How does homebirth work in England? || Chatting with independent midwife 'Lucy' about homebirth, the NHS, and regulations.

This is the first episode of Homebirth Around The World. A series where I chat with homebirth midwives and they share how homebirth works in their area. From cost, culture, insurance, becoming a homebirth midwife and working as one, this series aims to try and dy-mystify homebirth and raise awareness for homebirth. 

In this episode, I chat with Lucy from @lucybuddingwood who shares her journey to becoming an indepedent private midwife in England and how homebirth works generally in England. We chat a lot about insurance and the challenges in the system - quite different to home we in Australia may perceive it! 

Below are some resources worth checking out!

Homebirth, NHS midwifery, regulation and unions.

NHS Homebirth: Where to give birth NHS Guide, Birthrights Guide to Choice in place of birth, Homebirth UK (old site, gives some historical background to that 1990s/2000s surge in homebirth popularity

What is an Independent Midwife? NCT Guide

Zest Midwives: Membership for Independent Midwives to access intrapartum insurance.
RCM: Midwives' Union
NMC: UK Nursing and Midwifery Regulator
NMC guide to indemnity insurance

Albany Midwifery Practice: Overview via AIMS
Closure: How the flagship Albany Midwifery Practice, at the heart of its South London community, was demonised and dismantled Paperback – 11 May 2023

ARM: Association of Radical Midwives
Midwifery Matters (quarterly member's magazine of the Association of Radical Midwives, this is the magazine I Edit.)

ARM Archive on Homebirth (ARM member's archived discussion thread on homebirth, again this was probably mostly from 2000s/2010s.

#saynotobullyinginmidwifery Report, via ARM. This is a book by ARM members on bullying in midwifery and gives a really good insight into NHS midwives' experience within the UK. It isn't specifically about homebirth, but it goes really deep into the culture!!

