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

I can promise you there is no midwife in this country who would do a forceps or a ventouse at a home birth. There aren't even any midwife forceps practitioners though some do do ventouse but only in an MLU or a CLU.

A woman would have to be transferred into hospital for an instrumental, like she would for any other problem or for pain relief.

Midwives can resuscitate, they can manage a severe haemmorhage as best they can while transferring in. They're trained to manage a shoulder dystocia. So lots of emergencies they can deal with. But a forceps birth isn't happening at home in the UK.

Viva while your here could you answer a question for me?

One reason for women wanting a CLU birth is the promise of access to an epidural. Is there a good reason why this couldn't be offered in an MLU? Apart from an anaesthetist what other medical/obstetric input is required?

Viva I agree that I've never heard if a home forceps birth in the UK but they were in my birth kit so there must be done protocol for using then in an urgent emergency?

(I know that if things look like heading that way then there is transfer to hospital, but there must be the possibility if cases where there isn't time for that, eg very rural communities (helicopter transfer))

"One reason for women wanting a CLU birth is the promise of access to an epidural. Is there a good reason why this couldn't be offered in an MLU?"

Because it's changing the whole ethos of MLU's from places which support women who are low risk, and remain low risk in labour, to have normal physiological births.

Once you introduce an epidural into the equation, the labour is no longer low risk, and both the mother and baby require more monitoring. It's just not appropriate to do this in a setting where the whole thrust of care is directing towards promoting normality in birth.

It very much seems as there needs to be some sort of half-way house, for those who want more pain relief than can be offered at home/MLU but in other respects don't fit in the 'high risk' category e.g. like the smallish maternity hospitals which they went and closed down in the seventies and eighties.

normality in birth - do you mean a more natural approach to birth. Women who have breach, stuck babies, high blood pressure etc' should not be labelled 'not normal' (of course they're not the majority, but they're not freaks or failures).
Driving cars and wearing clothes are 'normal' but not 'natural'.

With care sector (health, childcare, social care) I have found the connotations of 'normal' are used very deliberately when campaigning, and describing a natural birth as a 'normal' birth isn't just because more women have it. It's because many campaigners believe women who want pain relief or even a C section for non physiological reasons (e.g. fear, past trauma) should be reminded they are 'going against nature' and 'different'.

It very much seems as there needs to be some sort of half-way house, for those who want more pain relief than can be offered at home/MLU but in other respects don't fit in the 'high risk' category e.g. like the smallish maternity hospitals which they went and closed down in the seventies and eighties.

Oooooh yes. Starts frantically playing the lotto because there aint none of that on the NHS in her city at the moment

Just want to add some perspective on this issue.

The Birth Place study, which is underpinning the new recommendations, found really striking benefits for women in planning a home birth, over and above the benefits from being in a MLU within a hospital, though not much above being in a free standing MLU.

Just to give you some idea of the figures, the rates for interventions for women deemed low risk at the start of labour are as follows:

Forceps delivery
Obstetric unit: 6.8%
Home: 2.1%

Ventouse delivery
Obstetric unit: 7.3%
Home: 2%

Emergency c/s
Obstetric unit: 11.1%
Home: 2.8%

When someone says 'I don't understand why anyone would want a homebirth', I do think it's worth pointing them in the direction of these statistics.

Would add, the figures for midwife led units in hospital were better than for CLU's, but still no where near the figures for home birth. They were double, rather than triple the rates, as the OU figures are.

I really do think it's not just about the furniture, it's about having midwives who really understand and know how to facilitate physiological birth. There midwives gravitate towards working in settings where they are able to practice these skills so I think you are more likely to find them on home birth teams, case-loading teams, and working in free-standing birth centres. Yes, you will also get some on the labour ward, but all the midwives I know who truly believe in the importance of birth being as undisturbed as possible in order to optimise normal labour physiology, really struggle with working on a busy labour ward and tend to get out as quickly as they can.

They were closed down because they were deemed 'not safe' on the same lack of evidence that home births were deemed 'not safe'. For the local maternity hospital it was nothing to do with flogging the land off for housing.

"It very much seems as there needs to be some sort of half-way house, for those who want more pain relief than can be offered at home/MLU but in other respects don't fit in the 'high risk' category e.g. like the smallish maternity hospitals which they went and closed down in the seventies and eighties."

