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

ProtegeMoi

I find your attitude a bit dismissive. I mentioned upthread that I was that 1 in 60,000 (my baby died shortly after being born). It's all very well saying that the risks are small, but when it comes down to YOUR BABY there is really no level of risk that most of us are willing to take.

I was a very low risk pregnancy and it would have been a completely straightforward labour and birth if it hadn't been for the prolapsed cord. Most of the damage was done at home while I was still in early labour, but thank god I made it to the CLU before he was born, so that the doctors could revive him sufficiently for us to spend a precious few hours with him before he died.

So, you know, SHUT UP with your bafflement about the idea of birth being dangerous. And your "more babies die in CLU". And try to put yourself in the shoes of someone who hasn't had as easy a ride as you have.

I do think there are two things here:

Interpreting risk is both a rational and an emotional decision that differs widely from one person to another.

Its all very well telling someone the figures for risk, but this is not sufficient on its on.

As Treats points out, figures go out the window, when it comes to your baby.

Feeling safe, is therefore as important as the cold hard statistics; ultimately you have to live with the consequences and therefore feel at peace and confidence in your choice for the sake of your long term mental health.

There is so little understanding in how different people prioritise and assess risk, often resulting in differing choices - and how important this is. I don't see much recognition of this in any aspect of maternity care and recommendations.

BTW, there is also another post about this, by a guest blogger here
www.mumsnet.com/Talk/guest_posts/2079571-Guest-post-New-birth-guidelines-the-idea-of-choice-needs-to-become-a-reality

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

The human race has survived, but lots of women and babies haven't... I find the inability to acknowledge and understand why its important both baffling and extremely ignorant tbh.

There is no way I would listen to a midwife and no way I would put my baby's life in their hands.

Naively I would have thought the opposite before having children, I worry about first time mothers being pushed into this. A risk is a risk, why would you take it?

This idea of birth being so dangerous baffles me, how on earth has the human race survived so long? WHAT? Have you any idea how many women and babies died in childbirth in the past (and still do in other countries)?

"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"

There are risks associated with having a homebirth - no doubt. Last minute emergencies like shoulder dystocia, cord prolapse, severe placental abruption etc, may well have worse outcomes in a setting where doctors, paediatricians etc are not immediately available.

HOWEVER - when you look at evidence the neonatal outcomes for the tens of thousands of low risk mums who chose to labour at home or in a free-standing birth centre over the years are no worse than for similar women who chose to labour in hospital.

In which case what must be happening is this: that there are risks to babies that come with having a hospital birth that are hard to identify, but are real. If this wasn't the case poor neonatal outcomes would be more common at home births than in hospital. And they're not.

Would add, that going on current evidence, having a baby in hospital is more dangerous for low risk mothers than giving birth at home - basically because being in the hospital exposes you to a very higher likelihood of needing emergency abdominal surgery, with all the attendant risks of blood loss, emergency hysterectomy, DVT's, infections etc.

"Maybe being in a CLU increases the risk of intervention."

No, not maybe. Definitely, and there is a mass of evidence to prove it.

"Naively I would have thought the opposite before having children, I worry about first time mothers being pushed into this. A risk is a risk, why would you take it?"

At the moment they are encouraged/pushed into having hospital births, where double the number will end up on an operating table, with no improvement in neonatal outcomes compared to similar first time mums giving birth in free-standing midwife led units.

That's an extra 6 women in every 100 having emergency abdominal surgery, with all its attendant risks, and no improvement in neonatal outcomes. IMO that's quite scandalous. A risk is a risk. Surgery is a risk. Nearly 1 woman in a 100 ends up in intensive care following a c-section. Isn't this a risk worth considering given that it's twice as likely to happen to you if you chose to deliver in hospital?

I always find it sad that, whenever there is a discussion of homebirth/MLUs it seems to turn into a fierce debate about safety, much of it fuelled by anecdotes or instinct. I also don't understand why a baby's death in hospital is labelled an unavoidable tragedy unless proved otherwise, but at home/in a MLU, it is often assumed to be caused by place of birth.

The fact is that we have a good study which shows that mere proximity to surgery and interventions doesn't improve neonatal outcomes (other than marginally when comparing first time mothers at home and in hospital). If we want more information, we should be looking for more studies to be commissioned.

To me, the big issues here seem to be:

• Why are NICE 'recommending' a type of birth to women? What does this say about our value judgements on the type of birth you aim for? I'd like to see a recognition that wanting a planned section, or an early epidural, is an equally valid choice.

• Why does all this stuff focus on low risk women? You can tip over into higher risk so, so easily (higher BMI, slightly low iron...). If women in MLUs have better experiences and outcomes, what about thinking about this big group of women and how we can bring those advantages into a more high-tech, clinical setting?

"Why does all this stuff focus on low risk women? You can tip over into higher risk so, so easily (higher BMI, slightly low iron...). If women in MLUs have better experiences and outcomes, what about thinking about this big group of women and how we can bring those advantages into a more high-tech, clinical setting?"

