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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good post AdamLambsbreath

I also feel safer in hospital, for my own reasons, and I've also felt judged (not on this thread) for having an epidural. Then women who choose homebirth feel judged for being unsafe, and that's not right either.

Isn't it sad that everyone feels judged and criticized, no matter what option they choose.

I was classed as low risk and told to go to the stand alone MLU and the MW tried to encourage a homebirth. I went to the hospital as I was desperate for an epidural after 8 hours at the MLU, ambulance took 50 mins all together. I had been there 15 mins wen my placenta started coming away, I was rushed to theatre put under GA and had an EMCS, if I was not there my daughter would have died.

Hospitals are safer, but if people know the risks home births are nicer

Thanks chalala

It is sad that women feel judged. Why one earth anyone who isn't a health professional would feel they can categorically say what other women should do is beyond me.

Luckily in real life, everyone I know who's pregnant or has kids has been supportive of each others' birth choices. Even when they're very different.

Hospitals are safer,

Except for a significant minority, they are not.

but if people know the risks home births are nicer Not necessarily.

Why on earth would a hospital not be safer? For an emergancy in which that baby needs to be out ASAP, where is the place they can offer that? For monitoring to ensure mum and babys safety where do you need to be? How can your living room possibly be safer than a room filled with heart monitors, doctors, pedestricians and the ability to get into theatre within 5 mins if bAby urgently needs to get out? If your newborn baby stopped breathing would you say 'homes are safer lets not go to hospital' ? Because just because you are 'low risk' doesn't mean that won't happen.

Home births are lovely and I would have loved to have had one but as I say if you no the risks, I was filled with 'low risk - everything will be great, you should birth at home it will be quick like yor first baby.. Better nicer safer' ECt so when my baby literally did have minutes to get out of me to survive it was a real shock. I wasn't given risks told to me as I was 'low risk' and I am greatful every day that I was in hospital or my dd would probably not be here.

It's a personal decision but I don't think people should be pressured into homebirths without knowing the full risks they are facing in doing so.

The study and a lot of these threads go through why a hospital isn't always safer. And I don't think women will be pressured into homebirths, more that hopefully everyone will have their decision respected more.

"What do the draft recommendations say?

The draft recommendations say that low-risk women (women without medical conditions or other factors that put them at increased risk) who have given birth before should be advised to plan to give birth at home or at a midwifery-led unit (freestanding or alongside).
"Alongside" midwifery-led units are based at hospital sites next to traditional obstetric labour wards, while "freestanding" midwifery-led units may not be at a hospital site.
Low-risk women who haven't given birth before should be advised to plan to give birth in a midwifery-led unit (freestanding or alongside). This is because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit.

How is risk assessed?

NICE has published a number of tables listing factors that may increase the risk of complications during birth and require admission to an obstetric unit.
These include having:
a chronic condition such as asthma, lupus or epilepsy
certain ongoing infections
a previous history of pregnancy-related complications, such as pre-eclampsia
risk factors that make the pregnancy more likely to develop complications, such as if the mother is expecting twins or the mother is obese
Your midwife should be able to provide more detailed advice about whether your pregnancy is low or high risk and why this is the case.
But the final decision about where to give birth is ultimately yours. You will never be forced to give birth at home or at a midwife unit if that is against your wishes."

Continuous monitoring forces the woman to lie on her back. It is hard for women to birth in a good position and be active in a consultant led unit. Women giving birth on their backs causes unnecessary problems. It makes the second stage slower and more likely that an instrumental delivery will be needed.

Why don't hospitals have better out comes for low risk second time mothers?

but this is turning into "homebirths are dangerous" / "no! hospitals are dangerous" again... the thread (as I understand it) is not meant to convince anyone that their choice is the wrong one, it's meant to celebrate the fact that women get to choose what they feel is best for them.

but this is turning into "homebirths are dangerous" / "no! hospitals are dangerous" again...

