right to choose - antenatal tests and birthplace

[AcornNest]

I am very lucky to have had a very straightforward pregnancy, very low risk and no concerns.

Because of the low risk pregnancy I have chosen a home birth. This was discussed at my booking appointment and at several other antenatal appointments and the midwives have been very supportive of it throughout (the first actually recommended it).

Throughout the pregnancy I have declined certain tests. I fully understand the reason for those tests, and my midwife was happy with the conditions under which I would consent (eg any other indications of problems). It was made very clear that it's recommended for xyz reasons, but also that I had the right to chose.

Now, at 36 weeks, I'm being told that I can't book a home birth because I have refused these tests (with midwife still recommending it). I was asked to meet with the consultant to see if they would sign off on it. Consultant didn't understand why she was seeing me, because she only normally sees high risk patients which I'm not. But their policy means that she had to recommend a hospital birth, although she was very apologetic about this and wanted to help but couldn't.

So all the medical advice I have been given recommends a home birth (if this were not the case I would not have one). But the official recommendation is that I have a hospital birth.

Do you think that my choices with regards to antenatal testing should affect my ability to choose my of place of birth?
And, if so, at what point should I have been made aware of this?

And this isn't about whether or not people think I've made the right decisions, this is about whether or not I should be bullied into medical tests that I don't want.

The choice to birth at home yours and yours alone. The Drs and midwives can recommend you do/don't but ultimately the decision rests with you. You may need to fight a bit to achieve this as it goes against their policy. I'd recommend looking at the AIMS(association of radical midwives) website as they have resources there that will help you with this. Best of luck.

Strictly speaking, if you notify the hospital that you are in labour and refuse to come in, they are obliged to send midwives to you. Nobody can force you to go into hospital.

That said, it's difficult to judge without understanding just what tests you've declined. (Blood tests? Scans? A low-risk pregnancy doesn't usually involve that many tests). The hospital does have the right to decline to admit you or provide certain forms of treatment if they feel it is not in your interest or not an acceptable risk and that doesn't constitute "forcing" you to take the tests. At a certain point they also might legitimately consider you not a low-risk pregnancy if you have declined to have the tests that would confirm that you are.

I wonder whether the consultant is in that position as because you have chosen not to have tests, they are not able to give a full assessment of the risk of home birth, therefore the recommendation has to be hospital birth. Not because there is a definite increased risk, but because they don't know there isn't one.

It is up to the health professionals to decide what care options they offer as at the end of they day they are responsible for the outcomes - they do not have to offer something that they think is unsafe.

However, I agree that if this is the reason why they are raising objections now, this should have been made clear to you when you were deciding on the whether to have the tests done. If your own midwife is happy, who is objecting?

Hope you manage to get it sorted x

OydNever:
Thankyou, I'll look at AIMS. I think I'm going to try for booking a home birth 'against medical advice', just need to work out how.

QueenAravis:
I thought you had to book a non-hospital birth? Nice to know that even if they stop me doing that they're still theoretically obliged to send a midwife.
If it had made me not low-risk I could understand that, but it hasn't (as the consultant specifically wrote in my notes). And if they want to make any particular form of treatment dependent on a test that's fine, so long as I'm informed that that is a condition in advance.
Additional risks related to the test result are negligible if all other tests are negative and there are no symptoms.
I'm trying to avoid saying what I've declined, I have my reasons and I don't feel the need to discuss them. I may get more support on here but I'm not in the mood to defend my decision right now and don't want to be told to let them do whatever they want just to make my life easier.

helly89:
Yes, I think that's exactly the point. But risk assessment should be carried out at every appointment, so I should have been told earlier that this would arise.
My midwife is happy but felt obliged to raise with head of birth centre before booking home birth. She is the one objecting I think (although not sure how the conversation went).

It might be something worth raising with PALS at the hospital - doesn't have to be a formal complaint, but can get concerns/problems heard and hopefully sorted by the right people.