Lucy's website www.lucybuddingwood.com

Transcript

0:02

Welcome to Birthing at Home, a podcast. I'm Elsie, host. I'm a home birth mom of two little boys, a doula in Melbourne supporting birth at home. I'm a mental health nurse and the co-creator of Home Birth Victoria. If you want to learn more about me, the podcast or my work, check out www.birthingathome.com.au. Before we begin, I would like to acknowledge the Wurundjeri people who are the traditional custodians of the land I'm recording on in Ngaam, Melbourne, Australia. I would also like to acknowledge the Aboriginal and Torres Strait Islander peoples have been birthing at home on country for tens of thousands of years prior to the British invasion and acknowledge that sovereignty has never been ceded. This episode is a part of the Home Birth Around the World series. In this episode, I speak with Lucy, an independent midwife in England. This was a mind blowing episode for me, which had about studying to become a midwife, being a home birth midwife. the British healthcare system and including some of the nuances, the cost of home birth in England and how private independent midwives navigate professional indemnity insurance. What an episode. Lucy also mentions and sent me a bunch of links to check out. So please see the description of this episode for those links. And if you know a home birth midwife in a country other than Australia, who might be interested in sharing how home birth works in their country, please let me know by sending me a message on Instagram birthingathome underscore a podcast, or they can send me an email as well birthingathome.apodcast at gmail.com. Enjoy. After Lucy and I listened back, we also just wanted to highlight that insurance terminology can get very confusing. We talk about private and medical insurance interchangeably in this episode. And we want to point out this is different to professional indemnity insurance. If you have any questions, always feel free to reach out. Welcome Lucy to Birthing at Home, a podcast. Thank you very much for having me. Thank you for joining me. And yeah, thank you for being a part of this home birth around the world sort of mini series that I'm doing. Are you able to give a little intro to who you are and where you're located? Yeah, so my name's Lucy. I'm an independent midwife in England and I live in the middle of England in Birmingham, the West Midlands. Yeah, amazing. And how long have you been an independent midwife for? I trained between 2017 and 2020. So in COVID, which was a really interesting experience. cool. Got my qualification in 2020. Yeah, then had two children. Yeah. So didn't work as a midwife during that period. And then I went straight into independent practice when my youngest was about three months old in 2022. Wow. Oh my goodness. Yeah, that's amazing. I apologize to listeners because I feel like I'm going to be repeating myself quite a lot, but that is fantastic that you're already an independent midwife so you can attend home births as I guess here in Australia we call it as like a primary midwife. you are. We would say a lead midwife or a named midwife. Yeah. Okay. Sure. Um, and like, what was the process for you in becoming a midwife? Like, do you study a bachelor of midwifery or like, what, what is it? Yeah, so the kind of traditional pathway nowadays is that you apply for a direct entry degree. So that's a Bachelor of Science in midwifery. Yeah, quite a few universities around the UK offer that. And it's a three year course where you spend about 50 % of the time studying things like anatomy and physiology and clinical skills labs on a university campus. Yeah, about 50 % of the time, so about 18 months, you would be working full-time equivalent for the NHS. So the hospitals and the trusts are linked up with universities. So you apply to the university and the trust provides a certain level of student placements. Yeah, so it's very, very I can't think of the word but like the trust and the universities work really, really closely together. So yeah, if your training is on site in the hospital or, you know, in the community is studying. Yeah. And like here in Australia, at least where I studied in Queensland on the Sunshine Coast. mean, maybe that's a little bit unique. I'm not sure how it is here in Melbourne per se, but you would get sent all over the place to do your placements in the in like the UK where you've studied. You know, did you get sent far from home to like attend these placements or what's that like? because the universities are really closely linked with the local hospitals. You can be very, very close to your clinical placement. If you've got I was I trained in Leicester. So Leicester University was De Montfort University is literally a stone's throw from the main city hospital. But if you were at a more rural university, you possibly might be traveling a little bit further, but you still have like a set placement location for most of your time. Yeah. And in the community placements that you do, you're allowed to attend home births and observe home births or. Yes and no. It depends on access. So in the UK, every single woman has the right to have a home birth, regardless of clinical status or medical opinion. Yeah. So none of this low risk high risk exclusion criteria. Yeah. But does that exclude you then? m as a woman or a student midwife. uh as a woman. em It's a little bit complicated. So you do have the right, eh but whether that right can always be facilitated. Conversation. em But yes, as a student midwife working in the community, you would have the opportunity to attend home births. But again, that's when so an example of how that kind of m access can work is that where I trained in Leicester. there was a new home birth team set up. So this was essentially a case loading team of community midwives who were dedicated to providing care to the women in Leicester who wanted to have a home birth. Yeah. And because they'd only just set up, they declined students accessing placements. uh I did manage to get a