Is this the end for home birth?
Supporters of natural childbirth came under attack after Caroline Flint, a leading midwife, was found guilty of negligence. At the end of a week of claim and counter claim, she talks exclusively to HESTER LACEY
Sunday 16 May 1999
Mrs Flint is one of this country's most highly regarded midwives. This week she found herself being prosecuted by the UK Central Council for Nursing, Midwifery and Health Visiting (UKCC). Her case has thrown her profession into turmoil and has focused a harsh spotlight on the whole principle of independent midwifery.
Caroline Flint had been investigated in connection with this particular case twice before - by the hospital concerned and the local health authority. Both concluded that she had no case to answer, though they did criticise her note-taking as not comprehensive enough.
On Wednesday she received a caution from the UKCC that will lie against her entry on the professional register for five years. Although the hearing found that she did not take adequate notes, take the mother's temperature and pulse after delivery, or recognise maternal collapse after the birth, it confirmed that Mrs Flint was not responsible for the death of the baby, which was due to oxygen deprivation before the onset of labour, and did not criticise her care during labour and birth.
The death of a baby is a terrible thing for both parents and midwife. For the parents involved, says Caroline Flint, it has been "a tragedy". But the case has also been a nightmare for her. Press coverage has been particularly vitriolic (as in headlines like: "Baby died `after blunders by top natural birth midwife'" next to pictures of a broadly smiling Mrs Flint). Although on meeting her it is obvious that she is naturally a cheerful, open woman, she is currently shocked, hurt and surprised. "I don't think the truth came across. There has never been any criticism of my care of the mother during labour, never any suggestion that my actions caused the death of the baby. The press were talking about `pools of blood' - that came out of somebody's mind. They said I earn pounds 100,000 a year - I wish!"
She knows she let the couple down over her note-taking. "One thing I have learned is that when a midwife takes notes that are not accurate it leaves both her and the parents vulnerable - there isn't a clear picture of what was done or said and people don't remember clearly."
Mrs Flint, a former president of the Royal College of Midwives, is director of the first independent birth centre to be set up in the UK. During the past year she has delivered two of her own grandchildren (she has been married for over 30 years, and has four grown-up children). She first knew she wanted to be a midwife at the age of eight, when her mother gave birth at home to her fourth child. "It was magical," she recalls. She is, she says, "very relieved that the case is over, and overjoyed that I can go on being a midwife because I love being a midwife so much."
At the same time she believes the death of baby Alicia Wright is being used in what she sees as a backlash against independent midwifery - and this case has made her feel particularly vulnerable. "There is a huge conflict of philosophy between so-called `natural' birth and medically managed birth. This couple are not part of that debate but they have fitted into it."
She points out that she is not the only independent midwife to be currently facing professional discipline: during the same week, Ann Kelly, Ireland's best-known independent home-birth midwife, was being tried by the Nurses' Board of Ireland on the grounds that she brings women into hospital too late, though statistically her results are better than those of any hospital in Ireland. The case has been adjourned and will resume in June. In France, independent midwife Suzanne de Bearn, who runs the only birth centre in France, appeared before the High Court in Bordeaux, appealing against a French law which suggests all babies should be born in large hospitals; the French court will announce its findings in September.
There are only 45 independent midwives practising in Britain - a handful compared to the 30,000-odd who work in the NHS. Although independent midwives are particularly open to the idea of a home birth, it is certainly not obligatory to have one, and these days it is easier than before to get a home birth with the NHS. So why are the independent midwives so important? The vital thing, says Ms Flint, is the strong rapport that can be established between mother and midwife. "It changes the balance of power and puts the woman in control of her pregnancy and birth."
The importance of developing a confident relationship between mother and midwife has been proven in various studies - it means less medical intervention in the birth and a far better experience for the mother. This was acknowledged by the government in the early Nineties. A 1993 government committee, Changing Childbirth, on which Ms Flint served, recommended that every pregnant woman in the NHS should develop this kind of relationship with a midwife - in short, that all midwives should start working more like independent ones.
"We made great progress," says Ms Flint. "But we have slipped back. Midwives set up pilot schemes everywhere - they worked very well. But most of them have been hatcheted for financial reasons." This, she says, led to a lot of midwives leaving the profession. "They had been waiting years to work like this. A lot of them said, `I can't go back to the old ways, so stuff it'." And, she points out, numbers of independent midwives are falling, not rising. "There used to be 140. But the Royal College of Midwives stopped providing professional indemnity insurance. This is extremely expensive. Ours is currently the only practice with insurance - I make myself vulnerable to actions because I am insured."
She is not the only one to be raising the alarm about midwives under siege. According to childbirth expert Sheila Kitzinger, "there is a witch-hunt against midwives who stick their heads above the parapet, midwives who aren't functionaries in big institutions, midwives who question, who challenge, who are innovative and do their best for women." In some countries this has gone further than others, she says: in the US, for example, the profession has been all but destroyed. "In many states they are considered as old peasant women who can't be trusted. And in Australia, if an independent midwife has to take a woman to hospital, the midwife is sent away and the woman is treated as though it is her fault there are complications because she chose to give birth this way." The German system too, she says, is highly interventionist, and other European countries are tending to adopt German or US-style techniques.
Wendy Savage, honorary professor and senior lecturer in obstetrics and gynaecology at the Royal London Hospital, also feels that independent midwives are perhaps investigated more rigorously than their NHS counterparts. Prof Savage is critical of the press coverage of Caroline Flint's case. "In anyone's practice, however good they are - and Caroline is a wonderful midwife - they don't always reach the highest standards in things like note taking, which was the major thing found against Caroline. A lot of the coverage involved points which were not in the end proven. It is very hard on a professional when negative things are reported in full and the other side is hardly touched on." And, she adds, "The climate in our society has changed so that if something goes wrong there is a tendency to think someone must be responsible, someone must be to blame. Childbirth is safer than ever before so people have come to think nothing will go wrong."
As a profession, midwifery is already beleaguered. The number of midwives registered in Britain has fallen by 2,500 since 1995 to a record low of 32,800. "Cases like this will certainly increase stress levels," says Melanie Every of the Royal College of Midwives. "Midwives will be anxious about finding the time to write up their notes, give information, give adequate care, especially in short-staffed units. Many are looking after several women at a time." She criticised "emotive" reporting of the case. "It makes women anxious and makes them believe that a lot of deliveries are dangerous when in fact the vast majority are not. It also creates the idea that all baby deaths are avoidable. No-one can guarantee that."
Both Danielle Forristal's daughters, Francesca, three, and Isabelle, seven months old, were delivered at home by Caroline Flint. Mrs Forristal speaks very warmly of her experience. "When you get pregnant, everyone has a horror story to tell you," she says. "It's all very negative. When you have an independent midwife the fear factor is taken out." She is, she says, no earth-mother - in fact she is a 37-year-old accountant. Although her own GP was initially sceptical, her birth experiences were extremely positive and she needed no pain relief. And, she adds, she was encouraged to seek conventional help when it was necessary - Caroline Flint sent her to an obstetrician at one point and took her for a scan at another. "I would love to be pregnant and give birth again," says Mrs Forristal firmly. "I had 100 per cent confidence in Caroline. To my mind women need more of this kind of practising, not less."
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