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.

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I think that there is an element of truth that fear can make pain worse. However it is naive to think that labour is going to be a flowery pain free experience. Childbirth was known to be painful thousands of years ago when it got a mention in Genescis as a curse for Eve eating the forbidden fruit.

I think it is best for a labouring woman to delegate worrying to a highly trained midwife. I feel the birthing enviroment has a huge psychological affect on a woman. The language that medical professionals use can either put a woman at ease or terrify her! I feel that helping a woman be relaxed increases the chances of a good outcome. Women need choice and to be listened to. As well as offering home birth we need to look at improving hospital care.

I agree that the film "the business of being born" really applies to the U.S.
However it does show the impact of excessive medicalisation.

I'd like to say that I was pleased to see them recognise that there should be one midwife per woman. But - hasn't just about every report for the last 20 years or more recommended this, with the situation getting worse not better over the years?

What worries me is that "women are offered full range of birth place options" is going to become "women find it difficult to get a straight answer as to what the consultant/midwife/other appropriate HCP would recommend as he/she is afraid it will be seen as trying to pressure them into making a particular choice."

I had the choce of ELCS or VBAC for DC2. I was perfectly aware I had that choice. The consultant kept telling me it was my choice. Great. But I wanted to know what he thought my chances were of VBAC actually working for me. Took me about ten minutes to get him to say that he thought my chances were pretty darn small, maybe 10%? I had the ELCS, no regrets.

As privatisation in the NHS England (business brand) we see the rise of 'associate doctors' who are less qualified It's no surprise that women are being encouraged to give birth at home.

Obviously, fully qualified doctors and hospital births will be available to women who can afford private healthcare.

I choose to have an ELCS. So you'd think I would be a fan of the sceptical ob.

Far from it. She's crackers. And twists stories to suit her agenda rather than looking and being critical of research properly. Its not helpful to women.

The place of birth study has a number of flaws but on the whole is pretty robust and a good piece of research. I think these recommendations are good in principle but I really do worry about how they will be viewed by hospitals.

Childbirth is so heavily politicised I can't help but fear what will happen.

The 2011 guidelines on maternal request cs are being widely ignored and ignorance on the subject is still endemic amongst even HCP. I can't help but think existing prejudices will still remain and/or women will find themselves not listened to and forced into a birth location they don't want.

So whilst there the guidelines are a massive step in the right direction and acknowledge that choice is important to women, I do worry and feel that the problems in maternity are deep rooted in attitudes of 'telling' women rather than listening to them.

I have a unique perspective as I had my first in the UK in the MLU and had my second two in the US at home with licensed certified professional midwives (CPM). I've also been in-training to be a CPM for the past 4 years, so it's always a huge passion that I have to make sure that the midwives that are extremely competent and experienced get notice. The process for training here is different as the traditional apprentice model is still being used by the governing body that oversees CPMs. There is talk of there being a change in the certifying process that will require all student midwives to attend an accredited midwifery institution along with their apprenticeship (where as right now there the ability for students to complete all of their training through self-study and years and years of apprenticing with an experienced preceptor). Our variation of MLU are "birthing centers" that are becoming a lot more popular and are getting coverage from insurance companies.

Homebirth here is still considered very "risky" by a lot of the medical establishment and a lot of people don't even know that it's legal! Our rates of homebirth in the state I live in are .9% of all births, but midwives here are SO busy! (Where I live it is legal for both CPMs and CNMs to attend, but there are still 5 states that consider homebirth completely illegal, some states will only allow nurse-midwives to attend homebirth and CPMs are illegal, so many discrepancies around the country!).

I do very much agree with what LaVolcan said in that transferring in the case of an emergency is much harder than what it's like in the UK. There are very few "midwife-friendly" doctors that we can consult with and there is 1 major hospital that tends to be more midwife-transfer friendly than others where I live. This is very different state to state (OR and WA for example are getting homebirths completely covered by insurance and doctors are opening their own birth centers with midwives, they are collaborating it seems very much like the UK set up and needs to start happening more all over the country!). We tend to have a problem with doctors either a) not knowing the facts of midwifery training or the safety of homebirth so there is hostility that way or b) view midwives as competition that are taking their business away. Both of which we run into and there is always that fear of transferring a client into a hostile environment where either we as midwives are mistreated or the client is mistreated due to her original choice of birth location. I have personally seen some horrible things done to mothers who ended up having their baby in the hospital due to a non-emergent reason (long labor, exhausted, slightly elevated BP, etc). It's a constant battle to have to prove that midwives (CPMs especially) are competent and autonomous experts on normal birth. We do have a very specific set of practice guidelines that we follow and update annually that spell out what our scope of practice is and what the screening process is for anything considered high-risk and unsuitable for homebirth, we have a stringent peer-reivew process that we must follow, there are professional non-profit organizations that meet quarterly, we are attending continuing education workshops and reading studies, licensing is happening in more states... I just wanted to make sure to point out that not all midwives in the US are nurse-midwives, nor are they just "lay midwives" who decided to hang up a shingle after attending 2 births. CPMs are legal and many are licensed!

