Fantastic news -new NICE guidelines recommends women are offered full range of birth place options

[organiccarrotcake]

The evidence has been there for years - home birth, and birth in midwife led units, is as safe as birth in hospital for many women. In fact, it's never been shown that hospital is safer, despite the recommendations in the 1970s where women were encouraged to birth there.

I do very much hope that this is not interpreted as putting pressure on women to birth out of hospital if that's where they want to be. It's essential that women birth where they feel happiest and that's the point of this - those women who want to birth out of hospital now have the guidance to back them up. Which is fabulous.

I will also point out that it's a woman's human right under EU legislation to birth at home if she wishes to. That hasn't changed. What has changed is that NICE have finally caught up with the evidence.

www.facebook.com/AIMSUK?hc_location=timeline

[salonmeblowy]

I am beyond delighted about the guidelines, particularly since my obstetrician gave me an all clear for a homebirth today. It is so wonderful to be able to have this choice and the feeling of empowerment, even at the point of just taking the decision to go ahead with it, is immense.

I had a good experience at hospital last time, but I am also convinced that giving birth at home will be so much better for me and my family. The new guidelines not only follow good evidence which has been available for decades, but also give back some agency to the mother.

[LaVolcan]

I welcome this too, for those women who want it, but I think 45 years of conditioning/emotional blackmail will not be overturned overnight. (Our local maternity hospital was closed down because two of the three surgeries in town refused to refer women there). I am not holding my breath that the Trust will re-open it in the near future and some of those doctors will need to retire before their policy changes.

[BananaPie]

I agree that women should be able to give birth where they want (as long as they're low risk), but I'm concerned that these guidelines will result in low risk women being pushed towards midwife led units when that's not what everyone will want.

I am considered low risk, and I don't feel I'm being offered a choice - it's being assumed that I'll want to give birth in a midwife led unit. I'm happy with the idea of gas and air as pain relief, but I think I would feel much more relaxed in the labour ward than in a midwife led unit.

[Chalalala]

home birth, and birth in midwife led units, is as safe as birth in hospital for many women.

The evidence I've seen actually showed that hospital births are safer... (or, that the overall outcomes were similar once all the more difficult cases had been sent off to hospital, which comes down to the same thing). But I'm well aware that numbers can be misleading, so happy to be proven wrong.

I think it's great to give a choice, as long as it's a real choice, and that all wishes are equally respected. Personally I would be an anxious mess if I was pressured to give birth at home, although I completely understand that it's the other way round for many women.

My other concern is that home births are only very safe if a lot of ressources and expertise are allocated to it, and I wonder if the NHS will be able to allocate the necessary ressources - given that costs surely play a part in this push for homebirths, I rather doubt it, actually.

[LaVolcan]

Which evidence have you seen to show that hospital births are safer? As far as I am aware no research has been able to do this. We have had more than 40 years of the majority of women being expected to give birth in obstetric units, so there should be plenty of evidence.

[Chalalala]

I know skeptical ob is, ahem, a little special, and I know the specific study she discusses is about the US, but I think this was the one I was thinking of:

www.skepticalob.com/2014/02/new-cornell-study-shows-homebirth-has-4x-higher-death-rate-than-comparable-risk-hospital-birth.html

[VivaLeBeaver]

Shame so many nhs trusts have closed down their midwifery led units to save money. Can't see them being reopened to be honest.

[LaVolcan]

I suspected that you might come out with something like the skeptical ob, Chalala, someone who is completely biased, has cherry picked her data to suit her agenda, and based on US data where midwifery does not have the same status as in the UK.

The NICE recommendation however is based on the Place of Birth study which was rigorous and matched like with like to eliminate bias and didn't just set out to prove an agenda. If they had found that hospital was safer, they would have said so. A similar study in the Netherlands a couple of years earlier found much the same results. Both the UK and the Netherlands are countries with well trained midwives.

As to why hospitals are not as safe, it's a good question: IMO possibly it's because they are shunting women through, without really knowing them, so hospital protocol is overriding care and partly now staffing has been cut to the bone, so there is no-one around to be alert.

Just going from my own two births - I felt that the midwife attending me at home was just a bit more on the ball - no handy button to push if a problem arose, so she had to be that bit better, and she was also vastly more experienced.

[salonmeblowy]

Chalala, quoting the skeptical ob's view on the study of the safety of home births in the US in this context reminds me of today's BBC's article about the updated NICE guidelines, where they finished on an optimistic note by quoting Lucy Jolin of the Birth Trauma Association saying that it is not always safe to give birth outside of the hospital. I think this is what LaVolcan means by 45 years of conditioning.

