Author: Debs Neiger Independent Midwife
Many of us don’t ever think about pregnancy, birth and the postnatal period as inextricably connected to Human Rights. We take for granted that our basic human rights with regards to dignity, autonomy and equality are respected when accessing maternity care. And of course, often they are.
But sometimes they are not. A hierarchical maternity care system, HCPs who don’t quite understand women’s bodily autonomy, staffing shortages, fear based clinical practice and worries about litigation make human rights transgressions happen in the context of pregnancy, birth and early parenthood.
And this worry is getting more acute now that we have new government/RCOG/individual NHS trust recommendations and restrictions regarding maternity care coming into play in this time of international turmoil and adjustment during COVID-19.
And rightly so.
Families are worried and are feeling less safe, and more anxious and scared as they are approaching their birthing time. Can I still birth in the way I had planned? Can I still have my homebirth? Will my birth partner be able to accompany me? What about waterbirths? Will they let my doula in? How about using gas and air? The fact that different NHS trusts are implementing different strategies on how to deal with this exceptional situation is unhelpful, when the guidance from the NHS/RCOG/RCM is relatively clear, if evolving.
Addressing your worries and concerns
First of all, the World Health Organisation states: ‘All women have the right to a safe and positive childbirth experience, whether or not they have a confirmed COVID-19 infection.’
You are still entitled to:
- Respect and dignity
- A companion of choice
- Clear communication by maternity staff
- Pain relief strategies
- And mobility where possible and birth position of choice
This is encouraging, yet it is very hard to reconcile this with reports of birth partners not being allowed into wards to support their loved ones through induced labour, restrictions regarding place of birth and what pain relief is available (particularly with regards to water pool use and gas & air).
I think the reality is that these are unprecedented times and we all, including health care staff are fumbling through as best as we can.
Yes, we have to be sensible attempting to slow spread of this virus. Yes, some visiting restrictions make sense. Yes, it is sensible to allocate staff so that it benefits the most people possible.
BUT, NHS trusts also have to take into account that pregnant/birthing/postnatal people are a very specific (generally healthy!) subset of our population, with very specific needs and in exceptional circumstances.
Things you may want to consider:
- In a Cochrane Review, continuous support from a person solely present to meet the non-clinical needs of a birthing woman leads better outcomes. This can be a partner, friend and/or a doula. Denying this emotional support is likely to lead to less favourable outcomes, particularly in the context of potentially scaled back postnatal care and general physical distancing. Furthermore, a doula is not simply a birth partner, they are an essential part of the multidisciplinary birth team just like an anaesthetist. Some women are ESPECIALLY in need of chosen support. Women with mental health issues, with previous traumatic experiences, with complex pregnancies, with previous losses, PTSD, BAME women, people who are LGBTQ+++ etc etc. Please state your needs clearly and firmly.
- Place of birth is also important to consider.We know that for many women, birthing at home is safer than birthing in hospital, even when NOT having to consider the impact of possibly contracting Covid-19……taking into account that entering a hospital, a literal epicentre of the virus locally in this pandemic, is increasing the chances of becoming infected, birthing at home (or in a standalone birthing unit) makes even more sense.
- Ambulance services are of course stretched currently due to increased demand and decreasing staffing levels. However, if midwives are still working in the community, women ought to be able to assess themselves what set of circumstances they are willing to accept; slight uncertainty of not being able to access an ambulance quickly in time of need and potentially having to use an alternative mode of transport or birthing away from home.
- Many trusts are maintaining their homebirth provision and are prioritising facilitating physiological birth, so it is worth negotiating with your local trust, but I realise even just getting in touch with people with decision making power might be difficult just now.
- Pain relief wise, gas & air ought to still be available to anyone wishing to use it as there is no evidence that its use is an ‘aerosol generating procedure’ and current RCOG advice is NOT to restrict its use, even for people suspected of having a current COVID-19 infection.
- Waterbirth is still an option, though the suggestion from the RCOG is to avoid it if COVID-19 infection is suspected due to the potential to infect midwives via faecal spread and the difficulty with absolute personal protection while caring for a woman birthing in water.
- Current guidance regarding caesarean section attendance by partners is as usual, with attendance only not advised if the caesarean is occurring under general anaesthetic. Many trusts seem to go against this guidance and are not allowing partners into theatre for caesarean section, the reasoning for this is to protect the partner from infection. This does not make logical sense to me, as whoever is birth partnering is also likely to live with the person undergoing the caesarean, so this is a moot point, and should be up to the birthing person and their birth partner to decide.
- One area that seems to be affecting a fair amount of women is the ‘no visitors on ante and postnatal wards’ rule. This means that women being induced are spending the early part of their labour without their chosen support. This part of labour can last many hours and even days. It can be distressing, emotionally exhausting and worrying at the best of times, but without a partner those feelings are often magnified hugely. Same issue is arising postnatally. If you are advised to stay on the postnatal ward for any length of time, this is likely due to clinical issues and therefore an increased need for social support. It is difficult coming up with a solution to this, other than to ask for reasoning and evidence for this restriction and negotiate a solution that works for you within the context of this current situation. There are no easy solutions to this, and there is currently a very fine line between protecting women’s rights and maintaining HCPs safety as much as possible. Are we getting it right? I’m not sure.
- Separation of mother and infant should NOT occur unless you are too ill to care for your baby yourself OR you choose to be separated due to infection.
- You can still decline any intervention you wish to decline.
- Women are starting to choose freebirth (birthing without a midwife/HCP) due to the restriction on choice of birthplace or birth partner. Many considerations go into making this choice, for many different reasons. Contrary to many HCPs opinion, it IS a valid and legal choice to freebirth, and it is not a reason for a safeguarding referral unless there are other unrelated concerns regarding the family.
SO, the bottom line is……yes, your human rights still need to be respected and you should have most options and choices available to you. However, trusts CAN make changes to service provision and are allowed to do so by law. However, they ought to be able to evidence that these changes are proportional and there are not alternatives available to you during this exceptional time.
There are a couple of brilliant articles put together by Birthrights, a charity protecting human rights in childbirth and you might find them very useful and reassuring. The articles also give you contacts should you need help challenging any decisions your NHS trusts are taking regarding your care:
Birthrights call to action: https://www.birthrights.org.uk/wp-content/uploads/2020/03/Final-Covid-19-Birthrights-31.3.20.pdf