little bit of experience in my third year because I m I made relationships with women who wanted home births. I followed the women rather than of course. Yeah, yeah, yeah. So that is in places where trusts have dedicated home birth teams. I don't actually know the statistics, but it isn't, not every trust has that. Yeah, okay. Otherwise it would be provided by community midwives who do on calls. Yeah. So if you were a student, you would then be possibly on call for home births. Yeah. Okay. I'm trying to understand it in the context of how it's set up in Australia. Are you able to, I don't know if this is too difficult of a question, but are you able to give a very brief explanation about what a trust is? yeah, yeah. So, I mean, I don't really know all the levels of management and organization. You have, I might be using these aren't necessarily the right titles, let's just show you have you have em regional health boards. And so all of this is publicly funded. So nothing that I'm going to be talking about, apart from myself, maybe is is private or independent or separate from the government. So this is all publicly funded. And so let's say that you have like the, so it's, it's regional health board, and then there will be various trusts sitting underneath that. So let's talk about Leicester where I trained. I don't know what the regional health board is for that area. but there was university hospitals of Leicestershire, which is the trust. And then sitting under the trust, which is the organization, there were two hospitals and various outlying health clinics and that kind of thing. So you would be employed by the trust and you would work in a particular hospital. Yeah. Okay. I'm trying to think of it, in, uh, in Melbourne. And I mean, plenty of people not from Melbourne will hear this, but at least in Melbourne, we have Western health, Northern health, uh Eastern health. And I feel like that isn't actually a Southern health, but, uh, and I wonder if that is, and you know, you get. sort of zoned to these areas. And yeah, there's usually like a main hospital associated with that catchment, I guess. think that that is maybe quite similar to what you're talking about with the trust, just different terminology. possibly the main difference is that the catchment is oriented around the GP that you're registered with. the GP registered with will feed you in to a trust. And that's only really relevant if you're on the border of something. Yeah. So you could possibly be on the border. So your closest hospital could be the hospital where you're not registered. Yeah, okay, depending on is yeah, hospital that will generally be where you're funneled. However, request that you are booked under a different hospital. So there's a possibility Okay, yeah, yeah, yeah. Thinking in terms of a home birth, you are, if it's an emergency, you're going to be taken to the nearest hospital regardless of whether you're booked there or your own, you know, preferences. Yeah, yeah, yeah, yeah. Yeah, actually, I'm just now remembering that I'm pretty sure, as I was just saying before we started recording that I lived in the Netherlands for a hot second. um And yeah, it was similar in that, you know, you could only choose a GP in a certain area from where your address was in, in Melbourne or in Australia. you could have a, if you wanted a GP that was two hours away, like you could have a GP that's two hours away. But they, in the hospital system, they funnel you in to maternity care via the referral pathway, if you're a hospital birth. But home birth now, since last year is quite different in that you don't even need a referral to access a private uh midwife. So if somebody is wanting, so women in the UK can access home birth via the trusts or okay. Yes. And then I guess that's perhaps similar in that there is probably a lot of eligibility or like exclusion inclusion. Yeah, think it's going back to women in the UK are considered to have the right to give birth wherever they choose. So you're booked with a GP and you can access maternity care, of course, without having been booked with a GP. But this is kind of the standard pathway. Okay, people are booked with a GP. Okay. So you'll speak to a community midwife at your GP practice. who will be an employee of the local trust. And so at every GP practice there is a midwife. Usually. What? But they aren't employed by the GP practice. They're employed by the hospitals. So you go to GP and some GPs want to speak to you first, but most you say to the receptionist, I'm pregnant, can I have an appointment with the midwife and you just see your community midwife at the GP practice. my goodness, what the heck? There are some areas where it's a little bit different. So this is really, really kind of unfortunately being closed down now, but you used to have some kinds of maternity hubs. So you might have like a standalone birth center. And you would have a midwife team that works out of there. Yeah, you could have your appointments there with the midwives who works there. Wow. Oh my goodness. And if you are, usually if you are wanting a home birth, the home birth team will do home visits. Yeah, my god come out to your house to do the visits. And so. Whether you go via the trust pathway for home birth or hiring someone like yourself as an independent midwife, is there a cost difference to the woman? Yes. So everybody in the UK is entitled to NHS care. Okay, point of access. Because obviously, it's paid for by taxes. Yeah. And that is also true for people who are ordinarily resident in the UK. So NHS number. So there is no cost at the point of access for the majority of the people who access the NHS. Okay. And so that's true with private, independent midwifery. How does the independent midwifery work? I'm completely independent from the trusts. Okay, come to me and they cut they have a contract with me. And I provide care to them according to their needs. And I charge them for that service. insurance that would cover that. Yeah, OK. Is there insurance for antenatal