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

It's interesting that you say a.homebirth midwife might see a high level of pain in a home birth as a possible sign of problems in labour - purely because my experience of hospital midwives was that they definitely did not see it that way.

I was massively dis-couraged from the HB I wanted

They really move you to the hospital if you ask for an epidural?

I am really surprised. That is great.

I am still uncomfortable with the idea of women being "encouraged" to do anything. They should be given unbiased information, have the options explained, and be allowed to choose.

I mean I was in the hospital and they wouldn't give me anything!

I would have thought if you were at home / a long way from hosp they would try and persuade you to "keep going" until it was magically too late anyway (as has happened to so many women giving birth in the hosp!).

I can only speak for myself, but when I've had a homebirth I had 1/2 midwives just for me, they were much more attentive to me than my hospital birth (which was basically 8hrs of being left alone because I couldn't possibly be in proper labour...)

I still asked for an epidural in transition! But I didn't really want one and mws knew me enough to know that and coach me through.

MLU co-sited with CLU : no problem

Freestanding MLU : not a chance sunshine.

More than a minutes sprint to theatre is too far away IMO.

COI: forceps baby, if mum had opted for anywhere further from theatre neither of us would tell the tale, and I've worked in a CLU and seen the number of scary transfers.

I think it should all be about choice. Women should absolutely be supported to have hb, mlu, clu or elcs on demand if they have been given all the information they need to make an informed decision.

I can't believe how badly resourced maternity services are in Britain.

We need more midwives, more doctors, more anaesthetists, more bf counsellors etc etc etc. I think it is an absolute disgrace the way that women are treated at a time in their lives which is both extremely vulnerable and extremely significant.

This is a critical point from the article:

" It [RCOG] added that assessments as to which pregnancies are low-risk are not always accurate."

This sentence also caught my eye:

"The only caveat it [Nice] included was that midwives should tell first-time mothers that "if they plan birth at home there is a small increase in the risk of an adverse outcome for the baby".

Let us be clear.

There is a small increase in the risk of an absolutely totally catastrophic outcome. People are not being given clear advice here. People are very poor at understanding risk. If you say 'small risk' people cannot assess what that really means.

However, if you say there is a 1% increase in the probability of your baby being brain damaged and potentially requiring 24 hour care for the rest of its life - then most people think that is a high risk because they think the outcome is too catastrophic.

We all buy house insurance because the loss of our house in a fire would be catastrophic even though low probability.

This initiative is about saving money. Not about what is best for women and babies.

However, if you say there is a 1% increase in the probability of your baby being brain damaged and potentially requiring 24 hour care for the rest of its life - then most people think that is a high risk because they think the outcome is too catastrophic.

That might be the choice you would make but I am not sure that all women would make that choice. For the sort of woman who doesn't want to go to a CLU in a million years, she is just as likely to say 1% isn't very high, why shouldn't I be in the 99%? What are the risks of hospital? Especially if the only brain damaged babies you know were hospital births which went wrong?

But manwithnoname, the suggestion is to recommend home or MLU births to second time low risk mothers for whom there is no increased risk in adverse outcome for the baby and a decreased risk of injury to the mother.

I don't think the advice is cost saving. NICE doesn't care that much about costs. They do seem to examine research and then make recommendations.

Our local MLU has recently been closed to save money. It cost a lot to staff a separate unit from the CLU.

I know someone who is involved with this initiative.

There is an 'agenda' being run by various interested parties.

I'll say no more than that.

Echoing some of the comments on this thread, I don't think MW should be advising any women about her birth choices. I do not think that a MW opinion or a local HA policy should influence a woman's decision.

I was actively discouraged not to have a HB or use the MLU with DS1. I found the MW quite adversarial in their approach if I did not comply with their wishes. I wouldn't be confident that any advice I was given was for my benefit or to save the NHS money.

I understand that there is a national shortage of qualified MW, so I'm not sure how these NICE recommendations are going to be progressed if the resources are not available to support them.

MLU co sited with CLU

I had a straightforward 1st pregnancy and labour in MLU and so could have had a home birth with 2nd which also straightforward pregnancy. Thankfully I didn't take this option as I almost bled to death following my 'normal' delivery and was glad of on hand medical care.
There are no guarantees of a straightforward delivery following a straightforward pregnancy and I'd rather have help in hand if needed.

It's about time!

Those worrying about the tiny risk of complications should know things are MUCH more likely to go wrong in CLU then MLU's! They don't decrease the risk at all, completely the opposite!

This idea of birth being so dangerous baffles me, how on earth has the human race survived so long?

Complications are rare, midwives are able to deal with the majority of them and if there is any worry at all support will be available, even if 30 mins away issues are usually spotted with enough time to spare this.

Midwife led care is safer, it's been proven over and over again! We need to stop this mentality of doctor = safe because with birth it dosnt apply and In fact intervention leads to intervention.

I think in principle the idea if not a bad one.

In practise there will be targets drawn up for this, which will I do believe will inevitably lead to women feeling pressured down a particular route rather than given unbiased information, and being free to truly make their own decisions.