For what it's worth I agree you don't have to detail/defend your decisions here - they are different to mine but everyone has their own priorities/preferences and as long as decisions are informed then that's up to each of us.

The law allows us to refuse any treatment if we have mental capacity and are informed, but there is no legal right to demand a particular treatment/care that is not felt by those who are being asked to provide it to be indicated or safe.

Having said that, it seems more like this is a blanket policy of 'computer says no' if all the right boxes aren't ticked, rather than actual clinical risk as you say, (possibly, but not definitely, a defensive legal position of the trust).

Again, see if PALS can move things on for you

Without knowing what you've declined it is difficult to say. But I would guess that they can't say you are low risk for a home birth if there might have been something in those tests that could make you high risk. For example if you had something like placenta previa and they'd recommended a home birth they could be in serious trouble. So to be on the safe side they won't.

Talk to your supervisor of midwives / head of midwifery or i your Trust doesn't have one then the manager of the delivery suite . They are very helpful . I've declined a few things including the GTT and am also high risk for other reasons , my consultant was mortified when I said I was having a homebirth but I had a meeting with the head of midwifery and she was very supportive and said the midwives would back me , because they have to .

It really depends what tests you have refused. If, for example, I had refused my 20 week scan and opted for a home birth, there is a very, very high probability that the baby and I would die. There have been absolutely no indications of any problems other than what was picked up on the scan but we couldn't survive a natural delivery.

Okay, I'll be trying to get an appointment with head of midwives then and we'll see what comes of it.

helly29: Legal position rules out the birth centre but it made no sense for me to go there anyway.

Since it appears that people think it's relevant, I've refused BP. No history or concerns about it being high, which everyone seems to assume, I'm just very aware that it's not reliable and don't think medical decisions should be based on what could be normal fluctuation. It's not, on it's own, a risk factor unless it's very high in which case there are symptoms. If there were other factors or symptoms at any point then my decision would be different. So far I've not yet had anyone able to contradict this.

It's different in pregnancy and women with no previous history can develop gestational hypertention and/or preeclamsia. You are right that other symptoms are likely to develop if left but they'd be hoping to catch it early through BP.
Like you say it's up to you but a medical professional couldn't say you're low risk with that as an unknown.

Oh god there's no way you could be classed as low risk with unknown BP. It just comes out of nowhere sometimes and the consequences can be devastating for you and the baby if it comes on during labour. I had never had high blood pressure in my life until I developed pre eclampsia. They really don't make a diagnosis from a one off reading, if you present with high BP on more than one occasion you're put on monitoring for 24 hours by which point they can usually rule out normal fluctuations. Other symptoms do come on with pre eclampsia but by the time you get to them it's often really serious.

It's totally your decision what you do and don't want and I hope you get the birth you want. But that's probably the reason for the obstacles you've encountered so far.

Oh and there aren't always other symptoms with very high BP. Mine was 170/120 at a routine antenatal appointment that Id come to feeling fine.

They only let you have a home birth if you are low risk. How can they tell if you are low risk if you don’t let them do any of the tests that show then you are low risk?

All we astax payers and they as professionals want is to make sure you can’t sue them for negligence when the decision is all yours and you have stppped them doing their job, so Just sign all the disclaimers, accept responsibility for your decision to go against doctors advice and get on with it.

You won’t let them put a cuff on you for 2 minutes? Seriously?

I have an independent midwife and know for a fact that none of those tests are mandatory, and that you are entitled to birth your baby however you wish.

If you want a home birth, just continue to tell them so. On the day of birth when you tell them you will be having the baby at home, they will.come to you, it is their legal obligation to be present at your birth. Don't be bullied into anything you aren't comfortable with. Your body, your baby, your birth.

But risking possible pre eclampsia and death of mother and baby is incredibly irresponsible, no?!