or postpartum or the whole thing is not covered? No, I'm not aware that it's being covered at all. Interesting. And so, so a woman becomes pregnant. so is she going to her, like the GP practice to see that midwife or can she reach out directly to you and say, Hey, Lucy, I want to have a home birth. Can you be my midwife? So there is no legal requirement to access any maternity care in the UK. she wouldn't have to go to the GP or have to contract me or any more someone like me either. But yes, she could, you know, just go with the flow with with the standard system or actively choose the NHS system. she might you know, research an independent midwife close to her, contact me and yeah, we take it from there. yes, women who hire independent midwives still have the right to access any and all maternity care with the NHS. It's usually a bit of a half and half system. So a lot of women will hire independent care alongside routine NHS care. Okay. And some will say no I don't want any NHS involvement I just want independent. Yeah. Okay. And yeah. my goodness. Yeah. I'm not sure if you know a whole lot about Australia, but it's, it's just so different. Which is exactly why I wanted to do these episodes. It's more separated, isn't it? Yeah. Well, I mean, home birth is just, uh, I mean, you know, I live in the home birth world, so it's not stigmatized to me, but as a gen generalization is very stigmatized, it's not supported. Um, I think maybe a question that I'm dying to ask though, in comparison to, you know, here in Australia is, so how much, I guess in pounds, it, uh, costing somebody to hire you for their antenatal birth postpartum care. Everything. Yeah. It can be up to £10,000. 10,000 pounds to... Holy moly. my gosh. And so people pay out, that's today on the 6th of April, that is uh just over 21,000 Australian dollars. um And so from, women don't get anything back at all for that. like claiming anything back. Well, via insurance or the state. No, it's literally like you are, you know, you're hiring somebody to provide professional service completely independent. You know, own contractor for the house, you know, be claiming you would there would be there's no mechanism. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Goodness. Oh, my goodness. And so I guess that's one of the things that is commonly cited in Australia as, you know, a point of accessibility barrier is the cost, because in Australia, can cost between. Well, I mean, the average, guess, is somewhere between seven and ten thousand dollars, which is Gosh. The third. Yeah, like three and a half, 4,000 pounds roughly, I guess. And I think, I mean, there's lots of factors that I think play a part in our low home birth rate, but I think that is a major part is that people just cannot afford that. But holy moly, up to $21,000 for independent private middle-wifery. I would caveat that with people obviously set their own prices. Currently is between about seven and nine. Yeah, okay. Yeah, yeah, yeah, yeah. Yeah, yeah, yeah. But I have seen prices as low as about 4,000. Yeah, okay. But my costs for attending a birth, so this is talking just the day of birth, can easily be £4,000. Yeah. yeah, well, it's similar here, um, for people wanting to know what the conversion is. It's about eight and a half thousand dollars. Um, similar to here in Australia, if you hire a private midwife, which is, you know, separate from the hospital system. Um, yeah, the birth is the biggest. I mean, that makes sense. Of course. Um, but yeah, no matter if you're there for 10 minutes or 10 hours, it is. About, oh, you miss it. It's like six, yeah, six, seven, $8,000 just for that. Holy moly. And so in your experience, so this is, this is, I guess, how common is it then for women or families to hire independent midwives, would you say? So I think that the key thing to understand about independent midwifery care in Britain, particularly today, is that home birth is free on the NHS. Yes. So every woman has the right to have a home birth in the UK. And historically, you know, maybe 80s, 90s, early 2000s, there was quite a big home birth movement and the home birth rates. NHS provided home birth rates were quite stable. m But particularly since COVID, m a lot of home birth provision was withdrawn. in uh in COVID women were told there was no access to home birth and they had to go to hospital to have their babies. So that has led to an increase in women seeking private and independent midwifery services. I think that the rates of home birth, they are still incredibly, incredibly low. So we're talking probably two to 5 % depending on trusts. mean, it's much lower than that, 0.5 to 5 % interest. Oh, wow. The average is about two to 3%. Yeah, goodness. And an even smaller number of women are accessing private and independent midwifery services, but that number is increasing. Because of the impact of COVID, home birth services have not yet fully been restored. And unfortunately, it also seemed to... There's like this hangover of somebody might not be available. Prior to COVID, you were booked for an NHS home birth. You had the right to have that. And there was felt to be a moral, what's the right word? Like a moral responsibility. Yes, okay. uh to provide you a midwife if you were labouring at home and asked for simply to attend you. I've heard this kind of thing before. Yeah, okay. I don't think that that was like a uh legal thing, legal responsibility. I think as this is the responsibility of the trust to provide a midwife for you at home, if you request one. COVID that moral responsibility has been really, really eroded. And women are experiencing home birth services being withdrawn overnight, or they are frequently being told that somebody might just not be available on the day. There's a lot of factors at play with understaffing in hospitals. So a lot of NHS home birth midwives are, they might go on call for a home birth, well, you know, they're on call for the home births in that area. And then there's understaffing at the hospital. So they are