Want home birth but there "might not be staff"

[Kopparbergkate]

I'm expecting DC2 and am nearly 38 weeks now. Ever since my booking in, I've said that I wanted a home water birth with this baby. I didn't have a pleasant time (putting it mildly) having DD1, albeit in a different hospital, and I am really really keen to stay at home; though I have also said throughout that if anything changed and I became high risk, then I would go in.

Anyway, the community midwife I have had for all my appointments has seemed keen and assured me that there is no reason I can not stay at home.... That is, right up until my 37 week "home birth check" at home last week, when she said that, of course, there's only one home birth team in this area (its a big rural area) and if they're attending another woman, then when you phone for a midwife, you'll have to go in to hospital. I asked how often that happens and she said it happened at least every month.

I've never had an issue with the thought that I might need to transfer in labour or indeed that I might develop a complication in pregnancy that means home birth isn't an option but that's not the case. I'm in tears at the thought I might phone up expecting to ask for a midwife and get told to come in instead and it's really worrying me (i guess partly cus of what happened last time). I have a doula and she's given me a letter template from an AIMS book to send to the supervisor of midwives basically demanding a midwife be guaranteed.

Thing is, I feel really torn; I do really want them to guarantee me a midwife and they have had months of notice but I also don't want to come across as an entitled arse making a huge fuss when NHS resources are limited etc etc.

Wwyd?

I'm surprised at some peoples sense of entitlement on this thread. Why is it the OP's right to a HB? If I'm in labour and I want an epidural but the anaesthetist is dealing with someone for a C-section should I demand they leave that woman and come and see to me? After all, didn't they know I might go in to labour on that day and shouldn't they have had the foresight to make sure resources were available?!?

Yes, OP crack on and demand away. Lets hope that your demands don't have a detrimental effect on someone else!

I think some of you might be surprised how little experience many midwives have of homebirth, even community midwives, and how reluctant many are to do them. Yes, you could stand on your rights but do you want your birth attended by a nervous or reluctant midwife?

OP, I'm a huge supporter of HBs and your right to birth the way you want to. I've had three of my four at home and on each occasion someone was brought in from another team as 'my' team weren't available. It didn't matter that I didn't know them, I was just grateful to have them there.

My hospital birth would have resulted in intervention , doctors, forceps, episiotomy etc simply because I had been pushing for two hours and protocol dictated that I should stop and accept intervention. Thankfully I had birthing patters who were clued up and knew what to ask.

There's less of a chance of intervention, you won't be taking up a delivery suite or post labour bed and for once in your life this is something about YOU. Personally I think it's the one thing that I wouldnt compromise on.

A HB is a wonderful thing. I hope you get yours and it all goes well

I'm also amazed at the sense of entitlement.

OP, you clearly had a bad experience last time and have built your hopes around a HB. I do hope you get one.

BUT, there will be one team on call, other midwives will be at home with their families or asleep. Do you think the NHS should pay thousands of pounds a month for a second team that's likely to be needed once a month? Or do you think there are lots of experienced MW sitting around in the hospital doing nothing waiting to be a backstop??

It may not be your ideal, but you're not being told to go it alone if there's no one available, just to use the hospital facilities. Maybe you could look at a Midwife led unit near you as a back up.

If you want guaranteed midwife availability then you will need to pay for an independent midwife. The NHS cannot support this. You are understandably upset but it is still unreasonable to demand something that's not there to give.

patchesmcp - but in turn your request for an epidural has meant someone else can't have it - so how is that fair on them? They've earned their right to treatment just as you have?

Those of you talking about 'a sense of entitlement' seem to have forgotten you're addressing a 38 weeks pregnant woman who has already clearly expressed that she is upset and distressed by the situation. Are you trying to make her feel guilty? Just back off.

Sh isn't asking for a service the NHS can't provide. Quite the contrary, she's asking for a service that they are contracted to provide. Midwifery is a 24 hours a day, all year round profession. There IS always somebody and that's as it should be.

Patches, that's a little harsh. The OP was worried about coming across as 'entitled' which is why she posted.

