Birthillogics #3 – denying ‘at risk’ women access to midwifery-led units

sara_wickham_birthillogicsWhy are so-called ‘at risk’ women denied access to the very places that could help reduce the chance of adverse events?

There is an important issue which I feel doesn’t get talked about as much it should. The implications of the way in which many women in the UK* with so-called risk factors are denied entry to midwifery-led units (MLUs) or birth centres.

*I am specifically talking about the UK here, where we have NHS midwifery-led units staffed by highly skilled midwives who have a duty of care to women.  Some of what I’m saying may well apply in other parts of the world as well. But I’m going to let people who are knowledgeable in their areas comment on that if they choose to.


Let’s clarify one thing though

Before I am misunderstood, I’d like to clarify one thing.  I am not for a moment saying that professionals should hold back from giving women adequate and accurate information in the interests of enabling them to make decisions about their experiences and care.  Indeed, where women do have genuine risk factors, we would be remiss not to say something along the lines of, “given your circumstances, my / our recommendation would be that you give birth in the hospital because … [insert genuine explanation, references and details of where to gather further information here]”.

I think that’s very reasonable.

As long as we accept a few things.

(a) The notion of a risk factor is not a concrete one and can actually be quite slippery.

(b) Women are individuals and so population-level rules aren’t always very useful.

(c) It is equally reasonable for the woman to accept or refuse/decline any suggestion or advice offered. In other words, to make the decision that is right for her and her family, whether or not it is in alignment with local guidance or professional recommendation.


Forcing women into corners

Because what is really bothering me is the number of women who are told something like this.

“No, you are not allowed to give birth in the midwifery-led unit under any circumstances. It’s because you have gestational diabetes / have a higher-than-average BMI / are having your first baby / are older than average / have had a previous caesarean section”.

Some of these women feel so forced into a corner by the way this shuts off the options open to them that they end up deciding to birth at home.

Not because this is what they really want. What they wanted wanted was to go to the MLU, please and thank you. But because home birth has now become the better of the two rather stark options that they have been left with.

I know that lots of women want to have home birth from the get go, and that’s great, and let’s make sure we carry on supporting them. I’ve been a home birth midwife for two decades now, so I’m certainly not saying this is a bad thing to do. But home birth isn’t what every woman wants, for a variety of reasons, and surely we can do better than forcing women into this kind of corner?



What are the risks, really?

I hereby acknowledge that there may not be an obstetrician, anaesthetist or paediatrician within 200 yards of a stand-alone midwifery unit. But that’s not a logical reason to deny a woman the right to give birth there. Particularly not if there is a higher chance of a problem and the alternative is that she will give birth at home. If the choice is to have a woman who may need a bit of extra help labouring in an MLU or to have the same woman who may need a bit of extra help labouring in her own home AND the woman herself wants to be in the MLU, then surely the MLU is logically the better choice?

Another issue is that, if the MLU is where a woman wants to be, that is the place where she is most likely to labour well and without so much need for intervention.

I’m amazed that those who are more led by fear don’t reason that midwifery-led units tend often (though admittedly not always) to contain more midwives and equipment than a woman’s home, and there may also be fewer issues of access if help is needed. That is, there is likely nowhere in an MLU that a woman can need to be carried out of that is going to provide a significant challenge for the local paramedics. None of these things are necessarily the be all and end all, as there are always ways around them when women do want home births, but I share them to illustrate what I see as the illogical nature of such a policy.


Why is choice denied?

There are a number of reasons why policy-makers are seeking to deny women this choice.

In some situations, it is done in the hope of making the woman see the enormity of her decision.

Well I’m sorry, but as someone who talks to women who make such decisions a lot, I know that the vast majority of them are already well aware of their enormity, They are also pretty well informed about their rights, the real risks and the paternalistic tactics that are used in an attempt to encourage conformity.

In other instances, there is a keenness to protect the ‘stats’ and safety record of the unit and thus ensure that it remains open.

