Anna Nelson and Elizabeth Chloe Romanis
For many pregnant people[1] due to give birth soon there is considerable anxiety about how COVID-19 will impact birthing plans. Those who have planned for home-births are concerned that their plans will be jeopardised by the announcements from some NHS Trusts that they are suspending home-birthing services. Private home-birth services are now ‘receiving an unprecedented number of calls from women seeking reassurance, antenatal care, postnatal care and homebirths’1 as those previously not considering home-birth reassess their options because of concern about attending hospitals.
Home-birth and COVID-19
In 2017, only 2% of UK births occurred at home but this is likely to increase during the pandemic, primarily because of increased concerns about the safety of the hospital environment, for both the pregnant person and new-born. Furthermore, both Birthrights and the Private Midwives group have expressed concern that some trusts may be planning to ban birth partners or are already excluding them in practice. The fear of one’s birth partner being excluded could also cause unease about birthing in hospital.
Such exclusions would run contrary to the Royal College of Obstetricians & Gynaecologists (RCOG) guidance which emphasises that, in line with WHO recommendations, birthing partners must be allowed in the maternity suite during labour unless they are suspected of having COVID-19.
There is a lack of evidence about what is actually happening on maternity units. However, in the current frightening and uncertain climate, even the existence of doubt about whether healthy birthing partners will be prohibited (regardless of whether it finds basis in fact) could have a genuine impact on people’s decision making about where to give birth. It is important to ascertain whether pregnant persons have been advised that only birthing partners with suspected of having COVID-19 are excluded.
Increasing demand, but a reduction in access?
Despite a potential increase in demand for home-birth in the UK, NHS Trusts have begun to suspend home-birthing services in response to COVID-19. Around a third have stopped offering home-births because of midwife shortages, diversion of resources towards coronavirus, ambulance shortages and to discourage women who may have the virus from homebirth, as RCOG recommends that women suspected of having COVID-19 should give birth in hospital. This is in case there are complications requiring immediate medical assessment and/or intervention.
However, it is possible that the nuances of the recommendations are not being effectively understood by those preparing to give birth, who may perceive them as meaning that all expecting women should deliver in hospital during the current emergency, rather than just those suspected of having coronavirus. Service users are increasingly seeking clarification about how they can give birth at home from sources such as private midwifery services.
This situation is distressing for those who were planning on delivering at home before the crisis developed and those who genuinely believe that birthing at home is safer for them. For many, having to attend hospital to receive medical support feels unsafe and counterintuitive, and may have harmful effects on mental health.
Non-hospital Birth and the Law
Pregnant persons are free to choose whether to give birth in a medical setting; they cannot be legally compelled to do so. The right to give birth at home is protected by the right every adult with capacity has to give or withhold consent for any medical intervention.
‘Home-birth’ refers to a birth at home attended by midwives. While there is no formal legal right to this type of birth in the UK, guidance issued to the NHS indicates that maternity providers should put in place measures to ensure that home-birth services can be offered.
‘Free-birth’ occurs when a pregnant person plans an unassisted birth (at home) that is not attended by medical professionals, though they are available. This does not include situations in which birth simply occurs before the planned arrival of a medical professional. Free-birthing is legally protected under the right to refuse medical treatment, although there are some restrictions on the actions of others present during such a birth (discussed later).
Free-Birthing in the Absence of Home-Birth
Though uncommon in the UK, free-birthing is sometimes chosen by people who feel unsafe or disillusioned with maternity services, have had traumatic experiences in labour or who want to give birth in an environment they can control ‘free from clinical interruptions and that enhances the physiology of labour.’ For many free-birth is not a ‘first choice’ but the result of home-birth not being supported. We worry that a number of pregnant people may free-birth during this crisis when they would prefer medical support. Free-birth is not inherently ethically concerning; it can be an empowering decision for many. However, when free-birth is chosen by a person feeling that they have limited or no choice because of the unavailability of essential services this is cause for concern.
Distress and Limited Autonomy During Pregnancy
It is hard to overemphasise the significance of childbirth in a pregnant person’s life, and the impact choices about delivery have on their body and self. The decision of how to deliver in such difficult times may be an agonising one. For those who are confident of their decision to stay home, a lack of support will be frustrating and distressing. Pregnant people who want to deliver at home may be faced with choosing between doing so without medical support or attending hospital against their wishes. These people, unable to exercise their birthing preferences, may effectively feel coerced by their circumstances. Limited resources will mean this is inevitable in some cases. However, this should be a carefully justified last resort.
These conditions add to ongoing problems faced by people hoping to assert choice in childbirth as a result of risk narratives. Pregnant people often report feeling shamed by health professionals for their choice to give birth at home. Some have even been reported to social services by health professionals for choosing to free-birth. This may heighten the pressure felt to birth in hospital, against their wishes and even whey home-birth would be relatively low-risk.
While a third of maternity services have suspended home-birthing programmes, a number remain active. Choice about place of birth has been reduced to a postcode lottery, which is devastating for those denied agency. Moreover, the lottery is significantly exacerbated by socio-economic circumstance; those with more financial resources can secure private assistance.
Potential Increased Risk
Home-birth has been recognised for decades as ‘safe for normal, low-risk women, with adequate infrastructure and support’ and in some instances has been found to be safer than hospital delivery due to a decreased likelihood of obstetric interventions with complications. There is little data about free-birthing outcomes. Moreover, lack of resources is more likely to be an issue where people are free-birthing rather than having managed home-births. When people feel that their best option is free-birth and where complications do arise (though still rare) a pregnant person is more likely to incur injury because of the limited resources available (such as ambulances) in the current climate.
Loss of Trust
We should be concerned about the potential loss of trust in maternity services amongst those currently pregnant and unsure about their options. Maternity services are undoubtedly working tirelessly to help pregnant people, however there are those who were preparing for a potentially unassisted birth at home, but now potentially face a choice between free-birth and home-birth, as they are unsure whether the option of home-birthing remains open to them. This situation is occurring against a backdrop of existing problems in maternity services – stigma associated with homebirth, the denial of maternal request caesareans, and news that some people are being denied pain relief during labour.
Legal Implications
If people elect to free-birth, they may not be aware of the legal restrictions attached to this course of action. Article 45 of the Nursing and Midwifery Order renders it a criminal offence for a person who is not a registered midwife or doctor to “attend” a women during childbirth (except in an emergency). Doing so can result in a fine of up to £5000. While this provision does not render home-birth or free-birth illegal – it is confusing and arguably perpetuates a medical hegemony over childbirth.
“Attending to” is not clearly defined in this context. Even those who have conducted research may be unclear about exactly what they are and are not permitted to do to support a birthing person. Not only could this risk them falling foul of their legal obligations, it may also add to feelings of anxiety and loss of control of the situation for both the pregnant person and others present during birth.
Conclusion
Maternity services are operating under very challenging conditions presented by the pandemic. We have no doubt those working within the services are doing everything they can to best support pregnant women. However, there are some important questions which should remain central in decision-making about the reduction/suspension of home-birthing services:
- Is this a last resort which is justified and proportionate?
- Have pregnant persons been sufficiently advised of their rights regarding choice of place of birth – be this in hospital, or at home with or without medical assistance?
Even during a pandemic, public health concerns must be balanced fairly against the need to respect choice and autonomy in childbirth, as to fail to do so could have implications which stretch beyond the end of this crisis.
[1] We use the term pregnant people/persons instead of women as an acknowledgement that not all people who are pregnant/able to get pregnant identify as women.