Services are in the state they are in because they are underfunded and undervalued. We see this across the NHS, old people sitting for hours in their own wet pants because there was no-one to take them to the toilet, people turned away again and again from non-emergency but still downright necessary day surgery. And this is partly because no fuss is made. Kicking up a fuss and standing on your rights is the opposite of selfish, it ensures that in the future the service will be valued and others will get access. By acting 'entitled' we preserve the service for others. By rolling over and saying 'oh well then never mind' we give policy makers the excuse they need to not invest. There are independent midwives who would be happy to act as bank staff to cover eventualities, but where is the push to set up agreements if NHS trusts can simply rely on intimidating frightened women who are vulnerable and in pain?

If you want guaranteed midwife availability then you will need to pay for an independent midwife.

Sadly, this won't be much of an option from October as independent midwives will no longer be able to obtain insurance.

Well said Northern.

That is upsetting. Ultimately they can't force you into hospital. If you rang them and said you were in labour and not coming in, they would find someone to send you.

And FWIW for all the "entitlement" proponents, home births actually cost significantly less than hospital ones (1997 prices were £2000 for a hospital birth (with a lot of that set aside for lawsuits / £700 for a home birth (no compensation if anything goes wrong)). Think on that before you go on the completely misplaced offensive.

Northern I don't know specifically about midwifery, but I do know that there isn't always somebody in the NHS.

I was with a friend who is a nurse at one of the DCs activities at the weekend a coupe of weeks ago. She had a call from a colleague basically begging her to come in, as a dying man had requested to go home, but the ambulance staff had refused to take him without a trained nurse escorting him. The ward was being run on minimum staff, and for one of them to do the trip would have left it with inadequate staffing levels.

She couldn't go in because her husband was working and she had no cover for her DCs. She felt awful. Her colleague did not know how she was going to tell the man.

Rightly or wrongly (and I believe wrongly) the NHS is getting stretched to unbearable limits. It seems that the OP will get her home birth on a best endeavours basis. They won't be deliberately trying to let her down and upset her, just as that ward were trying desperately to get that man home.

Sometimes it will be impossible, and the lack of financial resources available in the NHS would make using expensive bank staff to cover situations like these not an option.

Write a strongly worded letter by all means, but address it to David Cameron.

"sense of entitlement"

The fact is living in this country does entitle you to lots of things...... education, benefits, health care and home birth amongst lots of other things....

Going to hospital is more likely to kill you and your baby than staying at home (if you are low risk) and you are entitled not to take that risk (and save our NHS ££££)

and why should I have to go to hospital? Im a good 45 mins drive away, 1 hour + at times...... with my 1st baby i had 12 mins between knowing myself i was in established labour (transition) and giving birth..... how am i supposed to get there this time when it could be quicker? luckily last time a midwife popped in to see me 17mins before DD popped out.... (it meant i gave birth with only 1 of the 2 midwivs present though, the other arrived about 10mins after birth)

No way am I risking the most dangerous situation of all; unassisted unplanned birth by the road...

as for sense of entitlement i dont actually have a hospital that i am likely to be able to travel too..... yes there is a birth centre 20+ mins drive away (and yes it IS lovely, like a hotel) but i dont choose to sit in the car in labour.

my choice and i have a right to choose it (and would still be entitled to choose it of i lived right next door to the hospital)

Luckily for me, living on the edge of no-where, such a long way from the hospital, homebirths are very much supported here, and we have community midwives confident enough to do them....

I attend a small toddler group, rarely more than 10 families attend, and there are about 20 families that are regulars.... and out of these people 4 of us have planned homebirths!

When I went into labour there were no mws available, I just told them I would not be coming in and a mw arrived a short while later. Nice guidelines say all women in labour should be given 1-1 care (not that it often happens) if you go into hospital you would still be taking a mw away from other women. Ignore the people talking about a sense of entitlement, you are entitled to a hb! Staffing levels/ lots of other women in labour etc are not your problem, tell them you will not go into hospital and they will find a mw for you

It is not selfish of you to expect the NHS to provide the staff. Their staffing issues not yours. Get your doula to stand up for you - this is a common tactic. Good luck!

Northern this is an open forum, people are allowed to express views other than your own, so you shouldn't tell them to back off! The OP was actually asking for opinions on what to do, well now she has them. You might not agree with the views of other people but they can express them.

