NICE draft guidelines on giving birth - home birth or midwife led unit?

[KatieMumsnet]

Hi All

NICE (the National Institute of Health and Care Excellence) are in the news today with draft guidelines recommending that midwives advise mothers-to-be to opt for a midwifery-led unit (MLU) or a home birth when deciding where to give birth.

What do you think? Would these recommendations work for you? Would you still stick to a traditional hospital ward? Have you had a home birth and loved it? Or did you opt for a home birth or midwife led unit only to find out the resources weren't there?

Would be great to hear your views.

Thanks

MNHQ

And again same website If your baby does not have a newborn check in hospital, please telephone for an appointment when you get home from hospital. ..... a clear assumption that the birth will only take place in hospital.

GoshAnneGorilla Fri 16-May-14 10:04:51
Lemiserable you seem to be overlooking the fact that plenty of women do opt for elective csections, to them that is a "straightforward birth".

I must admit to wondering if this recommendation has been made in the context of the NICE update to CS which was extremely controversial and put a focus on women opting for them.

Promoting homebirth is actually a good way to help some women deal with anxieties. The update to CS focused on birth fear and anxiety but the message that was taken from it was primarily the idea of having a CS to tackle the problem. I have seen a lot of posts on MN that reflect that, with the second someone says they had a traumatic previous birth or are a first time mother with very strong fears or traumatic background, the automatic (and often only) suggestion is an ELCS.

Whilst making this an option, I do think is great there does need to be a range of different alternatives available rather than just relying on ELCS. It absolutely is the right thing for a lot of women, but not all. There is more than one way to skin a cat. Unfortunately, I think the whole thing really reflects the lack of understanding of birth fear and trauma - and what is causing it. Some of the primary reasons, seems to be substandard care and poor communication and involvement of women in decision making. Whilst this approach may improve things for some women, pushing women down a path they don't want to go down is precisely one of the problems.

I do worry, that if you were termed low risk, then if you happened to be one of those for whom an ELCS would be the best option rather than an homebirth, an therefore most in need of having your decisions listened to and respected then it could, in effect make the situation worse. It is very difficult for some women - particularly low risk women - to access an ELCS in these cases at some Trusts, and this could make it even worse.

Overall, it highlights the ignorance over the psychological side of childbirth, which is different for different women. No one size fits all is ever going to help everyone, but I do feel that this is what care pathways tend to produce - and this is what recommendations create. It is very difficult to go against a care pathway if you tick all the boxes for one route over another.

You are very much at the mercy of whether you end up seeing a jobworth who only follows procedure, or whether you end up seeing someone who takes the time to properly explore how you feel and what is as the heart of your fears and maybe can see that you are the exception to whatever rule it happens to be.

LaVolcan Fri 16-May-14 10:35:39
And again same website If your baby does not have a newborn check in hospital, please telephone for an appointment when you get home from hospital. ..... a clear assumption that the birth will only take place in hospital.

To be fair I've come across a lot of literature and language that neglects the experience of a great many women. For example, the automatic assumption within ante-natal care that you will go into labour and have a VB.

I find this extremely irritating, especially when I've been dealing with midwifes, who trot this out when dealing with me, when its all over my notes about my personal situation(I am having an ELCS). I find it quite ignorant and also alarming at times.

As per my message above, I think it just reflects the dominance of care pathways over actually properly dealing with a patient or acknowledging that there is more than one course of treatment.

Wow! That is like something from 20 years ago.
My GP is like "So would you like the community midwives - they're the home birth ones, or would you prefer a hospital?" But it was at 8 weeks. I was just a little because she knew full well I would be going to hospital for weekly blood tests and scans for the 1st trimester, so 'would you like' wasn't so much the case for me as 'you will be for 12 weeks anyway'.
I'm quite a demanding patient, and had checked stats/reviews for hospitals - I insisted on the one with the new onsite MLU, several birth pools, birth balls, lights... the profs who train the MW and surgeons... a centre of excellence rather than 'the local CLU' which her a bit in return.
But to her credit she said "well they're the best, I can see why you want them...I don't normally refer to them it's usually the notorious for rude MW and poor hygiene local..."
The way I see it, if they've recommended I need someone clinical to look after me because I'm 'risky' I want to be in a place where they'll do a good job of it (rather than a 'left in a grey room by an absent locum' type place).
But it shouldn't be up to the patient being clued up cynical and "I know my rights", it should be there for all.

Lemiserableoldgimmer - Goshann, the day you can find me a mum who actually would prefer a forceps delivery or emergency caesarean in preference to a straightforward birth is the day I'll start to reconsider whether doctors should recommend low tech settings for women.

