Birthplace study: the bigger picture

It was inevitable that yesterday’s Birthplace study would cause the kind of chest-beating, hair-tearing, teeth-gnashing media frenzy that is reserved especially for anything related to birth choices. Ah well! Important to let them all have their fun, eh?

Well actually no it isn’t. Being as it impacts on the lives of so many of us I think there should have been a few more valiant attempts to report this vital new research in its propert context and with accuracy. My blood pressure is several points higher having read a particularly fictional interpretation in The Sun (which I won’t link to for fear of similarly endangering your circulatory system) and I’ve found it staggering to watch the anti-homebirth/anti-choice brigade take the results of a study that demonstrate THE EXACT OPPOSITE of their agenda and twist them to create fear, panic and confusion.

So, here is my understanding of the study, with a few comments which I hope will be helpful to those looking at the news and wondering what to make of it. (NB I’ve actually read the study, which I think is helpful in advance of commenting).

 

Safety of the Baby

The study gives us new information showing just how safe birth is in England. We also, for the first time, have a really good sense of just how safe homebirth is – the verdict from the authors is that it is indeed VERY SAFE.

1. Giving birth in England is very safe. Wherever you give birth, however many babies you’ve had. The authors go to some lengths to state this. Outcomes for babies are very good in all settings. Hurrah!

2. In terms of outcomes for the baby, home, birth centre and hospital settings all have over 99% good outcomes for first/second/third/fourth (and on and on) time mothers. Poor outcomes happen in less than 1% of cases for all categories.

3. Poor outcomes are a set of things that happen to the baby varying widely in seriousness. Media reports relating to rates of baby death are inaccurate as the rates of this happening are even lower. Some ‘poor’ outcomes are much less poor than others.

4. When looking at the differences between outcomes across the three types of birthplace the least statistically significant gap is the one that has been most widely reported (I’ll go on to talk about the greatest gap in the ‘Safety of the Mother’ section below). This widely reported gap relates to first time mothers planning a homebirth. For this group the rate of poor outcomes for the baby rises from around 0.53% to 0.93%. The authors note that this is still a very low rate of poor outcomes and still a very safe level. They also explicitly tell first time mothers planning a homebirth that there is no need to change their plans and remind us that this small rise in poor outcomes doesn’t apply to women who have a second or subsequent baby at home.

5. The authors don’t know why there is this small difference though suggest more research needs to be done in to whether the demographic of the homebirth groups (older women for example) could impact, or other factors like the way maternity services are set up across the country.

6. I, like anyone interested in positive births that include (but aren’t limited to) good outcomes for the baby, am keen to understand this small difference better and for steps to be taken to close this gap.

 

Why is there a difference in outcomes for the baby for first time mothers?

I don’t know and neither do the researchers – there needs to be more research done.

I would however point (as the authors of the study do) to more work being done on how homebirth services are structured across the country. The study notes that there are huge differences in the way maternity services are structured in different areas. Nowhere is this more true than in homebirth settings. While it is difficult to set up an obstetric unit in a radically different way, homebirths are serviced in very differing ways even between neighbouring boroughs.

At my nearest hospital (Homerton Hospital in Hackney) we have a brilliant team of six dedicated homebirth midwives. They operate under a case-load system so women get to know their own midwife who visits them at home. Women also have the chance to meet all the midwives in advance so they will know the midwife who will attend the birth. The midwives focus solely on homebirth so they are invested in building the service. They know the procedures inside out and they do homebirths every week. The kit is second nature to them, working autonomously outside of a hospital setting is something they have chosen to do, have been trained in, are supported in by their supervisors and do every week.

In a neighbouring borough they have no dedicated homebirth team. Instead community midwives take it in turn to be on call. Some have more and some have less experience. Some are positive about homebirths and some are not. Some feel confident about working autonomously outside of a hospital setting and some don’t. Depending on the homebirth rate in a borough it’s possible that this kind of system puts a midwife and mother in a difficult position where the midwife isn’t accustomed to homebirth, doesn’t know the kit or procedures well and doesn’t feel well supported by her supervisor.

It’s hard to see how this could fail to impact on the statistics.