Of course, there are women for whom either statement could be true.

"Why don't hospitals have better out comes for low risk second time mothers?"

I was musing about this thread and that question overnight. I think there could be a number of reasons:

A lot of the large maternity hospitals were built at a time when there was still a feeling that we could improve upon nature. Think back to O'Driscoll in Ireland at that time who 'promised' women giving birth in his hospital in Dublin that no woman would have a labour of more than 12 hours. Now I am sure that almost all women if given a choice of "would you like a 12 hour or a 60 hour labour?" would say, "yes please" to the first option. What they weren't being told were that to do this, their waters would have to be broken, the syntocinon drip would be turned right up high, so they would need an epidural, become immobile, need forceps. If they had been fully informed, they might well have said, '"no thanks, that's not an improvement, I'll see how I get on first." Also the cynic in me says that since the smaller hospitals had been closed down, it was a way of managing the flow of women through the labour ward.

We are now finding that when it works at its best, we do not improve on nature. E.g. We now find that its beneficial for the baby to have the 'gunk' squeezed out of it as it progresses through the birth canal. More recently we have begun to discover that this also exposes the baby to the mother's vaginal flora and has important benefits for beginning to establish the baby's immune system. I have not explained this well, but this is still quite a new understanding.

Another reason: we tend to follow the Americans (rather too slavishly IMO). They had lost their midwifery tradition, and had an obstetric driven system with money as an important driver. Whereas until the 1970s at least we had a well regarded domiciliary service. I do feel that we virtually squandered the expertise of our district midwives, and didn't necessarily put anything better in place.

Some of the problems are lack of continuity of care, but I am not sure that this is the whole story because not all home birthers get continuity of care either.

Another surprising finding to me was that stand-alone MLUs came out as being as safe an option for low risk first time mothers. I wonder why this is?

Just some thoughts - I am sure there is no one answer. Personally I would be glad if this advice was implemented because I think it could have benefits for all women - low risk women could chose home/MLU without the emotional blackmail which (used to be) involved, thus creating less pressure in obstetric units for the higher risk women to get more attention.

but this is turning into "homebirths are dangerous" / "no! hospitals are dangerous" again... the thread (as I understand it) is not meant to convince anyone that their choice is the wrong one, it's meant to celebrate the fact that women get to choose what they feel is best for them.

^^This

This thread started off as a celebration that women now had support for whatever choice they might make. Here's the OP:

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 agree completely.

There's no right or wrong, it's RELATIVE. It's what's right or wrong for an individual person, given their feelings, circumstances and experiences. And we need to stop telling other women what they should think and what they should choose, just as each of us would want to have our own decisions respected rather than being hectored.

I'm now hiding this thread because it's just going to bang on along the same old lines with a few people arguing that Their Opinion Is Right. Not everybody, but still, there are hobby horses being ridden around here and the thread's just going to keep returning to the same 'No, this fact says hospitals are dangerous!' arguments.

You'd think that choosing a homebirth when it was a decision you had to fight for would make people want more tolerance and choice, but apparently not. Apparently it means that as soon as the evidence suggests homebirths are 'better' you turn right round and start judging back the other way, and making women who choose hospital feel like they're doing wrong.

Thank God the real world is nothing like this.

I think that people have quite passionate heated opinons on childbirth. Anything that relates to the safety of small childen is going cause passionate arguements. Just like arguements over private education or breastfeeding, people making different decisions is going make other people feel insecure. People sometimes see judging going on where there is no judgment.

Given that only 2 to 3% of births are home births nationally, I really don't think that there is any danger that women will be forced to have a home birth in the near future.

"
You'd think that choosing a homebirth when it was a decision you had to fight for would make people want more tolerance and choice, but apparently not. Apparently it means that as soon as the evidence suggests homebirths are 'better' you turn right round and start judging back the other way, and making women who choose hospital feel like they're doing wrong."