I'd have preferred an emcs to a straightforward natural birth. I genuinely would. I was low risk, had no reason to suspect that anything would go wrong with my labour (and what did eventually go wrong was a 1/000's chance where my baby fell ill), but I had absolutely no desire at all to go through labour and a vaginal delivery. I was prepared to give it a go because it is so impossibly hard to get an elcs for no real reason. I knew I wasn't petrified or having panic attacks about the birth, I just really didn't want to have a 'natural' birth. Had the option been more readily there to request an elcs from the outset I would have done so. Similarly, I would - and in a way did - willingly make the decision to have an epidural despite knowing it increases intervention. If someone had told me that it was an epidural and forceps vs no pain relief, I would have opted for the forceps.

Next time around I will be demanding an elcs.

Is that enough for you to start reconsidering?

Not everyone wants the same experience from birth.

For me having forceps under a nice spinal block to get DD2 out was the best part of her birth. Everything leading up to it, on the other hand was horrific.

But how many women put on their birth plan 'Go straight to forceps/EMCS as soon as you can. Please find me the riskiest options.'? I don't think so, some how.

It reads to me as Thurlow would have preferred and ELCS which she found difficult to get. GoshAnne - was it the forceps that was the best part, or the pain relief?

Either way, so much comes down to communication and listening to the woman concerned and not adopting a one size fits all model.

You can't really get an elcs for a first birth, can you? And I do get that - the costs are so high etc. But I just wanted to highlight that actually all women don't want a straightforward 'natural' birth because even a straightforward one isn't tempting.

LaVolcan getting my baby out was a major plus as was the pain relief.

Thurlow Fri 16-May-14 11:44:20
You can't really get an elcs for a first birth, can you?

Yes you can. Well in theory. In practise it really depends on where you are and the argument you put forward.

More often than not, you need some sort of psychological or physical case, but theoretically the NICE guidelines do say, that you should be allowed one anyway.

But like I say, it depends on the individual hospital policy more than anything.

(As for cost, if everyone had ELCS then it would be a cheaper option than everyone having a planned VB, believe it or not. Plus NICE also say there isn't as much of a difference in cost as you might think if you start to consider possible downstream costs - they concluded it was a cost effective option and that women should not be denied an ELCS on the grounds of cost alone).

I imagine unless you have a genuine anxiety of childbirth, as opposed to a more generalised 'I don't really want to do this if I don't have to' then you might be alright convincing them to give you an elcs. But you're right, it is hard to convince them. Having had a traumatic birth, an emcs or some other significant medical problems you are in a much better place. Plus more confident, I'd say. I know second time around I will feel confident to just sit there with a midwife and consultant repeating that I've read all the risk factors and made my own educated decision.

I completely agree with the general thrust of this whole discussion and that there is a lot that needs changing and home birth should be made easier for those who want to do it. I just wish it wasn't so wrapped up in the assumption that all women would chose that sort of birth.

Thurlow - you mean people actually WANT to experience fetal distress and failure to progress (the main reasons for forceps and emcs births) more than they want an uncomplicated labour? :-0

Is what you're actually saying 'I'm ok about raising my chances of fetal distress and my baby getting stuck/labour stalling, if it means I have less pain'?

Lemis, way to summarise that in the most extreme way

Thousands of women every year chose to have an epidural with its increased risk of fetal distress, failure to progress, medical intervention or an emcs because yes, they "have less pain".

Once in labour I did not, and would never, wish that my baby because ill or distressed so that I could have an emcs or epidural.

But I would willingly have had an epidural before 4cm had that been available, as it is in the US, even knowing the slightly increased risks. I would rather have had an elective, but with that not being much of a possibility for a first birth in the UK at the moment, my next choice would have been to have made the whole experience as pain-free as possible.

Thurlow, the real open endedness of the NICE guidelines, is down to the fact that it can be next to impossible to distinguish between a 'genuine' anxiety and a more general preference. Plus even if you have a more general preference, the act of actively preventing you access to an ELCS, may be in itself cause distress to a woman by removing that choice and NICE recognised this danger and felt that it was significant. Which is why, in theory, you should get an ELCS if you want one, regardless of the strength of your 'case' provided you can prove you understand the risks involved.

But as you say, with the obstacles that you face in reality, assertiveness plays an enormous role in being able to get an ELCS. Its something that is a lot more difficult for first time mothers to do as having a 'reason' to have an ELCS, simply make it easier to argue your case and give you confidence within yourself to fight your corner. I think the reality is that a lot of women don't even try because they don't think they will be taken seriously, when there is a chance they would get their choice if they pursued it.

That's very true, red, even with the NICE guidelines I can imagine many women think they'll just get turned away so they don't even try. It's a catch-22, really, that one. You feel as though you need one 'reason' to cling to to keep pushing for an elcs which most women generally only have after having had a child.

