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

Completely contrary to what NICE are recommending, I've often thought how nice it would be if hospitals could have a labour 'waiting room'. Instead of women being turned away from maternity wards because they're not in established labour, they could go and sit in a waiting room with other women who aren't quite ready. It's understood that they've not been admitted, and aren't being cared for by the midwives yet. There could be coffee and biscuits and magazines. A few TENS machines lying around. It could be quite nice.

A midwife could pop in every now and then and see who's really suffering and could do with some help. Once things get going, the mothers could easily be transferred to the appropriate part of the ward. There would be early warning if things were going wrong. And women would feel more relaxed because they wouldn't have the panic of getting to hospital and trying to get admitted.

A lot of the trauma women experience during birth is being turned away from hospital when they're in labour and I think this would help a lot.

Treats, I would like the same thing as well. In a low, slow early labour it is horrible being sent home because you feel as if you're being ignored. But a nice room with some sofas, a TV etc would be wonderful.

Agree with others that it's about child-birth being supported through proper resourcing and choice for women.

I had dd in the water-pool of the MLU at Tooting hospital, and apart from seeing too many midwives one after the other and not quite enough skin to skin contact in the pool immediately following her birth I think it was about as good as it could be.

This was in 1999 as well, but I don't feel maternity services have made much positive progress in the last 15 yrs since then, which is a shame as it's pretty clear what improvements are needed. If anyone out there is in any doubt they only need to lurk on a few Mumsnet threads. Post-natal care is one area where a few simple changes could make things much better for all.

Agree with quellerosiel How bloody dare they! Made me bloody angry also. I had a home birth but it wasn't supposed to be. I think it was called something like spontaneous delivery. It was all so quick I'd had DD before blue lights arrived. I was on my own so the ambulance operator more or less told me what to do. Only problem was I had to crawl to answer door. Not a good experience on the whole. Hospital for me if there ever is a next time

I'm all for women being encouraged to consider home births - I think changing the guidelines will really help to start the process of undoing those years of perception that home births are not as 'good' or 'advanced' as hospital births.
I had two home births with no pain relief other than a pool - and not because I'm some heroic/masochistic weirdo, but because I was so relaxed and comfortable I didn't need any.
Midwives who attend home births at the moment have to have a certain number of years experience, so you are actually far more likely to have an inexperienced midwife in hospital than at home. And I've heard so many tales of people being left to it in hospital until they were in terrible pain and panicking before they got any attention.
I think part of the perception problem is that people imagine a home birth is like a hospital birth in all ways except location. It's really not, it couldn't be more different. You have one-on-one continuous care (or two-on-one near the end) for a start, and you are completely in charge of what you do.
Having said that, of course home birth is not for everyone. You should labour where you feel most comfortable.

I don't think one option should be "recommended". The recommendation should be utterly personal depending on the mother's needs.

If homebirth is 'recommended' for most and it isn't for you (due to a medical condition) you're going to feel a failure/let down before you've even started. You might push for 'what everyone else gets' and it might cause a problem if it's not appropriate. Or, you might go in to give birth resentful, leading to a more stressed time.

If a homebirth is 'an option' for most, but there's an awareness that a hospital birth is also not 'bad' and many women choose it or need it, it's a different tack at a very emotional and frightening time for some.

I'm interested in how many people's midwives raised the topic of place of birth and discussed the risks and benefits of each in reasonable depth. Because a lot of people I know who had home births for their second baby didn't even realise that it was an option first time round, or thought of hospitals as safe and home/MLU as risky (and then had fairly grim cascade of intervention type births which put them off hospitals).

I had 3 homebirths and probably would have gone into a midwife led unit if there was one nearby. I just desperately didn't want to be in a hospital environment, and really didn't want to spend my first night with my new baby without my DH.
I was lucky my first MW was very supportive of homebirths, I don't see why they aren't recommended more. It's just as much a valid option for giving birth.