 

Safety of the Mother

The study doesn’t report explicitly on maternal safety in the same way it looks at outcomes for the baby. However it demonstrates a dramatic difference in the rate of interventions (all of which carry additional risk for the mother) depending on place of birth. Only 10% of mothers planning a homebirth will have an intervention  (like a caesarean or forceps birth) even if they transfer to hospital, whereas over 40% of low-risk mothers planning a birth in an obstetric unit will have an intervention.

1. 90% of women in England give birth in an obstetric unit and around 2.8% of women have a homebirth.

2. The study is comparing like-for-like groups and counts ‘planned’ place of birth rather than actual place of birth (i.e. if you start off in the homebirth group and end up transferring in your statistics stay in the homebirth category) which gives us a real idea of what the effect of place of birth has on the way the birth plays out. Commentators who say homebirth statistics look better because the group is lower risk or that people who have complications and transfer to hospital aren’t inlcuded are INCORRECT. This research wants to get real evidence about what the effect of birthplace is on birth and has done just that.

3. So we learn from the results that the further away you are from an obstetric unit the smaller your chance of an intervention. To be 100% clear this is still true if you have a complication and end up being transferred in.

4. Healthy, low-risk women will have over 40% chance of an intervention like a caesarean or assisted delivery in an obstetric unit. In a midwife-led unit in a hospital there’s a 24% chance which decreases to 17% in free-standing midwife-led care and right down to 10% for home birthers.

5. This is a resounding endorsement of the benefits of midwife-led care as a standard for low-risk women. Midwife-led care has identical outcome rates for the baby with dramatic improvements in intervention rates – getting more dramatic the further they move away from a hospital setting.

6. It is important to remember that while many women have interventions that have little or no long-term consequences for them, many  do have consequences (some serious) from these procedures. There is a reason many women want to avoid interventions – it’s not about ‘getting a medal’ for natural birth. The consequences of these procedures can range in severity from an increased maternal death rate and hemorrhage to injuries to the bowel/bladder/perineum and implications for future pregnancies. Traumatic intervention-filled births can also lead to short and long-term consequences for the woman’s mental health as well as sometimes causing initial breastfeeding and/or bonding difficulties if a mother and baby have to be separated or if a baby is suffering from head/neck trauma from an assisted delivery. Birth is not just about one day – it can have an impact on the rest of a woman’s life.

7. It is crystal clear from these results that the best chance of avoiding unnecessary intervention and its consequences is to give birth at home, with positive statistics also found in midwife-led units.

8. The media hasn’t really picked up on the fact that the model of care that we currently offer to 90% of women in this country has over 30% higher rate of intervention than the model of care that only 2.8% of women are currently accessing. These are women with the same low-risk status whose outcomes change simply because of proximity to obstetric units. Obstetric units are currently not a good place to go if you want to avoid intervention.


Costs

It is much cheaper for our stretched maternity services for a woman to have a homebirth than any other kind of birth. Obstetric-led units cost £310 more per woman than a homebirth, with midwife-led units coming in £130 cheaper than their obstetric counterparts. With our rising birth rates this is very significant.

Should we care about costs? I reckon we should. There’s a shortage of midwives, threats to homebirth and birth centre services and a huge strain on the system. The study demonstrates that 90% of women are currently accessing a vastly more expensive model of care. 50% of hospitals don’t have a midwife-led unit at the moment and homebirth services are under threat due to shortages and budgets. Totally flaming crackers in my opinion and a real call to action that a dramatic rethinking of our maternity services is needed. This study gives us ideas as to how we might best do that.


What would I like to happen following this study

  1. Everyone to get the message that giving birth is safe. We need to respect women’s choices anyway, but particularly as all the options have been shown to be safe
  2. Everyone to get the message that homebirth is safe
  3. Concerns to be raised about intervention rates in obstetric-led units and real comprehension that these levels are now demonstrated to be unnecessary
  4. Rethinking of maternity services to encourage and enable women to access midwife-led care which will give them the same good outcomes for their baby, with less chance of intervention and less cost to the NHS
  5. More research in to the small increase in poor outcomes for first time mothers at home. The imperative to do this is contained in the other findings of the study. Homebirth has the lowest costs and the best rates of ‘normal’ birth. It’s a clearly a good model of care and demonstrated to be very safe by this study. This gives us the call to action to understand that small increase in poor outcomes for the baby for first time mothers as we need to look at how to close the gap so that the service can be rolled out more widely
  6. Acknowledgement that the structuring of homebirth services needs to be looked at, both in terms of researching outcomes for babies of first time mothers and also for offering women real choice when choosing place of birth. The study should make more women interested in homebirth and we should be sure that we are offering them a real homebirth service

So calm down everyone and hold off on the hysterical hand-flapping. You’ve just been given some brilliant research that enables you to make good choices, appropriate for you. Not really anything to get your knickers in a twist about eh?