Firstly, the guidelines are very far from recommending home births for everyone or putting pressure on women to give birth outside of hospitals. Currently, the situation is quite reversed where low-risk women are, for the majority, giving birth in highly medicalised settings. Opting for a home birth, far from becoming a norm, is still seen as very much an alternative way to labour.

Secondly, with regards to the US study, there are several factors which make it irrelevant for the UK population. Off the top of my head:

1. Home birth attendants in the United States may be inadequately trained in the US.
   
2. There are no firm criteria limiting which patients they should see, and so they may attend deliveries for high-risk pregnancies.
   
3. Lack of universal healthcare provision means that pregnant and labouring women are at the mercy what they can afford in terms of antenatal care.
   
4. Distance from and availability of tertiary obstetric and neonatal units - transfer times to hospital in case of emergency will be much lower in the UK as we are a smaller and more densely populated country than the US, with a significantly better healthcare system.
   

There is also a question of bias to be seriously considered in terms of US health service, where the majority of births are heavily managed and the use of epidural anaesthesia is ubiquitous. Obstetric practice in the US is driven more by litigation culture than evidence-based medicine, with doctors favouring early surgical intervention.

Giving birth is always risky. Allowing healthy women to make informed choices with regards to what happens to their own bodies during childbirth must be a step in the right direction.

[Chalalala]

Oh yes, she clearly has an agenda - part of the problem is that it's very difficult to find sources on the question that do NOT have an agenda, since it's such an emotional issue. Everyone cherry-picks their data. (Possibly including NICE, since I am not convinced they are free from governmental pressure... their previous report highlighted the very poor quality of the evidence available, and also highlighted a "small but potentially significant" trend in the data... "Our best broad estimate of the risk is an excess of between 1 death in a 1000 and 1 death in 5000 births. We would not have expected to see this, given that in some of the studies the planned hospital groups were a higher risk population." They've changed their mind since then based on one single UK-based study, but it still means that at one point they thought hospital births were marginally safer.)

Anyway, about skeptical ob - totally agree that she's a little nuts, but the Cornell study she cites does say what she says it does, as far as I understand. I take the point about it being a US-based study, though. And I also had a great experience in the UK with midwives. It's the level of ressources given to the midwives I'm doubtful about, more than about their competence.

I'll just add that my understanding of stats and medical papers is shoddy at best, so feel free to correct me

I guess my main point is that different people with different agendas say different things, so I've never quite known who to believe on the topic. And I'm a little paranoid that the UK's new-found love for homebirths happens to coincide with a push for cost-cutting measures. I hope it's just a happy coincidence.

[LaVolcan]

Yes, the 45 years of conditioning is the blunt statement ''home birth is not safe', which later became, 'small maternity units aren't safe' without a scrap of evidence to support this, with the ' stock what if it goes wrong' and nothing like enough attention to iatrogenic causes of things going wrong.

salon - you could also add that in the US the only midwifery which is legal is that of the nurse-midwife, who is not an autonomous professional, as midwives are in the UK. The status of the midwife isn't protected as it is in the UK so non-licenced people can practice midwifery. Such lay midwives may or may not be competent.

In the UK a high-risk woman can still give birth at home if she chooses and the health authority is supposed to send someone to attend her, so some high-risk deliveries do happen at home. But a UK midwife would be duty bound to note that she had advised the woman to transfer, a lay midwife in the US may not or would almost certainly not be in a position to do that.

But we are not discussing the high risk cases - the recommendations refer to the substantial numbers of low-risk cases, and I welcome it because at the moment many are getting a raw deal - shunted back and forth because they are 'not in established labour', left unattended because one midwife is trying to look after two or three others. I always feel that we took a wrong turning when we started to emphasise the place of birth and not the quality of the attendants. it doesn't matter how spankingly good the equipment is in a hospital if there are insufficient staff.

(Climbs down off hobby horse.)

[salonmeblowy]

I am not entirely sure following the recommendations would save any money at all. The transfer rate for nulliparous women is still very high int he UK (45%) and home births, even if uncomplicated, remain expensive for the NHS requiring two midwives per delivery.

I would hope (but perhaps I am biased because of my own agenda of wanting a home birth for myself), that at least some of the thinking behind the guidelines is to do with the fact that, as LaVolcan mentioned, UK's midwives are one of the best trained in the world, making the UK potentially comparable to the Dutch model, where 20% women give birth at home and where outcomes are excellent.

As I said above, childbirth will always be risky. But in terms of outcomes, an uncomplicated vaginal delivery with a healthy baby and a healthy mother (physically and mentally) at the end is the best and cheapest result all around, which is also perfectly achievable for the majority of healthy women with good midwifery support. It makes sense for NICE guidelines to promote environments where such outcomes are more likely, for those women who want them. Just to add, I also have no issue with women preferring hospital deliveries, epidurals, caesarean sections, since I do not see it as any of my business and respect other women's agency.

