Evidence, Experience and Safety: Letters to Editor

"Mothers-to-be may get right to home birth", wrote Sarah Kate Templeton in The Sunday Times, 11 October 2015 (who also brought us "Women may get right to breastfeed in public" in 2007)Paternalistic, inaccurate headline and disdain for evidence aside, last Sunday's article on the proposed NHS voucher scheme was disturbingly biased.Essentially,  it fuels the ongoing 'experience vs. safety' debate-which-isn't-a-debate, by not so subtly suggesting that choice - especially of place of birth - is just misinformed women being self indulgent and/or irresponsible.  Below is my letter to editor, (which regrettably there was not enough room to publish, as he had received numerous letters on the subject). Three other letters to editor - from Sam O'Brien (not published), Beverley Beech (published in part) and Dr Tracey Cooper (not published) - are also posted below.

Dear Editor,I’m writing to redress the balance of Sunday’s ‘Mothers-to-be may get right to home birth’ - a headline implying we don’t already have the right to home birth, which we do. The European Convention on Human Rights, Article 8 protects every person’s right to respect for their autonomous choice about private life, including the woman’s right to decide the circumstances and location in which she gives birth. A better headline could be 'mothers-to-be may get respect for right to home birth'.But not just the headline is problematic.Templeton’s piece is angled to undermine the National Institute for Health and Care Excellence’s recommendation that healthy women with uncomplicated pregnancies give birth in community or midwife-led settings (NICE, 2014). It overlooks the compelling evidence base supporting a salutogenic approach to childbirth, optimising physiology, avoiding intervention and the contribution of midwife-led care to improving quality and safety in maternity (Sandall et al, 2015, Hodnett et al, 2013). Instead, the article is weighted towards the perspectives of Birth Trauma Association's Maureen Treadwell, spuriously claiming “the safety of community birth is yet to be conclusively proven” (what about Birthplace, 2011, Blix et al, 2012 and the other studies in NICE, 2014?), Care Quality Commission patient safety advisor James Titcombe and “doctors who believe the experience of birth is being promoted at the expense of safety of babies and mothers”.What childbearing women need and want for themselves and their newborn infants is to be healthy, safe, supported, respected and to give birth to a healthy baby that can thrive, after a positive and life-enhancing pregnancy and birth experience, whatever complications they may experience (Lancet, 2014).‘Experience’ and ‘safety’ are intrinsically linked, and cannot be separated, let alone opposed, as suggested by Titcombe and Treadwell. High quality, safe maternity care includes - and goes beyond – measuring mortality and morbidity, to encompass multiple outcomes, of which women’s experience is one. A woman is prioritising safety of the mother-baby dyad by trying to guarantee the ‘experience’ of continuity of care and the place of birth where she feels safe and relaxed - and where the evidence base tells her it is safe to birth. Medicalisation is not necessarily synonymous with safety. Women are not sacrificing safety for experience when they make the informed choice to birth outside obstetric units, avoiding increased risks of iatrogenic harm caused by interventions. Women make these choices based on individual interpretation of risks and benefits - which are physiological, psychological, emotional, social, spiritual, and vary from woman to woman. Safe and compassionate maternity care needs to anticipate and reflect these risks and benefits for individuals.Sadly, the article points towards the misogynistic and misguided notion that all this choice is just self indulgent and reckless, which it absolutely is not.Sincerely,Olivia Silverwood- Cope, midwife.

Here are three of the other letters to editor on the subject. (If there are any more which didn't make the cut, please post them.)1. Sam O'Brien, (the mother in the photograph accompanying the original article) writes: "When fighting for safety in birth, the experience matters.. Never have I felt less safe than when I was on the receiving end of a violent blur of procedures". Read Sam's letter here, which the Sunday Times did not include, but which she emailed to me.2. Beverley Beech, (chairwoman of AIMS) calls out the 'safety' propaganda: "If safety is truly the first priority, then the publicity should be alerting women to the risks of hospital birth.." Read Beverley's letter in full here - it was published in part by Sunday Times (paywall).2. Dr Tracey Cooper, (consultant midwife) proposes NICE guidelines advice on place of birth are more appropriate for women than "outdated perceptions or scaremongering". Click to enlarge Tracey's letter which the Sunday Times did not include, but which she emailed to me.Other prominent voices commented on  reports  that NHS  England-commissioned  National  Maternity  Review  may  recommend  women  be  given  maternity  vouchers  to  enable  them  to  choose  their  care providers. "Women can and should make the decisions about where they give birth", says human rights in childbirth charity Birthrights. See full statement hereI was also relieved to read Milli Hill's comment in The Telegraph, decrying the oversimplistic 'safety versus experience' argument: "Home births are not just for mad maternity evangelists - thanks NHS".To conclude this post, here is a reminder of the relationship between safety and experience as clearly defined in Birthrights' letter to the NHS Maternity Review, which lights the way on autonomy, dignity and human rights in maternity care.

Excerpt from Birthrights' letter to the NHS Maternity Review, 16 August, 2015