Bradford's Birthplace Conference Notes Re-posted

The new draft NICE guidance on birth place has caused a stir and some controversy.  Below I have re-posted the conference notes from the northern launch of the Birthplace survey which was the evidence behind the new draft guidelines.  It is a reminder that these guidelines are based on strong clinical evidence regarding safety, outcome, satisfaction and cost.   This evidence now needs to be implemented, the draft guidelines have to be confirmed and put into practice by CCG commissioning.  To comment on the guidelines you need to do so through a participating organization like www.aims.org.uk.

The Birthplace Conference at the Bradford Royal Infirmary was a wake up call for birth and midwifery. It was absolutely clear what women require for a normal natural birth – and it is not an Obstetric Unit! It was also clear that the myths of the higher cost of midwfery led units and safety fears, were all just that –  myths – well not even myths because myths require an element of truth.

I rarely take notes these days but once the conference had ended I wish I had!!!!! So I asked my friend and fellow Airedale Mum, Sally Watson, Student NCT Antenatal Teacher and all round good guy – if I could borrow her notes and publish them on my blog. She kindly consented and so here they are.

BRI 10 February 2012

Mary Stuart; Birth Place Study (see on SDO website, BMJ or NHS choices website)
All research on birth place has its limitations. The focus of this particular study was on outcomes for actual place of birth – rather than planned place of birth, this inevitably skews the data.
This research looked at 4 different places of birth, obstetric unit, freestanding midwifery unit, attached midwifery unit and home birth, comparing 65000 women
Primary aim of the study to compare intrapartum and early neonatal mortality and morbidity – by planned place of birth at the start of care in labour.
A disproportionate number of complications occur in obstetric units – this must be talked about!
Characteristics of those who choose homebirth – white, middle class, affluent, have a partner.
In all places there is a low risk of an adverse outcome (4.3/1000) where the mother is low risk.
Adverse outcomes included; stillbirth (14 in total), early neonatal death (18), neonatal encephalopathy (114), meconium aspiration (75), bronchial plexus injury (20), fractured humorous or clavicle (2)
Statistically significantly higher for first time mums (1 compared with 1.75)
Event rate is higher for homebirth than obstetric unit (3.5 compared with 9.5) the researchers were not able to say why this was, but said that the majority of the adverse outcomes were neonatal encephalopathy and meconium aspiration – there is no way of knowing the long term impact of these outcomes. Much was made of the infamous daily mail headline – the authors stressed that their reporting of the study was simply not true http://www.dailymail.co.uk/health/article-2065928/First-time-mothers-opt-home-birth-face-triple-risk-death-brain-damage-child.html the number of still births/ neonatal deaths were so small that it is of no statistical use to analyse these.
For nulliparous women there was a 45% transfer rate from home to hospital, for multiparous women this reduced to 12%
Birth outcomes;
C/S rate – 11.1% Obstetric Unit, 2.8% HB
Spontaneous vertex – 74% Obst Unit, 93% HB
Normal birth – 58% Obst Unit, 88% HB, 83% FMU, 76% AMU
Definition of normal birth – labour spontaneous, without episiotomy, forceps or ventouse (can include ARM, Syntometrine, pethadine).

Juliet Rayment (research assistant at city university of London, she focused on case studies Juliet.rayment.1@city.ac.uk)
She found that women were limited on where to give birth by the distance. Their choices really came from within the community – women talked about their friends, sisters, family etc. The more information they had, the more choices they had. Women wanted to birth close to home – don’t want to travel distance.
Also found that the leadership of an organisation/ unit set the tone for learning and accountability rather than blame, when things went wrong.
Women felt that their concerns about their health or the health of their babies was not always heard.
The study raised questions – are women receiving optimal care from Obstetric Units? The findings would suggest not – there is a need to find out what’s going on?
Cost according to place of birth (irrespective of outcome)
Obstetric unit – £1631
AMU – £1461
FMU – £1435
Home – £1063 (included with that are the staffing costs – yet home birth is still cheaper)
Look on BMJ website for full report.
Should advise low risk women to give birth outside of an obstetric unit, their outcomes are likely to be more positive, also much better obstetric health for subsequent babies.
One quote from obstetrician in the study “keep women away from us…we meddle”!