I quite like the idea of that waiting room, actually. And also of low risk women starting off labour at home with a midwife who is prepared to deliver the baby there or transfer to hospital based on medical reasons or at the mother's request. So if you went into labour, you could call a midwife who would come round and see how things are going and then stay if you were in active labour or come back layer of things were just starting and then at the point where things were starting to heat up and you would go to hospital you would decide where you wanted to be.

Well put, squizita - you're right, 'recommending' it could easily have that affect on women. Rather than recommending it publicly, it should be something that midwives discuss more thoroughly with the mum to be at the appropriate time.

I never had birth choices discussed with me. I fell into a really awkward category of knowing that I was moving PCT late in the pregnancy, so the community midwives that did my care for 3/4 of the pregnancy never discussed it at all - which, with hindsight, was really rubbish of them. By the time I turned for a booking-in appointment at 34(!) weeks at my new PCT, I was just informed that anyone who wasn't under consultant care gave birth in the MLU, which nearly prompted a massive panic attack as the only MLU's I'd heard of before then were completely separate from the hospital. This wasn't the case in my hospital, but it really did panic me for a bit...

I know a few people who were asked to make their decision about birth choices when they were 10 weeks pregnant!

The elephant in the corner is pain relief.

We are 'meant' to aspire not to have it aren't we? That's the 'good way'. That's the way in all the books with the soft focus covers.

But the truth is, people want pain relief. Which needs a hospital.

It might be physically safer at home... but for many women it would not be preferred for the taboo reason of actually wanting pain relief. But we're not meant to want it.

Not an elephant in the room: if you want pain relief e.g. epidural, you will opt for hospital. All the other pain relief can be given at home or in an MLU.

It's only going to be a problem if the 'recommendation' about home/MLU turns into compulsion, which I think is unlikely at present.

LaVolcan I mean socially. You are meant to want to do it without. That is brave, that means you have good birth skills, you are natural.

That isn't a practicality thing: it's an unspoken (or blatantly spoken) prejudice many women -often who deal with planning births - have. And they don't always advise impartially as a result. Even an NCT leader I know has admitted this.

Treats - I think that's a brilliant idea. Most of the worst stories I've heard involve or begin with women being turned away as they 'weren't ready' and being in a huge amount of pain whether they actually were in active labour (in the case of at least three of them) or were barely dilated.

squizita - Yes, this is a major issue and fear and the reason I didn't think I would actually be able to have a home birth. There's little expectation management and women put enormous pressure on themselves. I'm always careful to stress that I was really lucky that my pain was manageable - DD was in the right position and it was just one of those things where my pain threshold in labour and giving birth bore no relation to my usual ability to withstand pain (minimal at best).

It's key that midwives at booking-in and throughout are able to present all the options as equally valid, without an agenda and without pressing women to make a decision very early on, as Thurlow mentions. Again, and I guess I was lucky, I didn't decide to go for a home birth till I was about 35 weeks, and I was always made to feel it was fine to wait till I was ready to do that.

Part of the problem, perhaps, is that some people are so busy defending their 'position' on medicalised vs non-medicalised birth that individuals needs can get pushed out. It should always be about addressing the needs of individual women.

The NCT lady essentially had a straightforward birth, put it all down to hypnobirthing, breathing, stuff she taught... then her next was huge and back-to-back.
But I see online many women who think it's all in the method or in having a doula or having a home birth... rather than a far more complex set of issues.

Due our first this summer and have been offered all options, home birth discounted as no idea what to expect, MLU turned down as it is in a cottage hospital with no doctors and would involve a transfer to the proper hospital if anything went wrong so to save stress I'm going to the proper hospital straight away!

When I went for my booking in with my second it was with the resident midwife at my GP. The pct was promoting it's homebirth service at the team. (we have a dedicated team of nhs midwives, as opposed to the community midwives also covering Home births. They are very experienced and all pro-hb, obviously!)