RedToothBrush - I have to agree, other guidelines are being ignored, so will this be any different?

However, the woman who is prepared to stand her ground can now say 'NICE recommends this', which at least puts her in a stronger position to argue her case than she would be without that recommendation.

With a CS, the woman can ask to be referred to another consultant, if she meets a refusal the first time. The woman who wants a home birth/MLU birth could argue back against a blunt "It's not safe". No doubt it will then become and argument about her risk level, but at least the argument is starting from the position of the woman's health, which is a step in the right direction.

This is about cost-cutting saving the NHS money.

However, the woman who is prepared to stand her ground can now say 'NICE recommends this'

You're right in theory, but (like for C-sections) I just don't know how much it will help in practice. How many women even know about NICE? I know that if I hadn't been reading the posts of much more knowledgeable posters on mumsnet, I would have no idea what NICE is, and no idea that I can use it as an argument to stand my ground with a consultant. I probably would just have meekly agreed with whatever the doctor told me I should/shouldn't do...

I think RedToothBrush is completely right in saying that it probably still won't be about giving women a real choice. It'll be about telling them what's best for them, even if the definition of "best" has shifted a little bit.

So if MLU/home births offer a safer option for 45% of women and it happens to be cheaper, isn't that better use of resources and something of a win-win situation?

Or do we carry on with overstretched hospitals? The woman who can't get over the threshold of the hospital because they are too busy and is sent home again is being attended by no-one. The midwife running between three women in labour is only attending the woman she is with at that moment, so the other two are unattended.

EssexMummy123 - "This is about cost-cutting saving the NHS money."

That sounds like you think it's a bad thing? But if in any other area of care the offering tended to be limited to a poorer outcome and higher costs, we'd think the world was nuts.

This is a very powerful carrot to persuade the commissioners to commission a full range of services (which the old NHS system has supposed to have been doing since Changing Childbirth) and I am delighted.

I have few concerns that women will be bullied into home birth if they don't want it because the pressure of defensive practice would make that a Really Stupid thing for any HCP to do.

I think home birth is a good option in an urban area where a transfer to hospital can happen quickly if needed. Although my transfer took much longer than it should have done, as they were short of ambulances - that part was a bit scary. But from a practical point of view, I'm not sure how many mums-to-be in London and the south east live in accommodation with enough privacy. Would you want your neighbours hearing you in labour?

Phineyj you would be surprised at how much noise you can get away with without upsetting your neighbours. My ninety year old neighbours both gave birth in the east end. My street all got really excited when I gave birth. Another neighbour had had a home birth 3 weeks before me and I heard very little.

Giving birth isn't any noisier than sex. Most women do not scream their heads off for hours on end. Even if they do scream or swear briefly it doesn't matter. Occasionally you hear screaming or swearing in the street.

I think it's a positive thing that home birth is being recognised as a safe option for many women, however it's important to realise it does carry some risks.
For the majoritof my pregnancy I was low risk, and planned to give birth in a MLU however I then developed pre-eclampsia - the warning signs were there 2 weeks before anyone did anything about it. Therefore I gave birth in a consultant led unit after being induced.
If a woman is giving birth at home, I think it's vital they are closely monitored, and thresholds set for transfer.

OP - the stats you quote which compare "like for like" on risk factors: do they exclude women who have an epidural? As an epidural is known to increase the risk of CS.

If not, then I would assume the increased chance of a CS in a labour ward vs home birth/MLU, for equally "risky" mothers, is down to the increased use of epidurals.

