Midwives 'risk not being objective enough’ - The death of a young woman who was allegedly 'brainwashed’ by a midwife into giving birth at home raises questions about the quality of advice given to expectant mothers
The controversy over home births was reignited last week, with the tragic account of how a young mother bled to death after allegedly being “brainwashed” by a midwife into giving birth at home.
For Claire Teague, 29, this was her second pregnancy. Her first, in hospital in 2009, had ended with an emergency caesarean section, in an unsuccessful attempt by doctors to save one of the twins she was carrying. Yet despite this obstetric history, Rosie Kacary, an independent midwife working outside the NHS, allegedly convinced Mrs Teague that a home birth would be “more fulfilling” than one in hospital.
For healthy women with normal pregnancies, choosing a home birth has been seen as a perfectly safe option
Mrs Teague, from Woodley, near Reading, stopped breathing after the birth of her baby, a boy, at home in the early hours of August 1 2010. She was eventually admitted to hospital, where she started to bleed extensively, and died later the same day. Doctors found that one third of her placenta had been retained in her womb. This prevented the womb from contracting normally, causing extensive haemorrhaging.
At the Windsor inquest into Mrs Teague’s death, the coroner Peter Bedford was critical of the “poor quality” inspection of the placenta when delivered by the midwife and the “missed opportunities” to take Mrs Teague to hospital sooner. The case is now under investigation by the nursing and midwifery council, the statutory body responsible for standards of midwifery care.
Bleeding to death in childbirth remains extremely rare in Britain, and of course serious errors of professional judgment can happen anywhere – in hospital as well as in a patient’s home. That said, this case raises some critical questions about whether clear advice on the risks and benefits of home births is always given to expectant mothers, in particular those who have had problems in previous pregnancies.
Indeed, some specialists are arguing that home births are being promoted with enthusiasm bordering on the excessive. While in the UK home births are still uncommon (less than three per cent), the pendulum between hospital and home is “in danger of swinging too far the other way” according to Steve Walkinshaw, an obstetrician who helps draw up guidelines on childbirth for the National Institute for Health and Clinical Excellence (Nice). He believes that the midwifery profession “runs the risk of not being objective enough with advice – of being almost too close to the woman.”
For low risk, normal pregnancies, the benefits of a home birth are now widely recognised. Being in familiar surroundings, with the same midwife they have seen throughout their pregnancy, helps many women feel more relaxed and better able to cope. Labour can take place uninterrupted by a trip to the hospital and, if desired, family members can be present throughout. Younger children can feel part of the experience and be reunited with their mother and introduced to the new sibling sooner. “There’s good evidence that women who have midwife-led care, including home births, need less pain relief, have less interventions such as forceps and epidurals, are more likely to breastfeed and have a better quality birth experience,” says Sue Jacob, from the Royal College of Midwives.
On the other hand, there are clear benefits to being in a consultant-led unit – chiefly, the availability of the “best specialist care at the touch of a button”, she adds. On the rare occasion when things may go wrong, obstetric units can provide immediate access to obstetricians, anaesthetists, neonatologists and other specialist care including epidural analgesia and blood transfusion units.
Which is why it’s important for any woman who is deciding on whether to give birth at home to be advised of arrangements in place for transfer to hospital in an emergency – and why, says Ms Jacob, it’s vital for any midwife responsible for a home delivery to monitor carefully what is happening before, during and after the birth. “A good midwife will pick up on things she or he doesn’t feel happy with, and will always arrange a transfer to hospital if she feels it necessary,” she says. “There are systems in place to ensure midwives will work with hospital teams and their protocols, to ensure the best care.”
Most experts concur that in the UK, giving birth is generally very safe for both women and their babies wherever it takes place, with an overall figure of 4.3 “adverse events” (such as stillbirth or breathing problems in the baby) per 1,000 births among the 40 per cent of UK pregnancies regarded as “low risk.”
For healthy women with normal pregnancies, choosing a home birth has been seen as a perfectly safe option – although a more complex picture emerged last November, when a landmark study from Oxford University found that among first-time mothers in this group, the risk of anything going wrong with a planned home birth was significantly higher than with one planned in hospital.
There were 9.3 serious complications per 1,000 home births among women giving birth for the first time, compared to 5.3 complications per 1,000 hospital births. In addition, the study found a 45 per cent probability that first-time mothers planning a home birth would need to be transferred to an obstetric unit during labour or after birth.
“For the first time, we have reliable information to give to this group of women so they can make an informed choice,” says Prof Peter Brocklehurst, director of the Institute for Women’s Health in London, who conducted the research. He points out that while home birth is a safe option for women on their second or third pregnancies, the risk, although still very low, is higher for first-time mothers.
