Freedom of Choice in Maternity Care

Maternity care teams work in a range of settings: consultant led units, midwifery-led units, birth centers and in mother's homes.
The vast majority of babies (96%) are delivered in hospital units. The policy of society to encourage all women to give birth in hospitals cannot be justified on the grounds of safety.

An OB/GYN is a physician who specializes in medical and surgical care to women with focus on pregnancy, childbirth, and disorders of the reproductive system.

A nurse-midwife is a nurse skilled in assisting women in the prenatal period and in childbirth, esp. at home or in another nonhospital setting.

Midwife is a woman, who is trained to assist women in childbirth, who supports during labor and delivery, and supervises the general care of women and children before and directly after birth.

General practitioners may provide labour care at home or in the general practitioner maternity unit.

The Midwives Model of Care is based on the fact that pregnancy and birth are normal life processes. The Midwives Model of Care includes:
* Monitoring the physical, psychological, and social well-being of the mother throughout the childbearing cycle
* Providing the mother with individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support
* Minimizing technological interventions
* Identifying and referring women who require obstetrical attention

The Midwives Model of Care recognizes birth as a normal, natural process and support the use of less invasive techniques, such as position changes, waiting, hydro-therapy, and perineal support, that carry fewer risks to mothers and babies and are usually more effective. Research shows that midwives are the safest birth attendants for most women, with lower infant and maternal mortality rates and fewer invasive interventions such as episiotomies and surgical births (cesareans). In developed countries where midwives are the primary care providers for pregnant women, mortality and surgical birth rates are much lower than in the United States.

When considering how a birth is to be conducted, attention must be given to both risks and benefits. fundamental questions about the general management of labour, patients' satisfaction, and women's rights to choose their form of care. Safety is the foundation of good maternity care but this must take into account the emotional as well as the physical wellbeing of mother and baby.

Safety is measured by death (mortality) or illness (morbidity) during the labor and birth process and shortly thereafter. The countries with the lowest mortality and morbidity rates are those countries where midwifery is an integral part of obstetric care and where homebirth is generally practiced.

The application of this woman-centered model of care has been proven to reduce the incidence of birth injury, trauma, and cesarean section. Problem has steadily gotten worse over the last two decades. All obstetric procedures combined have nearly doubled since 1980, while certain procedures, such as medical induction of labor, vacuum extraction, and manually assisted delivery increased more than tenfold in that time. Each procedure carries with it risks to mothers and babies, and less invasive techniques exist for most of them. Furthermore, they are usually not medically necessary and are avoidable for the majority of women.

Hospital
Studies indicate that the majority of women liked to have a doctor in immediate attendance and around half wanted immediate access to epidural anaesthetic.
If a woman wants or needs to be cared for in an acute hospital setting, she should also be offered a choice of different acute units where this is practical. The type of care a woman is likely to receive can vary significantly from hospital to hospital, and even between different consultants in the same unit.

Home birth
For normal low risk women, research shows that home birth is as safe or safer as hospital birth and results in less intervention and less morbidity for mothers and babies. Homebirths are a gateway to promoting normal birth and a spur towards midwife recruitment and retention.

Free Standing Birth Center
search validates the suggestion that community-based intrapartum care of healthy women results in lower rates of analgaesia, lower rates of caesarean section, makes women feel more in control and generally results in a better experience of birth.

Simply making tests available is in itself an extension of choice. Testing and screening sometimes inhibit rational choice and sometimes encourage higher levels of intervention. We recognize that many women will want to have the tests available and support them in that choice but women do need to be fully informed of the purpose and consequence of all tests, so that tests are not treated simply as a routine part of the process of being pregnant.

Usually women will be offered at least one ultrasound scan usually from 10 weeks onwards, "to check the size and age of the fetus". Besides this, women are "usually offered a range of screening tests to establish whether the baby is developing normally"
Choice may be restricted if units implement policies effectively prohibiting certain types of clinical practice, for example vaginal breech births, or vaginal birth for twins.

Applying predetermined clinical policies will often mean that women will only receive information about that hospital policy, and finding out about possible clinical alternatives will be very difficult. Secondly, although different clinical choices may be offered to the woman during delivery (for example between opting for a caesarean section on the basis of a trace abnormality, and taking a 'wait and see' approach), the options may be presented in such a way that the woman feels that the only decision.

Drugs and interventions
A wealth of information and research shows that the medicalization of childbirth has been detrimental on many levels to mother, baby and family.

Around 63% of caesarean sections are classified as "emergency procedures". Health professionals and academics vary in their explanations for the rise in numbers of emergency caesareans, which include the use of continuous electronic fetal monitoring, the use of protocols which specify that labour must proceed to a set timescale, and the de-skilling of both midwives and junior doctors in 'normal' birth.

Given nearly all women who have no need for a caesarean section prefer not to have one and given the evidence that the current rise in caesarean sections does not improve outcomes in maternity services, the rising rate of caesarean sections suggests women are not being able to follow what would be their choice of delivery method.

Birthing pools in maternity units
are popular with women and can now be found in the great majority of maternity units. There is clear evidence to support the suggestion that many women find them a great benefit and comfort when giving birth. However, several of the submissions we received suggested that the mere existence of a birthing pool by no means guaranteed that a woman would have access to such a facility when it came to her labour or that she would be able to make as much use of the pool as she might wish

Birth in water
Reduces blood pressure, Gives mother more feelings of control, Conserves her energy, Gives mother a private protected space, Is highly rated by mothers - women who have given birth in water would do it again, Is highly rated by experienced providers, A gentler welcome for babies, Mother or father can more readily catch her baby, Bacteria is dissipated in water reducing infection to mother and baby, Cleaning up is easier, Moist air assist better breathing for mother specifically if asthmatic, Conservation of maternal energy, Less problems with breastfeeding after birth, trauma to mother means less trauma to baby, Babies brought into a world with less violence have a greater potential to integrate into the world with less violence

Provides a kind, gentle and loving entrance into this world for the baby, The women achieve achieve much comfort in the water, Reduces fear and anxiety, The body relaxes, Provides significant pain relief, Floating in a pool the woman can move unencumbered, Labour becomes easier, speeds up the labour, The woman can focus better inwardly on giving birth, Water imparts elasticity to the tissues of the perenium which reduces tearing, eliminates episiotomies, no need for 'pain-reducing' drugs, reduces the rate of cesarean section, ease of the mother tranferred to the child (intricately linked), Makes the experience of birthing a positive one, Water mitigates the sensory overload and shock experienced by the newborn

Partners
A woman may wish to have a relative with her as well as a partner, or an even an acupuncturist or aromatherapist. There is some evidence to suggest that a female birth supporter in addition to a partner has a positive effect on the progress of labor.
Some hospitals allow relatives to be present, some don't.

Birth suites
Several of our witnesses argued that the typical hospital delivery suite limited women's choices and intrinsically favored a medical model of care. The very act of immobilising women in a clinical environment to monitor them intensively to look for signs of pathology creates pathology as the flow, the hormones, and the behavior of normal labor is disrupted

We recommend that women should receive evidence-based information on the balance of risks and benefits of induction of labor at different times, so that those whose pregnancy continues beyond term can make informed decisions about whether to accept the offer of a medical induction at around 41 weeks or at any stage thereafter. Where women refuse treatment their decision should be respected.