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

People always say, 'what if it goes wrong', but do we all live our lives around the basis of not doing something in case it goes wrong? So do, some don't. There should be a balance of risks considered and the woman's feelings about what is best for her should also be part of the decision. Yes you may not have the medical knowledge of pregnancy and birth, but you know your own body.

If you feel strongly that you will want an epidural then that should be a factor in going for the CLU, but equally if you are scared witless at the thought of hospital then that should be a consideration also.

Like MollyB said, I would have considered an MLU for my first if the choice had been offered to me and I would probably have gone with that for the second. The whole emphasis on how wonderful the CLU was if/when things went wrong did not reassure me one jot and hence the homebirth was the right choice for me the next time.

I gave birth in a MLU downstairs from the traditional labour ward. I was the only woman in there that day and they locked it up behind me when I left. Several friends were told the MLU was closed when they went into labour, so I suspect the Trust is/was planning to close it due to 'lack of demand'. There was a world of difference between the two wards, and I'm so glad that I got the lovely MLU birth I'd hoped for.

I agree, there always seems to be a sense behind these sorts of surveys and stories that what all women want is a non-medicalised, midwife-led birth. And I don't doubt that the majority do. But there are some women who would actively chose to have a medicalised birth. If I'd be able to have opted for an elective cs for no medical or psychological reason, or have a US-style birth where they gave you an epidural nice and early, I would have.

The problem with MLU's that are separate from hospitals is also that women then aren't in a position to simply change their mind. Of course if they or the baby are ill they can be rushed to hospital by ambulance. But what if, 40 hours in, they think "sod this, I'm knackered, it's taking longer than I imagined and I'm not coping as well with the pain as I hoped, I really want an epidural and some sleep"? Surely that is far less easy to accomodate when it requires an ambulance transfer from one site to another?

Mothers giving birth in these situations are a pre-selected group of low risk births.

As far as the Place of Birth study went, it is true they only looked at low risk births, but they were matched carefully between CLU/MLUs and homebirths so the cricitism that you wouldn't see the same safety record is not valid.

As far as I know, no one has compared high risk births in different settings - I suspect it would be difficult to find a big enough sample. Some 'high risk' women do have home births though with no problems.

I think it is amazing that we haven't had a big outbreak of fatal infection amongst newborn babies as a result of them being jammed into congested labour wards with frequent turnover of patients, and often being bottle fed to boot. I am sure antibiotics are covering up some pretty parlous cross-infection control practices in large maternity units, and that can't be relied upon in the future as they are becoming less efficacious. Hospital is no place for young babies unless they have a serious medical reason for being there that outweighs the possible risk of infection. Economies of scale is not a good enough reason.

Everything that Treats said.

I was told I couldn't give birth in the MLU because my iron count was lower than their threshold - admittedly I then got pre-eclampsia and was induced so it wasn't a viable option anyway, but if an MLU can refuse admission just on iron levels, of course the stats are going to look good. There was also a thread recently about a woman being told she couldn't go to MLU because of her (incorrectly recorded) BMI.

I'd only really be happy on a MLU in a hospital where there were paediatricians and obstetricians available if needed. I'd just worry if I thought they weren't easily available.

I had a home birth with both of mine but I had to pay for an independent midwife to achieve it. Not sure I would have had the confidence to do that with the community midwives - I was happy at home because I had a totally experienced and wonderful midwife. I probablybwould have gone for the MLU if I couldn't have had an IM. I strongly believe that I didn't need pain relief or intervention BECAUSE I was at home, rather than it being lucky that I didn't need them IYSWIM.

LaVolcan - I'm sure you're right. I have a bit of a downer on statistics generally but especially when it comes to maternity care. When something awful happens to you, it's no comfort to know that you were the one in 60,000.

The wider point I was making is that every birth is different and that while statistics might be helpful for hospital managers to predict likely demand over time and populations, they're not helpful for individuals who are making decisions about their own births.