The pattern unfortunately seems to be that NICE draw up a recommendation and then every Trust in the country interprets it in a different way to each other to suit their own agendas. There are very few that operate on placing the individual woman at the heart of all decision making and empowering and supporting her in those decisions and reasoning behind it.

Not to mention that many women choose their place of birth primarily based on what is closest - not the facilities that they have. By directing women down this path, its not recognising the fact that convenience of location is of key concern. There will be groups who will find it difficult to go to the 'right' place because they don't have the means to get there (or to their antenatal appointments). Often these will be the most disadvantaged or those who struggle most to assert how they feel.

Trust in those treating them is key to how a woman feels about her pregnancy or birth. If from the word go, she feels pushed to 'choose' somewhere she isn't happy, this undermines her entire care.

In short, I think that the principle of the advice isn't bad, but in practice it will be corrupted by those implementing it, to the detriment of women because of the politics and lack of proper understanding of how you put women first.

It would be much better to see a more strongly worded guidance that encourages these institutions to focus more on supporting the choices that women make and as part of that, simply to show balanced information about the options for subsequent pregnancies. Instead, the guidance gives more power to institutions and takes it away from women in many cases.

I simply wish that women were treated as adults with more unbiased information and less of this business of 'should be advised' which too often is translating into a far more paternalistic 'will be told'. Let women be in greater control of their decisions.

Well said Red.

I don't see the point of a MLU that isn't in a hospital - surely you might as well just have a home birth? It has none of the benefits of a CLU plus none of the benefits of being in your own home and bed.

Those worrying about the tiny risk of complications should know things are MUCH more likely to go wrong in CLU then MLU's! They don't decrease the risk at all, completely the opposite!

I'm not sure on this. How easy is it to compare? I know they try to by looking at the statistics for similarly low-risk mothers who give birth in the different places, but surely the odds are that a lot of women who end up in the CLU anyway have something going wrong in some way with their labour? Even if it is just that the labour is very long and slow, so the woman chooses an epidural and transfers to a CLU, but then she's knackered anyway from the long latent phase and so her pushing is less effective and intervention might be needed then... How can these sort of figures be so readily compared?

Also everyone has to make their own judgement call. Maybe being in a CLU increases the risk of intervention. But the possibility of something going catastrophically wrong - baby not breathing, mum haemorrhaging etc - if you are not hear a hospital is going to be too high a risk for some mums to be happy with.

It looks to me like the strong message from this thread, alongside women being educated and given a free choice, is that many mums are happy to chose an MLU - if it is on site so that obstetrics are on hand should anything happen.

If a woman transfers to a CLU after starting off in a MLU or with a midwife attending a home birth that counts as wherever the birth was planned to be at the start of the labour. Otherwise the focus for nLUs and home births would look pretty amazing with no cesareans, no drugs, no forceps, and a teeny tiny rate of complications.

The Place of Birth study (on which this recommendation is based I think) took the place at the start of labour to categorise the information. Therefore the woman who transfers to a CLU from an MLU/homebirth would count in the stats for that category. This is how they can show CS rates for homebirths for example, when they are most certainly not being performed at home.

I am just not at all sure that a lot who end up in the CLU have something wrong anyway - it's what - 2% for home births, don't know what for MLUs, but I doubt if the total comes to more than 10% of all women given birth outside CLUs. Do 90% really have a problem? I sincerely doubt it and so it would appear does NICE.

To my mind this is the recommendation which should have happened back in the late 60s instead of the wholesale push towards hospital.

And really is being shoved in a room and being left to get on with it necessarily going to lead to them knowing there is a problem and timely intervention if necessary?

I think it's unfortunate that there is such a gap between midwife led care and consultant led.
As I mentioned I had a great birth with dd using a water-pool in MLU at Tooting Hospital (in 99) I was also impressed that my consultant did (perhaps unusually?) take the time to go through my hopes and birth plan before the birth even though it was a straight-forward pregnancy with no complications.
So I felt I was choosing a water-birth for preference with midwife care but other care being readily available should it be needed.
I think it's rather un-reasonable really to expect women to choose what sort of birth they will have when so much depends on how the birth progresses.
Surely it's not too much to expect midwives and doctors to work more closely together to give women the best care and birth experience possible for each individual and each birth?

These guidelines can get lost.

Low risk can become an emergency in few minutes. Any midwife knows this . If it's a straight forward birth then you leave the hospital as soon as possible. If you need the consultants then you are in the right place. End of

I would love to see more MLUs attached to or within hospitals. I was offered home birth with my first, but declined as I had bad SPD and suspected it wouldn't be straightforward, and the hospital had a MLU onsite with birth pools, which sounded ideal (looked like a spa with a NHS decorators budget!)

In the event I spent about 9 hours in the MLU before it was suggested that despite my fear, I have an epidural, and was trolleyed down to CLU for another 20 hours. But I'm sure many other women would have a much better time with straightforward births in the comfort of the MLU and getting better postnatal care there than on the CLU/postnatal ward.

Home births should be supported for those who want them, but it should be because women actually want them, not because they are scared of neglect in overstretched hospitals or forced to because the hospitals can't cope.