As for the SOB being nuts, she really understands nothing about the NHS if she thinks that the latest guidelines are all about promoting the economic wellbeing of midwives - quite aside from the shoddy medical research presented on her website, that particular quote gave me a chuckle. I, for one, find it hard to imagine our lovely midwives suddenly making a killing because the NHS is overrun with home birthing requests. It is a shame she understands so little about universal health service provision and its economics.

Quite how the new recommendations will work in the context of the shortage of midwives is another matter.

[Chalalala]

Hah yes I had the same thought about her stance on midwives! She may be competent about medical issues (or not), but she clearly knows nothing about our poor UK midwives.

In some ways I wonder if the home vs hospital debate is the wrong way to look at it, maybe the more important question is the quality of resources (human and technical) dedicated to each birth, whether they take place at home or in a hospital.

[Chalalala]

Btw sorry I didn't mean to derail this thread. Choice is always a good thing. (As long as it's supported with the proper information and resources.)

[LaVolcan]

Chalala - I personally don't think the Place of Birth study of 2011 had an agenda, or if so, it was to examine the evidence objectively. From memory, I think they had results from something like 65 thousand women, and I think they polled all the hospitals, but maybe a few didn't respond. So that can't really be called cherry picking data. I really do think that if they had found that hospital births were safer for all women, they would have said so.

I think it's a valid concern about staffing numbers - if more women are to be encouraged to give birth at home or in MLUs - they would have to increase the number of community midwives and reopen a good few MLUs, neither of which look like happening any time soon.

And as for the skeptical ob IMO 'charlatan' would be a better description than 'a little nuts'. The group making the NICE recommendations by contrast was chaired by Susan Bewley, Professor of Complex Obstetrics at King’s College London.

[EstRusMum]

Just wondering - when the statistics were done, did they count all the births that started at home, but ended up in the hospital as home birth or hospital birth? Because that way I would understand why hospital births are coming up as unsafe option.
Also I am worried that the guidelines will be abused by midwives and consultants and many women would be pushed to have a birth at home. My pregnancy would be considered as low risk, but I would never want to have birth at home. With new guidelines they could potentially say that this is what I should do.

[LaVolcan]

Yes, they counted the births that started at home but had to transfer intra-partum as home births, which is why the home birth stats show figures for forceps/CS which most definitely do not take place at home. Ditto for the MLUs.

I think your concern about being pushed to have a home birth could be valid, but it's such an about turn in policy that I don't think it will happen immediately. Certainly it did in previous times - my MIL had to fight hard for a hospital birth in 1959 because it wasn't her first. 10-15 years later you were treated as though you were a potential criminal for asking for a home birth.

[mythical]

Considering how hard some people have to fight for their right to have a homebirth i seriously doubt women will be pressure into them any time soon.

[salonmeblowy]

EstRusMum, we are honestly unlikely to see women being pressured into home births anytime soon. I know anecdote is not evidence, but I was a prime candidate for giving birth at home during my first and during this pregnancy, yet the option was never even mentioned to me, although I was under the care of community midwives for a large part of both pregnancies.

My DH is a medic and his NHS colleagues make no secret of the fact that they consider my home birthing choice, how shall I put it, unusual. The vast majority of his female colleagues preferred the predicability of a caesarean for their own delivery. One of my obstetric consultants, who I was seeing for an issue which has now been resolved, visibly winced today when I said I enjoyed childbirth and was looking forward to birthing at home. Still, she is smart and respectful enough to understand that there are no medical contraindications to my choice, even if our personal preferences do not align. They are all a million miles away from pressuring anyone to give birth at home.

LaVolcan, I found your opinion about prioritising the quality of expertise over and above the location of child birth immensely reassuring as applied to my own circumstances. Thank you.

Skeptical OB a charlatan, you say? But who will think of the poor babies that she absolutely must cut out of all the evil mothers, holding the foetuses hostage against their will in their suspect uteri. The woman gives surgeons a bad name.

[organiccarrotcake]

EstRusMum the stats from the Birthplace study were based on intended place of birth, so a birth planned at home remained classed as a home birth even if transferred, for the very reasons you mention.

Chalala - for mums birthing second or subsequent babies, the most severe outcomes were the same (as in death or severe injury or illness) but the less severe outcomes were very significantly improved with home birth or MLU birth. For instance, for planned home births or MLU births, the risk of a CS birth was about halved. Birth using forceps or ventouse, and other birth trauma and physical damage to mothers were significantly less out of hospital.

All this was the same for first time mums too, however, there was a very, very tiny increase in the most serious outcomes to babies which is sometimes described as 2x greater risk of babies dying if birthing at home compared to hospital or MLU (MLU still has same outcome as home). When the Birthplace study was first released this was the DF's headline of choice, rather than all the good stuff - and it wasn't even true.