This is an excellent point. How "low risk" should you have to be to access an MLU or NHS homebirth?

I also agree completely about other choices being valid and women should be supported to make the choice that is best for all their circumstances (not just physical but also psychological).

Also outcomes for women measured in terms of mortality and intervention (which is deemed "bad"). Morbidity for women rarely mentioned, it seems as long as she is alive the job done even if she is left in a right state.

None of this is straightforward. Women should be given info and allowed to choose including ELCS.

Penguins - "I also don't understand why a baby's death in hospital is labelled an unavoidable tragedy unless proved otherwise, but at home/in a MLU, it is often assumed to be caused by place of birth."

Just an aside really. It helped me to come to terms with my son's death to know that everything was done that could have been done. I wouldn't have had that reassurance if I'd been at home. I think the assumption is not that a death resulting from a home birth is CAUSED by the place of birth, but that there aren't the same opportunities to prevent the death that there might have been if they'd been in hospital - ifyswim.

Treats

I am truely sorry that you had had experience and lost your precious baby. I am speaking from the general risk of these situations and the statistics show that CLU's are indeed more dangerous. That of course isn't to say that things don't go wrong at home but a lot more things go wrong in a CLU.

I am sure you know how rare cord prolapse is and sadly in most cases there are no prior warning signs so cannot be predicted or dealt with. I can't imagine what you have been through. However please do not assume that those on the other side of the fence don't have their own reasons for being so and have not experienced traumatic events and loss themselves.

Once again I am very sorry for your loss.

The Place of Birth study most definitely did look at morbidity for the mother and found that it was worse for a low risk woman booked into a CLU. Strangely enough, the Press hardly mentioned this.

I pretty much agree with everything that Penguins says, although I think NICE is recommending things because that is what it does. I don't remember any fierce debate happening when NICE recommended that a woman who wanted a CS but wasn't deemed to have medical grounds for one, should be referred to a Consultant who would agree, so why is this recommendation different?

Re how 'low risk' you have to be to access a homebirth: you don't have to be 'low risk' at all. Some women labelled 'high risk' do go on to have home births safely. But yes, we should be looking to how we can improve the choices/quality of care for high risk women.

LaVolcan my point was that I have often heard of women with a minor issue (some test being one or two points outside the normal range or something) be tipped into the "high risk" category. I'm questioning whether this should prevent access to MLU or home birth (and yes, I know that you can insist on a home birth but it seems to be a right battle if you don't tick every single one of the NHS boxes).

"Also outcomes for women measured in terms of mortality and intervention (which is deemed "bad")."

Intervention is categorically 'bad' and 'harmful' if a healthy birth can be achieved without it.

"Morbidity for women rarely mentioned, it seems as long as she is alive the job done even if she is left in a right state."

Actually the new NICE guidelines are rooted very much in an acknowledgement that homebirth appears to result in very much lower rates of morbidity for women.

"None of this is straightforward. Women should be given info and allowed to choose including ELCS."

eurochick I am entirely with you on the importance of humanising birth and optimising outcomes for women who are not low risk. The care of women with medical issues has often been been actively hostile to the normal physiology of birth, with consequent high levels of intervention for women in this category.

Don't tick the boxes- that was me. Some of the boxes not ticked were I think caused by CLU production line births, and one - low blood count - due to my health. So I certainly had to be quite forceful to get a home birth.

You raise a valid point though - there are a lot of women who are not officially 'low risk' but nor are they 'high risk' but somewhere in between. I suspect that, rather like the 'average child' in schools, that these are the ones who get rather overlooked.

"Why are NICE 'recommending' a type of birth to women? What does this say about our value judgements on the type of birth you aim for?"

For the same reason they make recommendations about cancer treatment protocols. Because their job is to identify ways of delivering care which are linked with the best clinical outcomes and the best value for money for the NHS.

I was totally into empowered active birthing and really got into hypnobirthing for pain relief. I was fit and healthy and stayed active and walked a lot up until I went into labour.

All great on paper but I would have lost dc1 had I not been giving birth in hospital.

I also think this initiative is about saving costs.

When women used to give birth at home, how many did have bistro experienced and midwives as seen in the series meet the midwife?

Imo it's dangerous.

*bistro experienced
Birth experiences

Sorry not very clear but I ended up with emcs although everything before was textbook.

Intervention is categorically 'bad' and 'harmful' if a healthy birth can be achieved without it.

Healthy for mum as well as baby? Mentally as well as physically? When you hear from people with psychological birth trauma they often subscribed to this prior to birth: they feel failures because they didn't do it the 'right' way.
What about women with ruined pelvic floors a few years later. Does that not count because they 'achieved' birth?

What about a woman who has an elective C section or epidural, recovers well, perfectly happy? Is that 'bad' (let's take finance out of the equation: she paid let's say)? Why?
She is safe. The baby is safe. But she could have given birth naturally.
If she had not wasted any resources, would this be bad? Did they cheat!?!

