Open Letter - Restrictions In Maternity Services

Dear Professor Whitty & Mr. Matthew Hancock,
 
We are writing to express our concern over the continued restrictions and temporary policies in maternity care. Implemented during the initial outbreak of the Covid Pandemic, such restrictions were prudent but now, as lockdown eases and some NHS trusts are beginning to revert these rules, many others are continuing to restrict the rights of healthy pregnant women and birthing people for no apparent medical reason. We believe that the restrictions currently in place due to the Covid outbreak are not necessary, not based on scientific evidence, are disrespecting human rights and are not proportionate to achieve the objective of limiting the spread of the virus.

By continuing to forbid pregnant people from taking a partner with them to scans and appointments, and to only allow one birth partner for a limited time during labour, we believe that human rights are being violated and the health and wellbeing of parents and their babies is being carelessly flaunted. Human rights law requires that any decisions regarding restrictions on women’s rights are proportionate and are taken as transparently as possible. We believe that NHS England have not considered all options when continuing to enact these changes to our maternity care. We attach a statement from Birthrights dated 31 March 2020[1], detailing these human rights concerns.

Protecting the health of others is a legitimate aim but at a time when we are concerned about staff shortages amongst healthcare professionals, it is even more critical that NHS trusts think carefully about restricting birth partners who are a much wanted and needed sources of support.
 
Our concerns:
 
Birth and Perinatal Trauma and Mental Health
Pre-Covid, 45% of women described their birth as traumatic, and 4% of women developing PTSD[2]. Birth trauma adversely affects the long-term mental health of both mothers and birthing people, and newborns - we do not feel this has been properly considered. Birth trauma is sometimes unavoidable but whatever can be done to avoid it, should be done. The main cause is fear - not feeling safe and secure, thus slowing down the body’s natural physiological process and instigating medical interventions that would not otherwise be needed.

A systematic review by Dr Jenny Patterson et al, 2018[3], found that the biggest indicator for birth trauma was negative interaction with midwives. Covid-19 is undoubtedly putting more pressure on midwifery staff, which we believe means that women more than ever will find their experience traumatic.

The Royal College of Midwives survey of senior midwives found that the shortage of midwives on NHS maternity units has doubled since the start of the coronavirus outbreak. The WHO states that all birthing people should be accompanied throughout birth by the person of their choosing. This should also extend to scans and perinatal appointments.

NHS England are encouraging volunteers in other areas of the hospitals, yet birth workers are being refused access to maternity wards. Birth partners and doulas can greatly assist midwives by providing continuous support throughout labour and advocating for birthing people - making them feel safe and secure at all times and thus allowing them to birth naturally with less need for medical intervention, as confirmed by a Cochrane review.[4] That should be seen as a positive money saver for the NHS as well.
 
Increased freebirth rates
With no autonomy and few options, some women are considering birthing without any medical assistance[5] at all, particularly those with previous trauma attending an obstetric led ward. This raises major concerns as to whether women are receiving the best support and antenatal education available. We know there are currently NHS Trusts where there is no home birth provision and no midwifery-led birth centre provision. Whilst we fully support the choice to free birth, we are concerned that some women are free birthing not out of choice, but because they feel they have no other option. 
 
Birth doulas are prevented from going back to work
As self-employment grants and furlough come to an end and people head back to work, we are currently prevented from doing so, with no extension to our pandemic financial support. There was a promise from Rishi Sunak that no one would be left behind or forgotten, and yet we have been. It is imperative that now, as it is physically possible to do so, we should be allowed back to do our jobs - a role that is essential to supporting NHS midwives and birthing families when they most need it.
 
Our suggested solutions:
 
Please consider the following options to support women and birthing people who are not diagnosed or showing symptoms of Covid-19 to birth safely away from risk of infection and with dignity and respect.

Keep our Birth Centres Open
Many birth centres across England are still closed. This reduces the options for  otherwise healthy women to choose home births (which are also not on offer in some areas of the country) or hospitals, which for many is not conducive to a feeling of comfort and security that the human body needs to birth naturally, without intervention.
 
The other advantage of birth centres is that they are often separate from hospitals, therefore further reducing the risk of contracting Covid-19 by both patients and staff.
 
Reinstate home birth everywhere.
Keep community midwives separate and issue them with the appropriate PPE in order that they may attend healthy women and birthing people safely in their homes. Please help us support those who can, stay out of a hospital for birth, alleviate pressure on hospitals, protect our NHS staff and keep families safe from risk of infection and mentally well.
 
Birthrights, the UK human rights charity, have urged NHS Boards to make sure they have explored all alternative options before suspending home birth services. This includes exploring alternative means of transfer to hospital, contracting with Independent Midwives or considering whether students/Maternity Support Workers could be the second person at a homebirth. If the Board are not able to offer a home birth to healthy women and birthing people, they should be able to give a good reason why Coronavirus has changed their ability to offer a home birth, and to offer alternatives such as birth in a midwifery-led birth centre, where possible.
 
