Dilemma...ethical perspective?

[paradise lost]

So, as many of you know, we'll most likely be ttc'ing sometimes later in the year.

And as you also might know if you read my UC thread, we're looking at how to go about birthing this potential baby already.

In the UK homebirth is officially available on the NHS but it can be quite hard to GET the homebirth. The slightest medical thing can be cited as "unacceptable risk", i know of several women who were phoned at 36 weeks and told they couldn't have their HB due to staffing numbers, the UK has a higher HB transfer rate than other european countries, indicating that many "attempts" are thwarted once labour has begun (i don't know of course how true this is, but we're as thorough as France in our prenatal care so why do 15-20% more of our HBing women suddenly need to transfer when labour begins?).

Last time around i got an NHS homebirth. However i would be lying if i said i found it completely satisfactory (though equally neither DD or i was injured by the experience) and when we realised we COULD afford a private midwife i was pretty thrilled.

However i have been talking to female friends, some with kids, some without. And now i am questioning the idea of using an IM at all.

I believe in choice. I believe the NHS SHOULD be providing homebirths for women who want them and are appropriate (i don't think midwives should have to go to catch premature babies or babies of mums with known, serious medical complications!).

So how will the system change if people (i.e. me) don't demand that change?

My two perspectives:

1) there are only 6 independant midwives working in Scotland, and only 2 in the central area. To avoid having 2 women labouring at once they each take on 11 births a year. That means they can cover 22 of the 58,000 births a year, about 3000 of which will be at home. I do not know how much DEMAND there is for IHBM (independant homebirth midwives) in this country. Perhaps there are only 6 because there's not enough work for 7? Should i be supporting this important service so that it continues to exist? We are not so rich that the costs is insignificant - indeed it is VERY significant, but it is attainable. Should i do now what i could not before and use a service that is filling a hole in NHS care?

2) there are plenty of women who cannot AFFORD an IHBM. Do they not deserve a good birth because they cannot afford that service? Shouldn't we be demanding change for EVERY woman and making the fat cats who make it so hard for the midwives working at the rockface to provide this care sit up and take notice of the demand? Also i was not harmed by my birth, merely mildly dissatisfied. What if i book the IM and another woman who was butchered and left with PTSD last time she gave birth cannot book, then has not option but to go back to the NHS when she is full of fear about her next birth and not able to fight like i would be, having already achieved her goal once before?

In some places in the South of England the HB rate in 2007 was 14%, and the vast majority of those births were NHS. In Scotland NO region managed more than 2.7% HB's in 2007 and overall the national HB rate for scotland was just 1.5%. WHY? Because women in this part of the country do not ask for and do not get homebirths.

I do not believe having an NHS HB will be a major sacrifice or too much stress. I at least know what i'd be getting into and have far more experience than i did before, and one successful HB behind me when the scare tactics are brought out. The stress involved will undoubtedly be far lower with an IM, but a big part of me wonders if that is an acceptable reason to dodge another opportunity to encourage change in the NHS which will benefit ALL women.

Anyone feel like helping me nut this one out?

Bx

[alioops]

Hun IIRC, in your other thread you mentioned not liking the midwife that attended DD's birth. Are the NHS MW's on a caseload or is it pot luck who shows up? If it is pot luck, how would you feel about getting the same MW or one with a similar attitude? If you want a relationship with your MW, to be able to bond with her, and know that you will have that support during birth and the NHS is not caseload, then I would go IHBM, if you can get caseload, and therefore know exactly who will arrive when you are in labour, then go NHS.

[paradise lost]

Hun IIRC, in your other thread you mentioned not liking the midwife that attended DD's birth. Are the NHS MW's on a caseload or is it pot luck who shows up? If it is pot luck, how would you feel about getting the same MW or one with a similar attitude? If you want a relationship with your MW, to be able to bond with her, and know that you will have that support during birth and the NHS is not caseload, then I would go IHBM, if you can get caseload, and therefore know exactly who will arrive when you are in labour, then go NHS.