told to go and do a shift in the hospital instead. eh And then if someone goes into labour, there's no one available, you have to go into the hospital. Yeah. So that is one of the biggest reasons that women are coming to me. They are saying that they're really worried that home birth services are going to be withdrawn and they just want a guaranteed home birth. I wouldn't say it's the number one reason that women come to me personally, but that is a big factor. Yeah, yeah. And so um in oh like the UK or whatever, do you have to have two midwives? Wow. uh OK. There's the added level of intrapartum insurance. So this is indemnity insurance. And stop me if I'm going into too much historical detail. no, this is perfect because Australia is a mess with indemnity insurance right now. This is very on topic. So there are unions. So let's talk about the Royal College of Midwives. is the RCM. Historically, the RCM provided indemnity insurance to midwives. m For intrapartum, like the birth as well. was more it's all before my time. it's it's sure I don't have a full understanding. But it was more a case of em emergencies. okay. I can't remember fully. But yeah, yeah. What was important was that intrapartum insurance wasn't required at that time. Yeah. So the insurance was a lot less rigid and lot less formalized. So independent midwives could attend births without having to think too much about insurance requirements. the RCM did have some insurance cover in place. if we're talking about midwives that work in the NHS doing home birth, they covered by the trusts in general. same here. Yeah, yeah, yeah. So whether the insurance was required by law or not is probably still not really relevant to NHS Midwives because it's all covered by the trust anyway. Yes, yeah, yeah, yeah. But in, I can't think of the exact dates, but maybe it was 2013, 15, something like that. The legislation was changed in Britain and it now became the law for independent midwives to have intrapartum insurance specifically. And there were a couple of insurance models available. It was a very new market, so people were finding their feet and trying to come up with things, maybe on a slightly casual, informal basis. And from 2017 onwards, that became much more rigorous and formalized. And there was a very short period where independent midwives were not able to access, um, Interpartum Insurance because there were no providers in the UK. And so at that time it was also a rule that you had to have the intrapartum professional indemnity insurance. Yeah. Okay, so there were a couple of years where it was not possible to hire an independent midwife. Well, unless she was prepared to act illegally. Wow, yeah. birth, birth. Yeah. So I'm coming around to it. Don't worry. Yeah, no, I just, there's so many parallels. It's a little bit scary actually. And I know, yeah, I understand that. And then after COVID, maybe it was 2001, maybe it was 2002, they developed a new model, which has been spearheaded by a company called Zest. And Zest, I am registered with Zest and they are like a membership company. for support of midwives. And in order to join Zest, and it's run by midwives, you have to meet certain criteria. So obviously, you have to have, we're talking just about midwives, they do take on, take on do-ers and that kind of thing. But like, you know, just putting that to one side. You have have registration, you have to meet certain levels of mandatory training, safeguarding certificates, that kind of thing. And They then act as an introduction. So they introduce you to a private insurance broker from whom I know, I know, from whom you are able to purchase an annual insurance. m I don't know what the insurance word would be. Like a product. Mm, product, yes. And then per birth, you buy a premium to attach to that product. So we are talking about thousands and thousands of pounds of costs per year. The capitalism is really capitalism-y. original question. In order to meet the insurance requirements of this particular insurance broker, you have to two Zest registrants attend a birth. And that may include some doulas, but they have to be registered with Zests and kind of meet the same requirements, obviously, apart from being a midwife in that particular circumstance. So, yeah. So yes, have to plan to have two Zest registrants attend an independent birth. m And in the NHS, it used to be the case that you needed to have, it's very trust dependent and they have their own policies. It used to be the case where you needed to have two NHS midwives attend to meet the m NHS. protocols and policies. Trusts are categorizing women as if they are what they deem completely low risk, then a maternity support worker can attend that birth in place of the second midwife with another well, and they will be an NHS employee as well. Wow. I feel like in some ways I'm looking at our future. I don't know if you are aware of what happened or the history of professional indemnity insurance in Australia for midwives, but in 2010, the APRA, the Australian Health Professionals Registry Authority or whatever it is. Yeah, yeah, yeah. They took over all nurses and midwives in Australia. I mean, there was there's more but nurses and midwives and created the same rules for everyone, including professional indemnity insurance, but there was no insurance company that had an intrapartum product. And so I think there was a lot of advocacy work done and Finally, I think the evening before it was all put in place, an exemption was made. And so since 2010, up until uh last year, the government each time the government changes or whatever, they just renew this exemption. guess they put it in the too hard basket and, you know, just keep putting the exemption. So in Australia, the private midwives still attend home births. again, separate to publicly funded midwifery where the hospitals or the health services paying for their own intrapartum insurance. The private midwives attend the births at home without an insurance product because there is no insurance product. And