I agree, there always seems to be a sense behind these sorts of surveys and stories that what all women want is a non-medicalised, midwife-led birth. And I don't doubt that the majority do. But there are some women who would actively chose to have a medicalised birth. If I'd be able to have opted for an elective cs for no medical or psychological reason, or have a US-style birth where they gave you an epidural nice and early, I would have.

Or worse, the implication that that is what you ought to have.

I agree that sometimes births can be over medicalised and this leads to further interventions being required and the birth being longer and more difficult, but I have really changed my mind about home birth and don't believe that the majority of women actually can give birth without some medical intervention. The simple thing is that we are not deer or sheep but bipeds who do not birth easily, so while being calm, informed, prepared and breathing properly certainly helps in all sorts of ways, and the opposite makes things much worse, the shape of your pelvis or other parts of your physiology will mean that you can't give birth easily. Also women having children later and being more obese brings its own risks. Even if you have a low risk pregnancy it doesn't mean the birth will be straightforward.

Also giving birth without pain relief- what other massively painful procedure would you go through without pain relief?

If everyone had home births, the midwives would re-skill in this regard pretty quickly and this would become routine practice.

I lost a baby after an apparently healthy straightforward pregnancy. Low risk doesn't mean no risk. I would always want to give birth somewhere where intervention is possible.

if an MLU can refuse admission.... but in that case, as far as the Place of Birth study went, she wouldn't be classed as low risk, so would have been excluded from the study. This was a rigourously conducted study with substantial numbers of women's births involved - so it's not a question of taking a handful of births and extrapolating.

But what if, 40 hours in, they think "sod this, I'm knackered, it's taking longer than I imagined and I'm not coping as well with the pain as I hoped, I really want an epidural and some sleep"? Surely that is far less easy to accomodate when it requires an ambulance transfer from one site to another?

Is it? A friend's daughter had just this experience recently - turned away from the CLU she was booked for because it was too busy. Spent twenty minutes going up the motorway to the next, and was turned away again because she wasn't deemed to be in established labour. This happened at least once more. Sixty hours on she finally managed to get admitted and got the pain relief she needed. At least in an ambulance instead of a car, they would have had gas and air!

I booked into the MLU at the hospital. Low risk pregnancy. Looked like home from home. Lovely little kitchen for DH to make snacks for himself and me. Lovely peaceful postnatal ward.

Looked amazing on the tour, was thinking about a HB, but we don't live near a hospital so decided on the MLU as the safer alternative.

Waters broke and I rang the MLU to let them know. They were closed due to staff shortages so I had to go to the main labour ward. I panicked as I am not a hospital lover, then things went a bit wrong. Contractions stopped. I was told this was because I didn't feel it was safe and my body was waiting.

Long story short. Had a very very long three day labour and a forceps delivery. Would it have been quicker and easier in the MLU? I don't know. But the aftercare would have been better. Unfortunately the "care" I received in the post natal ward has put me off having anymore dc.

I wanted to go on the MLU next door to the CLU, however a couple of days before the consultant told me that they weren't quick enough at transferring you to the CLU if there was a problem and she advised me to go CLU. As it turns out we did need intervention - baby got stuck the wrong way round so glad i took her advice.

I think today's announcement is probably a cost cutting thing.

I think what is evident is that some people's contractions hurt a lot more than others when they are not in established labour. And the odd lucky person doesn't notice until they have to push the baby out.

The first time round after NCT classes (that were good on everything else) I was somehow left with the impression that contractions are just a bit worse than period pain until you nearly get to the second stage. I didn't think I would be in agony at 3cm dliated and it added to how worried I was as I was thinking "Something is wrong - it shouldn't hurt this much, should it?"

DD1 was born in hospital I hated it! Some very good MW, some indifferent ones and an arrogant, straight out of Holby consultant.

DD2 was born at home, beautiful. No fuss at any point the NHS MWs couldn't have been more helpful or professional, they were great.

I think women should be given as much information and options as possible and then be supported in whatever choice they made.