I don't think that anyone has been judgemental on this thread. All they have said is that there are risks wherever people choose to give birth. Giving birth in a consultant led unit does not guarentee access to an epidural or necessarily better outcomes. There is not a risk free way to give birth.

I found it extremely easy to organise a homebirth. I had the support of both my GP, midwife and hospital trust. I didn't have to fight at all for a homebirth. I could just as easily chosen the consultant led unit or the midwifery led unit. In fact I know someone who was low risk who had an elective c-section for tokophobia in my area.

Choice in childbirth is a postcode lottery and NICE want all women to have the level of choice I had.

Another piece of good news...

maternity death rate falling

Its good news AND depressing news imho.

They have reduced deaths resulting directly from the pregnancy (thrombosis, haemorrhage and pre-eclampsia). However they haven't changed the rate of indirect deaths at all (eg suicides, flu and heart disease) for over a decade.

Three-quarters of deaths were in women who had medical or mental health problems and the research team called for "joint specialist and maternity care" which would see experts in a patient's illness working alongside midwives..

It just shows the lack of joined up thinking within maternity in the UK. Everything is done in isolation with little cooperation between departments which isn't helped with the way budgets are drawn up.

It also suggests that lots of those deaths are also preventable.

Whilst I welcome the news, I do think it shows up our healthcare system more than it congratulates it, as that death rate is still higher than a lot of our European neighbours.

AdamLambsbreath your argument about women's experience mattering is absolutely right, and in fact is the one which is normally used against women wanting a homebirth. I see plenty of people arguing that their "experience" (as in, a decent one), is not as important as the health of their baby (although the evidence clearly shows that actually home birth is sometimes safer - not always).

What actually matter is what the woman herself wants. This new guidance will hopefully give more women the chance of getting a home birth, and perhaps will encourage Trusts to open new midwife led units.

I honestly don't think it will mean that any significant number of people will judge women for choosing the perfectly valid choice of a CLU. Choosing to have pain relief is as much of a right as choosing not to. You have every right to make the choices you want to make for your own body.

Your baby, your body, your birth. Hopefully now there will be more choice offered, and less judgement on ALL choices.

Chalala The Birthplace study had a doubling of neonatal mortality for first time mothers after adjusting for non returned forms and risk factors and this doubling is consistent with lots of other studies.

The risks are small BUT it is terribly dishonest to say that birth outside a hospital is safer for first time mothers. The Royal College of Obstetricians has not supported the birth outside a hospital unit or alongside midwifery unit for first time mothers unless they are clear about risks.

By saying birth outside hospital is both safer and cheaper, women will struggle to get birth in hospital in many trusts - so no epidurals without arguing for transfer, no neonatal facilities on hand and the need to transfer in emergencies.

What many women want is better care but WITHIN hospitals where they can have doctors on hand and epidurals when they request them.

That 'golden' choice is not on offer but this is what many women would prefer. Why should women have to settle for second best?

after adjusting for non returned forms
How do you know what the non-returned forms would have said?
The NICE report isn't saying that birth is safer outside hospital for first time mothers. It is saying that for low-risk first time mothers an MLU is a safe option.

women will struggle to get birth in hospital in many trusts.
I doubt it:the NICE recommendations about CS have often been ignored. I can't see much happening with this one - except more home birth services being cut back and more MLUs closed.

Lavolcan, it says for first time mothers that the intervention rates are lower and there is no difference in adverse outcomes for the baby in a free standing MLU. The first is correct but the second is not: neonatal deaths were double.

The problem is that trusts are cash strapped - MLUs are cheaper. The reasons c/s is more difficult to get is that it is marginally dearer.

It is all about cost and if birth outside consultant unit is deemed cheaper and just as good that's what women will get - dressed up as 'choice'. But choice needs to exist in the context of accurate information not spin.

Its not just money, but the politics of control. I think that hell will freeze over before women are forced to have a home birth.

