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

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

Very much so, red. I can't imagine home distressing it would be feel that you were being pushed to give birth at home because you were low risk when you didn't want to.

LaVolcan for me it is several friends who smilingly declare their perfect natural home births. Then at darker times it cracks, there are tears, flashbacks ... talk of how they wished they'd 'allowed themselves' pain relief. They have psychological/mental health issues because of the mantra that you 'should' be natural.
I don't know if it's just in my area but in some places, it really is almost like a cult.
In contrast, some others who had planned C sections or wrote 'epidural' on their birth plans seem genuinely happier, stitches and all.
When they get together, what comes up? Pain relief. Always that topic. Some feel they were conned, quite frankly.
Again, anecdote.

Agree with squizita.

her 15.16 post

People who opt for a homebirth, are a self selecting group though.

They feel they will be more relaxed at home, and the argument is that this therefore helps the birthing process because of the hormones this helps.

But what of women who wouldn't feel relaxed at home if they went ahead with a homebirth? Would they get the same benefits from hormones or would they suffer from more anxiety because they aren't in a hospital where they would personally feel safer. And are women who choose to give birth in a hospital already a more anxious bunch than their homebirth counterparts?

We do need to really seriously consider these flaws in evidence as they are crucial to understanding why homebirths should be supported AND why women might also need support in a hospital setting.

Unfortunately, the information we have, is a correlation rather than necessarily a clear cause in the difference.

I don't disagree that there is probably a good case to be made about 'trigger happy' responses in hospitals but simply increasing the number of homebirths doesn't necessarily improve outcomes. Conversely there may be more delays that become commonplace to the detriment of women, if we don't fully understand whats going on here.

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.

This sums up my concerns: to what extent are people happier with home births because they actively chose them? Would this immediately reverse if the wrong women (e.g. peer pressure in my earlier post) for the wrong reasons had them?
Are people unhappy with hospitals because they 'just are' bad ... or do we need to invest time, money, thought into making them better?

I like hospitals.

I would always want to give birth in or very near to a hospital.
The midwives who "cared" for me with DD1 were horrible.
The kindness and care that I received was from the medical people.
I have had 2 sections and they were both great.

If I were to have another child I should be allowed to choose to be in or near doctors, and frankly I think I should be allowed to choose VB or section as well.

Many women I know who will not be in any "poor outcome" stats struggled with various physical and psychological problems after VBs.

Really I think women need to have all the options open to them.

in doctors lol

I meant in or near hospital

I didn't like the doctors that much

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

Not necessarily - the Place of Birth stats largely confirm Majorie Tew's earlier work showing that there was no evidence that hospital births were safer. Her analysis was of births from (from memory) the late 50s to the late 60s. In the late 50s it was extremely difficult to get a hospital birth, so her stats must have included a substantial number of women who didn't feel strongly about having a home birth, but had little choice in the matter.

ProtegeMoi - apology accepted. I didn't assume that you haven't suffered trauma and loss, though - I was just calling you out on your dismissive attitude towards the inherent dangers of childbirth. Your original post seemed to imply that this wasn't even worth worrying about.

I'm interested in your 'more things go wrong in a CLU' stats though. Don't you think it's likely to be the case that people are in a CLU BECAUSE things have gone/ are going wrong?

LaVolcan, I wonder if those earlier statistics would be slightly less valid nowadays because a hospital birth is so much more the norm. Nowadays many women expect to give birth in some sort of medical setting, therefore a home birth is no longer just the societal norm, but a minority choice?

I'm not disagreeing that home births should be much easier to arrange than they currently are for those that want them, but 60 year statistics from a very different set up that will, inherently, take into account maternal psychological and their state of mind/expectations for birth, are probably not too relevant to a 21st century discussion.

LaVolcan did she research psychological damage (given the slightly draconian attitude to such things in the 50s-60s) and any long term issues we'd now treat as standard (e.g. pelvic floors) as well?
And also, in the 50s-60s, hospital equipment, attitudes and so on would also be very different? Certainly gynecology was way behind and surgery under general was more dangerous in the 50s-60s (not to mention epidurals).

Squizita to answer your post of 15:51. Having had a hospital birth with an epidural which didn't work properly and a home birth where I was thinking that 'this is getting a bit uncomfortable' and suddenly found myself pushing, I remain baffled as to why others want an epidural. But that is anecdotal......

E.g. in the 60s-70s they thought women with heart shaped uterus' couldn't have children. It is now known they can be corrected and some women have kids and don't even realise! They thought standing up too much and stress caused miscarriage, and so on.

La Volcan, thats still comparing apples to pears though!

Studies done in the 1950s though to the 1960s are not representative of the demographic today, nor is it reflective of our cultural beliefs that may underpin our fears.

Whilst our definition of low risk in theory should not have changed, there are still big differences in things like age (particularly for first time mothers), diet and ethnic diversity which will have changed the range of what what low risk covers.

Also, in the 1950s and 1960 I think our cultural view of hospitals being a place of safety - with regard to childbirth - was very different. You need to change underlying cultural beliefs, that can be very subconsciously ingrained into us at an emotional level. In years gone by, hospitals were not as trusted as they are now and that will have affected the way in which women felt psychologically too. I'm sure there would have been cases where women would have been happier to go to hospital and had a better outcome. Trouble is, there simply isn't the data, to draw up the conclusion you have - and that is really the point I'm trying to make here.

