Shepherd's Bush, 1993: the midwife's tale: Thanks to a rethink on childbirth, Lesley Spires and women like her could be in demand. Celia Dodd joins her on her community rounds

'I was terrified of home births when I was first a midwife. But experience of them gives you confidence to trust mothers, and not immediately think of everything that can go wrong.' Lesley Spires, a community midwife at St Charlotte's Hospital in west London was on her way to the first visit of her day, to book a home birth at the Dabson household.

As we parked outside the smart Victorian terrace in a slightly seedy London street, I could not help thinking that it looked like a home-birther's house: no net curtains and a fabulous old sofa glimpsed through the front bay. On Lesley's patch in west London, home births have doubled over the past two years to about 30 a year, but it is still a middle-class option.

Most midwives either work on labour wards or are involved in ante- and postnatal care. Community midwives such as Lesley do more of both, often seeing mothers through from early pregnancy to labour and beyond, regardless of whether they have a home or hospital delivery. If the recommendations of last week's report from the Department of Health - Changing Childbirth - are implemented, the working lives of midwives all over the country will become more like Lesley's.

Mrs Dabson was ten weeks pregnant with her second baby. She told Lesley that she thought her previous labour had been long and painful because hospitals made her tense. The midwife agreed: 'First babies often progress very quickly at home, perhaps because the mother is more relaxed. One of the most important things about home birth is that a woman is in her own territory, whereas a hospital is the doctors' and midwives' territory, which can erode her self-confidence.

'For a midwife, a home birth is far more satisfying because the lady herself is more satisfied. What the midwife gets out of it is through the mother, or through the family. If you feel that you've helped that woman to achieve a happy and successful delivery, that in itself is rewarding.

'But the midwife also carries more responsibility at home births. If you're not sure about something in hospital you just ask the doctor to pop in. At home, you can't just ask the obstetric flying squad to have a look - you have to be absolutely certain about your decision to call them.'

During seven years as a community midwife, Lesley has done this only once, when a baby's heartbeat was decelerating fast and she could not get hold of the GP who had agreed to cover. It was during the ambulance strike, and her first home delivery, but the crisis was over before the flying squad arrived, in an army truck driven by a soldier with police escort.

Lesley Spires' only reservation about home births is that the emergency services cannot always respond quickly enough when things go wrong: 'In cases that need immediate attention a woman may not get help for herself or the baby before they become quite ill. That's one of the arguments consultants use against home births. I would argue that if more women are demanding home births, let's improve the emergency services.'

The Dabsons seemed impressively clued up about all the risks, but Lesley was careful to make sure: 'You have to let the women who are having home births know what risks there are, and you have to allow them to make the decision for themselves.'

Mrs Dabson has obviously spent a great deal of time comparing births with friends, who seem to have run the full gamut of alternative pain relief. One friend found the agony of contractions was greatly relieved by a reflexologist massaging particular areas of her feet. Mrs Dabson is keen to try this during her own labour, as well as homeopathic remedies. She also would like her mother-in-law to be there.

The Dabsons were evidently cheered by Lesley Spires' enthusiasm for suggestions other midwives might dismiss as wacky. Her line is: 'If it's something that really helps, why not? It's your labour, it's your show; I'll stay in the background.'

Not all home births are quite so carefully anticipated. When she started working in the area, Lesley was called out by a distraught couple who had a German woman they barely knew in labour at their house: they had offered to put her up for a night six weeks before and she had refused to leave. She also refused to go into hospital. Lesley remembers: 'I went to try and persuade her, but by the time I arrived there was no time to call anyone. I was really nervous; she was 42 and hadn't had any antenatal care, so there could have been a problem.'

Lesley's next appointment was with a shy West Indian teenager living with her mother. The girl was in her typical teenager's bedroom, where a hand-drawn poster illustrated the slogan 'The hand that rocks the cradle rules the world', and the portable television was showing an old western. She was having a struggle breastfeeding because of flat nipples, so Lesley suggested that she tried expressing milk before feeding the baby, to make her breasts less sore.

The room was warm and stuffy. As we left, Lesley mentioned, as if in passing, that it might be good to get some fresh air on such a lovely day. She always offers advice in this rather casual way. It may not be intentional, but it makes it easier to swallow. Lesley gently told the mother of another baby we visited, whose jaundice was worsening, that the sun shining into the basement room would have the same effect as phototherapy, the hospital treatment for the condition. The baby needed a blood test. Back at Queen Charlotte's, Lesley analysed the blood herself and was able to reassure the mother within hours.

NEXT on the rounds was Yasmin Haniff, whose labour Lesley was disappointed to have missed. In fact, the birth had taken on secondary importance, because Yasmin's two-year-old son had been rushed into hospital on the same day. As soon as the baby was born, Yasmin had to be transferred to the other hospital to comfort him.

In the bedroom of her council house, in the shadow of the motorway, Yasmin discussed the Asian tradition of baby massage, while Lesley took blood from the baby under the watchful eye of his protective older sister.

Lesley's chances of delivering all the women she visits during pregnancy will increase considerably in October, when a pilot scheme of one-to-one midwife-led care starts at Queen Charlotte's. She is looking forward to getting away from the frustrations of fragmented care: 'There's nothing nicer than if you've booked someone, looked after them all the way through the pregnancy and happen to be on call when they go into labour.'

It is also the way midwives worked 30 or 40 years ago. Lesley is pleased that the practices of the past are being revived, alongside modern technology: 'Midwifery was much more personal then - all midwives knew their mothers. They also worked far more in the community than in the hospital, because they were attached to GPs.

'Over the last 30 years the role of midwives has been eroded. There is now the opportunity for midwives to re-establish their role. But there's no way we'll be working in isolation - that would be stupid. We need to be able to turn to obstetricians if there's a problem.'

Lesley works in the community where she lives, and frequently bumps into mothers she knows. As we left a flat in a tower block on a notorious Shepherd's Bush estate, a young woman hanging out her washing greeted her warmly.

But traffic and street crime have changed the modern midwife's working day. Lesley has never been attacked herself, but says she has felt threatened at times: in lifts, or walking from the car to visit a house after dark. 'If we're going to a home birth in an area we're worried about, we ask the husband to keep an eye out and see us in,' she says. 'But with home births increasing we'll have to think more about personal safety. We're going back to the old ways, but it's a different world we are living in now.'

From October, Lesley will be on 24- hour call for half the week rather than one or two days as she is now. It's an intrusion into leisure time and family responsibilities that many midwives may resist. Lesley's two sons are grown up so she has more freedom than most. She's happy to increase her own commitment because she knows it will bring greater rewards: 'If you're bleeped at 2am to go out to Mrs Bloggs who you've never met before, you don't want to get out of bed. If it's Mrs Smith whom you know, you go with a different attitude.'

LESLEY was persuaded into midwifery soon after she returned to nursing when her husband left her 10 years ago. Against all her expectations she took to it immediately, and headed straight for the community. She likes the autonomy and is genuinely interested in people, in heroin addicts as much as in well-heeled Chiswick women 'You end up being a friend more than a health professional,' she says. 'How often do people in other professions say, you're great, you're doing a really good job? In midwifery mothers really appreciate you.'

'You get near to the delivery, and straight afterwards everyone's buzzing. It takes a couple of hours to clear up, then there's an awful period when you've got to get down to the notes when the adrenalin's gone and the tiredness hits you - that's hard.

'But every birth is special. When you've delivered a baby you feel as high as a kite. It's always a miracle - you think, God, isn't that amazing. You look at the baby and think, how did that baby fit inside there, let alone how did it get out? It's a real privilege to be there at the most important moment in people's lives.'

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