Against the grain: midwives' experiences of facilitating home birth outside of guidelines

02 June 2020
13 min read
Volume 28 · Issue 6

Abstract

Background

Midwifery standards promote autonomous decision-making and informed choice, resulting in maternal home birth choices which may contravene guidelines. There is a paucity of evidence exploring midwives' experiences of managing these choices.

Aims

To explore the lived experiences of midwives facilitating home birth outside of guidelines.

Methods

A qualitative design using an interpretive hermeneutic cycle to analyse semi-structured interviews.

Findings

Participants reported confidence in supporting maternal choices, identifying barriers including other birth supporters. Perceived levels of risk, previous experience and safety concerns impacted on confidence. Peer, unit and professional midwifery advocate (PMA) support were identified as being beneficial to midwives.

Recommendations

Expansion of birth choices clinics; implementation of dedicated home birth teams; guideline review for midwife led birthing units; expansion of the PMA role; implementation of a structured debriefing service and further research looking at women's choices, and the impact of the loss of midwifery supervision.

Historically, childbearing women were generally young and healthy, yet societal changes and fertility treatments have meant women who are older or with pre-existing conditions becoming pregnant have an increased risk of adverse outcomes (Geraghty et al, 2019). Coupled with this, there is a justified but increasing, focus on achieving a fulfilling birth experience, retaining choice and control; perceived to be prioritised over medical professionals' opinions of maternal and neonatal well-being (Buckley, 2009). Consequently, some women decline routine maternity care, including choosing home birth against medical guidance.

The ‘National maternity review’ (NHS, 2016) and National Institute for Health and Care Excellence ([NICE], 2017) recommend that women have choice of birth setting. Feeley and Thomson (2016) suggest that not all women are provided with information regarding home birth, as overstretched and at times inflexible maternity services appear to oppose unconventional choices. This is at odds with the Nursing and Midwifery Council's ([NMC], 2018) guidance and UK law (Human Rights Act, 1998) which advocate respect for autonomy and choice.

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