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

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. Yes exactly.

"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."

As a setting for birth for healthy, low risk mothers, CLU's have not proven their value. They are valuable as a back up service for when birth goes wrong, or for women who are unwell, or have pregnancy complications.

On the basis of current evidence, if you are a healthy mother the single most influential choice you can make in relation to your birth, is choosing to labour in a CLU. You want your birth to go tits up? Go to a CLU and you will be doubling your chance of needing emergency surgery, and not improving the chances of coming home with a well baby. That's what the evidence suggests.

"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."

There really is nothing useful to be had from comparing these situations. Many women in Pakistan have had no antenatal care, are living in poverty and have their baby at home with no back up service from hospital, and no properly qualified birth attendants. It really has no relevance to the UK and planned home birth.

It has relevance when people say things like "homebirth has been the default mode for 99/100's of human history".

hospitals HAVE improved outcomes

IMO for the genuinely high risk cases or e.g. rhesus babies - yes. For low risk cases - for those women who get shunted back and forth because the hospital is too busy to attend them. Is that really an improvement over 50 years ago? I think we could spend all night discussing this.

Postnatal care? Sorry, IMO that is one area where things are substantially worse.

'homebirth has been the default mode' is a statement of fact.

Moving almost all women into a high tech setting to labour is a very recent, and in mammalian terms, very radical, intervention.

It needs to prove its value as a setting for birth for healthy mothers and not just as a provider or medical back up for women experiencing complications.

Yes, it is a statement of fact. But saying there was higher infant mortality in the past is also a statement of fact.

Previous posters have already made this point, but a supportive and effective birth service within the NHS should also allow for women to opt for medicalised births with a high level of pain relief used too, which would not be appropriate in a home birth situation.

The ability for many women to opt for an epidural if they want one is, imo, a very big improvement. There is no right or wrong way to give birth and if a woman wants to do it with as little pain as possible, she should be assisted to do that as much as possible,

Postnatal care? Sorry, IMO that is one area where things are substantially worse.

I wouldn't really argue about that. I totally agree with that.

As a side point, I've just been staying with a Dutch friend and she asked how long we got assistance at home after the birth in the UK. I was shocked when she told me they had health visitors who spend all day at home with them helping them adjust and care for the baby for several days depending on how their birth went, told visitors when it was time to leave and let the mother rest and even helped make tea and toast for visitors! (Incidentally, she went against the grain there and had a hospital birth despite being low risk, which I thought was interesting. The reason being that she simply felt safer doing that. She also said that she still had a personal midwife who came to the hospital with her to support her despite her choice not to have a homebirth).

Let's agree to disagree: The vocal minority AKA homebirth brigade can continue to have their babies at home while the rest of us can go to the hospital.
Thank you

Thurlow, what is the relevance of high historical infant mortality rated to this issue, which is about the suitability of obstetric units as primary birth settings for healthy women? Nobody is arguing for a return to the days before scans, antenatal care, properly qualified midwives and doctors and safe caesarean birth!

Re: epidural, according to the Quality Care Commission service survey, the vast majority of women who request an epidural in the uk get one within the hour.

Of course it's right and good that an epidural service is there for all mothers who request it, and it should be improved on from where it is right now. (But not prioritised IMO above increasing midwife numbers if the budget is limited).

However, it's also right that women are clear that opting to labour in an environment where epidurals are available appears to increase your chances of needing emergency surgery to safely deliver your baby. At least women can think through their priorities. I have no doubt there are many people who would swap an intact perineum and abdomen for the option of a painless labour.

Rhianna - this is an issue about how maternity care should be delivered to optimise NHS spend and to achieve the best clinical outcomes. Of course women's choices are also important. There is no suggestion that anyone will limit access to hospital birth.

Perhaps I am naive: I saw these recommendations as a welcome move away from the 'if it goes wrong throw technology at it' approach to one where it's more 'how can we make this go right?' and where the quality of the attendants is prioritised. It's just as important that the woman who needs a complex CS gets the best person for it rather than gets fobbed off with someone more junior, as the low risk woman getting a decent midwife.

La Volcan I think that it should be like that, but I'm far too cynical to believe that it will improve the experiences of care unfortunately. Plus I don't believe that we are really know why there is a difference between homebirths and CLU births properly because we don't properly understand birth - you equally can't promote the more natural route than the technology route for the same reasons.

One thing I find hard to understand is why it seems to be so hard for hospitals to include a good homely, reassuring MLU with probably a water-pool or two, and other birth friendly paraphenalia such as birthing balls and mats etc, as part of their provision for low-risk births, or for most births really until and unless the progression of labour indicates that a more medical approach is needed on that occasion.
The medicalised atmosphere of hospitals seems so pervasive and I do find it interesting that they seem to be unable to truly rise to the simple challenge of providing something that is more woman friendly and conducive to a straight-forward uncomplicated birth.
If Tooting hospital still has it's water-pool and MLU as it did in '99 when dd was born then other hospitals could learn much from them - better than when I had ds a few years later out here in the provinces (though his birth was OK too)

Epidurals don't mean "painless labours" unfortunately.

I was aware that opting for an epidural meant a small risk of intervention, but it was an easy decision for me.

I live near a big city hospital where there is a MLU within the maternity department.

This seems to be the ideal scenario, so you have the choice of a midwife led birth with water pools, beanbags and bubble lamps etc if you are low risk - but the reassurance that you are one floor away from the delivery suite should things go wrong.