More contentious is the question of what advice should be given on the appropriateness of home births for women who have had complications (such as an emergency caesarean) in a previous pregnancy, or who have had problems in their current one. While Nice recommends that anyone who has had a previous caesarean section should be advised to have her baby in an obstetric unit, some midwives who support home birth argue that past complications should not necessarily rule out a subsequent home birth.
“It’s not a black and white situation,” says Ms Jacob. “You need to assess each case on its merits and work in partnership with the woman and the antenatal team. Every woman has the potential to have a home birth.” What is important, she says, is the provision of adequate resources for good antenatal and postnatal care by trained midwives, fast access to emergency services and careful monitoring by the midwife at home.
However, Mr Walkinshaw, a consultant at Liverpool Women’s Hospital, argues that for women who have had a “complex birth” in the past, “it’s a different ball game”. A caesarean section in a previous pregnancy, for example, means there is a risk of uterine rupture during a subsequent vaginal delivery. Although uncommon – the risk is one in 200 – this is a potentially life-threatening event for both mother and baby.
“If a woman ruptures while in hospital then we can deal with it immediately,” he says. “ If something happens at home, with the best will in the world, it takes time for a transfer to hospital to take place, and there is a risk that mother and baby will come to harm.” Similarly, if the placenta is implanted over a previous caesarean scar there is a risk of a retained placenta and severe haemorrhage – one of the highest risks in obstetrics.
“The thing that has always exercised me if I’m talking to a woman who has had complications – in the current pregnancy or the last pregnancy – is that we know what the risk [of a further complication] is in hospital because that’s where the studies have been carried out. But we don’t know what the risk is at home.”
Mr Walkinshaw is at pains to point out he supports women’s choice about the place of birth. “We have to trust women, to give them the correct information and let them decide. But I’m not sure that we are being honest about our uncertainties. To allow a choice free-for-all, to tell high-risk women they will probably be OK is, frankly, unethical.
“We have a duty to say if we don’t think something is safe. As professionals we have worked together over the years to get our maternal mortality and perinatal mortality figures as low as possible. If women start to make choices that move those numbers up, we have a duty to say so.” To this, Prof Brocklehurst points out that independent midwives, as private practitioners, may not adhere to NHS guidelines.
Some professionals have “very short memories” adds Mr Walkinshaw. “They forget that women ended up giving birth in hospital in the Fifties because too many were dying unnecessarily at home, often from preventable haemorrhages. It’s a myth that the move came from nasty male obstetricians, that the government forced women into hospital. In fact, the call for safe hospital care came from women themselves.” ( telegraph.co.uk )
The controversy over home births was reignited last week, with the tragic account of how a young mother bled to death after allegedly being “brainwashed” by a midwife into giving birth at home.
For Claire Teague, 29, this was her second pregnancy. Her first, in hospital in 2009, had ended with an emergency caesarean section, in an unsuccessful attempt by doctors to save one of the twins she was carrying. Yet despite this obstetric history, Rosie Kacary, an independent midwife working outside the NHS, allegedly convinced Mrs Teague that a home birth would be “more fulfilling” than one in hospital.
For healthy women with normal pregnancies, choosing a home birth has been seen as a perfectly safe option
Mrs Teague, from Woodley, near Reading, stopped breathing after the birth of her baby, a boy, at home in the early hours of August 1 2010. She was eventually admitted to hospital, where she started to bleed extensively, and died later the same day. Doctors found that one third of her placenta had been retained in her womb. This prevented the womb from contracting normally, causing extensive haemorrhaging.
At the Windsor inquest into Mrs Teague’s death, the coroner Peter Bedford was critical of the “poor quality” inspection of the placenta when delivered by the midwife and the “missed opportunities” to take Mrs Teague to hospital sooner. The case is now under investigation by the nursing and midwifery council, the statutory body responsible for standards of midwifery care.
Bleeding to death in childbirth remains extremely rare in Britain, and of course serious errors of professional judgment can happen anywhere – in hospital as well as in a patient’s home. That said, this case raises some critical questions about whether clear advice on the risks and benefits of home births is always given to expectant mothers, in particular those who have had problems in previous pregnancies.
Indeed, some specialists are arguing that home births are being promoted with enthusiasm bordering on the excessive. While in the UK home births are still uncommon (less than three per cent), the pendulum between hospital and home is “in danger of swinging too far the other way” according to Steve Walkinshaw, an obstetrician who helps draw up guidelines on childbirth for the National Institute for Health and Clinical Excellence (Nice). He believes that the midwifery profession “runs the risk of not being objective enough with advice – of being almost too close to the woman.”