This is understandable, but how dreadful it is that we have created a system in which we perceive that we have to deny some women the ability to make certain decisions in order to keep options open for others.

I don’t want to end without adding that this is no fault of the local midwives, who often have no choice but to adhere to the criteria insisted upon by their employer. Some midwives who have questioned this have been told that it’s about risk management and/or that it’s the thin end of the wedge.

What is this wedge, I often wonder, and what does the fat end look like?

Because a wedge which becomes fatter as women and families get more and more of their decisions respected is a wedge whose thin end I would hereby like to wholeheartedly support.


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photo credit: Caution: Life Involves Risk via photopin (license)

6 comments for “Birthillogics #3 – denying ‘at risk’ women access to midwifery-led units

  1. Lizzie
    March 10, 2015 at 8:53 am

    Hi Sara. This is fantastic! I’m in Australia and women who are classified as “high risk” miss out on so much – unless they are willing to fight long and hard. I actually wrote my own article on this topic and shared it the same day you shared yours!!

  2. March 14, 2015 at 11:14 pm

    I am an independent midwife who recently supported a Mum having her 5th baby in a midwifery led unit. Her first baby was born by c-section but the following 3 all normally but in hospital. She herself is a nurse and her husband a doctor. We had a lovely relationship but on the day she went into labour at 41+2, nobody supported me and every midwife at the birthing unit was opposed her experiencing her one and only waterbirth. A healthy pregnant, lovely labour and a calm, loving room to birth in. I felt that the other midwives wanted her to fail so that they could blame me. I never not trusted the mother or my abilities. She had the most beautiful waterbirth of her 4th daughter. The baby’s hand was up by her face and as I put my hands into the pool to help deliver, that baby held on to my hand. Happiness all round for the family but a list of complaints awaited me from my colleagues.

    • March 15, 2015 at 8:51 pm

      So sorry to hear you’re feeling unsupported by some of your colleagues in New Zealand, Tilly. But I’m really glad you were able to support that woman despite the difficulties you experienced and I know there are NZ midwives who would be right there with you … some have commented elsewhere on this blog or on my facebook page, so I hope you know there’s a wider tribe out there 🙂 x

  3. Bb
    August 1, 2015 at 8:52 pm

    I’m unfortunately classed as ‘high risk’ due to bipolar. I work in a demanding job in nhs and I’m very very well controlled, even through pregnancy. Im on a very low dose of meducation and my consultant and midwife a are so happy with me they have agreed a homebirth for me!! Yet I would have preferred to go to MLU, but it goes against there policy!! How on earth does it make sense. Ive even hired a doula to support me at home as I felt I had no other choice but to request a homebirth. My bipolar doesn’t stop me from pushing out a baby! I have perinatal support for afterbirth. How does this make sense?!

    • August 3, 2015 at 9:29 am

      Thank you so much for sharing this example, B. It doesn’t make sense, but hopefully by highlighting these issues, we might get more people to see the effects of these unhelpful population-level policies. I wish you and your family all the very best for your birth and babymoon 🙂

  4. Becky
    December 17, 2016 at 8:27 pm

    Brilliant article I wasn’t allowed to give birth in a MLU. I had low blood platelets (I was in hospital for days waiting to be induced and under the care of a blood specialist. He wrote a special plan for the doctors to follow (no epidural, no forceps etc) he was worried my baby had the same condition – so no water birth that I really wanted. (The day I was induced my blood improved dramatically) When it came to the birth none of the doctors had read the notes, luckily I was able to explain the full situation but this left me terrified as there was such a lack of communication. I didn’t feel in safe hands and I found the doctors very formal, like i was a number. I craved a friendly face or some kind words but got none, I felt like a nuisance. My first experience of birth and it was 24 hours of hell – I’m still upset by the whole experience 16months on. I think this contributed to my anxiety in the weeks following the birth x

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