In practice this meant that towards the end of the appointment the MW said "here's all your paperwork, and I'll pop this leaflet about Home birth, you're low risk so would be suitable and if you've got any questions there's a number to ring." I said that I was interested and she explained a bit more. Which was great. Perfect.

What I've never had explained particularly well was how you go about opting for mlu vs clu. I'm not the only person who rocked up at local hospital and ended up at clu rather than mlu and didn't realise until afterwards!

Perhaps we are just unlucky that local hospital is rarely open for tours so nobody knew which bit of hospital was which...

I had two low risk pregnancies- one relatively straightforward birth that I am convinced would have been totally uncomplicated if I'd been in a MLU and encouraged to move around Etc.

So fast forward to birth no two. Under the new nice guidelines, I would have been encouraged into a MLU or home birth. It was really quick, 5 mins pushing, no assistance needed, and DC delivered just an hour after labour started. Then bang- mec in the waters, massive post partum haemorrhage, retained placenta, emergency surgery.

I am very relieved to say I was in a MLU attached to a CLU, so had a 2 min wheel on the trolley with DH By my side and my DC in my arms. It makes my blood run cold to think about how terrifying it would have been if I'd been in the standalone MLU or at home. I would have been blue lighted to hospital (40 mins journey, and that's after the ambulance arrives) without my DH or DS. Probably well over an hour till I could have been in surgery.

I would be terrified for any of my friends if they elected a home birth. I agree with PPs who say MLUs attached to CLUs are the way to go.

I think its a shame so many MLUs are been shut down and no home birth service provision in some areas due to cost cutting.

I had a CLU birth with my first, it was horrible. Despite being a really uncomplicated pregnancy and labour they weren't ready for me and were telling me to stop pushing until they were ready. I had an episiotomy because they hadn't managed to monitor ds. We were both fine but it was stressful.
For my second I had a MLU birth, the unit is lovely but I was only there for 20mins before dd was born, with only a student mw in the room because they didn't believe how close she was to coming.
I'm now pregnant with dc3 and am opting for a home birth. As long as all goes to plan, I'm looking forward to having a shower in my shower, a decent cuppa and getting into my bed with my baby.
I would rather have my baby anywhere than the local CLU, it is not an option at all for me.

Agree that the elephant in the room here is pain relief.

Women who give birth or at home are not going to be removed to hospital while in labour because they want more pain relief. They get moved if something goes wrong with the birth.

(Correct me if I'm wrong on that but they don't move women because they decide they want an epidural do they? God knows it's hard enough getting one when you're already IN the blimmin hospital from what I've read on here).

So, tick a box for non-medicalised non intervention birth. Irrespective of whether the woman would in fact have given her right arm for an epidural if she'd been somewhere she could get one.

Could there be anything in that? Like I say, correct me if I'm wrong.

I don't like the idea of "encouraging" women who have never given birth before into situations where they will not be able to access all options of pain relief.

At the moment women are given the choice (if one is available) - what's wrong with that.

I think women should equally be "allowed" to choose to give birth in hospital, and have an ELCS if they want.

I am not terribly comfortable with these proposals, posts upthread by squizita also chime with me.

Of course they move women who want an epidural. It usually hurts a lot less at home at home but because of this midwives will often see a level of pain that can't be managed at home, or a desire to transfer to hospital as an early indication of problems in labour, unless it's at that bit of transition where you go crazy and get the adrenaline spike where she might wait a couple of minutes to see if you stay pushing a baby out.

I thought that something like 40% of first time mothers who transferred did so because they needed more pain relief?

I don't think at the moment there is any talk of not 'allowing' women to give birth in hospital, but I suppose it could come about. What I don't think we would want to see is the 1950s situation where a woman who wanted a hospital birth had the greatest difficulty getting one, or the late 1970s/early 1980s situation where getting a home birth was nearly impossible.