The research is clear[6]; the risks of homebirth for healthy mothers and babies are very low but the risks of contracting Covid-19 at a vulnerable time such as in the antenatal and postnatal period are not. We are aware the main reason given for the withdrawal of home birth services is pressure on the ambulance service. Although some women choose to transfer from a home birth, research shows that emergency situations account for less than 5% which is around 2-3 transfers a day across the whole of the UK. Non-emergency transfers can certainly be done in a private vehicle.
 
The other reason we have been given is that home births require two midwives and there are going to be staff shortages. A second midwife is also required on delivery at hospital, not to mention the consultants and junior doctors on ward, the anaesthetists whose services are statistically made more necessary in a hospital environment, the porters, the nurses, the postnatal midwives and the kitchen staff. We understand there is no NMC requirement for two midwives to attend a birth and we know that 1:1 care during labour makes a profound difference to the experience and outcome of labour. Given the real risk of viral load in a room full of people, would 1:1 midwife care at home not be preferable and safer at this time? Could the other roles not be better supporting our NHS during the Covid-19 crisis if birthing people can be supported by one midwife and a birth partner, assistant, doula, or student midwife to birth at home and in birth centres?
 
Allow partners into antenatal scans and appointments.
When a majority of birth partners are from the same household as a birthing person, there is no additional risk (and therefore no reason) why they should not be allowed to scans and appointments. Especially if they are wearing PPE. Fathers and birth partners are missing hearing their child’s heartbeat for the first time or missing being there to support their loved ones if a scan shows bad news. No one should have to discover that kind of news alone when there is no additional risk caused by a partner attending.

Allow two birth partners, both in the labour ward and at home births, throughout the entire labour and birth. 
Most NHS trusts have instigated a policy whereby birth partners are only allowed on a labour ward and not in the antenatal or postnatal ward. Birth partners are also being restricted to one, instead of two. Although we understand that due to infection control birth partner access must be limited, we have concerns over how and when it will be decided that a woman is in active labour, particularly for those who have previously experienced sexual abuse or have mental health concerns.

​Of all the restrictions, it is this that women are getting most anxious about. As most restrictions have been lifted in other areas of our lives, i.e. we can now go to the pub, go shopping, have our haircut, and get a massage. It seems extremely excessive to still limit who a birthing person would like with them at the birth of their baby - especially when birth partners can shield before the birth, be tested for Covid and also wear PPE.
 
New national guidance from NHS England “Visiting healthcare in-patient settings during the COVID- 19”[7] says “The number of visitors at the bedside is limited to one close family contact or somebody important to the patient. However, where it is possible to maintain social distancing throughout the visit, a second additional visitor could be permitted in circumstances including partners of women in labour” This should mean that you are able to have a second birth partner, for example for emotional support, provided the birth room is large enough to allow social distancing.
 
The NHS England guidance also says that “Other people who are in attendance to support the needs of the patient, for example a familiar carer/supporter/personal assistant, should not be counted as an additional visitor. Patients may be accompanied where appropriate and necessary to assist with the patient’s communication and/or to meet the patient’s health or social care needs.” Clearly this should mean that someone with particular support needs should be allowed another supporter in addition to their birth partner.
 
Our collective intent as birth practitioners, is to support women and birthing people to have a positive and safe experience of birth. We are thankful to our dedicated maternity professionals and understand how challenging it must be at this time. As doulas, we are here to offer our support to birthing people during this time and help take the burden off the NHS with our offers of antenatal education, birth preparation, birth support and mental health support. We look forward to meaningful dialogue on what can be done to improve this situation and how we can help support maternity services.
 
We would also like to add that Scotland, Northern Ireland and Wales have already changed all the imposed restrictions on birth partners, support during antenatal and scan appointments and are putting the health of families on top of their agenda. Surely as the leaders of the United Kingdom, England should be leading the charge on such matters.
 
Yours sincerely,
 
Kicki Hansard
Abbi Leibert
On behalf of the members of The BirthBliss Academy

[1] https://www.birthrights.org.uk/wp-content/uploads/2020/03/Final-Covid-19-Birthrights-31.3.20.pdf
[2] https://www.tandfonline.com/doi/full/10.1080/02646838.2018.1504285
[3] https://www.tandfonline.com/doi/full/10.1080/02646838.2018.1504285
[4] https://www.cochrane.org/CD003766/PREG_continuous-support-women-during-childbirth
[5] https://www.theguardian.com/lifeandstyle/2020/apr/05/expectant-mothers-turn-to-freebirthing-after-home-births-cancelled
[6] https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(19)30142-7/fulltext
[7] https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0524-visiting-healthcare-inpatient-settings-5-June-2020.pdf