I feel I was pretty lucky actually, as I had the option of CLU, MLU or home and my midwives were quite happy for me to keep my options open until I was actually in labour. So I started off at home but as labour progressed and ended up being very lengthy I decided to go to the CLU for an epidural. I would hate not having the option of adequate pain relief.

Postnatal ward was not much fun though (does anyone have a good experience of pn?) so with DS2 we got out of there in 6 hours.

Also giving birth without pain relief- what other massively painful procedure would you go through without pain relief?

Not everyone does find it massively painful. But it is annoying that women who do need pain relief can get turned away from hospital because they are deemed not to be in established labour.

Yes, my early labour was very long and intensely painful and I would have sold my right arm for some pain relief or even a pool during it, but not being in established labour meant I wasn't allowed anything. Not that that is entirely relevant to this discussion as the current guidelines mean you're not likely to get anything before 4cm, regardless of whether you have opted for a CLU or an MLU.

The best guidelines, to me, should say that there are several options of places for giving birth and women should be supported to give birth wherever they want.

I've always suspected that part of the problem is that labour and birth is so commonplace for some of the people involved in women's care and decision making, sometimes they forgot that it is not commonplace for the woman in labour. As BomChicka says, I was also so thrown that my early labour was so long and so painful that it might easily have been a vicious circle and my worry made it longer.

I chose to have a home birth with my DD. Very comfortable pregnancy, felt that I could do it, but was totally open to transferring if need be (and half-expected it – I had a bag packed). The local MLU opened a few months after DD was born, and had that been an option I may well have chosen it. I think I would have hesitated to go for hb if we weren’t so close to the hospital – 10 minutes and multiple potential routes there.

I think it is a totally personal thing and definitely not right for everyone. All births carry a risk – if you overthink it, it’s terrifying whatever context you choose to give birth in.

I had two midwives with me at all times (and 4 for 45 minutes, as there was a shift change and the first lot were hoping to see the baby!), which made me feel a lot safer than the stories I’ve heard of women being left alone in active labour for hours. And I also felt safer being out of reach of hospital infections, as others have mentioned.

All this said, I would never suggest it’s ‘better’ to have a hb or the right choice for everyone. I’m 15 weeks now with DD2 and I will go through the same decision-making process as last time. Despite a fantastic experience with DD1 I am not set on hb again until I know the full set of risks for me personally. Also, if I was in more pain than last time (i.e. that couldn’t be managed with TENs and G&A,) or felt fearful in any way, I would be in hospital like a shot!

FiveFingerDeathPunch - I’m not sure why you think that a midwife attending a home birth would be ‘inexperienced’. My lead midwife was extremely experienced and did an amazing job coaching me through a two-hour pushing stage. I felt totally safe despite my long labour as I felt that she was erring on the side of caution all the way, suggesting that she would call an ambulance if I went on for any longer in order to avoid putting the baby at risk and eventually giving me a very expert episiotomy, with even more expert stitching directly afterwards.

I have to say, I think this is very suspect. There is a VERY thin line between encouragement and forcing, whether this be obviously forcing or not. The mere act of "encouraging" a woman to have a home birth might make her think that this is the goal and make her feel guilty for making the "wrong" choice. I only say this because this is how I can see myself feeling when the time comes.
IMO, best practice should be laying out the available options, the pros and cons of each and allowing the woman to make an educated guess. Too long have women lacking control over their bodies at such a vulnerable time. Each woman deserves the time, care and support to make the decision she is happy with and be supported in it.
This news made me irrationally angry, how dare women be made to felt that the choice they make is not the right one for them? How dare women be pushed one way or another when it comes to their baby and their bodies??
And breathe... probably read too much into this but it don't half make me blood boil!!

How many women really get a choice? How many are told the pros and cons of each option? For many there is no MLU available anyway so that is one option ruled out.

I should have said, in relation to the choice aspect, that I wonder how much of a lottery this will still be. In my area (one of the highest in the country for hb) the choices are laid out very clearly without any pressure and they are genuine choices - I know this hasn't always been the case elsewhere.