You can have pethidine and gas and air in MLU's and at home. The only thing you can't have is an epidural, and once you have this you need all the technology and the medical support that goes with it.

Given that epidurals increase the likelihood of your baby experiencing fetal distress in labour there is NO WAY I'd want to have one very far from experienced doctors and operating theatres. Which is what you get on a labour ward.

Birth away from a medical setting is only safe if you don't fuck around with it. Start fucking around with it and you are better off in a more clinical environment as your labour is more likely to become complicated.

I basically agree with you Lemiserable but having had two generations of women told that home/small hospital births are 'not safe' without a scrap of evidence to show that they are not, it will be quite hard to change attitudes overnight. The way that the Place of Birth study was reported in the Press didn't help: they concentrated on a slightly higher risk to the baby at a home birth for a primiparous woman; they hardly reported the significantly greater morbidity to the mother in all cases, as you show above. That there is a significant benefit to the mother and no disadvantage to the baby in the overwhelming majority of cases needs to be got across if this recommendation is to be taken seriously.

At the same time, some women do need more pain relief than others and their needs should be accommodated.

I really do think it's not just about the furniture, it's about having midwives who really understand and know how to facilitate physiological birth. There midwives gravitate towards working in settings where they are able to practice these skills so I think you are more likely to find them on home birth teams, case-loading teams, and working in free-standing birth centres. Yes, you will also get some on the labour ward, but all the midwives I know who truly believe in the importance of birth being as undisturbed as possible in order to optimise normal labour physiology, really struggle with working on a busy labour ward and tend to get out as quickly as they can.

I've found a similar situation in my work environment, the problem is (for example with my work) if you get a kid dealing with certain agencies for good reason, you get people who work in a different way to certain other agencies because it's a culture. People who don't fit in gravitate elsewhere. The poor kid can't choose where they go, just as the woman who might experience need a blood transfusion due to a blood condition after a regular VB with gas and air can't help needing to be on the labour ward. Even though clearly in her case it is for a risk, it is also clear she can give birth 'naturally'. So clearly something in the culture of the system has to change - to me, saying labour wards are too clinical, tell people to go somewhere else, isn't the solution (as there are people who are going to need a hospital). The solution would be sort out the hospitals so that natural birth is respected and surgical care is well managed if needed ... surely?

Then women could make an informed choice, not feel they're trading off risks OR equally if they can't because they're high risk, they're not sitting there with people saying "oh well you had a crap time, bad luck that's kind of your fault for being in a hospital, everyone knows they're rubbish."
Which, I'm sorry to say, one post on this thread (only one) pretty much says - which means people think that. :(

"So clearly something in the culture of the system has to change"

I think that's going to be a struggle.

The vast majority of the population - including policy makers - see birth as a medical event which is dangerous except in a medical setting. That's why birth centres are underused and home birth is such a rarity. Both doctors and midwives often practice defensively, and I'm really not sure how anyone can get around this. The midwives I know who practice in CLU's struggle with how to work in a very protocol driven setting where there is an obsession with risk management. You can chuck around a few bean bags and painr the walls a soft shade of purple, but the basic ethos of CLU's will be much, much harder to change.

I think thats slightly unfair squizita. I think there are several posters who have made posts which have questioned the premise of why CLU look to be performing badly somehow.

I have made the point repeatedly that we don't understand what is making births at home or in a MLU 'better' and that the assumption is its the place rather than really looking at the 'why' more. The recommendation has been made using evidence of a correlation rather than a cause which scientifically is slightly worrying... I do think that might not directly say what you put in your post above, but it does question the foundations of the message that is being recommended as a pathway and does challenge the assumption that has been drawn up out of the recommendation.

I just want to agree with some other posters that the focus on "normal" birth is never helpful. It suggests there is an overall right way and wrong way to give birth, which is patently untrue in a general context. All there is is a woman's preference for the kind of birth that she would prefer to have, whether that is a home birth or a medicalised CLU birth.

It's like how you phrase this, Lemiserable - 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. I know you did not mean to come across as commenting on different women's priorities, but in the wrong light sentences like that could come across to someone as being told their priority for having as pain-free a birth as possible is in some way wrong. Not sure I've explained that properly but I hope it makes a little sense.

IMO there shouldn't be any comment from the medical profession on the right or wrong way to give birth, just support to facilitate the birth that a woman would prefer.