FWIW, I know that the hospital I am attending do have a general policy of NEVER refusing a request for an ELCS. They take the attitude that they should explore the reasons for an ELCS but be supportive of women's choice regardless of the circumstances. They have found that in many cases, simply providing support and building up trust has been enough to help women change their mind of their own accord and without pressure. They have suggested various, out of the ordinary options to me about other things, so I do think that just discussing and providing alternatives that someone may not have considered may help to give confidence. To put it bluntly, its just about giving better, individually tailored care.

The experience I have had, so far, does make me believe that they really do achieve this without pressure.

if everyone had ELCS then it would be a cheaper option than everyone having a planned VB, believe it or not.

I find that very hard to believe given the number of people who need to be involved with a CS. With 800 000 births per year that is 2191 per day!

Some large hospitals have 8000 births per year. Going at it 24 hours a day without a break they could get through them all if they took no more than 55 minutes per CS. Realistically, how many can they do in a day and how many people are involved?

LaVolcan, its something that NICE picked up on - an optimum percentage of CS births (its a pretty high figure).

Its actually something that appears to be happening in effect in China. In part because of the sheer volume of women giving birth. The effect of scheduling everyone in, means that they can 'process' women quicker and reduce costs that way, by making it such a factory production line.

Pre-childbirth I was very pro-midwifes, natural birthing etc. Now, I'd opt for a very medicalised birth if I had to do it again. My preference would be to have no midwifes and just doctors/consultants with an ELCS.

I had a wonderful surgical team when I eventually ended up with an emcs for DS, the midwifes on the other hand were just useless. I'd be very annoyed at being pushed towards a MLU for a second pregnancy.

I'm not happy with the stats this is based on, you could drive a coach and horses through them. For myself, I had a MLU in a hospital, both times. I wanted to be within rushing distance of the surgeon.

Red I don't know whether they still have a one child policy in China but it seems to me that it's really the only way they could get away with that.

It all seems very reminiscent of the induction craze of the 70's where it was deemed 'more efficient' staff wise to give birth on a weekday 9-5. I think the Royal Free came unstuck over that one.

Or again when the fashion was that no woman should labour for more than 12 hours: cue the drips being cranked up to the max.

Or no woman should tear - so the routine episiotomy came into being.

And in all, this time and time again, it's women's wishes being idiscounted and a lack of communication and a one size policy. I could envisage that in ten years time it could be home birth-vaginal birth; hospital-CS, whatever fashion gets latched onto next.

And in all, this time and time again, it's women's wishes being idiscounted and a lack of communication and a one size policy. I could envisage that in ten years time it could be home birth-vaginal birth; hospital-CS, whatever fashion gets latched onto next.

Yep that's my concern too.
And when this fear is raised it seems to get confused with 'taking sides' (i.e. everyone is expected to be vehemently pro or anti something, rather than saying "fund it all properly and give sound advice").

What makes you unhappy about the stats josie?

At the end of the day money and power talks - even in birth.

My wife's best friend paid for ELCS at private hospital. No questions asked. Got offered a tummy tuck and liposuction at the same operation on a day that she preferred to fit around her 'busy' schedule.

That's what the celebs have so they 'look gorgeous' 2 months later having magically dropped all the bay weight for the red carpet at the Oscars.

My wife had a VB at our local hospital. The senior MW was clearly reluctant to allow her to have epidural despite being firmly informed DW wanted it. All sorts of excuses and delays.

The MW only agreed when she flicked open DW's file to see the name of the most senior consultant on the front page. After that the MW was practically falling over herself to be helpful.

When a surgeon turned up later to stitch DW we got chatting and it turned out the surgeon's husband was also the most senior consultant anaesthetist in the hospital and a personal friend from years ago at university when he was doing his medical training.

The MW overheard this and personally pushed DW in a wheelchair to the postnatal ward.

If you are wealthy and powerful (or perceived as powerful) you will get good care and the care you want. If you are poor and powerless you will get the care someone else decides.

My sister, single mother on her own and terrified giving birth for the first time was left to almost give birth on the floor of the Reception area in the hospital after being told she wasn't 'ready yet' despite being in advanced stages of labour.

"And in all, this time and time again, it's women's wishes being idiscounted and a lack of communication and a one size policy. I could envisage that in ten years time it could be home birth-vaginal birth; hospital-CS, whatever fashion gets latched onto next."

On the basis of...?

95% of women currently give birth in obstetric led units.

Most don't need the level of medical input that is available there, and most don't request an epidural.

So, on the basis of new evidence (the Birth Place Study 2011) a new recommendation is put out suggesting that women be encouraged to consider birth in low tech settings, where there is evidence of significantly better outcomes, and higher patient satisfaction.

And this apparently is a sinister development which will end in women being forced to have homebirths.