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

Indeed I agree La Volcan. This is the trouble when you start talking about things being driven purely by cost. Things that are not in the best interests of women, are liable to come out favourably as it takes the human element out of care. Its part of the reason, why I don't think using cost to justify poor care is ever acceptable. I don't think focusing on cost is very helpful a lot of the time, as we can't afford NOT to treat women well.

"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."

95% of the women I see who go through our local birth centre - which is free, beautiful, and provides one to one care - fall over themselves to praise the way they are looked after in labour.

You don't always get 'optimal care' if you are a private patient. There have been studies done in Australia showing that paying a private obstetrician to manage a vaginal birth puts a mother at much higher risk of ending up having emergency surgery or needing a forceps delivery, than if she had delivered in a public hospital. No improvement in neonatal outcomes. I have met many women in the UK whose experience reflects this.

Not denying however, that many women get substandard care in the NHS. Not enough midwives, too many mothers. Too many women experiencing complications. It's a recipe for a shit experience. Which is why NICE is recommending that more low risk women consider giving birth in low tech settings - because it hopefully (on the basis of current evidence) will result in fewer complicated labours and fewer women ending up needing obstetric input, taking pressure off labour wards, and so improving the experience of those women who need to be therefor medical reasons or for reason of wanting an epidural.

On the basis of...?
Past form Lemiserable.

Like the Peel report's recommendation of 1969 that all women should be offered a hospital birth very quickly became "no woman should have a birth elsewhere" accompanied by heavy doses of shroud waving.

I am all for this current NICE recommendation, and read the Birth Place study from cover to cover - but given the way it was reported, and given what is happening with this debate I can see its recommendations being twisted.

A slight aside, but the GP practice I quoted above which talks about needing the nurse and the GP for maternity care used to state categorically that they didn't support home births. They changed this after the Birthplace Study came out. Funny that - they could no longer bark "it's not safe" at the woman who asked .

"I don't think focusing on cost is very helpful a lot of the time"

It's the job of NICE to consider how to get the best bang for the NHS buck.

They have a limited amount of money and they need to optimise the way services are delivered to satisfy the largest number of people. Promoting a pattern of care for which there is evidence of good health outcomes and high patient satisfaction (as birth centres and homebirths do) which also saves the NHS money by reducing the number of women needing obstetric input in labour is absolutely logical and appropriate.

LaVolcan - the difference between past decisions made about the way maternity services were delivered, is that now the focus is on improving outcomes on the basis of the best quality and most up to date evidence. And women are better informed. The previous wish to move all births into hospitals wasn't done to save money, it was done because it was the view of doctors and legislators that it was safer for all women.

And there has always been a home birth service available. Women however, stopped requesting home births because they were told they were unsafe.

Lemiserableoldgimmer Fri 16-May-14 13:18:47
"I don't think focusing on cost is very helpful a lot of the time"

It's the job of NICE to consider how to get the best bang for the NHS buck.

They have a limited amount of money and they need to optimise the way services are delivered to satisfy the largest number of people. Promoting a pattern of care for which there is evidence of good health outcomes and high patient satisfaction (as birth centres and homebirths do) which also saves the NHS money by reducing the number of women needing obstetric input in labour is absolutely logical and appropriate.

Actually NICE focus on cost AND effectiveness AND whether their are more long term effects further downstream which would not be included in the store front price tag.

Unlike the pencil pushers who only see bottom lines.

"but given the way it was reported, and given what is happening with this debate I can see its recommendations being twisted."

Personally I trust politicians, on the whole, not to make radical legislative changes about the way maternity services are delivered on the basis of what they've read in the Daily Mail.

I don't.

I can name a few who rely on the Daily Mail more than the research out there.

"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."

I assume you're talking about the stats in the Birthplace study Josie?

What glaring mistakes have you spotted that the advisory bods at the RCOG, NHS and the RCM have missed?

Personally I trust politicians, on the whole, not to make radical legislative changes about the way maternity services are delivered on the basis of what they've read in the Daily Mail.

If you'd said this before all the recent sleaze, I'd agree. But sadly we've seen it happen with everything from going to war to courts/crime legislation to how exams are run... and what's scarier, never mind Daily Mail scary as it is it's the Sun and Sun Sunday AKA News of The World that policy makers often court.

I agree with you Lemiserable, but when there are cuts which gets closed down? The freestanding MLU - which doesn't usually save money unless they can flog the land off.

I can't see how things are going to change until the message is got across that the baby's health is not being put at risk and the woman's own morbidity is substantially reduced. But if you spent 50 odd years of screaming that a particular option is not safe (even though there was no evidence for that), then it's going to take some time for the message to sink in.

Nor can I see changes coming quickly when women say, 'I/my baby would have died if I had been at home, but they saved the day', but failing to ask whether this problem was caused/exacerbated by the hospital policy/lack of staffing/inappropriate staffing.

The comparison shouldn't be, IMO,'it went wrong in hospital, but it would have been worse at home', it ought to be, 'What happened with the management of the birth in XX CLU: would the same thing have happened in YY?', especially when they are both hospitals serving a similar demographic population.

I am an old cynic though.

I've had 2 CSs, 1 EMCS and 1 ELCS, both for medical reasons. In my first pregnancy I was planning to go to the MLU for a VB and I was really happy with that proposal (ended up being induced on the labour ward, which was also fine). The MLU is in my local hospital, 1 floor below the main labour ward. If the MLU had been in a different building to the hospital there is no way I would have opted for it. For me the risk - however small - of not being able to access hospital care in the event of an emergency far far far outweighs any benefit that a MLU offers. I wasn't 'afraid' of giving birth, but I was aware that some women haemorrhage, some babies end up in distress etc etc.

I also can't imagine anything less relaxing than giving birth at home. The prospect of having to do that would be enough to put me off having another baby!

