Guest blog by Emma Ashworth
**Please read the update at the bottom of this blog**
“If you arrive at the home of a woman and she refuses to allow you to access her home or to provide care to her, you must explain that you will need to leave and explain this decision to her. You should inform the woman that you will be happy to return to provide care should she want you to do so. The conversation should be fully documented.”
York Teaching Hospital NHS Foundation Trust: Home Birth Guideline Version No: 9, August 2017 – August 2020. Page 7
This quote from the York homebirth guidelines could lead to catastrophe.
While the senior midwives at York have said that they are reacting to a situation where they were not permitted in the house, the worrying phrase is this, “[the woman] refuses to allow you… to provide care to her”.
Women have been told that if they decline blood pressure monitoring, or intermittent monitoring, or even vaginal exams that their midwife “has been told that she must” leave their house and abandon them without care. Midwives have argued that if the mother doesn’t want to have interventions or tests, why should they even be there? What is their purpose? The knitting midwife expectantly and watchfully waiting in the corner, only intervening when necessary, does not seem to be the type of midwifery that York Trust is aiming for despite the fact that this type of midwifery leads to the best outcomes as is seen by the results of independent midwives.
Women have reported that midwives have coerced them into vaginal exams that they didn’t want with the threat of leaving them to birth alone. They have had to make the decision to allow someone to penetrate their vagina when they didn’t want them to, or to be left without clinical care for themselves or their babies.
In a discussion with one of the senior midwives at York Trust, I was assured that the threats that women were experiencing were not the intention of the policy, and that recently midwives had stayed with women despite the women declining certain interventions. I was also assured that the midwife that I spoke to would take my feedback to the community and home birth midwives to ensure that there was clarity in the guideline. She also confirmed that the guideline was in the process of review, so perhaps the very clearly written text in the current guideline saying that women in their own home are not permitted to refuse to have someone’s fingers inside them if they want a midwife to stay will be removed. However, despite my attempts to follow up this with the Trust, to date (7th August) I have not received a response to my initial or follow up requests.
In the meantime, Birthrights and AIMS have worked together on this issue, leading to an information sheet for women and midwives who might find themselves in this situation.
There are some really key points here that the Trust and its midwives need to consider about these guidelines. Midwives are under an obligation to act within the law, and coercing women into interventions is illegal. While the Trust may argue that there is no point in the midwife being there if the woman doesn’t want to have some clinical checks, we need to remember that women can decline any or all interventions at any time – and that a midwife’s role is far more than vaginal exams and listening in to a baby’s heartbeat. There is huge value in her being there, offering her support and knowledge and if necessary being able to intervene clinically. The Trust’s argument that there’s no point in the midwife being there belies the fact that skilled midwifery is in stepping in when needed, not about taking blood pressure. We need to remember that many of these interventions are not necessarily helpful, and can be harmful in some situations (and can also be very useful in others).
The AIMS information sheets on vaginal exams discusses some of the pros and cons of routine vaginal exams. Their sheet on monitoring in labour explains some of the risks and benefits of intermittent and continuous monitoring. If a woman wants to decline auscultation now, she can accept it for her next contraction, or decline it again. If a midwife forces her into a check on the threat of abandoning her, the stress of that on the woman may itself severely impact on her labour, and could cause damage to her or her baby, and the midwife is legally responsible for this. A midwife who undertakes an intrusive examination after obtaining consent through coercion needs to know that she is committing an assault on that woman, and that she could be criminally charged. Part 1.5 of the Nursing and Midwifery Code states that midwives must “Respect and uphold people’s human rights.” And 2.5 says, “respect, support and document a person’s right to accept or refuse care and treatment” 17.1 of the Code states that midwives must, “take all reasonable steps to protect people who are vulnerable or at risk from harm, neglect or abuse.” And yet, this guideline is instructing midwives that they must either neglect a woman, who while she is in labour she is by definition vulnerable (by leaving), or abuse them (by committing assault). At the same time, if the midwife refuses to follow the guideline and stays with a woman who declines some or all interventions or checks during her labour, she is at risk of being disciplined by the Trust. And if she leaves, she and the Trust are likely to be liable for any adverse outcomes to mum or baby!
If women find themselves in the situation where they are being coerced in their own home, I would advise that they remind the midwife of her obligations under the NMC code and the law. Showing the midwife the Birthrights document could be enough to encourage the midwife to break out of the intolerable situation that she’s been forced into by this unfair and unreasonable Trust document. Know that what is being asked of you in your labour is not reasonable, it is not normal practice and it is not something you need to say yes to.
Midwives – rise up! You are autonomous practitioners and you cannot accept the risks to your own safety and practice that this guideline traps you in. You need to escape because no matter which way you choose you are exposing yourself to risk. Be part of the fight to change this guideline! Stay with women and request support from senior midwives (who have assured me that they will give it). Don’t let this happen to you and to the women you’re caring for!
Update: January 2019
I have been advised by the Head of Midwifery in York that the guidance was updated in late 2018 to reflect the Trust’s recognition of this issue following conversations with me. They have also put into place a training day for midwives to ensure that they understand the amendments. However, it currently remains that midwives must be able to speak to the woman (whether she wants it or not) and remain in the woman’s birth space (whether she wants them there or not), otherwise the midwife must leave her home. This is not the case in hospital. We continue to campaign to change this position.