Lions may be what I said comes across as harsh to the OP, that wasn't what was intended. I don't think she is coming across as entitled at all. She's asking for advice which she now has. My point was that other people who say demand it, it's your right sound entitled.

I appreciate that HBs might be cheaper for the NHS but the majority of people prefer to give birth in hospital so that is where the NHS will focus their resources, as it benefits the majority of people. As has been said, they can't have masses of midwives on standby on the off chance someone goes into labour who wants a HB. The resources aren't there for that, and they need to prioritise the resources they have.

At the end of the day it comes down to money. If we want a better NHS we have to pay for it. If you feel that strongly write to your MP and tell them you'd be happy for them to raise taxes so more money can go into the NHS...I'll be surprised if anyone does.

I should add, the one thing I think which has not been handled at all well for the OP is the midwife team not telling her until now that there might be a problem. When she expressed her preference for a HB, it should have been made clear at the outset that there is no guarantee that she could have one due to resources. If that had been the case, we might not be having this discussion now, as the OP might not have pinned her hopes on it.

I think if I was the OP I'd be highlighting that to the midwife team, as it is something they should and can easily address for the future.

Patches: it's all very well saying that she should tell the midwife team now, so that something can be done about it. From what OP says it's quite clear that they know there have been staffing problems for a number of months, but despite this, nothing has been done. What's going to make them change now?

The majority may well choose hospital birth, but in areas where good homebirth services are established, about 10% do choose them, which is quite a sizeable minority.

Unless people do start to make a fuss, maternity services will stay in a mess.

Patches - sure go ahead and exercise your right to express views that will upset a vulnerable person. I wouldn't want to interfere with your right to be as aggressive as you wish against somebody who has already expressed distress and (misplaced) guilt.

I repeat - maternity services in the OP's area have already been contracted to do homebirths. This isn't a question of paying for something unplanned. This is a scheduled service that the Op wishes to access. Difficulties in offering that service are not of her making. It's not about needing a better NHS. it's about the NHS that there is managing a service effectively. Do we tell patients who can't have a hip replacement because of staffing that it's there fault for expecting something the NHS couldn't deliver? No we don't, we all know it's a service delivery issue.

I think the further problem here is that homebirth is seen as a luxury, not as a normal (and cost effective) way of receiving care.

To add to what Northern says: if OP just accepts that there won't be the staff and she will have to go into hospital, the health authority will be able to continue to say that they don't provide a home birth service because there is no demand.

The hospital isn't actually obliged to send a midwife. They can send a paramedic ambulance. They have to provide medical support of some kind, but it doesn't have to be a midwife. They probably will find a midwife, but they don't have to if they really really can't.

Sorry to have disappeared last night; I had decided I was going to write the letter to the SoM today so, having made the decision, I took myself for a nice warm bath and the best night's sleep :)

Having read all the responses since then; I'm a bit less decided... however, I keep coming back to a couple of things inspired by reading the links people have posted and everyone's thoughts. This is where I am at the moment:

What I am entitled to is not my decision to make - that has been decided by NICE, in the same way they decide what drugs and treatments for illness can be funded. NICE have decided that I am entitled to have an NHS attended home birth if I choose. As far as I can tell, NICE could have said that there is only a responsibility to provide x homebirth/community midwives per area and beyond that, everyone goes to hospital but they didn't. If the hospital trust have an issue with affording to staff everyone's homebirths, then its open to them to lobby NICE to change the guidelines. It is not my responsibility to manage their budget and tbh I don't even know if it is a budget issue. Also the hospital I would need to go to has 8 birthing rooms and almost 3000 births per year and yet they manage to resource it and it has not closed to admissions at all in more than 2 years; if they can juggle the staffing appropriately for that (presumably including covering staff illness and unexpected problems) so that they never have to turn women away, they can do it for home births too.

I've also found the latest review of maternity provision in the area where one of the recommendations is to increase the number of home births. My doula has also put me in touch with a local IM who sometimes covers extra homebirths for the neighbouring home birth team (same hospital trust, just different community MW team).

