The withdrawal of the homebirth policy has been a well-kept secret. The NMC— along with managers and employers (so often the enforcers of their view of nursing and midwifery codes and standards)—are, in respect of homebirth, failing women, midwives and the wider public. In doing so, they have reduced the standing and reputation of the midwifery profession, which can no longer be trusted to attend women who birth at home. As such, the powers that be are putting women and infants at unnecessary and avoidable risk.
Finally, the NMC Code tells us that ‘while you can interpret the values and principles set out in the Code in a range of different practice settings, they are not negotiable or discretionary’ (NMC, 2015: 2). This means nothing to a woman wanting a homebirth if midwives have no freedom to exercise their clinical judgement and are prevented by their employers from carrying out their professional obligations and duty of care. If this lamentable situation continues, women will seek to birth at home without midwifery help and, if this comes to pass, what point is there in having rules, regulations or, indeed, a regulator?