Claire Watkinson's baby is due this week, and what she would really like when she goes into labour is to stay put. "I like the idea of giving birth in familiar surroundings," she says. "I think I'd be more relaxed and I know there's research to show I'd have a better chance of a trouble-free delivery. And I like the idea of being at home straight after the birth - I think it would be easier to settle into a routine with the baby."
Watkinson has had a straightforward pregnancy, and from a medical point of view she has been told there should be no problem with a home delivery: it is now generally acknowledged that for women without medical problems, birth at home is at least as safe as birth in hospital. Despite that, though, for Watkinson a home delivery isn't an option - because she lives in Peterborough. She is one of the current victims of what has become known as the home-birth lottery - the fact that, increasingly, it is not your state of health or your obstetric record that dictates whether or not you can give birth at home, but your postcode.
Any choice Watkinson had about whether or not to give birth at home - a choice the Department of Health supports and says every woman should have - disappeared a few weeks ago when a message was scrawled on a whiteboard at the Peterborough Hospital maternity unit. It said that Peterborough and Stamford Hospitals NHS Trust had decided to suspend its home-birth service until further notice. Watkinson, who says her midwife had seemed as keen as she was on the possibility of being with her for a home birth, heard the news at a parentcraft class, and was very disappointed.
Another Peterborough midwife who read the whiteboard message was Paul Beland, a community midwife with 11 years' experience and a big supporter of home deliveries. He had to break the news to a client that her planned home birth had been banned. But when the client, Louise Cutteridge, went into labour a fortnight later, he attended her at her home for the delivery of an 8lb 8oz boy, Jonny. Three days later the trust suspended him and he has since been dismissed.
Beland says he knew all about the trust's home-birth suspension when he agreed to go to Cutteridge's aid - but, crucially, he didn't think it was sustainable. He believes that a midwife's first obligation is to a patient, not an employer. "The guidance given to midwives is contradictory," he says. "It says we have a contractual duty to our employer, but also a professional duty to provide care for women and it acknowledges that we would not wish to leave a woman in labour at home unattended, placing her at risk.
"I was being told I couldn't attend a birth at home as a trust employee, but I knew that as a midwife I couldn't leave a client to give birth without professional care. My interpretation of this was that my duties as a midwife were overriding. But that's not how the trust saw it."
Beland is planning to appeal against the trust's decision to sack him, and may also take a case of unfair dismissal against his former employer. "Their case would be that I didn't follow a reasonable instruction, so what I'd have to do is argue that the instruction was unreasonable."
It's an instruction that certainly seems unreasonable to women who may be weeks or even days away from a home delivery they have been looking forward to and planning for. And if a home-birth service is suspended, women are usually powerless to do anything about it. Pregnant women, like other patients, have the right to get themselves referred to the care of another health trust - but trusts will not, for understandable geographical reasons, provide home-delivery services for women who live beyond their boundaries. The only other option, if it is an option at all, is to pay around £2,000 for the services of an independent midwife who works outside the NHS and specialises in home delivery. But not all areas of the country have independent midwives working in them: Peterborough, for example, has none.
Sometimes it doesn't even take anything as formal as a message on a whiteboard to dash a woman's dream of a home delivery. Cathy Warwick, midwifery head at King's College Hospital, London, chairs the midwives committee at the Nursing and Midwifery Council. She says she gets letters from women who say they were "duped" into believing they were going to have a home delivery, only to have the chance withdrawn at the last possible moment. "They say they booked for a home birth and were told they could go for a home birth and then, with just two or four weeks to go, they were told that staff shortages meant there was little or no chance that it could go ahead, and that they would probably need to come into the unit to deliver.
"It's very, very, very unfair. I think it's worse than being told from the outset that there isn't a home-birth service at all. That would be a tragedy, but doing this is dishonesty."
No one is sure how widespread the practice is of suspending a home-birth service, or of withdrawing the option to individual women at the last minute. Some women complain, others - no doubt distracted by the demands of a new baby - don't. There is no single place to go - some contact the Nursing and Midwifery Council, others their own health trusts, some the National Childbirth Trust, which later this year plans a survey to find out more about the extent of the problem. But there is evidence that more women than are currently getting one would like a home birth: research done by the NCT in 2001 found that one in five women is interested in finding out more about home births but only about one in 50 actually goes on to have one.
