Re. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective
Thanks to NHS Sussex, I was lucky to be at the Birthplace conference on Friday at the Royal Society of Medicine representing the Brighton and Hove MSLC.
BSUH midwives Maggie Rogers (labour ward) and Marion Wilyman (community) were there and will hopefully be at the next MSLC on Friday 9th to present their perspectives on the findings.
I thought it might be useful to share my take on the day, from a user’s/lay person’s point of view.
A series of presenters from the NPEU research team talked through the key findings of the various parts of the study and I’ll try to list them here briefly but as accurately as I can. (You can see a full summary with links to the report at https://www.npeu.ox.ac.uk/birthplace/results)
The researchers looked at 64,538 birth records of low risk women and their planned (not actual) place of birth in England. This is the largest study of its kind (I believe) ever carried out in the UK.
In the 64,538 births, they found there were a total of 250 ‘primary adverse outcomes’ for babies.
This term covers: still birth after start of care in labour ; early death of the baby after birth ; various degrees of brain damage ; inhaling meconium ; fractured bones (presumably from manoeuvres associated with shoulder dystocia ?).
It was unclear whether in the case of inhaling meconium or fractured bones, how many babies went on to make a full recovery (this is something I wish I’d asked).
There were no maternal deaths in all the 64,538 case but as far as I can see – and I don’t think the study took into account suicide in new mothers due to post natal post traumatic stress or post natal depression.
The overall average rate of these serious ‘primary adverse outcomes’ where ever the PLANNED place of birth for low risk women was 4.3 per 1000 births – that 0.43% chance of something serious – but not necessarily fatal – happening to your baby if you’re low risk – where ever the planned place of birth. The study concluded on this point that BIRTH FOR LOW RISK WOMEN IN ENGLAND IS VERY SAFE !
So then these 250 ‘primary adverse outcomes’ were broken down to show the chances of something like this happening depending on the planned (not actual) place of birth: either home, a freestanding birth centre or midwife led unit (FMU), an alongside birth centre or midwife led unit next to an obstetric unit (AMU) or an Obstretric led unit (OU).
The key findings were:
There is no significant difference in ‘primary adverse outcomes’ for babies of mothers choosing to birth in an FMU, AMU or OU. This is great news for midwifery led care.
Women planning to birth in a FMU or AMU had significantly fewer interventions including fewer emergency c-sections and more normal births than women who planned to birth in an OU.
Plus the study around cost effectiveness showed births in FMUs or AMUs are more cost effective for the NHS than births in OUs.
The study concludes on this point:
MIDWIFE UNITS ARE SAFE FOR THE BABY AND OFFER BENEFITS FOR THE WOMEN PLUS ARE BETTER VALUE FOR MONEY FOR THE NHS.
With women choosing home birth – there are small differences between outcomes for first time and second time (and third etc) mums compared to birth in an OU.
For second time (and third time etc) mums, there are no differences between numbers of ‘primary adverse outcomes’ between planned home births or planned births in freestanding or alongside birth centres or an obstetric unit – great news for second time (or third etc) mums planning homebirth (there were actually slightly less ‘adverse outcomes’ for babies of second time mums planning homebirth than babies of second time mums planning OU birth – but the difference isn’t statistically significant).
For first time mums choosing home birth, there is a small difference in risks to the baby that is just into statistical significance – there were 9.3 per 1000 ‘primary adverse outcomes’ for babies born to low risk women whose had planned a homebirth, compared to between 3 and 5.3 per 1000 for births planned in an OU (the figure depends on whether these low risk women had extra ‘complicating factors’ like prolonged rupture of membranes, abnormal vaginal bleeding or high blood pressure).
BIRTHPLACE CONCLUDES THAT HOMEBIRTH IS SAFE FOR BABIES OF LOW RISK WOMEN IN ENGLAND, ESPECIALLY FOR BABIES OF SECOND TIME MOTHERS.
Despite this finding, you may have seen the press headlines screaming ‘home birth three times more risky than hospital birth’. The journalists were picking up on the difference between ‘adverse outcomes’ for 3 babies per 1000 births where a woman had chosen OU and 9 babies per 1000 births where a woman had chosen homebirth for a first baby. This is still less than 1% risk for first time mums choosing homebirth – but as usual the press delight in distorting the facts and scaring pregnant women.
Not surprising, there was lots of discussion around these numbers at the conference – questions around what the adverse outcomes particular to home birth might be; the actual place of birth as opposed to planned place of birth; whether these 9 babies per 1000 had their safety compromised by the high rate of home to hospital transfer for first time mums (birthplace found an average 45% transfer rate for first time mums); discussions around transfer rates being varied and dependent on midwives’ confidence in homebirth…
More research is clearly needed around this area – nationally and locally – in order to ensure homebirth is as safe as it can be for first timers (For example, in Brighton, where we have a traditionally high home birth rate, how do our transfer rates compare to this 45% transfer rate for first time mums ?).