Choice is a wonderful thing. It would be great if there was a genuine balance of options available so that all women could choose between home, MLU and hospital care. But I do think that MLUs should be, wherever possible, close to or in hospital grounds.

Lemiserable Personally I trust politicians,...

Red I don't Nor me.

Surely one of the first things needed is for a longer discussion of birth choices between the mum and the midwife? Most people I know didn't get much of a discussion at all. But a slightly longer and sensible discussion which puts forwards the pros and cons of each of the four possibilities (home birth, MLU, CLU, ELCS) and allows a woman to make an educated choice herself, with that choice then respected and supported.

"
But I do think that MLUs should be, wherever possible, close to or in hospital grounds."

Why? Because of an assumption that it will lead to fewer baby deaths and better outcomes for women?

There is no evidence that birth centres in hospitals are safer for babies than free-standing birth centres.

There is evidence on the other hand that the outcomes for women are significantly better if they go to a birth centre not attached to a hospital.

I sincerely hope that when decisions are being made about the way maternity provision is structured, that they take the evidence into account.

"But a slightly longer and sensible discussion which puts forwards the pros and cons of each of the four possibilities (home birth, MLU, CLU, ELCS) and allows a woman to make an educated choice herself, with that choice then respected and supported."

I would agree with that, BUT if tomorrow all women who wanted it were fully supported to chose an elcs, the system would collapse, as there isn't enough obstetric support or postnatal provision to allow this to happen.

Can you see the government shovelling a load of money into any part of the NHS where they wouldn't be able to show an improvement in clinical outcomes in either the short, medium or long term?

I can't.

I didn't say they had to change the availability of all options overnight. They're not going to suddenly change the availability of ELCS's any more then they are going to suddenly change the availability of home births, as currently more money needs to be spent on getting the right people etc to make these possible.

It's the same argument for home birth - if tomorrow loads more women said they wanted a home birth, there are not enough midwives available to support that.

If you're not willing to allow a reasonable discussion with support for the woman no matter what her choice, what other option is there?

Just for the record, just because you increase the number of ELCS, does not mean you end up increasing the overall CS rate by as much as you might think. You might decrease the EMCS rate in the process, and you might reduce the number of instrumental deliveries done in theatre too.

The idea that it would cause the system to collapse is therefore not necessarily true. Certainly pressure on obstetric services is not likely to be as catastrophic as you think - especially if you consider that the biggest problems are with out of hours care rather than during regular working hours.

And as Thurlow states, many of the same arguments are used against homebirths in terms of strains on the service - despite the fact that a homebirth does come out cheaper.

To increase homebirths you would need to reallocate resources from one area to another and invest in that particular service - which will make savings elsewhere in maternity services, because its more cost effective in the end. There is a case that allowing ELCS would also have a similar effect.

I think there is a weird fear that by allowing ELCS more easily that flood gates will open. I don't believe this to be true. Its still very much the case, that despite everything women generally prefer to have a VB. Women who actively want an ELCS (and are given appropriate care and support) are still a minority. Imho, giving good care and a service women can trust, is ultimately the best deterrent/most persuasive argument against an ELCS and for a VB.

"If you're not willing to allow a reasonable discussion with support for the woman no matter what her choice, what other option is there?"

Eh?

Of course all women should have time to discuss how they want their birth to be managed, and support for their choices!

I meant, Lemis, that you made the point that the conversation about all the different birth options shouldn't happen because there isn't the capacity for an increased number of ELCS.

You said I would agree with that, BUT if tomorrow all women who wanted it were fully supported to chose an elcs, the system would collapse, as there isn't enough obstetric support or postnatal provision to allow this to happen.

The exact same thing applies to home births at the moment. The system isn't yet ready to support a sudden increase in demand for home births.

You sounded as though you were trying to limit the discussion.

"I think there is a weird fear that by allowing ELCS more easily that flood gates will open. I don't believe this to be true."

Even a 5% rise would be crippling to emergency services.

Some hospitals have rates of elective c/s of 17%, others serving similar populations have elective c/s rates of 10%. Why shouldn't the hospitals with lower rates rise to the level of those with the highest rates?

And ironically, the hospitals with the highest elcs rates also have some of the highest rates of induction, forceps deliveries, unplanned c/s rates....

Even a 5% rise would be crippling to emergency services.

Why would a rise in ELCSs cripple the emergency services?

There is a difficulty around ELCS and reasons why women request one that can't be fixed overnight. If you have had a bad birth there are then many reasons why you might want an ELCS, and for many women they are not reasons that they are going to be talked out of by the promise of having better midwife care.

For me and some of my friends, the only way to 'talk us out' of a future ELCS is to actually go back in time and fix what happened during our first birth - which for some of us wasn't just due to the medical care we received.

So I can see where you are coming from in that an induction that results in an EMCS is quite likely to lead to a woman who is adamant that she is having an ELCS next time around. But that is not a quick fix, and we do have to include the wishes of second, third, fourth time mums in these conversations. It's a much longer fix, looking at making sure women are supported properly during their first birth.

And why are those ELCS being done?

Those hospitals have have high rates - are they currently done on medical advice or because more women are requesting them?

Its an important question. Without addressing the reasons behind ELCS then you can't explore why some places have higher rates than others.

And when the is no universal standardised recording system to do this on a national level (despite recommendations to introduce one), you really can't work out whats going on.

I am noting here that the hospital I am attending currently has an ELCS rate of 10%. A hospital which strangely already has a policy of never refusing an ELCS...

Love the idea of home births but my midwife advised me to consider my plans for a home birth very carefully for my first. I did and she was right. It was a textbook pregnancy but a terrible birth followed by a general anaesthesia and four hours in surgery.

Have been in hospital for planned sections ever since.