Disclaimer: The views expressed are that of the individual author. All rights are reserved to the original authors of the materials consulted, which are identified in the footnotes below.
By Pia Malla
Introduction
This article examines how the NHS has continued the provision of maternity services during COVID-19, namely maternal request caesareans and home-birthing. Healthcare services have been significantly overwhelmed during COVID, meaning a greater strain on resources for maternity services, and limiting policies have had to be put in place. However, any resulting barriers to accessing services must be analysed to consider the impact on pregnant women’s health and autonomy.
Montgomery v Lanarkshire Health Board
The leading case of Montgomery v Lanarkshire Health Board[1]established that doctors have an obligation to involve patients in decision-making relating to their care, and that it can be informed by non-medical considerations.[2] This obligation involves treating patients as ‘adults who are capable of understanding that medical treatment is uncertain of success and may involve risk, accepting responsibility for the taking of risks affecting their own lives, and living with the consequences of their choices.’[3] The right to make informed, patient-specific decisions, conferred by Montgomery, imposes a duty on healthcare providers to facilitate that process, and thereby enhance the autonomy of patients. [4] Therefore, the provision of maternity services to pregnant women must be guided by this fundamental principle- even during the pandemic.
Maternal Request Caesareans (MRCS)
Trusts have had varying responses in relation to the provision of MRCS. Some allow MRCS with stringent conditions (e.g. only allowing them where vaginal delivery is not a safe option), whilst other hospitals have issued blanket policies against them.[5] These policies must be questioned in light of the effect on pregnant women’s health, and the principle of autonomy established in Montgomery.
There exists a prevailing narrative that MRCS are purely elective and not a clinical necessity, which acts to justify limitations on its availability. However, this narrative undermines the significance of MRCS, especially for women with underlying health conditions which would be exacerbated by vaginal delivery. Data provided by Birthrights tells us that most pregnant women who opt for MRCS have physical or mental health problems they wish to circumvent via choosing a caesarean section, as they believe this to be the best option both emotionally and physically, for themselves and their baby.[6]
Furthermore, some opt for MRCS to avoid the risk of an emergency caesarean, which can be a traumatic experience. Feelings of loss of control and lack of dignity can contribute towards developing PTSD post-birth. Such trauma can have severe implications for pregnant women.[7] For example, psychological stress is known to alter the functioning of the neuroendocrine and immune systems of over 18% of pregnant women, increasing their risk of pre-eclampsia.[8]
Home-birthing
A third of NHS Trusts also suspended home-birthing services in an attempt to direct more resources towards the front line. Blanket removal of home-birthing services is especially inappropriate in the context of the pandemic, when pregnant women may feel greater anxiety about entering hospitals. It also has the unintended effect of increasing free-birthing: the ‘active decision to birth without trained health professionals present’.[9]
Subsequently, Trusts have removed blanket bans, and replaced them with limitations on home-birthing such as imposing the signing of ‘homebirthing contracts’ which attempt to put any risk of harm on the pregnant person, while not barring access entirely.[10]
These decisions fail to take into account guidance put forth by NICE or the NHS which state that options of birthing in non-hospital settings, at home or midwifery centres should be discussed with pregnant women,[11] as well as the autonomy of pregnant women ought to have in choosing their method of birth in accordance with their personal circumstances. There are several complicated considerations that arise during COVID-19 which may compel pregnant women to decide to home-birth including the risk of infection at hospitals. These need to be effectively balanced against resource-based arguments, which include shortage of ambulance and midwifery services.[12]
Intersectionality
There is an urgent need to adopt an intersectional approach in analysing the impact of restricting maternity services on pregnant women who are also ethnic minorities. The abuse and mistreatment of pregnant women by healthcare providers, known as obstetric violence, is far more likely for Black and Asian pregnant women.[13] Existing endemic structural racism faced by ethnic minority women seeking and accessing healthcare will be reflected in maternity care. Thus whilst adopting COVID policies, research should be undertaken to assess and minimise this impact on these women.
Conclusion
Lydia Zacher Dixon states ‘how women are treated in labour and birth, mirrors how they are treated in society in general’.[14]The NHS response to maternity services during COVID is symptomatic of a broader culture of misogyny in healthcare and beyond, which fails to properly balance the needs of women.
There are no reasonable justifications for robbing women of their decision-making powers during childbirth to the extent of imposing blanket bans on MRCS and home-birthing. Therefore, any such policies should be removed in light of their disproportionate burden on pregnant women.
[1] [2015] UKSC 11
[2] ibid [80]
[3] ibid [81]
[4] C Pickles, Leaving Women Behind: The application of evidence-based guidelines, law and obstetric violence by omission,’ in C Pickles and J Herring (eds.) Childbirth, Vulnerability and Law (Routledge 2020) pp. 149.
[5] S Lintern, 'Coronavirus: NHS hospitals accused of using crisis as excuse to deny women caesarean sections’ <https://www. independent.co.uk/news/health/coronavirus-caesarean-sections-nhs-hospitals- maternity-a9514356.html> (The Independent, 2020) accessed 20 May 2021
[6] Birthrights, ‘Maternal Request Caesarean’ <https://birthrights.org.uk/wp- content/uploads/2018/08/Final-Birthrights-MRCS-Report-2108-1.pdf> (BirthRights, 2018) accessed 11 April 2021
[7] Birth Trauma Association. ‘What is birth trauma?’ <https://www.birthtraumaassociation.org.uk/for-parents/what-is-birth-trauma#> (Birth Trauma Association, 2018) accessed 25 April 2021
[8] P Vianna, M E. Bauer, ‘Distress conditions during pregnancy may lead to pre-eclampsia by increasing cortisol levels and altering lymphocyte sensitivity to glucocorticoids’ (2011) Medical Hypotheses 77, 188-191
[9] C. Feeley and G. Thomson, ‘Tensions and Conflicts in “Choice”: Womens’ Experiences of Freebirthing in the UK’ (2016) Midwifery 41, 16–21.
[10] EC Romanis and A Nelson, ‘Homebirthing in the United Kingdom during COVID-19’ (2020) Medical Law International 20 183, 187
[11] National Institute of Health and Care Excellence, ‘Intrapartum Care for Healthy Women and Babies Clinical Guideline’ (December 2014) para 1.1.2.
[12] H. Sherwood, ‘Midwife Shortage Doubles’; N. Davis, ‘NHS Trusts Begin Suspending Home Births Due to Coronavirus’ (The Guardian, 2020) <https://www. theguardian.com/world/2020/mar/27/nhs-trusts-suspending-home-births-coronavirus> accessed 25 June 2021.
[13] A Lokugamage and A Meredith, ‘Women from ethnic minorities face endemic structural racism when seeking and accessing healthcare’ (BMJ, 2020) <https://blogs.bmj.com/bmj/2020/03/05/women-from-ethnic-minorities-face-endemic-structural-racism-when-seeking-and-accessing-healthcare/> accessed 12 April 2021
[14]L Z Dixon, ‘Obstetrics in a Time of Violence: Mexican Midwives Critique Routine Hospital Practices’ (2015) 29 MAQ 437, 447
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