The final thing that makes me less accepting is the timing of being told - at my booking in and at subsequent appointments whenever home birth has come up, my midwife has been careful to remind me that mine or the baby's condition might change so as to make staying at home inappropriate. She's explained the policies on baby being breech or me developing GD or going "overdue" etc etc and impacts on whether I can stay at home and that's absolutely fine. What's not fine is to wait until I'm 37 weeks to say, and by the way, as well as all those other issues, we might not be able to staff it. I'd be much less upset now if she'd included this as a possible issue all along.

Anyway, the upshot of all of this is that I intend to phone the SoM today explaining that I have found out there have been problems in the past and rather than it all coming as a surprise and an emergency when I'm in labour that I insist on staying at home, I'm letting them know in advance. I'll follow the call up with a letter also setting that out.

Thanks to everyone who's responded. I'll probably end up going massively overdue and ending up being induced in hospital anyway... (yes, I know I have the right to refuse that too but I've made my own decision as to how many days over I'm happy to go whilst all is well)

actually goodgumdrops a midwife is obliged to attend anyone who call her who is in labour....

the hospital may send an ambulence as well or to arrive faster (as midwives have to stick to speed limits like the rest of us) but everyone is entitled to a midwife to be present at their birth and to choose the place where they birth.

I there is no one else its down to the midwife who answers the phone / speaks to the lady to attend the birth...

Good luck OP

also even if you have GD or a breech baby who are over due etc etc, you can still choose to homebirth, regardless of their policy....
Its YOUR choice, not theres no matter what.... even with quads etc etc, its always up to you, and unless you have been sectioned under mental healthy, you can not be forced to give birth in hospital under any circumstances... you have to agree to it

As a mother who birthed at home and plans to again with my second I can absolutely understand where you are coming from.
On the other hand I am also a midwife working in a depressingly squeezed NHS. we have 2-3 midwives on call each night, most nights are quite but occasionally we have one or more women labouring at home, in the situation where more than three women labour at home then we are screwed. We can call the supervisor who has to attend and we could beg labour ward to send staff but if they are also busy what are we to do? It is an extreme and unlikely circumstance but not outside the realms of possibility. In the scenario I have described I am unsure who you think they might send out to you? Desperately call another midwife who is not at work and is resting in the middle of the night between two twelve hour shifts- I am not sure I would agree to come in in those circumstances when I am not at work.
So I agree there should be adequate provision for homebirths but in the situation where it is impossible to find someone to attend simply parroting "this is my right" will put yourself and baby in danger.
I am concerned about this very issue for my own birth however I feel it is your right but sometimes plans need to be changed for safety sake.

Finally my team has received that AIMS letter and whilst I understand the points it contains it is a very aggressive format and upset a number of colleagues. I think the points can be made in a more reasonable manner.

LaVolcan you've missed my point I think regarding telling them now. I appreciate telling them now won't assist the OP, but it may assist other people in the future, as hopefully the midwife team would then make clear from the start to others that it may not always be possible to have a HB due to resources. This would then enable them to manage their expectations.

Northern - nice aggressive response from you there. I'm sure the OP appreciates this is Mumsnet not Netmums and if she'd had wanted a warm cuddly response simply agreeing that it wasn't fair she could have posted there. She didn't, she posted here and asked for opinions. Fair enough my opinion seems to be in the minority, that's fine, that's what makes this website interesting, reading about and debating the merits of other people's opinions and then perhaps changing yours as a result, or do you simply post and agree with people just to make them happy. If so, how altruistic of you.

OP I hope that your hb goes as you want it to and there is no medical reason for going in.

When in labour and you call, if they say there are no midwives, then repeat what others have said. Thanks but I shall be at home waiting for a midwife. They have to find a hcp suitably qualified to deliver your baby. If they don't, and you have an unassisted birth with their knowledge, they are breaking the law.

Worst case, in my area anyway, if there really were no NHS midwives anywhere, they would have to pay for a private midwife to attend you.
When you go into hospital, you are taking a midwife away from someone else so location really shouldn' matter.The more women who ask for a hb, the more the NHS will have to provide for.

Personally, I wouldn't worry about writing letters or getting upset now. Your doula is your gatekeeper. When you are in labour, she can communicate your wishes and they will send a midwife. There is a small chance theywill send an ambulance but that is rare and no one can force you to get in it.

Wishing you all the best.