I had my first baby on Saturday at home. We live in a semi, and I did warn the neighbours I was having a home birth (they are expecting in January, so no problems there) it was a really positive experience, I had a birthing pool in the kitchen and had a very calm 12 hour labour, no noise, fuss or screaming - very chilled out. I had 2 amazing midwives, and a student midwife who was fantastic. I was transferred to the local hospital afterwards as I needed stitches, and I lost a bit of blood, but it wasn't an emergency, and I chose to stay the night on the post natal ward to get some help establishing feeding and again the midwives were really helpful. As with all these things, it's down to the individual to make their own choice and hopefully now there will be more options for people to consider.

Do the stats take into account the temperament of the mother? Excluding women who have an epidural is quite easy to do. However a naturally anxious person is unlikely to choose a home birth. I believe that some people have a far more laid back temperament. If fear and anxiety leads to birth complications then would you expect naturally anxious people to have a higher incidence of traumatic births wherever the births take place.

I hope I have not upset anyone by suggesting that fear tenses up the body and screws up the birth process.

I knew the midwife who delivered my baby at home. It reduced fear as there was already a professional relationship. May we should have domino care for women who need a hospital delivery. The midwife would do antenatal care, come to the woman's home in early labour, accompany her to hospital, deliver the baby and then do post natal care.

I realise this is no great contribution to the discussion but I saw this headline and I want to say thank you for such an interesting thread on the topic, it is helping me to understand a lot more about it.

Personally, I hope this will mean that, at least with time, women will feel like there are more options or be presented in better detail what the options are. In my first pregnancy I was adamant that I'd want to be on the labour ward, "with the doctors". When I went to the antenatal class at the hospital around 32 weeks I learned all about the MLU which is in the same building. I left with a much better understanding and then realised that was my preferred option and the best of both worlds, in my opinion - midwife led, but based in the hospital to calm my nerves about transfers. I was very happy birthing there.

On the other hand I was very frustrated in the class because they wouldn't say anything about the labour ward, clearly preferring that women choose the MLU.

I'm now in my second pregnancy/birth however and this time around they have been much more open to all different possibilities, be it labour ward or MLU, epidural or G&A, and so on. I would really hope that all women could get this standard of care and respect for their preferences, as well as the opportunity to understand what the options are.

I can only offer my own experience, which hopefully will help other women deciding which birth to choose.

As a healthy mum with healthy pregnancies, I thought about homebirth many times. I thank God every day that I didn't do it. I would have certainly lost my third child, and possibly my first too.

My second and fourth would have been absolutely fine as a home birth.

Ultimately nobody could have predicted the complications that arose from the birth of my third son. It was a matter of seconds, there was no way on earth we could have got to even an ambulance let alone near a hospital in the time required to save his life. Nothing to do with interventions of any sort, before someone jumps in with that one....I don't want to go into details of it, but it was just one of these things that does happen now and then.

I would say that it will be fine in most cases but looking back I am so glad I did not chance it as I could not have lived with the consequences - if you can live with the small risk then go for it, as the statistics are stacked up in favour of everything going well xx

Do the stats take into account the temperament of the mother? Excluding women who have an epidural is quite easy to do. However a naturally anxious person is unlikely to choose a home birth. I believe that some people have a far more laid back temperament. If fear and anxiety leads to birth complications then would you expect naturally anxious people to have a higher incidence of traumatic births wherever the births take place.

I think this is a really good point. My biggest bugbear about hospital births is how utterly crap the care is for women in early labour, which ramps up anxiety hugely and is bound to affect outcomes. Many hospitals won't admit a woman until she is in active labour which is just brutal really, involving fruitless journeys to hospital only to be sent home again, or else left panicking at home with no professional care until being allowed to come in. The domino system which provides support at all stages makes much more sense.

There are certain conditions like a prolapsed cord which are invaraibly fatal with a homebirth. However patients with risk factors for a prolapsed cord are strongly advised against homebirth. The risk of prolapsed cord is why breech babies are usually delieved by c-section.

However fatalites do happen in hospitals as well. The fact that there are not enough midwifes to give women one to one care means that problems are not picked up as quickly. I feel the policy of not admitting women until the very last minute is a huge risk.

My SIL give birth in the hospital lift because she was deemed not to be in labour. If she had experienced any complications en route then the chances of either her or her baby surviving would have been less than a homebirth.

If fear and anxiety leads to birth complications then would you expect naturally anxious people to have a higher incidence of traumatic births wherever the births take place.