Theoretically you get a named midwife who should show up when you're in labour. In reality they do not provide this. They can't, they're SO stretched. So it'd be pot luck, but TBH after my last birth i'm perfectly happy, whether i have an IM or NHSM, to call when i'm starting to push and just have the midwife for the last few moments of labour and first few hours afterwards anyway. If i'd done that last time (you never know "when" that is with #1!) my medwife, sorry midwife, would have had far less scope to change the course of things. I have great support and do better without strangers during labour anyway, so it's not a huge concern either way. I could certainly try to push for a named MW again though, since it's something they're supposed to provide.

Bx

[Oorki Galoorki]

i think in your heart you know your going to go with the IM... you can choose her(or maybe him) and they are guaranteed(sp) to rock up.
i really think you should meet up with these women soon (even before ttc) so you can put your self at ease with which way your going.

i think on the activism side i would support the small business providers over a government run scheme even though the costs are hugely different

[LimeSlice]

I really cannot make any comment on homebirth or midwives (I ended up with a c/s and was denied a homebirth outright from the beginning lol)
But in reference to your activism/moral question...I understand your confusion! Going with the similar theory to your second point, have you thought that you can attain the IM, so perhaps given that the places for NHSHB are sooo limited, you would serve women in a worse financial situation better to go for the IM (As opposed to worrying you are forcing someone into another disappointing birth experience.)

It seems that either way you aren't guaranteed to get the midwife you will meet and form a rapport with during your pregnancy, and that you actually want as little intervention as possible even from the midwife, so perhaps the activism concerns are really your only concerns iykwim?
I can only see point in supporting an ailing system if your support will truly make a difference, if anyone will even take note of that support, or if that support wont in fact stress that system or deny someone the ability to use it who doesn't have the other option that you have.

Have you considered a completely independent birth at all? Or do you want amidwife (even if it is pot luck)?

Hope that makes sense...alternatively if it is complete rubbish, just ignore me! lol
I just think that if you are truly interested in the activism for HB in Scotland, there are so many other ways to do it other than submitting to an inferior service to prove a point.

Good luck hun!

[Ca Plane Pour Moi]

Such a tough one! FWIW, in the south of England we're given horror stories about why we shouldn't homebirth (or rather, our husbands are!) and you can wait up to 20 hours before they send a midwife out, the advice is "we have no midwives available, just go to hospital."

So I'd be going independent if I wanted a midwife there. Because I don't trust the NHS one jot... but you're in a different situation.

Maye go NHS but when they fail you then you can have a freebirth. Am I at all colouring what you should do with what I would do now?

[Janie]

I wouldn't try to sway you either way Bec......

but have you considered that by using the NHS service when you don't strictly have to (although I know it would be much easier financially) you could be using up a HB spot that someone else wants? Someone who may not be able to afford another option (ie. IHBM)? I know full well that that is not at all how it should be, and I agree that everyone should have access to the same, high-quality care, but in reality it's just not how it is ATM.

I know it's not a progressive thought, and you may feel totally unaffected by it, but I thought I would put it out there anyway. (I'm not at all suggesting that it would be unfair if you did decide to have a NHS HB ).

[krysalyss]

I think go with the IM. If there is only a demand for two IM in the area then the NHS won't think improving their services are worthwhile because it obviously isn't what the community wants. The more demand for IM the more the NHS is likely to think that is what people want. I would go IM and then pursue advocacy of better homebirth services in a different way.
HTH

[Snacks]

If I'm to be honest, I would probably go the IM too if I could afford it, simply because I would want the best birth for myself
As others have said, you can still advocate for better public HB services, and you have already had experience with it so can speak with authority.
If it were me, I don't think I'd be selfless enough to risk obtaining the birth I want in order to make a point (albeit a very noble and important one).
But maybe I'm just a heck of a lot more selfish than you

[paradise lost]