Red I was referring to one specific post with quite a flippant rhetorical question in it, essentially saying it was your own fault if you had a bad experience in hospital. The poster hasn't contributed much else to the discussion at all TBH.

I don't even want to quote it: as someone who cannot birth at home (medical condition which creates risks for my wellbeing immediately after although my body is perfectly capable of the vaginal delivery part- and in the past I would have miscarried 90% of pregnancies) it was offensively flippant and essentially suggested I was going to have a bad birth and it was my fault.

Not at all the same as people who say that for most women, recovery is quicker with a home birth etc'.
There are some people who do sadly take a Jeremy Kyle "well what did she expect" approach.

BTW I have to be in a hospital because:
-I have a clotting syndrome which has caused losses and issues outside pregnancy, so will need my blood testing/monitoring
-I had a molar pregnancy last year, meaning I need tests on the placenta immediately after birth and a shot of chemo in the (1% chance) rogue cells are lurking in there.

So I understand why I'm best off CLU - but also that I'm not going in with a physiologically higher than average chance of instrumental or C section.

Hence the idea that women in the CLU who can give birth vaginally have 'made their choice' and should accept issues (as that one post earlier suggested) is worrying and inaccurate.

I think the epidural issue is what is going to make a lot of women choose CLUs regardless of how much "normal" birth is promoted. I would love to see CLUs with comfy furniture, low lighting and birth pools - maybe those things would make women less likely to need/want epidurals when it came to it - but ultimately many women will still want the option of adequate pain relief if necessary.

"I have made the point repeatedly that we don't understand what is making births at home or in a MLU 'better' and that the assumption is its the place rather than really looking at the 'why' more. The recommendation has been made using evidence of a correlation rather than a cause which scientifically is slightly worrying... "

I don't find it worrying at all, because I'm not focusing on what makes home birth, and undisturbed birth in birth centres less complicated (ie 'better' - because a birth which progresses normally and ends in a spontaneous delivery of a healthy baby is generally optimal in health terms for mother and baby). I'm interested in what is going on in CLU's that is resulting in such a spectacularly high rates of dysfunctional labour.

And there's been loads of research into how the way care is delivered impacts on outcomes. We know that the following are associated with a higher rate of spontaneous birth (ie, birth without c/s, forceps etc)

case loading care
one to one care
continuous care
not using regional analgesia (associated with higher instrumental rates)
not using continuous monitoring on low risk women

If you go to a CLU you are

• more likely to be continuously monitored,
• less likely to have one to one care,
• more likely to have an epidural
• less likely to have met your midwife before

It's not really much of a mystery to midwives why women in birth centres and home births have more normal births. You only need to know a little about the normal physiology (especially the hormonal physiology) of birth to start to see how hostile labour ward practices, and atmosphere and ethos can be to a functional labour. An example of this is with time limits being put on labour. The ACOG (US college of Obs and Gynae) and the RCOG have recently reviewed evidence on the definition of 'normal' labour lengths, and come to the conclusion that the active phase of labour doesn't actually start at 4cm for most 1st time mothers, but at 6cm, and that labours generally are probably longer than we believed was healthy or normal, especially the second stage of labour, which can sometimes extend to 3 hours or beyond and still end in a healthy birth of a well baby. Midwives working under their own steam have always observed this to be the case and have, quietly,been sometimes 'allowing' women to labour longer than was previously recommended to give them a better chance of a normal delivery. But on a labour ward it might be difficult for a midwife to act against protocol, even if her instincts and knowledge suggest that it's the best for the mother.

"I just want to agree with some other posters that the focus on "normal" birth is never helpful. It suggests there is an overall right way and wrong way to give birth, which is patently untrue in a general context."

I entirely disagree. It's important to ground any discussion of birth with an acknowledgement of the normal biological process because it helps us make sense of things that are clinically beneficial, and things which are clinically harmful. That's not to diminish the importance of women's feelings and preferences in relation to birth, and acknowledging these does require we abandon all reference to normal biology when discussing a physiological process. That's not passing any sort of value judgement on anyone - the 'best' birth is, in a very holistic sense, the one which ends in a well and happy mum and a well and happy baby.

"but in the wrong light sentences like that could come across to someone as being told their priority for having as pain-free a birth as possible is in some way wrong."

That would be entirely in the eye of the beholder, as it was not implied in my comment.

