A Compromise for Change

When I first became involved with birth centres in the USA, they were seen as something of a compromise by many of those involved in setting them up; offering neither the benefits of the hospital surgical facilities, nor the environmental advantages of being at home (Katz Rothman 1983). Yet the compromise worked, with birth centres springing up in different states and offering women havens for normal birth experiences amidst a rising cesarean rate and proliferation of birth technology. Although some of these birth centres have inevitably fallen along the way, others are now well-established community centres, celebrating significant birthdays with the help of hundreds of the children who were born there.

Some years later, midwives, mothers and supporters of out-of-hospital birth began campaigns in the UK, in an attempt to make the birth centre compromise an option for women over here. We have also lost some of our first birth centres but, again, others have survived and are showing just how effective this model can be for everybody involved in pregnancy and birth. But while compromise has been a useful tool in enabling small groups of women to achieve the birth they envisioned, there is little room for complacency.

When Kitty Ernst (1986: 32) defined a birth centre as, “a place where women give birth” (as opposed to being ‘delivered’ by somebody else) and, “a place for the practice of midwifery”, it seemed to me that she was searching for a broad definition which would encompass a wide range of examples, yet also placing boundaries between midwifery as an autonomous, woman-centred art, and midwifery as an adjunct to obstetric practice. Yet in this urge to recognise that there are always examples that embody the spirit of the definition if not the letter, I fear we may, in the UK, be in danger of missing the point.

I have heard several people involved in the birth centre movement talk about the fact that a number of places described as birth centres may not actually be birth centres when we analyse what this term really means. If you look at some of the maps depicting the location of UK birth centres, you will more dots than you might expect. Whether every one of these dots represents a place that is truly centred on the experiences of women and the practice of authentic midwifery in a home-like setting is debatable.

For sure, birth centres are not only about comfy double beds, patchwork quilts and nice paintings on the walls. But all of these things serve to add ambience ~ and to make the setting more homelike and relaxed. While the atmosphere and philosophy of the birth centre and its staff are obviously far more important than the décor, we may need to ask ourselves whether the term ‘birth centre’ is appropriate for a setting which more closely resembles a clinical area than somebody’s living area or bedroom?

Equally, being ‘freestanding’ has been a key component of the birth centre philosophy in a number of countries. I don’t suppose there is a single midwife who has attended births at home or in a birth centre who hasn’t had at least one moment when she wished she and the woman were in the hospital, but for every one of the scary moments there are thousands of happy moments when everybody was delighted they were not. There is a palpable difference between being in a place which is simply and clearly about normal birth and midwifery, and being somewhere which is a ‘holding tank’ for the next-door labour ward only as long as your labour remains normal.

I suppose it really depends on whether one sees “birth centre” as simply another term for a place where babies are born, or as a concept which is intensely political, grounded in the normalcy of birth and autonomous midwifery and needing careful nurturing by those who value this. If we are not careful, we will be turning the compromise on its head. We could seek to attain a truly useful compromise by having a home-like environment that isn’t quite home and skilled, autonomous midwives who have appropriate technology but not a fully staffed operating theatre. Yet, if we don’t hold onto what a birth centre really means to women and midwives, we might be offering women so-called birth centres which bear no resemblance to people’s homes at all, yet which have all the staff you could ever need on the other side of a door. Which, when you think about it, comes pretty close to the definition of a hospital…

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A version of this article was first published as Wickham S (2003). A compromise for change. TPM 6(11):23.


Ernst EKM (1986) Nurse-midwifery in the freestanding birth center. pp 32-35. In: Rooks, J, Haas JE (Eds). Nurse-midwifery in America. A report of the American College of Nurse-Midwives. ACNM Foundation, Washington DC.

Katz Rothman, B (1983) Anatomy of a compromise; nurse-midwifery and the rise of the birth center. Journal of Nurse-Midwifery, 28(4): 3-7.