last year, it looked very much like there was going to be a sudden cutoff of midwives being able to being allowed to legally attend home births because you know, they said, okay, well, we're finally going to get rid of this exemption. And there was, yeah, so much advocacy work put into trying to stop all of the possible disasters that would happen from them thoughtlessly saying that. It's an ongoing issue here in Australia. We've got until the end of 2026, I think, and the exemption will be stopping then. And they've got kind of 18 months to work with insurance companies or product providers or whatever to create a product specific to intrapartum care. But yeah, goodness me, it feels like. I feel because that is one of the concerns about the cost, how a private midwives going because you have to then pass that cost on to the families and it's already like, yeah, my gosh. And so that is truly already happening. That's really scary. Wow. It is scary. And I, I, I'm very suspicious of insurance in general. In my personal life, you know, not just, not just yeah, yeah, Yeah, likewise. because it's it's all about well, it's it's the word insurance isn't it? It's yeah, against something which may never happen. And the reality is that it generally isn't required. However, it's a legal requirement. Yeah, yeah, yeah, yeah. one's having to jump through these hoops for a legal requirement that doesn't necessarily have any groundings in reality based in reality. Yeah. You know, the whole, the whole thing's just, it's yeah. Like I said, the capitalism is capitalizing. Yeah. Yeah. Even that you have to like pay a fee for someone else to connect you with someone else who can broker something for you. It's it's so crazy. uh really smart model, actually. I it sounds really complicated. And it is, but it has set things up to work really well for independent midwives. The cost aside, which is massively prohibited for prohibitive for the majority of women. Yeah, but as an independent, independent midwife, working in this model, it is really good. Yeah. Okay. Yeah. So. economy and access to support and that kind of thing. Yeah. Okay. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. I'm kind of blown away. And so in England, what would you say inclusive of uh trust home births and private, sorry, independent midwife supported home births? What would you say like the percentage is roughly? It will be very dependent, but I think it is between 0.5 and about 5%. Yeah. Yeah. Yeah. Yeah. I can't actually off the top of my head, remember what it is Australia wide. And similarly, it differs depending on where you are. I want to say that it's like 0.6 or 0.7 % Australia wide. 5 would be great, wouldn't it? 5 % would be great. They've done studies that sort of predict that if just 5 % of women had home births, or I don't even know if it's have them at least. No, I think it is have them. I was going say plan or have them, but I think it is have them. The amount of millions of dollars it would be saving the healthcare system is wild. interesting case study example, not sure of the right words, called the Albany practice in the UK. Have you heard of that? So, before COVID, there were several models that were set up that were, you'd say probably more private. Yeah, they were private and then they might be contracted by the NHS. So, forgetting the whole intrapartum insurance thing, which is new. you know, kind 2017 onwards, maybe from 2000s to 2017, something like that, that there started to be these practice models put together. And the Albany practice was based in a particular area of London. And it was contracted to the NHS. So you had private or independent midwives running their own practice as a case loading team that was then contracted to the NHS. So women in this particular borough, maybe it was of London, which is like maybe a postcode catch one area, were eligible to receive their care via this contracted practice. And what's really, really interesting about the Albany model is that it took a mixed risk caseload of women, particularly from a em deprived area. what they did that was very unique was that everybody was booked with this practice, regardless of where they might want to give birth, you know, if they were kind of open to a home birth. Yeah, yeah. so let's say you went into labor, the midwife would come out to you. And you would make a decision at that point about where you wanted to give birth. Oh, obviously, if if there was never any intention of having a home birth, then maybe you would go to the hospital. I think you should probably get one of the Albany midwives on because they were so much more than me, obviously. But you had a mixed risk caseload of women from a very deprived area. accessing free at the point of access, healthcare from private midwives contracted by the NHS, who would come out to you in labour, you'd make a decision together about where you wanted to give birth. And the rate of home birth was huge. I don't want to say anything because I can't remember, you know, maybe it was 49%. But it was significantly higher. So that type of service where the decision isn't necessarily made until you're in labor, you know, you're still very open, you're still very, you know, that you're going to be supported, whatever your decision is. I can just imagine, obviously, there are women who, who, you know, you and I are going to be really familiar with, where they want home birth. That's, that's exactly what they want. But the majority of women are actually somewhere in between. home birth for them may be scary because they don't know what it's going to be like and they don't know who's going to be there to support them. But but we do know all of the evidence supports home birth for the vast majority of women. They can have access to the appropriate support backed up, crucially backed up by a well resourced, well skilled obstetric hospital based system if needed. And so for those women who kind of fall into the gray area to have that, you your midwife comes out, labor is