Guest post: New birth guidelines - 'the idea of choice needs to become a reality'
New draft guidelines from NICE say that most mothers should give birth in a midwife-led unit or at home. Here, Louise Silverton from the Royal College of Midwives explains the evidence on which the guidelines are based - and argues that more midwives are needed in order for women to really be given a choice.
Director for Midwifery, Royal College of Midwives
Posted on: Wed 14-May-14 10:45:38
(22 comments )
Yesterday, the National Institute for Health and Care Excellence (NICE) published draft guidelines which recommend that more women experiencing 'straightforward' pregnancies give birth in midwife-led units or at home.
The major catalyst for this was the publication of the Birthplace report in 2011. This was an exhaustive look at how safe birth was for mother and baby, based on where they first received care during labour. These settings were hospital, midwife-led units (MLU) and home.
This is an important step from NICE. It marks the beginning of a shift, from a system that sees hospital births as the norm to one where births outside of hospital will hopefully be more common.
Currently around 96% of births occur in hospital. I'm not sure that this is the option 96% of women would make if they had a real choice – and real choice is important, because a woman has to be happy and comfortable with the environment in which she gives birth.
Some women may choose to give birth in a hospital in an obstetric unit led by doctors. Even there, most of the births and most of the care is delivered by midwives and maternity support workers. Others may want a MLU. These can be in hospital alongside obstetric units or can be stand-alone units out in the community, where the care is delivered by midwives without the involvement of doctors. There are doctors available to step in if any complications arise, but women will need to transfer to receive this care. Women report greater levels of satisfaction with MLUs than for hospital births: the care is often more personal and less medicalised, and women are less likely to have medical interventions such as caesarean sections.
There is therefore a great need to promote the benefits of midwife-led care and home births to women, and to dispel negative myths around them. Of course women will have concerns about giving birth outside of a hospital environment - for decades the official message has been that hospital is good and safe, and outside is unsafe.
Currently only about 2.3% of births take place in the home. Women giving birth at home are in familiar surroundings, often with family and their other children around. Being at home tends to help them relax more, which helps in labour.
All of these choices have pros and cons, which is why it's so important for women to know what choices are available and what they offer. Health professionals will help and advise, but ultimately it needs to be the woman's decision.
That's why it's essential to promote the benefits of midwife-led care and home births to women, and to dispel negative myths around them. Of course women will have concerns about giving birth outside of a hospital environment - for decades the official message has been that hospital is good and safe, and outside is unsafe. All births carry some risk wherever they take place, but the evidence shows that births in MLUs or at home are just as safe, possibly safer - for low risk women - due to the lower intervention rates. It also shows that although home births may not always be the best option for a woman having her first baby, the difference in risk between having a baby at home or in hospital is actually very small.
If a woman is having a home birth, the chances of transfer (before or after birth) to hospital in the Birthplace Study were 12% for women who had already given birth, and 45% for first time mothers. The vast majority of these transfers are not emergencies, they are controlled and organised. They are normally done because a birth is not progressing as quickly as expected or for pain relief. The same applies to births in MLUs (with rates of 9.4 and 36%). We have to remember that pregnancy is a normal body process - midwives are skilled at detecting potential problems and will take action early so that intervention, if needed, is at hand. In the study, even after transfer, most women did not need help to give birth.
Ensuring women are aware of these facts is one step in empowering them to make their own decisions around childbirth, but a number of other things also need to happen. Too often, the choices NICE recommends are not available to every woman, and too often, this is through lack of beds or midwives. There needs to be more investment in midwife-led care, midwife-led units and in home births. We also need to ensure that midwives in training get jobs when they qualify so that we have the right number of midwives to deliver these services. It is then that a choice that exists in theory will become a choice that exists in reality for all women.
By Louise Silverton
NICE also recommended that any woman who wants a CS should be able to have one.
The reality of how that has been interpreted by every NHS Trust in the country is different, leading to wide disparity in experience. Whilst in principle the idea is good, I do not believe that this recommendation will lead to an increase in choice for women.
Indeed, whilst it will help some women I also think I it will create the opposite effect, with women in some areas, being actively pressured down a particular route they don't want to go down, rather than being free to make the decision themselves due to institutions interpreting the recommendations to suit their agendas rather than that of women. The way the recommendation is worded puts power in the hands of institutions rather than women themselves.
I feel the wording is hugely important - unfortunately I can't help but feel that the outcome is that women are not really being given a choice when the word 'advised' comes into the equation. It won't be long before targets for this are brought in and questions will be asked about why certain Trusts aren't achieving 'a high enough' take up of the advice increasing pressure on midwives to put it harder. This then conflicts with the principle of undue pressure damaging the validity of consent. It damages the trust between women and midwives when women feel pressured.
I would like to see far more emphasis placed on encouraging choice and giving information - without a preference being expressed - by authorities. Pressure needs to be placed on institutions to support women regardless of their preferences for where to give birth, rather than pressure placed on women to consider a particular pathway. Awareness rather than advice, which has a proven record of being misused in a paternalistic fashion against, rather than for women.
