advice for getting the homebirth i want when "decision" wont be made until 36+5

[nannyl]

At the moment in 28+5.
Im having an uncomplicated (first) pregnancy, and I always see my (lovely wonderful) community midwife on a Friday so Im always X+5.

Anyway i have known since before i was pregnant that I intend to have a home birth. Now im pregnant and have researched it even further i know the decision is right for me.
Its what i want, what i have a right to have, and MY choice.

I also know that midwifes / NHS like to think its their choice, but the reality is its mine.

I have been talking about having a home-birth since my 9 week booking appt. My midwife has always maintained that they dont make the decision until my 36week apt (which i will have at 36+5)
(I have not yet bothered to have the "its MY choice" discussion cause i dont see the point... at 9 weeks anything could have happened and even now i could have a premature baby and have to go to hospital)

The midwife has always said they dont decide until 36 weeks as there is lots of paper work, and no point doing it, if there are last minute complications, which i understand.

However if my baby is breech (today she was head down but of course can move) I will STILL be wanting and insisting on a home birth. (Im sure that wont go down well!)
Also in the event that my BMI is slightly above the limit of 35 (I doubt it will be, im only a size 12) I will still be choosing a home birth.
Or if there are any other minor risk factors which matter to NHS (but not to me) I will still be choosing a home birth against their advice.

It strikes me that on the Friday, less than 48 hours before i become term on the Sunday, i could have to start my battle for my right to a homebirth. (and this doesnt give me much time to fight my corner if necessary)
Also when Im so close, i want it to be all sorted and not wondering at 36+4 if i will be allowed to give birth at home!

Does anyone have any ideas?

Also if baby is breech, and NHS really have a strop id happily go for an IM, but it doesnt give me much time to find one, if i only call them, when i could go into labour at any moment, and they will have bookings / plans etc.

Id rather use the NHS (and have met 2 lovely community midwives out of the 5 that might attend already) though, and on the positive side, because i live so far from the hospital home births are very much supported in this area, much more so than in many other areas.

I have already been admitted to my hospital (I have no choice regards to hospitals, there are no others close enough) with HG, and (unless in an ambulence for an emergancy) i do not plan to go their willingly, at all, ever. It was awful (another thread lol)

Of course if there are complications during the birth i'll have no choice, but to go in, which is fine, and if baby is transverse (or if placenta was in wrong place; its not) I accept that a homebirth is positively stupid, and id be admitted for a CS, but otherwise i intend to at least try to give birth at home, as is my right.

Has anyone else had the decision made SO late in pregnancy?
I am normally super organised with everything (i have my birth pool, towels, waterproof sheets etc all ready ) and I find it stressful that its my decision and im not allowed to make it until just a matter of hours before becoming "term".

Also i know the midwives here like to deliver home birth stuff so its ready. Well if i dont get 'booked for a home birth' until Friday at 36+5 will they really get the stuff here before Monday? 37+1?

(and yes i know as its my 1st im highly likely to go overdue anyway, but i still want to be all ready!)

Any advice welcome!

Babyonboard, on this thread you've made one of the nastiest comments I've read on Mumsnet. NannyL is clearly feeling robust enough not to be too upset (well done, NannyL), but regardless of your views about homebirth, telling a heavily pregnant woman that you hope she bleeds to death is inexcusable. You should be ashamed.

And what about doctors (like my sister) and nurses and midwives who choose to have homebirths? Are they also deluded and spoilt and ignorant? Or perhaps just guided by ALL THE EVIDENCE.

Babyonboard that was a nasty comment about bleeding to death.
On the subject of PPH the wife of one of dp's colleagues had a PPH in hospital, with a junior doctor in the room who just fannied about for ages while she turned the colour of the sheet. She was really sick, and in ICU for ages, partly because of the delay in doing anything about it ie giving her fluids and arranging for theatre.

Working in the emergency services, I do like to think that a paramedic would have had the situation under control more quickly, and ime coming into hospital in a blue light ambulance focuses the mind of HCPs and results in quicker, life-saving action being taken a lot more than being 'safely' on a ward.

the invective directed at the op seems to come from know-nothings.

the Netherlands neonatal mortality was one of the best in europe - better than both France and the Uk. 30% Hb IIRC.

The perinatal mortality rate in the Netherlands is pretty abysmal though.

Neonatal mortality looks at children up to a year, while perinatal mortality refers to third trimester up to 1st month of life, so gives a better insight.

www.bmj.com/content/337/bmj.a3118.extract

And the response to that study:

"Too early to question effectiveness of Dutch maternity care system
Ank De Jonge, senior midwife researcher Ben Willem Mol, Birgit Y Van der Goes, Jan G Nijhuis, Joris A Van der Post, Simone E Buitendijk
Midwifery Science, AVAG and the EMGO Institute for Health and Care Research, VU University Medical C

With interest we read the study from Evers et al. on perinatal mortality and morbidity in the Utrecht region, one of the 12 provinces in the Netherlands. This is the first study ever to show a higher mortality rate among births that started in primary care compared with secondary care. We have concerns about the methods used.

First, although the title suggests that this is a prospective cohort study, the entire population at risk has been defined retrospectively and was based on postal codes of the catchment area of one university hospital. All intrapartum and neonatal deaths were included from hospitals and midwifery practices within this area, but potentially not all births. Midwives in practices at the periphery of the catchment area will also care for many women in neighbouring regions. These births have not been included in the study, unless the baby died. This will artificially inflate mortality rates in midwifery practices.