What is clear is that in some areas there is a strong pro-home-birth policy - with correspondingly high home-birth figures, and no history of ever withdrawing the service - while in others there is little beyond an acknowledgement that "it's available if it's what women want" and a service that is vulnerable to being cut at short notice if there are staff or funding problems.
Mandy Renton, general manager of the woman and child service unit at the Peterborough Trust, says there isn't a huge demand for home births in her area. "Women here haven't been asking for them," she says. "It's my role to respond to what they are asking for." She says home births keep two midwives tied up at a patient's home when they could be helping several women in labour in the maternity unit.
Critics argue that midwifery heads such as Renton should be staffing women, not units. "They say it's about resources, but if the service was managed differently then home deliveries could make far more efficient use of a midwife's time," says Beland. "A labour ward has to be staffed round the clock at the same level, regardless of whether it's packed or there's just one woman there. With a home birth, the midwife's skills are concentrated on where and when they're really needed: with a woman in labour."
Peterborough is certainly a far cry from south Devon, where the home-birth rate is around 11% compared with a national average of 2.5%. In south Devon, home delivery is the very first suggestion made to newly pregnant women by midwives when the subject of where to have the baby crops up. And, says Lynne Leyshon, head of midwifery there, there's no pressure to decide early about whether to go for home or hospital. "Women can decide to stay at home as late as when they go into labour," she explains. "You often don't know what you'd really like until the last minute. We send a midwife to make an assessment at home once labour has started and, if all is going well, a woman often just decides to stay put."
Leyshon's service is revered the country over by organisations that support choice in childbirth: Mary Newburn of the NCT says that she is exactly the sort of inspired, far-sighted midwifery manager the NHS needs to make a difference to its often derided, midwife-starved service. While Renton in Peterborough is moaning about having one in 10 midwifery posts vacant and having to advertise as far away as Australia for new recruits, Leyshon in Devon has a list of midwives who are queuing up to work for her - and not just because the countryside is lovely.
The obvious conclusion is that providing a thriving home-birth service is about a lot more than giving women an option: it is also a sign of a contented and valued midwifery workforce. What's more, trusts with a good home-birth rate often have a midwife-run birth centre - a kind of "home from home" unit, where women are encouraged to have drug-free deliveries. And, since research shows home births and birth-centre births tend to require lower rates of intervention and to end less often in emergency caesareans, they are also less likely to be battling with ever-spiralling caesarean section rates, which everyone from midwives' groups to the government now believe should be cut.
For Beland, the way forward is simple: instead of just supporting a woman's right to ask for a home birth, the government should enshrine the right to home delivery clearly, and in law. But not everyone is convinced: some activists will tell you, privately, that if the issue was pushed to wide public debate they're not so sure that it wouldn't go the other way, and we might end up seeing a law that required all women to deliver their babies in hospital.
One thing that would help, they say, is more evidence about the safety issue. Research is already clear about how safe and sensible home birth is: if you're a low-risk mother and you plan a home birth, for example, you are half as likely as the same mother who books into hospital to end up needing a caesarean, a forceps or ventouse delivery. It's also less likely that your baby will need special care, and you will find it easier to establish breastfeeding. But for decades the public was persuaded by the medical profession and the political establishment that hospital was safe and home was risky, and turning that deeply engrained perception around will take time and more statistical evidence.
The Nursing and Midwifery Council, meanwhile, is reviewing the guidelines it issues to midwives who, like Beland, find themselves being pulled one way by an employer and another way by their heart and their patient. If Beland does decide to pursue a case for unfair dismissal, the outcome of that will be significant.
At the sharp end, though, it is still women like Watkinson who are paying the price. Renton says she hopes Peterborough's current crisis will be over by the end of the month and that the home birth service can then be reinstated. But that is too late for Watkinson: her baby will have been born by then. In hospital.