I think my sticking points are that the NHS SAYS it will provide HB's for anyone who wants them. The NHS isn't ailing, it is being poorly managed at the moment. A few years ago the government began heavily subsidising young people who choose to go and study midwifery because the system doesn't have enough midwives, but now their training is complete and there are no jobs because they're not putting the necessary money into the maternity SERVICE. And the shift at the moment, despite the increase in demand, seems to be larger and larger obstetric centres and away from midwifery care. It seems to me that unless women begin to loudly demand the births they want and are entitled to the government will quietly pack midwifery and with it a wealth of skills, away. The DEMAND for HB isn't that high, but both the IM's in this area are fully booked all year around. So though they regularly have places for new clients (obviously) they tell me that they do not have gaps in their work calendars.

TBH either way i will be having a more or less unmedical birth anyway. If i book the IM i plan to call when i'm getting into serious labour, and have her sit in the living room until i feel i want her with me (which i might not) and with the NHSM i'd just have DP call them when i'm pushing already.

The whole point of the NHS is that they SHOULD NOT limit places. They pledge that HB is available to all those who want it, and they need to provide it. The limit on home births is a false one - have you ever called the GP with a cold and been told he is full up for colds this week, you need to have your cold next week?! It's absurd! Do they provide maternity care or not?! Unfortunately the best way to put pressure on the government to increase maternity staffing and make HB a more accessible option is for women to demand HB. I'm not particularly scared that they won't send the midwife when i call in labour because if they say they don't have anyone i will tell them my baby is coming, my HB is booked and if they don't send anyopne and me or my baby come to harm then my family will seek legal recourse to the full extent of the law. In the UK at least part of the pledge midwives take when they qualify is that they will never refuse a woman in labour who asks for assistance. They cannot legally refuse me. And if they just drag their heels i don't really care, i plan to catch my own baby this time anyway!

I don't think you're selfish Snacks. Not at all. I suppose i'm too socialist! And feminist. I just think that if i am going to take myself seriously i need to have my money where my mouth is and not just have my mouth going. I have several aquaintances who go on about the state of education and supporting the system but when they have kids they send them off to private school for their education. Unfortunately for a socialist system to function well people have to show faith before they might feel it...

Bx

[Ca Plane Pour Moi]

I've been thinking about this, Bec.

I'm not a socialist. Not by any means. BUT, I do support some socialist ideals, I'm just tougher than the current government. The NHS is something I do support. And think should be available for all. By all means, have non-necessary surgery speeded up at a private clinic (I prefer private when I used it for my non-essen but NO-ONE should have to go private for, for example, birth, cancer treatment and diagnosis, neurological investigations (which is why it took me over a year!)... it's necessary and urgent and should be provided by the NHS right now, when NEEDED (I think I've waxed lyrical on wants and needs before LOL). There should be no such thing as an independent midwife, the NHS should provide...

Ethics. I would go NHS just because they SHOULD do this, it is in their charter and mission statement and whatever other management bull-talk they give this stuff. Even if they don't turn up, they should give you the option. Not "sorry, busy, hospital only" - don't go!

Anyway, just going to turn into a rant if I keep going. Ethically, I'd go NHS.

[Midwife Melissa]

Hi there,

When governments provide free HB services, they do tend to place more conditions around the birth than what you would find if you employed an IM. There are also issues around service availability, as you've pointed out. While the service should be better, it's not. By all means, stamp your feet, but if you are really set on having a HB on your terms, employ an IM. Should you have to? No. But it's the way it is at present. Talk to the NHS and let them know your concerns, but at the end of the day, they are not obligated to provide homebirths under all circumstances, just the circumstances they deem to be safe (physically and in terms of staff numbers). Hiring an IM will completely get around this.

You can help things in the NHS in other ways, but if getting a great birth is important to you, then I'd say hire an IM.

Melissa.

[Cyathea]

Go unassisted, or get a great doula

That's what I did at my birth just over 2 weeks ago, it was by FAR my best birth...