This is the elephant in the corner attitude I'm talking about.

Why is there this reluctance to accept that some harm is caused iatrogenically? I had a forceps delivery with my first. No doubt others would be grateful that they saved the baby's life. For myself, I am sure they caused the problems in the first place but I will never be able to prove it one way or the other.

For me the birthplace study gave me something of a lightbulb moment. I had noticed MLU births all seemed to be pretty straightforward and CLU births seemed to have more problems but that was anecdotal. The study put flesh onto my observations-there was more than anecdote about them.

I think there is nothing wrong in essence with a body like NICE recommending something based on the evidence. NICE's job is NOT to make a judgment. HOWEVER there is a problem with how this is then interpreted by Trusts - and this is the problem lies; not with NICE itself as such. NICE has a very difficult job, imho, and whilst a recommendation might be X, Y or Z I do think we always need to examine and look at its weaknesses, and situations where the recommendation may not always be appropriate for individuals.

Hospitals Trusts need to understand this human element when it comes to recommendation and to respect that this is not a license to pressure women down this route. They are the ones that implement the recommendations and in order to do this, they must fundamentally understand the concept of 'undue pressure'. Part of understanding a recommendation, is not just looking at the headline and generalised preference, but also the thought process that NICE has gone through to come to that conclusion. What are the driving principles that make them choose that recommendation?

In this particular case, its not just about physical outcomes. One of the strongest arguments for homebirth, is the element of choice and women being in control and feeling safe. Choice is something that needs to be linked to emotional and mental well being - as much as physical wellbeing.

This is where there is something of a problem in evidence. One of the good things about homebirth is there is strong evidence that this is beneficial to women because of the psychological side of childbirth. But there is a catch to this; precisely because all this evidence is based on women who WANT to give birth at home and have been free to decide to do that. This makes it fundamentally flawed. If the situation changes and we have a lot more women pushed into having homebirths, when they have reservations about doing so or feel pressured to do so by the recommendation, you might start getting a very different picture. The benefit might be about be about being in control and being 'allowed' and supported in your decisions about giving birth as much as the place of birth...

NICE have clearly recognised part of this, and the benefits of women having access to facilities of MLU and homebirths if they want it and thats actually the important point. Its not the remit of NICE to think about how this will actually be implemented or whether their recommendation will lead to pressure being applied in a way that negates the benefits of free choice.

The NICE recommendations also come in the context of cultural belief; anything that gives weight to an ideological argument will be used to try and further that belief. This means it is easy to be critical of NICE because they appear to be 'on one side' rather than another. Its a little unfair, as NICE can't control the media spin on the evidence presented to them.

This is why I say, I think in principle the thoughts and intentions of the recommendation are good. Its the bit after, that I'm more concerned about.

I've already seen this being leapt on in the newspapers by people with an agenda, rather than an ability to promote the idea of free choice. The Telegraph have published a pro-homebirth article, which is fair enough to a point as they have an opposing article too. Its just a shame its factually inaccurate and quotes "(the World Health Organisation states they should be no more than 10 to 15 per cent)" which is bollocks as WHO abandoned this position way back in 2009.

But the truth is, we could do with balanced rather than polarised debates which do the key thing of simply understanding that recommendations are one thing, but all women are not equal and having varying needs and anxieties which mean that one size fits all, doesn't always work. The principles underlying the recommendations are usually more important.

• comment about WHO was in reference to CS rates.

I had my first in the wonderful, but now defunct, Garden Hospital ( later the unit was at Lizzie and John's) They were not too concerned about long labours there and I was told that if I'd been in an NHS hospital I'd have been advised to have forceps or a C section due to slow progress.

The constant attention of designated midwives and my wonderful consultant Faith Haddad supported me so much that I didn't want pain relief and had a good experience despite a labour that lasted nearly 24 hours.

I find hospitals very aesthetically unpleasing, I want to be surrounded by nice people and feel in control and I just think an NHS hospital would have been a disaster for me. I'd have been screaming out about Human Rights and threatening t report them to CQC the minute I didn't feel in control. Accordingly I had no 2 at home and despite shoulder dystocia the midwives coped very well, and most important DS1 was there for the birth too, he was only 3 and wouldn't have been allowed in at the hospital.

I think it is sad that a natural process has been taken over by doctors to such an extent.

This is the point I am trying to make lavolcan, je interventions can cause new problems then they solve!

I have known a child that was left severely disabled after forceps delivery gone wrong. The mother is adamant she did not need forceps just more time as there was no fetal distress etc. to cause them to act faster. At a home birth or MLU they wouldn't have been so forceps happy, even if they felt they were needed there would have been a slight delay possibly giving her more time and her child may have had a life free from their disability. This side of things is often overlooked.

So many people say I would have died etc. I I were at home as I needed forceps, a section etc. statistics show that if they were at home they wouldn't have needed those interventions in the first place hence there wouldn't have been a risk at all. Obviously with exceptions at not all births are possible intervention free.