For low risk, normal pregnancies, the benefits of a home birth are now widely recognised. Being in familiar surroundings, with the same midwife they have seen throughout their pregnancy, helps many women feel more relaxed and better able to cope. Labour can take place uninterrupted by a trip to the hospital and, if desired, family members can be present throughout. Younger children can feel part of the experience and be reunited with their mother and introduced to the new sibling sooner. “There’s good evidence that women who have midwife-led care, including home births, need less pain relief, have less interventions such as forceps and epidurals, are more likely to breastfeed and have a better quality birth experience,” says Sue Jacob, from the Royal College of Midwives.
On the other hand, there are clear benefits to being in a consultant-led unit – chiefly, the availability of the “best specialist care at the touch of a button”, she adds. On the rare occasion when things may go wrong, obstetric units can provide immediate access to obstetricians, anaesthetists, neonatologists and other specialist care including epidural analgesia and blood transfusion units.
Which is why it’s important for any woman who is deciding on whether to give birth at home to be advised of arrangements in place for transfer to hospital in an emergency – and why, says Ms Jacob, it’s vital for any midwife responsible for a home delivery to monitor carefully what is happening before, during and after the birth. “A good midwife will pick up on things she or he doesn’t feel happy with, and will always arrange a transfer to hospital if she feels it necessary,” she says. “There are systems in place to ensure midwives will work with hospital teams and their protocols, to ensure the best care.”
Most experts concur that in the UK, giving birth is generally very safe for both women and their babies wherever it takes place, with an overall figure of 4.3 “adverse events” (such as stillbirth or breathing problems in the baby) per 1,000 births among the 40 per cent of UK pregnancies regarded as “low risk.”
For healthy women with normal pregnancies, choosing a home birth has been seen as a perfectly safe option – although a more complex picture emerged last November, when a landmark study from Oxford University found that among first-time mothers in this group, the risk of anything going wrong with a planned home birth was significantly higher than with one planned in hospital.
There were 9.3 serious complications per 1,000 home births among women giving birth for the first time, compared to 5.3 complications per 1,000 hospital births. In addition, the study found a 45 per cent probability that first-time mothers planning a home birth would need to be transferred to an obstetric unit during labour or after birth.
“For the first time, we have reliable information to give to this group of women so they can make an informed choice,” says Prof Peter Brocklehurst, director of the Institute for Women’s Health in London, who conducted the research. He points out that while home birth is a safe option for women on their second or third pregnancies, the risk, although still very low, is higher for first-time mothers.
More contentious is the question of what advice should be given on the appropriateness of home births for women who have had complications (such as an emergency caesarean) in a previous pregnancy, or who have had problems in their current one. While Nice recommends that anyone who has had a previous caesarean section should be advised to have her baby in an obstetric unit, some midwives who support home birth argue that past complications should not necessarily rule out a subsequent home birth.
“It’s not a black and white situation,” says Ms Jacob. “You need to assess each case on its merits and work in partnership with the woman and the antenatal team. Every woman has the potential to have a home birth.” What is important, she says, is the provision of adequate resources for good antenatal and postnatal care by trained midwives, fast access to emergency services and careful monitoring by the midwife at home.
However, Mr Walkinshaw, a consultant at Liverpool Women’s Hospital, argues that for women who have had a “complex birth” in the past, “it’s a different ball game”. A caesarean section in a previous pregnancy, for example, means there is a risk of uterine rupture during a subsequent vaginal delivery. Although uncommon – the risk is one in 200 – this is a potentially life-threatening event for both mother and baby.
“If a woman ruptures while in hospital then we can deal with it immediately,” he says. “ If something happens at home, with the best will in the world, it takes time for a transfer to hospital to take place, and there is a risk that mother and baby will come to harm.” Similarly, if the placenta is implanted over a previous caesarean scar there is a risk of a retained placenta and severe haemorrhage – one of the highest risks in obstetrics.
“The thing that has always exercised me if I’m talking to a woman who has had complications – in the current pregnancy or the last pregnancy – is that we know what the risk [of a further complication] is in hospital because that’s where the studies have been carried out. But we don’t know what the risk is at home.”
Mr Walkinshaw is at pains to point out he supports women’s choice about the place of birth. “We have to trust women, to give them the correct information and let them decide. But I’m not sure that we are being honest about our uncertainties. To allow a choice free-for-all, to tell high-risk women they will probably be OK is, frankly, unethical.
“We have a duty to say if we don’t think something is safe. As professionals we have worked together over the years to get our maternal mortality and perinatal mortality figures as low as possible. If women start to make choices that move those numbers up, we have a duty to say so.” To this, Prof Brocklehurst points out that independent midwives, as private practitioners, may not adhere to NHS guidelines.
Some professionals have “very short memories” adds Mr Walkinshaw. “They forget that women ended up giving birth in hospital in the Fifties because too many were dying unnecessarily at home, often from preventable haemorrhages. It’s a myth that the move came from nasty male obstetricians, that the government forced women into hospital. In fact, the call for safe hospital care came from women themselves.” ( telegraph.co.uk )
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