In fact, it's yet again not that simple. The numbers of babies dying was so immensely tiny that there was no significant difference between those who were born at home or anywhere else. Only by combining those figures with a number of serious outcomes, such as meconium aspiration syndrome and many others, were the numbers made significant - from 5 in 1000 to 9/1000. 13% of these 9 were babies who died either in labour or within a week of birth. So about 8 of these 9 babies will not have died.

Compare some other stats:

Multiparous women:

episiotomy: 15/1000 (home), 23 (MLU), 35 (alongside MLU), 56 (OB unit)

CS birth 7 (home). 8 (MLU). 10 (alongside MLU). 35 (OB unit)


So for NO medical reason women who planned to birth at home EVEN if they ended up birthing in hospital) had a 7/1000 risk of a CS birth compared to a 35/1000 risk in an obstetric unit. That, my friends, is outrageous. Stats for CS birth in nulliparous women are significantly higher as is usually the case, at 80/1000 (home), 69 (MLU), 70 (alongside MLU). 121 (obstetric unit).

80 women in 1000 ended up with a CS birth who had planned to home birth. 121 who planned to vaginally birth in hospital, going in with the same "risk factors" had a CS birth.

That is why the 2x likely your baby will die headlines, and (indeed anything) what the "Sceptical OB" writes about a 4x risk is just meaningless, and does NOT inform us.

Part of any campaign is to increase MW numbers. Homebirth is cheaper than hospital birth - even with two midwives. Properly set up and run, it's cheaper on so many levels.

• Fewer hospital rooms needed, maintenance of which is hugely costly. Cleaning of a room, new sheets, etc, in labour and postnatal covers the cost of the midwife's additional hours with having two at a birth.
  
• Fewer CS births or instrumental births which are hugely costly
  
• Lower costs in follow up care of the women who were physically damaged in birth, say by a CS birth or episiotomy, etc.
  
• Less pressure on psych services due to women feeling more positive about their births when they go well (and more do, I'm talking over a community here)
  

Just to throw a few out there. There's many more.

[organiccarrotcake]

"For instance, for planned home births or MLU births, the risk of a CS birth was about halved. " Sorry - my own stats (taken from the NICE guidelines) show my mistake. It was about halved for first time mums. Second and subsequent was hugely different with massively better stats for homebirthing mums.

[emmahere]

And if anyone is looking for a brilliant social enterprise that is actually covered by insurance for giving birth at home privately - can I recommend the midwives who I used for the birth of my twins at home - Neighbourhood Midwives, who've also commented on the guidelines here neighbourhoodmidwives.org.uk/midwife-news.php

[ReallyTired]

The US has poorer outcomes than the majority of developed countries including the UK. The US spends more on maternity care, but has poorer outcomes for both mothers and babies.

The cascade of intervention is a massive concern. Sometimes excessive monitoring can cause more problems than they prevent. (ie. monitoring a mother so much that she can bearly move.)

I had two good birth experiences. My first child was born in hospital and my second was born at home. I am relieved that I chose a homebirth as dd's birth was so quick that we would have never reached the hospital in time.

I am not sure how valid stastics are as home birthers are a fairly select group. Women who opt for a home birth tend to be better educated (in that they have done their research), financially better off and possibly (?) more intelligent than the average UK woman. It takes a lot of confidence to give birth at home.

[LaVolcan]

Thanks for the link to the film. I have only seen clips before. I didn't know it was available on YouTube.

Why are there more interventions than necessary in obstetric units? IMO In the early 70s when the push was on to send women to hospital and a lot of the large hospitals were built, the technology was still quite new, and was introduced with perhaps misguided enthusiasm. (There was a good Horizon programme on this dating from 1974 which might still be available on i-player as part of 50 years of Horizon, showing selected progs.) Now I suspect it's because hospitals are so rammed with women giving birth, it's 'speed things up to get people out - we need the bed.'

[Chalalala]

I saw the movie on Netflix when I was pregnant with my first. It definitely opened my eyes about something I had never thought about before (I am from France, where birth is medicalised as a matter of course and epidurals are the norm - almost no midwives, everyone is followed by consultants. Similar to the US, but with better outcomes I believe.)

But reflecting on it now that I've had DD, it overstates the case a little bit imo. Mostly because it's focused on the US, and many of its points don't apply to the UK. But also more insidiously - it gave me this idea that birth should be natural, empowering, that I shouldn't need an epidural, etc etc. But then when I found myself needing pain relief and needing intervention, I felt a little cheated. And like it was my fault, too, that I hadn't done it "right". It's taken me a while to realize that it wasn't my fault, birth can be a shit experience and that's just the way it is.

That being said I do understand the need to overstate the case, when you are coming up against an unquestioned status quo.