"ing to make a lot of women choose CLUs regardless of how much "normal" birth is promoted. I would love to see CLUs with comfy furniture, low lighting and birth pools - maybe those things would make women less likely to need/want epidurals when it came to it"

Last lot of NICE guidance suggested that all women should have access to a pool to use, if it was clinically appropriate. I definitely think more pools on labour wards would cut epidural rates.

I know you didn't imply it, I was simply saying that was how some people might see it. If you read through a lot of threads on MN you can see there are women who feel that have 'failed' because, to them, the use of the word 'normal' in relation to an intervention free birth can imply that a birth with intervention is 'abnormal'.

It is a huge difficulty because you are right and the ideal for the majority of women, health-wise, is a calm, intervention free vaginal delivery and the aim should be to find a way to encourage and support women to achieve this. But just a casual glance through MN will show you that something about the current way of the healthcare community and the press etc promoting intervention free births (and breast-feeding too) is leaving some women with the impression they have failed.

I don't know whether it is the tone of the message, or the content, or what - but I don't think it can be ignored when it is affecting women's psychological well-being post-birth.

"because, to them, the use of the word 'normal' in relation to an intervention free birth can imply that a birth with intervention is 'abnormal'."

But a birth with intervention IS, in a biological sense, not normal. This is a statement of fact. Ironically, given that intervention free births are now much rarer than they used to be, medicalised births are actually socially normal, but still biologically abnormal.

"But just a casual glance through MN will show you that something about the current way of the healthcare community and the press etc promoting intervention free births"

But we need to be flagging up the huge increase in interventions in birth because they're harming women and they're often avoidable. I don't think birth professionals should be downplaying this issue to make women feel better, when it's causing so much avoidable harm.

"but I don't think it can be ignored when it is affecting women's psychological well-being post-birth."

Well perhaps the way to do this is to take attention away from women and put the spotlight on health professionals and institutions, and for mothers to understand that other people's involvement in their birth will be many times more influential on the outcomes of their labour than anything they can do for themselves.

I agree with your last point about getting women to understand and accept that lots of things can happen that will affect their labour and birth that are completely out of their control, though not all of these have anything to do with medical staff.

An intervention free birth might be 'biologically' abnormal (we assume, though I have a vague memory of reading that instrumental deliveries aren't actually that recent) but the fact remains that many women see the use of the term 'normal' as having that flip-side of failure. I don't think this is something we can just shrug off.

To me one of the huge difficulties in this whole conversation is that so many women are in a position to see how medical intervention saved them or their baby (I am one of them) who feel very strongly about the benefits that medical intervention in birth and see it on the whole as a positive thing. On the other side, many women have had problems caused by medical intervention and would have preferred a home or MLU-based birth.

Threads like this always go the same way, though they are always interesting - it's such a personal thing that it isn't really something many women are going to budge on.

Well perhaps the way to do this is to take attention away from women and put the spotlight on health professionals and institutions, and for mothers to understand that other people's involvement in their birth will be many times more influential on the outcomes of their labour than anything they can do for themselves.

The trouble is, alongside all the knowledgeable women out there, there are a vocal select few who have jumped on the 'if you breathe right it will be OK' bandwagon on the internet and in RL. And they are often the bluntest and most vocal.

Then when people think of the issue, they think of them.

So whereas the message would ideally be "if you are healthy, HCP should be enabling you to have a comfortable birth without interventions which could lengthen recovery time" what you sometimes see out there is "my birth didn't hurt because my body and psyche are 'right' and I went to the 'right' classes... if yours went wrong, you must've done something wrong.'

Such smug posts often get short shrift on MN birth and pregnancy forums - but they're all over the internet. It's almost like 'victim blaming'. I've seen similar comments on BFing ("women who don't just want their tits for the bedroom" being a particularly charming comment on one).

I've even seen a straight faced one suggesting women who are medically complex should just not have babies (like in the past) ta-daaa, saving the NHS cash and meaning everyone can have a home/MLU birth. Honestly. It wasn't on MN and most of the replies were a bit but clearly someone thought it was OK to say that...

Sorry forgot to add, in case not clear - I agree 100% with the quoted paragraph.
Just pointing out that there are some people who might on the surface be pro-woman with birth, but actually it's not coming from the same place: they're almost pleased that one way (their way) is safer than another way (for other people so who cares).