How to Commission a Homebirth Serivce – by a CCG Commissioner

Notes from 2nd July NCT Birthplace conference, Birmingham Medical School

Diane Reeves Accounting Officer for Birmingham South Central CCG:

Commissioning a Homebirth Service

These are a mixture of my notes of the presentation pulling points from the power point slides. I have labelled my comments clearly and where I have lifted slides the extra speaker comments are in italics from my notes. Italics can also denote my interpretation of what was said.

For the full slide presentation and recording go to:

Personal story –She was present at the birth of her sister in 1965, and 3 years later with her younger sister she ‘giggled’ through the birth of her brother. Diane is a GP by profession and has 4 children. Three were born at home, one against medical advice.

Comment: in her talk this experience and understanding clearly influenced her work as a clinician in this area and she was open about the fact that it had. She said that she convinced her peers with medical evidence, but her personal experience was what kept this as a priority and kept her pushing with her CCG colleagues. It also helped that her Commissioner colleague for maternity services at the CCG was a GP who, along with her siblings, had been born at home. They both felt that peer to peer discussion was what worked in pulling this off.

It was clear from Diane’s presentation, her colleague the commissioner in the audience and the senior Clinician speaker earlier in the day that there had been a number of them convinced of the need, and wanting to set up, a homebirth service in Birmingham, however, the barriers had been too great until now.

Key barriers were:

  • Finance and tariff issues- introduction of more granular tariff
  • Lack of published evidence-Birthplace study endorsed the safety- published 2011 BMJ
  • Interaction of evidence with clinical commissioning – lack of pathway from evidence to implementation. Need for leadership.
  • Increasing population, young city, high birth rates- links to capacity – easier to do more of the same?
  • Under-used home birth service because not dedicated – on call midwives pulled into labour ward leading to patients not satisfied (promised service not happening). Not promoted as a result.

GPs were also wary and unconvinced about having such a service:

What were the GPs concerns about the service?

GP HB survey findings

GP survey circulated in July 2013

42 surveys completed

Main concerns:

  • Medications •Attendance – •Transfers •New baby checks

Comment: Key concern seemed to be that they would be landed with situations beyond their competency: they would be called out to a birth or be involved in night transfers. Thought they would have to do the baby checks – but midwives can do it. Worried be responsible if things went wrong when they had no control over it. Clear that most GPs had little expertise in this area and were unaware of latest research on homebirth and other research findings.

W hat made it succeed:

  1. A cross section of convinced and committed professionals pushing for it over a long period of time. Doctors, midwives, women.
  2. Peer to peer advocacy important.
  3. Building sustainability in terms of finance and numbers is important right from the start – the service had to work on the Maternity tarrif alone – this has been a problem with past projects.

What made it happen? Key success factors

  • Evidence, data, choice and capacity issues creating a mandate – ie the combination of the medical evidence, the choice agenda in public health policy and the hospital capacity issue – too many babies being born for the Obstetric Unit to cope with.
  • Enthusiastic provider team (MWs and OBs), enthusiastic (female) GP commissioners- with a desire to improve choice and reduce interventions for low risk women.
  • Non recurrent spending requirements- initial pump priming . To get the results and the savings long term initial investment has to be made.
  • Work to promote it to GPs- educational events, GP networks Peer to peer education seemed to be key.
  • MSLC support – the MSLC kept raising this issue over years ( I get the impression that they were fed up of raising it by the end) but it kept it on the agenda until all the elements were in place
  • “Big social conversation” engagement events- reaching diverse communities (but BSC patients only at present) Community participation not a top down approach (more of this in another presentation)

I would add strong leadership from CCG Commissioners – who were female, mothers and had personal experience of homebirth. It is a strategic thing.

Commissioning for Quality

  • Intra-partum transfer review and benchmarking – ensuring that transfer rates do not exceed the Birthplace average
  • Continuity of care is important: 3 or fewer midwives through whole package of care. Another presentation by the head of the HB team said that they decided not to do 121 midwifery but team care due to staff lifestyle balance – but the standard is that women meet 3 or fewer midwives during the entire pathway.
  • Breastfeeding rates 75% – high BF rate is expected and delivered
  • Incident reporting and monitoring – this has to be as rigorous as in a unit
  • Diversity of users – not just for hippies

Diane showed a video of an interview with South Asian couple. They could not understand this thing about being given toast after the birth. She said ‘Why am I being given warm bread? Is it some kind of ritual?’ Remembering the cultural aspects of communication and birth!

Sustainability and where they are at: 240 births is the breakeven point for sustainability and in their first year they are on target to meet this point within three years. For equity however the HB team needs to be rolled out across Birmingham. Also, HB team in first year – none of the GP concerns have been realised!!!

Message to everyone out there:

  • Build sustainability into your business plan
  • Strong cross professional leadership needed. Key here was GP leadership.
  • If it fails this time around keep pushing: its time will come.

Place of Birth not a Choice anymore?

Below is the AIMS response to the shocking statements made midwives and barristers at the RCM conference regarding women’s right to choose where they give birth.

AIMS response:

“At the Royal College of Midwives Annual Legal conference midwives were told ‘that women can’t insist on a home birth if the NHS doesn’t have the capacity to provide it’ (Barbara Hewson, a leading barrister) and that ‘A woman’s right to choose must be constrained by the art of the possible,’ (Lorna Muirhead, past President of the RCM).

The following is AIMS response:

‘Choice not an option for some’

If the argument is that ‘Choice of birth is not an option for some’ then perhaps we should be arguing that choice of hospital birth is not an option for fit and healthy women who want to be delivered in an expensive obstetric bed.  The research is quite clear.  Obstetric units are less safe for low risk women and babies.  The women run an increased risk of avoidable interventions and surgery and the babies are, for example, more likely to be exposed to drugs that seriously affect their ability to breastfeed .  Sadly, comparative studies of home/hospital outcomes do not include mental health; if they did, we suspect the advantages of home would be even greater.

While the law in this country restricts supervision of birth to midwives or doctors there has to be, therefore, a balancing responsibility of the profession to provide a midwife when asked.  If the profession wishes to change this law by giving itself the right to refuse attendance then it should be open to anyone to provide midwifery services at the birth – roll on lay midwifery; the alternative is abandoning women who birth at home to birth alone without any professional attendant.

It is irresponsible to suggest that hospitals should be able to withdraw home birth provision, it puts women at risk unnecessarily.

Furthermore, Laura Muirhead also reveals her lack of understanding of normal birth.  ‘Students are only exposed to normality. When qualified and they need to interpret CTGs or cope with a PPH, they can’t.’ Students are not ‘only exposed to normality’ indeed, they rarely see it.  What they see is a continuous stream of women subjected to a wide variety of interventions that pervert the normal progression of labour and it is no wonder that 30% of them end up with a caesarean section.  Suggesting that ‘if continuous monitoring is right for a woman, then we can’t give her the choice not to have it’ reveals Lorna Muirhead’s worrying and erroneous assumption that interventions can be imposed on women .  To do so is an assault, and it is illegal see
Beverley A Lawrence Beech