This is just about the most important question in midwifery. A woman's right to choose where she gives birth says a lot about the system that's offering her maternity care.
In the UK, it’s a situation that’s recently been impacted by some changes to midwifery law. In particular the removal of supervisors of midwives.
The basic answer is: if a woman with complex needs chooses to give birth at home, even if a medical team and trust feel it’s unsafe, care must still be provided.
Unfortunately in practice it's a lot more complicated than that.
Back in 2016 if a woman with complex needs was planning a homebirth, a meeting might take place with the head of midwifery, obstetric team and a supervisor of midwives.
Or if a client was in labour and no plan had been made, there would be a supervisor of midwives to call to try and find a solution. Supervisors of midwives were on call 24/7.
These days because supervisors of midwives no longer exist, the process is different. England, Ireland, Scotland and Wales all have different approaches to supervision but it’s now employer based as opposed to midwifery profession/NMC based.
In England, ‘Professional Midwifery Advocates’ (PMAs) have now sort of replaced supervisors.
However, they don’t have legal responsibility towards midwives in the same way as supervisors did. It’s now the trust who have this responsibility. Supervisors can encourage education for midwives and good communication between midwives and clients but they no longer regulate. Some trusts offer 24/7 support from PMAs and some don’t and midwives are telling me it's a weaker style of advocacy for women.
There are also some other challenges midwives and women are facing around homebirth.
As we all know, we are thousands of midwives short in the UK. Trusts can refuse to send a homebirth midwife due to lack of staffing and this does happen. (I have heard of one trust who got fined for doing this repeatedly).
I’m also hearing from homebirth groups that sometimes paramedics are sent to provide care for labouring women in lieu of a midwife. Paramedics are amazing in emergencies. But a labouring women needs a professional able to support her normal physiology and recognise when medical expertise is needed. Paramedics haven't been trained to conduct planned homebirths.
Another alarming report I've heard from midwives is of social services being sent to visit women planning a homebirth against medical advice. This seems very unkind and unhelpful to me, unless there are true social issues that need addressing.
Finally, there may be times a midwife feels she's not the best person to attend a certain woman - for instance if a baby is on its way in the breech position.
If a woman is labouring and a midwife refuses to attend her because she’s not skilled enough for the situation, it’s unclear what the legal ramifications would be. It might end up with the NMC trying to investigate whether that’s true, though obviously that's not very helpful to the woman when she's needing a midwife there and then.
As far as I know, human rights laws mean that if a trust tried to stop a midwife from attending a birth and any harm came to the woman or baby, the trust may have breached the ‘right to life’ (I’m quoting from Birth Rights legal charity here).
Often in practice a woman will be asked to sign to say she understands the risks and midwives are sent to support her, though any of the above situations could happen.
Essentially, any woman still has the right to birth at home. But the logistics can be complex.
Has anyone been through this recently, as a woman accessing care or as a midwife? I’d love to hear what happened to get it clear in my head. Please comment below.