I don't think there is much real understanding within the establishment of what is woman centred care and how you go about achieving that without pressuring women. There are a few hospitals achieving this, but too many fail to properly understand the difference between 'advising' and 'telling' women.
Until this is understood properly and the highest level of the NHS recognise the problems, misuse and disparity of care that many of these recommendations are creating on a local level then I don't think we will achieve the free choice that lie principally at the heart and intention of the recommendations. They are all too often lost in the translation at point of service. Its very sad.
Great post. Though I'd never choose a homebirth or myself, I support every woman's right to do so if she wishes. High risk women included.
This, however, sounds like someone's idea of a cost cutting exercise. It's telling that they try to minimise the greater risks for primagravidas, and that so little mention is made of pain relief. I agree we need more MLUs. We also need sufficient anaesthetists to ensure that my experience and that of other posters, ie being denied epidural due to resource constraints, stops happening. NICE should also mention that, because the fact is that we need more investment in maternity services generally!
I think this is wonderful news, and RedToothBrush's points are also important: there is always the danger that legislation can be twisted by institutions in order to override a mother's preferences and therefore if women are to be empowered by a new ruling like this, the wording is crucial.
100% agree with red here. The NHS in some respects can make C section Mums feel like second class citizens. this push towards homebirth might endanger some women. Even small details like distance from a hospital can make a massive difference to baby and mummys health. It is NOT about choice lets be clear, its about the NHS chosing for mums a certain method of delivery.
whats the saying? mother knows best... we should be respected to know our own bodies and minds.
I had an awful time with my first and ended up with an EMCS. Hate to think what would have happened if I'd been at home. First time mothers should NOT be encouraged to have home births IMO.
I'm with Chunderella, sounds like cost cutting to me as well and does fail to address pain relief choice: if they are going to have anaesthetists at the midwife-led units, then ok. Otherwise this is not acceptable, how is a reduced set of options a statement of choice?
Birth should be a wonderful, positive time for mothers; real choice isn't rocket science and the failings are still frankly embarrassing.
Redtoothbrush and chunderella are amazing CB posters/experts....
How is telling women that they have three possible options Home/MLU/CLU a reduction in choice if prior to that they thought the only option was a CLU (or if you are in a city a choice between CLUs)?
Granted that in many cases there is no MLU so it's one option which doesn't exist.
"(NICE) published draft guidelines which recommend that more women experiencing 'straightforward' pregnancies give birth in midwife-led units or at home. "
its not about choice its about pushing one agenda over another. for more read targets, ethos changing, etc etc.
its all in the wording.
NICE recommended that women who requested an ELCS and were turned down should be referred to another Consultant. Was that also seen as pushing an agenda?
On the whole people on MN seemed to view that recommendation positively. This recommendation they seem to view negatively, and I wonder why.
Not that the CS recommendation was necessarily implemented.
... as Red's very comprehensive post above explains.
Because there's a difference between saying more of a certain type of birth should happen, and that women who have already decided on one type should be able to get it. This would be fine and dandy if they'd said that all women ought to be given better information about homebirth, and/or better access to it.
Ah yes, I see the difference. However, since it seems that the CS recommendation can be ignored, I have no doubt that this one could go the same way:especially with regard to MLUs. Trusts have been busily closing them down, I can't see them rushing to reopen them.
Yes, obviously this may be completely ignored. There is that.
Having said that, if the experiences on this board are anything to go by, I get the impression most women who really want a CS and have the tenacity and ability to apply the right pressure manage to get one. I'm not saying everyone does, but there are buttons to press. Like a lot of things, I think it's probably about system navigation skills.
What Red said. Just because women are pregnant doesn't mean that they suddenly become incompetent to make medical decisions. They should be properly informed about all options and given a choice.
I think there are ways in which it could be made much easier to make a choice. I think all these recommendations will do will be to set up preferred pathways, which are difficult for women to deviate from.
Why is choice not currently easy for women, needs to be looked at. I don't think its just about a culture which decides what is 'safe'. Its also about how the system itself works and tries to restrict choice, either actively or inactively, to get women to comply with which ever option suits HCPs best. This cultural definition of whats 'safe' is one that has formed not just because of faith and belief in hospitals but also because it suits HCPs to process women routinely down a particular prescribed pathway. Its convenience within the system that has become ingrained and often has nothing to do with whether its 'safe' or not. Its just an excuse.
We already have a system where you are supposed to be able to choose where to go. In reality if you make a choice, you are often making life difficult for yourself in a variety of way. I have chosen a CLU in another Trust, rather than my local one and its a massive pain in the backside, despite coming across midwives who have been supportive of this. However when I've read comments from other women, who have chosen to go somewhere outside their local Trust, they don't always get the same reaction and in some cases, have come across rather hostile and territorial HCPs who seemingly 'don't approve' of their choices.
I've found it difficult to work out when and where I am supposed to get community midwife appointments and its hard for the hospital to help me, because 'they don't know whats normal in my Trust' and my community midwives, haven't been sure when I need to be sent for X appointment, because they 'don't know at how many weeks, the hospital I am at normally does it' because it apparently differs between Trusts.