I think that there is a certain amount of evidence which would be consistent with this theory, but I don't think its been 'proven' as such. I've seen a couple of studies along these lines, so it does seem to suggest there is a certain amount of self selection going on which we shouldn't discount as a cause of differences between home and hospital births. I'm not sure just how good the studies below are but they certainly do raise a few worthwhile questions if nothing else.

The influence of women’s fear, attitudes and beliefs of childbirth on mode and experience of birth - Helen M Haines, Christine Rubertsson, Julie F Pallant and Ingegerd Hildingsson 2012 reported this:

Three clusters were identified – ‘Self determiners’ (clear attitudes about birth including seeing it as a natural process and no childbirth fear), ‘Take it as it comes’ (no fear of birth and low levels of agreement with any of the attitude statements) and ‘Fearful’ (afraid of birth, with concerns for the personal impact of birth including pain and control, safety concerns and low levels of agreement with attitudes relating to women’s freedom of choice or birth as a natural process).

At 18 -20?weeks gestation, when compared to the ‘Self determiners’, women in the ‘Fearful’ cluster were more likely to: prefer a caesarean, hold less than positive feelings about being pregnant, report less than positive feelings about the approaching birth and less than positive feelings about the first weeks with a newborn.

At two months post partum the ‘Fearful’ cluster had a greater likelihood of having had an elective caesarean; they were more likely to have had an epidural if they laboured and to experience their labour pain as more intense than women in the other clusters. The ‘Fearful’ cluster were more likely to report a negative experience of birth. The ‘Take it as it comes’ cluster had a higher likelihood of an elective caesarean.

Another earlier study in Sweden from 2011

Found that fear of childbirth affected obstetric outcomes and increased the frequency of emergency and elective cesarean sections. Induction of delivery was more common among the women with fear of childbirth (16.5%) as compared to the women without this problem (9.6%). Women with fear of childbirth who were scheduled for vaginal delivery were more often delivered by emergency cesareans and they also more often requested elective cesarean delivery.

Its all also very consistent with observations and theories from pro-natural childbirth campaigners with regard to the importance of oxytocin and being relaxed in childbirth.

So I do think its VERY important we don't get too carried away with pushing women down certain routes, and really do get to the heart of why there is this difference between home and hospital births in seemingly comparable low risk women. .

I think its great to support women at both ends of the spectrum, and I also feel ELC should be open to more women.

How a woman feels when going into labour is crucial, if she feels safer at home, brilliant....if she feels safer with an elc, so be it.

At the moment ELC are looked on as a drastic option at the high end of the scale.

I would argue a difficult birth, significant blood loss, use of forceps, stitches below are drastic.

ELC should be considered a normal option along with supportive home birth.

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So I do think its VERY important we don't get too carried away with pushing women down certain routes, and really do get to the heart of why there is this difference between home and hospital births in seemingly comparable low risk women. ."

I think we need to look at how to make pregnant women happy. Better ante natal care with the time to discuss issues would empower women. I feel uncomfortable with the natural childbirth bridge bullying women into a particular option. I feel uncomfortable with the suggestion that homebirth is reckless.

I think we all want to avoid crash c-sections or instrumental births if possible.

It's a pity that this debate is becoming one on home vs. hospital, when the recommendations strongly featured the role of MLUs.

I was part of a group fighting hard to keep the local unit open a number of years ago. We won that time, but because of the constant "it's not safe, what if it goes wrong" attitude, women were still steered away from it, usage didn't increase, so on the next cost cutting round it was closed, (and our group had disbanded and no one else took up the fight). No matter that not a penny was saved, the facility was lost, and I can't see them re-opening it in a hurry.

If there had been the evidence to say that yes, they are safe options for a significant number of women, then maybe it would have been better used, and our maternity services wouldn't have come to the pretty pass that ReallyTired describes in her post of 9:46. It's worth repeating that at present a significant number of women are not being attended at all because they can't get admitted, or they are left alone because the staff are overstretched.

You might say that the midwives aren't there - but when the local unit closed, some midwives left altogether because the travelling to the main hospital and back on top of a heavy shift was more than they could cope with.

I got involved with this group because I was one of those women forcibly steered away from using the MLU and I am 100% certain that I would have had a better standard of care if I had been able to use it.

On a separate issue: a piece of research that I would like to see done would be a comparison between CLUs. Are there some which have similar results to MLUs/home births? If so, what are they doing to achieve this? What about those units which have high intervention rates for low risk women - why? Lots of questions needing further probing.