progressing really nicely, you're feeling really comfortable, really safe. Why would you not stay at home and have a home birth? I think that's an incredible model. It's very critical because it was withdrawn. Yeah, well. But yeah, that was that. So before this whole Interpartum insurance, Malarkey kicked off. That was the model that we were starting to see in Britain, but that's shut down. Wow, yeah, that is such a shame. my goodness. It just sounds like good, doesn't it? Yeah, because I mean, like you hear so many stories. Well, I hear so many stories from people that never planned a home birth. Home birth is like not on their mind, but they've gone in and a good example is, you know, they've gone in and within two hours or something, they've had their baby. It's like, you just drove 30 minutes to the hospital. Why did you do? That's it. yeah, it's just, what would you say? mean, you know, everybody's probably going to have a different sense of it, but what would you say the cultural sort of view, broadly speaking, of home birth? Like, what's that like in England? it, is it, because here, like I was saying in Australia, it's, you know, It's still something that people like, it's dangerous and it's for hippies. And, um, that's so weird. Why would you want to do that? It's unsafe, et cetera. What, what is it like in England from your perspective or what do you hear? I want to say is that it's marginalized and access is often, you know, not really facilitated. And there are a lot of comments, you know, on the the Daily Mail online talking about how risky it is. But I think that that's a that's an incredibly insular perspective. when I did my dissertation, which went on to be published, I looked at free birth in the UK. I looked, this involved researching home birth in other countries. And I'm a little bit ashamed to say that I was absolutely blown away that it gave me the perspective of how good the system is in the UK for home birth. I want to say, because I do see so frequently that it is marginalized and thought of as something that that is only for hippies. I'm yet really on a global perspective. It's, it's, it's really very acceptable, very accepted. If you were to say that you were planning a home birth or that you'd had a home birth, the majority of people wouldn't really bat an eyelid. Yeah, you people would say, Oh, you're brave. Yeah, thinking about how they feel they couldn't have cope without an epidural themselves. And people often talk about the pain and the perceived mess and that kind of thing. But that is where maybe the majority of the misgivings are as opposed to Oh, my God, no, so radical, so dangerous. Yeah, okay. Yeah. individual experiences might vary. But the majority of women if they sat down with their community midwife, that community midwife should be open to the idea of talking about home birth. m Yeah, well, I think it's like fantastic that in many or most, uh you know, GP practices or whatever that there is, you know, a midwife that sort of able to give a bit of an unbiased in a way, I guess, delivery of the options, because here in Australia, prior to November last year, again, you know, to even have, um, so in Australia we have Medicare, which is the public health, whatever, how, whatever you want to call it. and you can get Medicare rebates tiny, tiny amounts like tiny for antenatal and postnatal period. They're tiny. makes not a lot of difference, but. you know, any money is better than no money. And so to access those rebates, you had to have a referral from a GP. Um, so. I mean, there was two problems, two major problems is that when we would go to the GP say, Hey, I'm pregnant. And the GP would say, okay, public or private and not even consider the home birth option. If somebody went to them and said, I actually want to have either a home birth or not even mention the word home birth, but I want private midwifery care or some other variation. GPs were declining those requests to put referrals in. know, number one, the majority, I mean, still today, even though that requirement to have that referral has been removed. GPs are still owned, like that is the first point of contact when you're, when you think you're pregnant is to go to the GP and they are saying public or private. And so most people don't even know that home birth is an option. And all they hear is that, it's for hippies, it's dangerous. And of course, similar thing, like the news outlets hear all, you know, the free birth and everything. It's, you know, they're just, sensationalizing things that they don't actually understand. And it's just, yeah, like if, if everybody could just have access to somebody who would actually give them what their options are, even if it costs $10,000, $21,000, 10,000 pounds, whatever. I mean, that would be like such a big step because right now You know, most people don't even know it exists here in Melbourne. There has been an increase in publicly funded home birth programs, but they're not all risk models. They're only low risk and you very, very quickly get excluded. You can be kicked out up until I think that in every single program, there's an appointment at 37 weeks. maybe, and that is the make or break point. But even then, if you go over 41 plus six, you get kicked out of the program. It's. It's. You know, it's fantastic for some people, but I mean, even for me, I have big babies and that's an exclusion criteria, so like I wouldn't even be allowed to access it. Um, we do have again, it's really conflicting to talk about because my heart wants to say, home birth so restrictive in the UK, you know, women are risked out all the time. But my head says on a more kind of global basis, that that it is really, really amazing that in the UK, every woman does have the right to have a home. She may have a massive battle on her hands to actually have that home birth facilitated? But that right still remains. it is true that this is NHS care, so taking me out of the picture, that only so called low risk women are considered eligible for a home