Why it’s illogical to deny ‘at risk’ women access to midwifery-led units

An increasing number of women are being told that, because they are ‘at risk’ or ‘high risk’, they are ineligible to give birth at state-run, out-of-hospital birthing centres, also known in some areas as midwifery-led units.

There are several reasons why such policies are problematic.

Perhaps the most important is that women are being denied access to the very places that could help reduce their chance of adverse events during labour and birth.

In this blog post, I explain what the problem is, and why such policies are illogical.

A few important caveats

Let’s clarify a few things first, though. I understand that there are birth workers who think that, if we just left everyone alone, and promoted physiology, no-one would have a problem.

I’m absolutely not one of them.

There are some situations where hospital birth, induction of labour and elective caesarean sections are genuinely warranted. Situations where, for instance, there is a known and significant problem, such as serious pre-eclampsia or placenta praevia.

It’s also important to remember that things can unexpectedly go wrong, no matter how well we prepare or little we interfere, which is why it takes several years to train as a midwife or doctor.

Trained health care professionals have a legal duty to give women and families adequate and accurate information in the interests of enabling them to make decisions about their experiences and care.

Indeed, there are quite a few situations where a midwife or doctor would be remiss not to say something along the lines of, “given your circumstances, the hospital/NICE recommendation is that you give birth in the hospital because … [insert honest and clear explanation, references and details of where to gather further information here]”

Such conversations are important and can be helpful, when done well.

It is, of course, 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.

But, as I have often written about in my books, there’s an important difference between an actual, diagnosed medical condition, and a risk factor. And this is where things can get a bit tricky.

The problem with risk

Often, the women who are told that they may not birth in state-run, out-of-hospital midwifery-led units or birthing centres are also being told that this is because they have risk factors. Sometimes, this is expressed as being ‘at risk, or ‘high risk.’

But what do those terms actually mean?

The concept of risk is a slippery thing. When health professionals refer to risk, they are almost always referring to the mathematical concept of probability, which simply describes the likelihood (or chance) that you’ll have a particular problem.

If we were being nice and clear, we could tell you that you have a one in 1500 chance of having high blood pressure. Then you can weigh up your options, and decide whether the side effects of the medication you’re being offered to reduce your blood pressure are worth it for you. Women are individuals, so population-level rules aren’t always very useful, and people place different value on different things. You might feel safer in hospital, but someone else might not. It’s okay that we want different things from each other.

Less helpfully, people will sometimes tell you that, because you have a risk factor, you are (for instance) twice or three times as likely to have a problem. But if you don’t know what the chance of having a problem in the first place was, that’s meaningless. Especially if you can’t do anything to change the risk factor.

In health care, many people don’t talk about risk in a helpful or clear way.

The very use of the word risk often scares people into thinking they have a high chance of experiencing something horrible. In the maternity services, the concept of risk is sadly often used as a means of justifying excess interventions, and of denying women and families things that they would like to access, such as midwifery-led units, birth pools and the opportunity to go into labour spontaneously.

We call it shroud-waving, and I discuss it more in What’s Right For Me?

Forcing women into corners

Over the years, so many women have told me that they have been told things 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 felt 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, sometimes having a freebirth without a health professional.

Not because that’s what they really wanted. What they wanted wanted was to go to the midwifery-led unit (or use the pool, or have a home birth), please and thank you. But, when faced with two very stark options, where one of those options means entering a system full of people who don’t seem to care about them or their wishes, it doesn’t always feel as if one has much choice at all.

This is often not the fault of the local midwives, who have no choice but to adhere to the criteria insisted upon by their employer. Midwives who question this have been told that it’s about risk management and/or that it’s the thin end of the wedge. Some are threatened with losing their jobs if they make a fuss.

And I know that lots of women opt for home birth or freebirth from the outset. I was a home birth midwife for three decades, so I’m certainly not saying this is a problematic thing to do. But home birth isn’t what every woman wants, for a variety of reasons. We can do better than force people into such corners.

A lack of evidence: the example of BMI

It’s not just about autonomy, choice or common sense, though. There is also a lack of evidence to support denying some women access to midwifery-led units.

BMI is a good example of a risk factor that is used to deny women access to birth centres or midwifery-led units. When I wrote my Plus Size Pregnancy book, I heard from so many women who were denied access to birthing centres because of their size.

Yet, when I looked at the evidence, I found something astonishing.

Not only was there no evidence to support the policy of denying larger women access to midwifery-led units, but there WAS evidence showing that larger women did far better if they laboured and birthed in midwifery-led units instead of obstetric units (in other words, a standard labour ward or delivery suite).

What does the evidence really say?

As I discuss in my Plus Size Pregnancy book:

Women with a higher BMI who are cared for by midwives have fewer interventions than women in consultant-led care, but equally good outcomes for themselves and their babies.

Women with a higher BMI do particularly well in midwifery-led settings, where they are less likely to experience the over-intervention and weight bias that is sadly so common in health care.

There is evidence that, even in hospitals, a midwifery-led approach leads to better outcomes for women than an obstetrician-led approach.

Evidence ignored in favour of illogical policy

An abundance of evidence is being ignored in favour of illogical policies that mean that women with a higher BMI are more likely to face the monitoring, weight bias, and interventions that create a higher chance of them being told they need a surgical birth.

After which they may be told, “it’s a good job you were in the hospital, because you were in the right place when you needed a cesarean.”

But the problems that led to the caesarean might not have occurred if they had been in a midwifery-led unit.

It’s not good enough.

But maybe, by highlighting the problem, we can encourage more people to understand their rights, and perhaps get on board with calling for change.


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