We shouldn't speculate on whats happening and why too much - because its not actually very scientific. Its just a theory that has not been proven.

While we have such limited understanding of fear and how to treat it and how important choices potentially are to outcomes, listening to and supporting women in their choices is perhaps the best we can do - rather than pressuring them in anyway.

But women with a heart shaped uterus did get pregnant then. An elderly friend who was a community midwife in those days delivered such a woman who then had a retained placenta because of it. Only then did they find the problem - so my friend was exonerated of any mismanagement. It really was something she could have done nothing about. (I think baby and mother were fine BTW.)

But how many more women did she deliver with that condition? We will never know. I don't know how many babies she delivered but that is the only one she reported as being a problem.

"I'm interested in your 'more things go wrong in a CLU' stats though. Don't you think it's likely to be the case that people are in a CLU BECAUSE things have gone/ are going wrong?"

Yes - but this is also true of women who are deemed low risk at the start of labour. The Birth Place study looked at outcomes for this particular group according to where they planned to deliver, not where they actually did deliver. Which is how they arrive at a c/section rate for mothers who've opted to have a home birth. This figure is the number of women who transferred in from home for medical help in labour. The CLU figure in the Birth Place study only includes those who started off in the unit, and were deemed low risk when they were admitted.

"Many women I know who will not be in any "poor outcome" stats struggled with various physical and psychological problems after VBs."

All previous research has found higher rates of satisfaction among mothers who opt for a home or a midwife led birth.

I do feel that too many women attempting vaginal births in busy hospitals will get substandard care (down to there being a shocking midwife led shortage, and partly down to a lack of skill in facilitating and supporting normal birth on the part of some midwives who've spent their lives working in a highly medicalised environment). If we spent the same amount of money on them as we spent on women having epidurals and planned c/s, so that they could all have continuous one to one care in labour, in an environment which was a bit more conducive to normal births we'd probably see a very big drop in the number of unhappy mothers.

"We shouldn't speculate on whats happening and why too much - because its not actually very scientific. Its just a theory that has not been proven."

The theory which hasn't been proven is that delivering low risk women in hospital results in better outcomes.

Homebirth has been the default mode for 99/100's of human history.

The decision to deliver all women in hospital was made on the basis of incomplete and misleading evidence, has been very, very expensive, and has led to an absolute explosion in the number of complicated births in healthy mothers.

.....and has led to an absolute explosion in the number of complicated births in healthy mothers. Without there being a trade off of improved outcomes for the baby.

'this is getting a bit uncomfortable' and suddenly found myself pushing, I remain baffled as to why others want an epidural.

But I doubt you really think all women think it's a bit uncomfortable though? For some women the pain haunts them for years. Hypnobirthing etc' means nothing for them.
What I am talking about is this cult-like idea that if you breathe right etc' it will should be fine. Which even after it clearly didn't work for them, some women I know recite like a guilt-ridden mantra until a bad day/a few glasses of wine.

But women with a heart shaped uterus did get pregnant then.

Yes, midwives knew this.
But gynie docs wrote papers about how they couldn't! I've read some extracts.
Exactly why, back then, hospitals were not up to the job much (for different reasons to today).

No the problem is more that we don't really know who IS low risk and who isn't because we don't understand childbirth enough. Even the place of birth study did raise questions about how we assessed whether a low risk woman was low risk.

Homebirth being the default mode for 99/100s of human history, is not a reason alone to advocate it. Mainly because whatever way you look at it, hospitals HAVE improved outcomes - not only in mortality but also in ways to deal with birth injuries.

Any comments that refers to birth hundreds of years ago really are beyond my comprehension.

You only have to look at other places in the world to see why moving from just homebirths to also having hospital births are a good thing for maternity. China is a particularly good example.

I do feel that too many women attempting vaginal births in busy hospitals will get substandard care (down to there being a shocking midwife led shortage, and partly down to a lack of skill in facilitating and supporting normal birth on the part of some midwives who've spent their lives working in a highly medicalised environment). If we spent the same amount of money on them as we spent on women having epidurals and planned c/s,

Sorry just being picky but surely women having epidurals DO have VBs?
And maybe the term 'non-intervention' is better than 'normal'?

Just being picky because I completely agree with this: we need to make all birth services better funded, trained staff and so forth... so that whether you have a birth pool with no interventions at home or a C section, you'll never feel neglected, never be neglected, but neither be treated like a number/case-study but rather cared for.

Homebirth has been the default mode for 99/100's of human history

And so has a very high level of infant mortality.

In the UK the average for neonatal mortality is 4.2/1000. In Pakistan it is ten times that level.

My homebirths were both incredibly, incredibly painful. Pain like I have never known that took over me completely. But the pain was only a small part of the picture. I loved my homebirths. They were infinitely more positive experiences than the one in hospital with the epidural. Even though the epidural didn't officially 'fail' it was awful in various ways.

But that is an illustration of why I feel uncomfortable with NICE recommending a 'type' of birth. It's not like treating an illness, where most people's aims are generally aligned and based around recovery (yes, I realise that is an oversimplification and there are issues about when you move to palliative care, etc.). With birth, yes everyone wants a healthy baby, but the evidence shows no real difference on that score. Outside of that, women can and do have very different priorities.