Second, the study was conducted in only one region in the Netherlands. The intrapartum and neonatal mortality rate was twice as high as in recent national studies among women in primary care at the onset of labour (1.39 versus 0.65 and 0.52 per 1000)1;2. Although classification bias and underreporting may have played a role in these retrospective studies, it is unlikely that half of all deaths would have been missed. In another prospective study of perinatal mortality cases only 3.5% additional cases were found as compared to national registration data 3.

Strikingly, in Evers' study 67% of all babies that died during labour were born in primary care. This means that either the midwife noticed fetal distress too late to refer a woman because the birth was imminent or a deceased baby was born so fast that the midwife arrived too late to a woman's home. It is very surprising that these situations were much more common than referral before birth. In Amelink's national study, only 5% of intrapartum deaths were among births that took place in primary care 1. This discrepancy suggests that the study sample may be rather different from the national population.

Given the limitations of the study, the conclusion that labour starting in primary care carries a higher risk of delivery related perinatal death compared to labour starting in secondary care is premature from a scientific point of view. The authors correctly state that "their findings are unexpected and deserve further evaluation". Previous audit studies did not find that features of the Dutch maternity care system were related to preventable perinatal deaths 3;4. The results of Evers' study call for an urgent review of all mortality cases in the audit study announced by the authors. In addition, perinatal outcomes in other regions need to be examined. Ideally, a large national prospective cohort study should be conducted. The suggestion that "the obstetric care system in the Netherlands possibly contributes to the high perinatal mortality rate" can not be made based on these data alone.

(1) Amelink-Verburg MP, Verloove-Vanhorick SP, Hakkenberg RM, Veldhuijzen IM, Bennebroek GJ, Buitendijk SE. Evaluation of 280,000 cases in Dutch midwifery practices: a descriptive study. BJOG 2008; 115(5):570- 578.

(2) De Jonge A, Van der Goes BY, Ravelli AC, Amelink-Verburg MP, Mol BW, Nijhuis JG et al. Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG 2009; 116(9):1177-1184.

(3) Wolleswinkel-van den Bosch JH, Vredevoogd CB, Borkent-Polet M, van EJ, Fetter WP, Lagro-Janssen TL et al. Substandard factors in perinatal care in The Netherlands: a regional audit of perinatal deaths. Acta Obstet Gynecol Scand 2002; 81(1):17-24.

(4) Bais JM, Eskes M, Bonsel GJ. [The determinants of the high Dutch perinatal mortality in a complete regional cohort, 1990-1994]. Ned Tijdschr Geneeskd 2004; 148(38):1873-1878.

Competing interests: None declared

That's true WidwoWadman - but it doesn't necessarily follow that the infant mortality rate is high because the Netherlands support homebirth. The author of this article seems to think that HB isn't the problem but more a lack of communication between MWs and consultants resulting in a poor identification of women with increased risk factors, combined with some social problems making some demographic groups much more likely to have poor outcomes regardless of birth place (for various reasons, including smoking, diet and lack of antenatal care).

UPDATE

thought id add, been to midwife today at 31+5

Have been discussing home birth (its no longer too early to think about) and baby is in the right position etc.

So long as baby not born early etc, (or other major complications between now and then) I have full NHS support for the home water birth i plan...
and my (lovely wonderful) midwife, who i have seen throughout my whole pregnancy will do her best to be there personally .

Such a relief.... it is now officially official that i want and plan a homebirth
One more appt with midwife at her clinic then the rest of my care here in my own home.

Thats really good news :-)

That's awesome news, nannyl.

I think because people generally like to be in control of what's happening to them, it can be really hard to wait til 36 weeks to have the HB conversation. But once you get there, it's highly unlikely you will be denied if you're a good candidate. They could handle it better however, by saying "we'll make the decision after 36 weeks, but if you're still low risk then it shouldn't be a problem".

Please let us know how it goes!

Great news, pleased for you.

Firstly you need to calm down a bit - it is early days. And no, they will not deliver a homebirth kit to your home before 37 weeks - that is prefectly ok as if you go into labout before then you should go in anyway. What they mean by waiting until you are 36 weeks to book it is they will not put you on the rota until then - how on earth do you expect to plan that far ahead????

Look, they do this all the time, they know you have a right to a homebirth and they also know that the majority of transfers in from homebirths are for first timers... this will probably not be the case for you but it is a fact.

My genuine advice to you is try to be a bit more flexible, you do not know what is going to happen, your baby being breech right now is absolutely no indicator for how it will lie nearer the time.

I say all this as someone who has had one preterm birth rather unexpectedly in hospital and three straightforward homebirths after that. When I have another baby with all being well and good I will have it at home too. Please try not to be too hard and fast about everything, please be flexible because having to climb off your high horse whilst in labour is a long fall.

pinky....

at 31+5 its now been agreed..... so long as everything continues to be fine
My midwife probably got bored discussing it with me at every appt!... and my next midwife appt, (all being well of course) will be the last that is at the surgary, the rest will be at home.

Paperwork will be done during week 36, and i'll collect the homebirth kit myself, from the midwife led unit at 36+6....

Baby just needs to behave herself for 5 more weeks, and arrive by 10 weeks time!