I agree, Really tired. I don't think that women will be forced into home birth because they are quite midwife intensive and there aren't enough midwives.

What I do think will happen is that district general hospitals with full maternity services (epidural/neonatal/doctors/operating theatre) will be downgraded to freestanding MLUs effectively meaning that most women will have to travel miles to get to a consultant unit. If they are low risk they are going to come under heavy pressure to go to the freestanding MLU.

Lots of law firms are horrified as they are already getting lots of cases from free standing MLUs

www.leighday.co.uk/Blog/May-2014/Birth-without-doctors-know-the-risks

www.pattinsonbrewer.co.uk/mylegalopinions/birthing-centres-dangerous-places-to-have-a-baby/

morestats I have read the Place of Birth study. As I recall it said that adverse outcomes were doubled for first time mothers at home, from a very low base. I also believe that they lumped all the adverse effects together, and that some feel that this was not valid. Not being a statistician, I can't comment. Where is your evidence that neonatal deaths were double?

I am bemused by the cost arguments. Some people are saying that home births/MLU cost more, because of the one to one midwifery required, others say that they are cheaper. It can't be both. The Place of Birth study said that home births were cheaper factoring in the one to one midwifery.

MLUs may be cheaper but it doesn't seem to stop Trusts closing them down and once they are gone they are harder to reopen. I am not holding my breath for the local unit to reopen any day soon.

"Lots of law firms" It sounded as though the solicitors quoted had an agenda. One wonders exactly how many women in the CLU get the immediate attention they need from a doctor? Of course, problems never arise in hospital at the weekends, when the consultants and anaesthetists may well have to be called in from home. So lawyers never get such cases. Forgive the cynicism, but I don't believe this.

La volcan the table showing just over double the adverse outcomes for babies of first time mothers in free standing MLUs is Table 59 in the Birth Place study. The doubling of deaths is Table 26 BUT the sample size is too small to be definitive. However, the doubling of deaths related to ALL births (first and subsequent) and did not account for the excess of women with complications at the start of labour in the obstetric group so the actual increased risk to the babies of first time mothers in freestanding MLUs is probably higher.

I am certainly not being anti MLUs - many women report really positive experiences particularly when birth goes smoothly. I just think that choice is meaningless if it is based on spiked information politically motivated to save costs.

MLUs can be dearer if they are underused (ie. women not opting to go to them) but at fuller capacity they are cheaper than consultant unit according to the NICE cost analysis which is why I am worried about 'directed' choice: the sums only work if you can get more women to 'choose' them.

Most of the MLU closures at present have been based on underuse or safety concerns.

I entirely agree with you though - women don't get the care they should in consultant units but may be we should be improving consultant unit care so that women get the quality of holistic care associated with MLUs but without, in the case of first time mums, having to compromise safety.

morestats In practice we seem to be agreeing with each other - double the adverse outcomes is what I said, and doubling of deaths was too small a sample to be definitive. That's not quite as black and white as 'doubling of neo-natal mortality'. But why are people getting so angry about this? NICE didn't recommend that first time mothers gave birth at home, although some undoubtedly will chose to.

I am not sure that women necessarily opt not to go to MLUs. E.g. locally the nearest one is now further away than the consultant unit, and I am not sure how many get completely unbiased information: Advantages of MLUs/ disadvantages, advantages of CLUs/disadvantages. How many women are told, for example, of the times the CLU has been so busy that it closes to new admissions, so they might be running around trying to find a hospital to take them?

I don't think the information is motivated to save costs. What I suspect will happen is that fewer midwives will be expected to attend more women, until the system goes into total meltdown, or women start to get really, really angry.

After all, they have been recommending for at least twenty years that one midwife per labouring women, and one already known to her at that, gives better outcomes. What has happened over those twenty years? Staffing ratios on labour wards are worse than ever, postnatal care appears to have collapsed. Unless the political will is there, nothing will happen.