As it happens I was induced so was in the delivery suite but the midwives and doctors involved were great and I was able to keep mobile, use a ball, play music etc despite having two drips in my arm (poor DH spent most of the time chasing me with the drip stand on wheels as I roamed around the room).

So... from my own perspective and experience I would never choose to have a home birth and if I am honest I can't understand why anyone would. However I respect that there are those who do and if that choice gives them a positive start to the not always easy first few weeks of adjusting to a new baby, then that is a good thing.

However, I think that has to be within a reasonable cost framework - I don't know what costs more, a home birth (particularly one that goes wtong) or a hospital or MLU birth. What I do know is that I spent quite a few nights on the post natal ward where there was often one midwife (plus auxiliary support) to 15 women and 15 babies. That is not good enough.

The most pertinent point here is how will this level of service be provided with such a critical shortage of midwives? And actually I'm personally a very firm believer in informed choice. Give women the right information regarding risks and benefits of home birth, mlu and hospital birth and let them make the choice.

Wine - I may be wrong, but my understanding was that basically a straight forward homebirth or MLU birth was cheaper for the NHS than a similarly straightforward CLU birth. It's harder to compare when you get into 'things going wrong' because there are so many variables. I'm ure someone else has more information though.

When talking about alongside MLUs I think a big issue is the quality of care available to those who end up on the CLU. Not in a medical sense, but in the sense that there is no support for natural birth in many CLUs which operate alongside MLUs. And many women who end up on the CLU aren't there because they would prefer an early epidural, but because they didn't tick some box. Our local MLU is lovely, but if you end up on the labour ward there is nothing. No birth balls, no dimmable lighting, nothing. I think that the harsh division of women into 'low' and 'high' risk does a great disservice to women in my area. Slightly low iron and wham, all the support system if you wanted a natural birth is taken away from you.

I had my first baby in hospital - started off in the mlu but ended up transferring to the clu because of failure to progress/OP baby and ended up with a forceps delivery I theatre. Secand time round I opted for a home birth which was amazing. I really would recommend it to anyone, but I'm not sure I would've opted for it first time round. My Dh took a lot of persuading to agree it was a good idea.

Penguins ...exactly my concern.

It seems very easy to say "CLUs are a bit crap... use something else instead". Well what about those who cannot or choose not to?

Rather than saying it's a never-changing fact they must be crap, they should invest some funds and time in improving them to be as well run as home birth and MLU services.
Before Florence Nightingale, hospitals were dirty and it was taken for granted dirt went hand in hand with surgery. Now we'd laugh at that.
Why can't you have a hospital which is comfortable and compassionate? Why can't we train/expect HCP not to knee-jerk and panic? Why can't they (as they do in some CLUs) have dimmer lights and music facilities and birth balls?

They aren't good enough... ignore them and use something else is not a satisfactory answer IMO. Otherwise it's like saying 'healthy, confident women get the cream of birth services... they'll steer clear of crappy old CLUs... and those other women were going to have a crap time anyway (or if not, it's THEIR FAULT for choosing a CLU)'. If you think that's extreme look at the post upthread which more or less tells us if we get forceps at hospital we shouldn't choose hospital... well not everyone can birth at home.

I had a low risk first pregnancy and was booked into the mlu. But the birth centre was full, so we were told to go elsewhere (miles away) and then suddenly, (it was mid-december) the snow just fell down - think blizzard! Phoned another hospital, waters broke, went in and while I was on the monitor, dh - not midwife! - noticed heart-rate dipping. Ended up with very rushed emergency cs at only 4cms. If we'd been at home, ambulance would never have got there in time through the snow to save dd1. Thankfully, she's fine. With dd2 - wasn't given choice because of first cs. Glad to be in hospital though - not sure if mlu or not as all happened very very fast - was put on antenatal ward as they said only 2cms - went from 2-10 in 2 hours and barely made it to labour ward - she was out in 12 mins and in total shock so needed reviving. Either way, both times, glad to be in hospital where the necessary equipment and staff were readily available.

Quite squizita - if some CLUs can provide birth balls, rocking chairs, pools etc. why can't they all?

But it's not always money: some fairly grim CLUs in terms of decor can have compassionate helpful staff which can make all the difference.

Sometimes it's just attitude. E.g. it's just as easy to say to a woman - 'you are not advised', as to say 'you are not allowed' except that the first statement begs the question 'why am I not advised?' but the second shuts down dialogue.

LaVolcan yes, but the unfortunate thing with human nature is we can train-train-train BUT if someone's hard-faced, that's how they are.
I wonder if certain trusts 'suit' certain personalities? Leading to a kinder culture in some and colder in others. That's something money and (clinical) expertise wouldn't fix.

I find that with my work - some schools/youth centres/Child Services teams are cold hard factories and employees tend to like that, some are very warm and supportive and attract more 'people people'.

To all the people who ask "what happens when a HB goes wrong?"

My HB went much like Kerry Katona's recent birth.

What people don't realise is that a lot if medical equipment is delivered to the home prior to a HB.

There was neonatal resuscitation equipment, just as you have in CLU, which the MW used, just as she would have in hospital.

The only things they don't do at home are inductions, epidurals, c sections and placenta removals.

They even bring forceps.

People should really find out what HB is like before they start ranting through ignorance.