Denying 'at risk' women access to midwifery-led units

Why 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 outset, 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.