Then there is notes. Why on earth, there is not a standardise format nationally for maternity notes, is utterly beyond me. It just makes me realise we really don't have a National Health Service. All it does is highlight just how much we have a regionalised health system, with next to no connection with neighbouring areas. Indeed I think it encourages rivalry rather than cooperation. I've had to guide my community midwives through my notes as they have struggled to find information as they are not used to the format of my hospital's notes. At best its frustrating, at worst its potentially dangerous. It begs the question why would midwives support you going somewhere outside their normal patch/pathway, when they themselves struggle?
And finally, there is funding. I personally haven't had a problem with it, but I was talking someone on MN in a similar situation to me, who had enormous problems navigating the system, and even more difficulty with her ante-natal appointments, because despite being given the choice of hospitals at her booking in. Her local Trust was refusing to provide standard midwife appointments with their community midwives, because she was planning to give birth in another area. She was told it was because money would only go to that Trust and not to them. And the hospital she was at was unable to provide them either. Her GP has stepped in and said they will do them, after being told of the situation (and being shocked at it).
This is why I am very sceptical of how recommendations will benefit women, as I do feel, that the best it will achieve is to change one preferred route for the system with another, without involving or helping women in the process.
Its the way its directed and the obstacles that you face in making choices that are as important as the cultural ideas of where is 'safe' to give birth. Really simple changes which make it easier for women themselves to choose. Its currently an incredibly un user-friendly set up all round for anyone who doesn't just want to do what they are told. Its really has lost sight of who its there for and who its supposed to help which is really the core problem. At the moment, its just set up to serve the individual Trusts and their interests and this recommendation won't change that. All it will do, will give them another opportunity and means to tighten their budgets, which I fully expect them to take advantage of unfortunately.
I have spent some time pondering this issue. In practice, I would be surprised if it made the slightest difference to what the trust/health providers decide to offer, so those who don't like the recommendation needn't get upset and those who think it's a good idea needn't get excited.
I say this because I vaguely remember that the Government had promised that a 'choice guarantee' of home/MLU/CLU would be offered (depending on the woman's circumstances) by the end of 2009. Yet the Place of Birth study reporting in 2011 showed that 49% of Trusts only offered a CLU. So much for a guarantee. If that could be ignored I would imagine that this will apply even more so to a recommendation.
(Yes in theory anyone can have a home birth, but some trusts have a 1% rate while others have ~10%, suggesting that only the latter really offer a choice.)
This is not really about choice, it's about saving money.
In reality, women accessing NHS maternity services have less choice than patients in almost any other setting. Can you imagine a cancer patient paying to go private just in order to ensure access to adequate pain relief?
Women should be able to have any kind of birth they want (assuming they are informed of all risks): home or hospital, VB or CS, with or without pain relief. This is so far from the current situation that it's barely worth discussing and all this latest move will do is pressure women to give birth at home in order to save the NHS money.
To cope with increased home births and make it an effective service they would have to beef up Community Midwifery, which would cost money rather than save it. I can't see that happening.
I know I am cynical but I think they will just carry on squeezing more women into CLUs without increasing the staffing and keep cutting to the bone, and keep their fingers crossed and hope for the best. If you think of the grim state that postnatal care is now in: a generation ago women stayed in for 4 -10 days as a matter of course.
BTW I am not sure that NHS Maternity services are the only ones starved of cash: the services for elderly patients can be pretty crummy.
I am hoping for a home birth for my first baby but I haven't been able to really discuss it. My midwife was very dismissive and I have no idea where to take it next. I am unfortunately on the border of a few risks - so I am overweight (although not hugely) and I will be 35 by a week on my EDD.
I am not dogmatic about it but it is my preference and I would at least like somebody to take the time to discuss it with me. I feel like I'm on a terrifying treadmill to a high intervention birth and it's stressing me so much. If I give birth in a hospital I will probably have to do so alone.
Sorry I'm not adding much am I?
LaVolcan yes and mental health services. All the services where people are so desperate (and perhaps not fluffy news story material) they will 'settle for less'.
I agree: choice is all well and good on paper but we need the funds to back up the recommendations with proper facilities and staff!
But home birth trained midwives ...cost money.
MLUs ...cost money.
Gynie surgeons to perform c-sections ...cost money.
...so there will be a lot of women who know what they want/need and realistically may not be able to access it.
The CLUs are already up and running so on the surface seem not to be expensive. Well, not unless we recognise they don't have to be mucky, understaffed and run down! Because they are chock-full and over stretched, if they are to help the 'higher risk' women who really need them... it will cost money!
Too many stories of women - who might be the very ones who need an eye kept on them- abandoned in the CLU left to get on with it by rushed staff - or knee jerk reactions re intervention because of pressures.
Some people are of the opinion 'well CLUs are crap - that's just the way it is' ... easy to say for those who can only use HB or MLU facilities but cold comfort for a high risk woman who wants a vaginal birth but at the hospital.
Splendide the 35 thing really shouldn't be too much of a problem if you are otherwise in good health.
Although again... that seems to vary and be used as a fob-off by HCP from place to place... London no one bats an eyelid, other places they act like it's 85 not 35!
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