Mary Newburn (NCT)
Talked about the birth centre research study, found that physical environment led to psychological safety. For the women in the study it was important for them to see the place/ the atmosphere, once there, they felt compelled to birth there.
Why women chose to give birth in birth centre (some of the reasons they gave); they heard about it, being allowed, all natural, comfortable, calm and appealing, it made sense of how labour works, husband can stay, could ‘see myself there’, midwives get to know you, holistic approach, feel safe/ confident.
The midwives in the birth centre have a different mentality
– a belief in normal birth (not the conveyor belt production that Dennis Walsh talks about)
– Connection with a woman
– Understanding birth physiology
– Inspiring confidence in women
Midwives who worked in a birth centre from an obstetric unit talked about ‘pushing boundaries’, forget instincts and what you feel/sense in the room.
Parents talked about how it was like “going into another world”, the midwives provide continuous care, a firm support.
One of the fathers used the analogy of labour as like going to the gym ‘two more bounces on the birthing ball, then we’ll get you into the shower…then we’ll move somewhere else’
Midwives talked about “walking the line” between competing pressures and demands.
Knowledge and resourcefulness of early labour – a lot more needs to bedone on how to support dads/ birth partners support women in early labour. Mary Nolan has undertaken recent research into dads involvement – in Midwifery journal in past month.
Recommendations from the report; need a consistent welcome in the birth centre, and quiet time (unit was not always quiet), there was a heavy focus on the birth and lots of privacy post birth – but not so much support – couples tended to be left alone, yet there is a need for BF support, there is huge disparities in respect of who accesses the unit – still groups of the community who are not using the birth centres. There followed a general discussion with midwives from birth centres in different areas – all talked of referrals coming from the same midwives – with other community midwives not referring – it was felt that this was because they didn’t believe in natural birth.

Jane Munro (RCM) campaign for normal birth July – August 2010
They had 1000 returned surveys from 24 units (46% response rate which is pretty good)
67% Obstetric Units
1% Home births
32% Midwifery led unit
Found a link between instrumental delivery and semi-recumbent position. Although the majority of women in the study laboured upright, 49% birthed on the bed
RCM produce cards with different birthing positions on for midwives – include 22 images
Home births;
52% reported HB training in their initial training, 71% had experience of a homebirth in the last 12 months, 58% didn’t have any CPD on home births since qualifying
57.6% of the respondents said that their area always offered a home birth service
Confidence in attending a HB – 50.4% said very confident, 37.1 confident (slide went away before I could take the rest down)
There was some discussion about taking beds out of the rooms in birth centres – one midwife said that in her unit the bed flips out of the wall. A woman can use chairs/ sofa and the bed is only pulled out if particularly long labour and she wants to sleep – or afterwards. Other midwives talked about sitting on the bed or raising the bed so women can’t get on!

Chris Warren – Yorkshire storks
Talked about her statistics.
In 48 deliveries since 2005; 25 homebirths, 2 PPH, 6 forceps/Ventouse, 12 CS, 1 Elective CS, the rest hospital births.
They have had no emergency transfers to hospital (blue lights), their transfer rate is 10% (more for primips).
Women do not choose bad options when it comes to place of birth – they are scarred into it.
Look at evidence based guidelines for midwifery led care May 2008 (unsure of reference – might be RCM!)

Evidence is not enough to keep a Birthcentre open

The freestanding Jubilee Birthcentre in Hull is to close. IN the light of the birthplace evidence this is bad news and short sighted, the cost benefit anaysis given in the Birthplace study makes it difficult to see how it is justified. Government and regional health authroities should have policies of building birthcentres rather than shutting them, and making them default places for low risk women to attend, rather than the curent system where the default even for healthy women with no issues is an obstetric unit.

Here is the link to the news. Below that, is an insightful comment by Professor Lesley Page,  responding to the disappointment of local midwves in this region.

http://www.rcm.org.uk/midwives/news/midwife-led-birthing-centre-to-close/?utm_source=Adestra&utm_medium=email&utm_term=

Lesley Page says: I think we need to re frame this. First it is definitely short sighted when birth centres are closed, particularly given the current problem with our low normal birth rate and high intervention rate. I am always so sorry to hear about these closures. The financial arguments for closing rarely take into account the reduced costs of interventions financially and on women themselves ( and their families).Often the staffing could be made more cost effective. But, although we should be realistic it is important not to be pessimistic. What we have to do is alter the view point-we are in the beginning of a paradigm shift, and although some birth centres are closing there are more, I believe, than a few years ago. We are all leaders and here is what we have to do-really talk to women and their partners about why out of hospital birth should be considered seriously, tell them about the hormones and effects they have.tell them about the risks of unnecessary intervention. For the development of midwifery we need to have confident midwives support those who need to increase confidence. Make birth centres as cost effective as possible. This by: possibly creating caseload practices around them,and making them development areas for midwives to learn from each other, skills, tips, latest research, how to stay competent and confident. Birth centres should be part of the rotation for new midwives and all midwives should be encouraged to work in them for a while. Lets make the culture in them buzzy and dynamic where midwives and others talk to each other about and evaluate how we make birth normal and safe, and how we can make midwifery fulfilling for us midwives. Evaluate methods such as hypno birthing in the birth centres. The future is too important to be pessimistic-and I sense there is a change-it wont happen overnight-so lets hold onto that future.  www.lesleypage.net