The other finding extremely relevant to Brighton and Hove was that in England, first time LOW RISK mums have a 11% chance of c-section if they choose OU birth – BUT its only 2.8% for choosing homebirth; 3.5% for choosing a freestanding midwife unit and 4.4% for choosing an alongside midwife unit. A massive difference ! This is devastating news for obstetric units and tax payers money – and its surprising the press didn’t pick up on this as a headline.
As we are yet to have a local midwife unit in Brighton and Hove, and we are trying to reduce C-Section on the labour ward as part of the ongoing ‘Normalising Birth’ programme, we need to ensure local first time mothers aren’t put off choosing homebirth by the irresponsible press.
This places even more pressure on an already stretched midwifery work force, who will need to spend time talking to women about their choices. Maybe the MSLC could help BSUH put together a ‘BSUH’s response to Birthplace’ leaflet, reassuring women about the findings, mentioning our own local stats to help the midwives reassure women – especially first time mums – that homebirth is a safe and supported option in Brighton and Hove ? We can talk more about this on the 9th.
In the meantime, feel free to send over any questions you may have – one of co-investigators has offered to forward them onto the research team. Also feel free to send this link round to other parents and user reps (doula’s, antenatal teachers etc) and anyone who might find it useful.
Below are useful links to position statements/responses to Birthplace from the various professional bodies and consumer groups, plus the press statement from Cathy Warwick of the Royal College of Midwives.
Chair, Brighton and Hove MSLC
Press release from Cathy Warwick, General Secretary of the Royal College of Midwives (sorry have been sent the text, can’t find the link):
Commenting on the release today of The Birthplace in England Research Programme (Birthplace) by Oxford University’s National Perinatal Epidemiology Unit (NPEU), the Royal College of Midwives’ (RCM) Chief Executive and General Secretary Cathy Warwick said:
“This ground-breaking research makes a very important contribution to the evidence base for women and health professionals about the safety of childbirth planned in different settings for women at a low risk of complications. The RCM hopes that its findings will be widely used and will help health professionals support women to make informed choices about their options when considering where to give birth. It should also influence the planning of high-quality maternity services across the UK and internationally.
“This study demonstrates clearly the safety of midwife led-care. For women who do not have complications associated with their pregnancy, planning to give birth at home or in a midwife-led unit (MLU), whether it is close to a hospital or not, is as safe as planning to give birth in a consultant-led unit. This study confirms the results of other studies showing that women planning to deliver in these settings experience fewer medical interventions and complications than in a medically-led service.
“Rates of birth without medical intervention are significantly increased in planned homebirths or those in midwife-led units. Women expecting their first baby should be advised that they are as safe planning to give birth at a midwife-led unit as a consultant-led unit. They will experience less medical intervention in labour, such as caesarean section, forceps delivery, and blood transfusion. They are also more likely to use water for birth and or (for pain relief and avoid an episiotomy (planned cut). Most of these women will actually give birth in a midwife-led unit. For those who will require transfer during labour, it is vital for these women that there are excellent systems of communication and transport for their safe and swift transfer.
“The study’s outcomes are excellent for women having a second or subsequent baby and it is uncommon for these women to have to transfer from their planned place of birth when in labour. The RCM believes that this is a landmark study and there is now a substantial evidence-base to strongly support such women planning to have their baby at home or in a midwife-led unit. This study has important and wide-reaching implications for planning and delivering maternity services.
“Where a woman having her first baby is considering birth at home, she needs to be aware that whilst the vast majority of babies will be well, there is a chance that wherever she gives birth, the baby may have a poor outcome and at home this chance is slightly increased. However, the need for medical interventions in labour, such as the need for pain relief, remains less than in a consultant-led unit.
“This study backs the policy of choice (supported across the UK) regarding planning place of birth. It is critical if we are to improve women’s experience of childbirth, reduce unnecessary medical interventions, such as caesarean section, and ensure safety that this research’s findings are taken into account and studied closely by policy makers and NHS commissioners, who hold the purse strings for funding.
“Maternity professionals should be asking themselves two critical questions in the light of this research: Why should there be a slightly increased risk in planning homebirth for first-time mothers; and why should women with no complications during pregnancy experience unnecessary and, sometimes harmful medical interventions during a hospital birth? Midwives and obstetricians must work together to ensure that wherever a woman plans to give birth the outcome is successful with positive results for mother and baby.
“Why, in times of limited financial resources, is a decision often made to curtail or cut a homebirth service or close a free standing midwife led-unit? If mothers and babies are to get the best care they deserve and limited resources are to be used effectively, this is the wrong response. The right response for mothers and babies is to keep these services open, making sure women understand the advantages associated with homebirth and midwife-led units, thus ensuring their greater use and cost effectiveness.
“Women giving birth for the first time will need this research’s finding’s to make a fully informed decision, as to choosing their place of birth. Midwives need to support these women and help them understand the full ramifications of the research’s findings.”
“There needs to be a seismic shift in the way maternity services are provided now because the way services are currently delivered wastes taxpayers’ money. For appropriately selected women, births in midwife-led units and home births have been shown to deliver better care for fewer costs. The Government has called for the NHS to deliver more for less and this is exactly what an increase in homebirths and midwife-led services will safely deliver.”