I should add that I am planning a home birth in the next 2 months. My midwife has told me at every appointment that any test is completely my choice, and puts no pressure on me what so ever.

All of this "you aren't low risk because you don't know your BP" is a crock of shit.

Midwife here. The choice of where to birth your baby is yours and yours alone. The role of the consultant midwife isn't to "allow / forbid" you a homebirth, but to discuss the risks and benefits with you to ensure that you're making a fully informed choice.
PPs are correct that preeclampsia doesn't always cause other symptoms. And if you were to suffer an eclamptic fit at home during the labour the impact on you and your baby could be life-threatening.
But there is usually a middle ground to be had in these discussions. If your reason for declining the BP checks is that you don't feel they are reliable, would you consent to having some bloods taken nearer your due date, or to send a urine sample (PCR) to the lab, which both have more diagnostic value for preeclampsia? It wouldn't rule out preeclampsia developing during the labour but it would help confirm that you're low risk beforehand, which is all that any antenatal monitoring can do.
At the very least the midwives should be able to summarise their discussion with you in your notes, and document that you're aware of the risks but you would like a HB regardless. This at least reduces the likelihood that they'll get sued if something goes wrong, which is probably part of their concern. (The other part of course being your wellbeing - but you are an adult and entitled to make your own decisions about that.)

If you aren't concerned about your BP, then why won't you just let them check it (it will take all of 2 mins) and then you can avoid this whole issue?

**They only let you have a home birth if you are low risk. How can they tell if you are low risk if you don’t let them do any of the tests that show then you are low risk?

All we are taxpayers and they as professionals want is to make sure you can’t sue them for negligence when the decision is all yours and you have stppped them doing their job, so Just sign all the disclaimers, accept responsibility for your decision to go against doctors advice and get on with it.**

^This.

You're not high risk because of declining BP monitoring however, pre eclampsia can and does present without any symptoms whatsoever which calls to question how would those responsible for your care know if you did deviate into a high risk category?

Taking a BP in pregnancy allows health professionals to understand what your baseline is and therefore recognise a deviation from normal.

If your Bp was raised at any point, other tests would be offered to ensure wellbeing. Pre-eclampsia isn't just a high blood pressure, there are markers in urine and blood and fetal growth issues which are used to make a diagnosis.

If you want to refuse Bp readings, that's your choice, but do it knowing all of the reasons it's being done. Informed choice means knowing all of the information, benefits and risks.

If you'd ever seen an eclamptic fit, there's no way you'd want to risk one at all, let alone at home.

This is possibly one of the most ridiculous threads I've ever read on here, and that is saying something!

If you can't understand why it would be negligent of the NHS and downright dangerous for you and your baby if you were to suffer an eclampsic fit at home, then you really need to read up on how serious eclampsia is.

Preeclampsia isn't the only issue. Undiagnosed hypertension puts you at higher risk of placental abruption or stroke. It can develop at any point in pregnancy and would be exacerbated in labour. It also increases the likelihood of hypoxia in labour due to reduced placental function, plus limits options for dealing with haemorrhage. If you're also saying you'd decline BP in labour the staff would be negligent if they weren't giving you all the information of potential consequences. I'm not sure why you think BP isn't reliable, manual readings seem to be more accurate than electronic so perhaps look into that.

Hippydippydoo, please don't dismiss my near fatal experience as a crock of shit. If I hadn't had my blood pressure checked, I would have probably suffered an eclamptic fit. So not knowing bp can in some cases be risky.
If blood pressure is unknown, it is impossible to know whether a pregnancy and planned labour is really low risk.

If you feel so strongly about having the perfect birth experience and have the luxury to choose, that's great. But hospitals have to take into account the possible risks to the baby too.

Sorry but I don’t understand or respect an individuals decision to put a baby at risk.
I presume your a first time mother, as soon as you hold your baby you’ll understand both your babies life and also your own. I have never been soo careful with my own life to ensure I am there for my children for as long as possibly can be.