birth. However, that eligibility criteria does not prohibit women who fall out of it from requesting a home birth. Maybe let's talk about before before COVID. But my understanding of how the system worked was, you'd go to your booking appointment with your community midwife based at the GP. And she would take a risk profile from you, you know, obviously asking you obstetric history, medical history. And was a period in time where if you were considered completely low risk, she should be recommending home birth to you. In reality, maybe that didn't happen so often because the percentages were still really low even then. um But now I don't think that happens so much. And it is more a case of if the woman herself requests a home birth. then that request will be assessed against her risk factors. And that request will either be encouraged or discouraged, or maybe facilitated or not facilitated. So if you have risk factors, so let's say you had a PPH in your first birth, or you've got gestational diabetes this pregnancy, or you're over 40, or you're under 18, or whatever. then the community midwife would say to you that it's not recommended that you have a home birth. It's not in our guidelines to offer home birth to you. But you can go to Birth Choices Clinic in the hospital or you can meet with the consultant midwife who will put a plan in place and allow you. access a care plan and be facilitated in that planning of a home birth. But I think that many women perceive that to be an incredibly hostile path. And of course, it should all be caveated by on the day you make that call. I'm in labor, the hospital might just say, there's no one available to you. regardless of your risk status. Yeah. So yeah, you it's it is. It's very, very flexible. Everybody has the right to have a home birth. That right isn't always supported or encouraged. And in many cases, if you are perceived to be high risk or fall into a high risk category, the hoops that you have to jump through in order to have your home birth signed off is probably the right language can be prohibitive for the vast majority of women who might choose to access that. Yeah, even worse case on the day is the midwives who come out to you are not supportive. Hmm. So they are employed by the hospital to provide care to you, but they may not be happy about that. Yeah, really scared about providing. so called low risk care to so called high risk women. Yeah, there might be notes on the hospital system. Talked about staff perceptions of women's attitudes. And all of that can turn what should be a rights based system into a very hostile environment. Yeah. Holy moly. I, I'm so excited to be able to talk to you and also to do this series because my mind is blown over and I knew there was a reason why I wanted to do this. I'm just, I think my brain is just like, yeah, like blown away. is possible that if you spoke to somebody else, if you spoke to a home birth midwife, or if you an NHS employed home birth midwife, you had a really, really good support team and, yeah, the trust was was managed in a really supportive way. That she would say things are completely different. She would say no, no, no, you know, in our trust, our home birth model, it's really supportive. We support breaches, we support twins at home. But of course, I am speaking to the women who feel marginalized by that system. Yeah. So I probably would say that we have a really strong home birth culture in the UK. And unfortunately, over the past five to 10 years, that has started to be eroded by some things that we've been talking about COVID, the the new insurance stipulations, the closure of standalone midwifery birth centers. But I have absolutely no doubt that there are really good home birth teams out there who advocate for even incredibly high risk women and that those women have really well supported journeys to accessing home birth. Yeah. Yeah. And I guess that's part of the, you know, the issue, I suppose, here in Australia as well. Although um most states don't have, well, I don't know if most states, but certainly there's not a lot of publicly funded home birth programs. think Victoria and New South Wales have the most. And even then it's, yeah, well, I mean, in some ways it's kind of like a postcode lottery because it's, luck of the draw. If you, uh, you know, live in the radius of, free, you know, for example, the program that got set up 10 years ago. So they're quite supportive of home birth because they've been doing it like, and they've, you know, sort of perfected the process. Whereas, you know, the one that's, you know, started last year, like they're very nervous and very like hesitant to take on. you know, people that may not be like the lowest of low, low, low risk. And, you know, it's it all just depends. I mean, yeah, the hospital hospital culture and I mean, who who's even in charge of like the management? It's here. It is really dependent on the maternity midwifery managers. uh So you've got managers who maybe have had home birth themselves. Yeah. And interestingly enough, that is where the good home birth teams and the supportive systems tend to be. And then obviously, if you have managers who may be a little bit less skilled and slightly more risk adverse and maybe would have made personal decisions that differ from home birth. Maybe the home birth culture in that trust isn't going to be as strong. Yeah, gosh, Lucy, I feel like we could literally talk for hours. I'm going to wrap it up by saying thank you so, so much for sharing your insights into midwifery and home birth in England. um Did you say that you had written something about free birth? Yeah, so my dissertation was published in 2021. And I'm also the editor of a midwifery magazine. wow. OK, amazing. I will ask you privately for those details and I can include them in the description. information about the Albany practice. Yes, yeah, yeah, yeah, absolutely. And yeah, I'll have to figure out how to get somebody from the Albany practice. sorry, I'll catch with you. Okay, good, good, All right.