Comments
10 Responses to “Birthplace study: the bigger picture”
  1. An excellent article. Thank you for putting this positive message out there. Such a shame the media have been creating more fear in the minds of expectant parents when the study really shows, as you say, that birth in the UK is very safe regardless of where the woman chooses to give birth but if she’d like to have a normal/natural birth then her best chance is to plan to birth at home (which has so many benefits for mum and baby). As a HypnoBirthing practitioner, I see many women afraid of birth and looking for ways to ease that fear. At least by the end of the HypnoBirthing course they realise they can trust in their ability to give birth and to surround themselves with the kind of support that is right for them for it but sometimes it takes a lot of release work and re-education to get past all the fears implanted by our society and the media in particular.

  2. Doula Caz says:

    Fantastic article! So nice to read an objective presentation of the facts!

    I, too would really like to know what the discrepancies are between first time and subsequent births.

    Pain relief seems to be the main reason for transfer, so maybe we should be looking at better antenatal/preparatory care (hypnobirthing, antenatal classes, water birth workshops), so that women feel less fearful about the sensations they might feel during labour and delivery. Just basing this idea on the premise that less fear equals less pain.

    Altering perceptions and expectations of first time mothers could turn those transfer rates around.

  3. Caroline says:

    Fantastic article! So nice to read an objective presentation of the facts!

    I, too would really like to know what the discrepancies are between first time and subsequent births.

    Pain relief seems to be the main reason for transfer, so maybe we should be looking at better antenatal/preparatory care (hypnobirthing, antenatal classes, water birth workshops), so that women feel less fearful about the sensations they might feel during labour and delivery. Just basing this idea on the premise that less fear equals less pain.

    • Mary says:

      I totally agree re pain relief – also noting that “slow labour”, as reported by the BBC, was a common reason for transfer from home to hospital, I wonder if better preparation/education could be an answer. I haven’t read the research so don’t know whether “slow labour” was REAL failure to progress, or whether there was just IMPATIENCE from mothers (and midwives) with unrealistic expectations of first labours . Posterior position, for example, is so common these days and many first-time mums have no idea that this can mean a long, gruelling first stage, during which you may have no support whatsoever with community midwives only prepared to stay with you once you’re in “established labour”. Unsurprisingly, frightened and disheartened women opt to transfer to hospital in such circumstances, where drugs and other interventions are too easily on hand, as the research has indicated.

      • Familia says:

        Hey, I took a seesmter of statistics, so I totally resent being called a lay person. (Ha ha). This reminded me that there was something recently I thought of sending you to read just for this reason, but I can’t remember what it was.Just one question for now. I’m either misunderstanding or overlooking the part about reporting neonatal mortality as a percentage of the whole population. Where is that?

  4. Hi! I tripped on this post through a Facebook post. I am a birth junkie (doula, writer, researcher) in Michigan, USA. I’m currently researching African-American birthplace choices in the US. Thanks for this post! I am reading a great book called “Thinking, Fast and Slow” which is helping me (finally!) to understand why negative birth outcomes loom SOOOO largely in everyone’s imagination. This book (a book about psychology and statistics, not usually my favorite subjects, btw!) is helping me understand why so many women and doctors make the choice to use unnecessary interventions. It appears that humans usually make this sort of irrational choice. (Check out the chapter on the fourfold pattern!). Anyway, appreciate your post!

    • Giovanna says:

      Your a true Angel! So wrohty of fighting this tough Maternity Battle, and dispelling so many wrong myths. Your a god-send for all of us Mothers and Midwives xoxox Rose

  5. BTW, even though I am advocating natural hospital birth here in the US, I am a huge homebirth supporter!

  6. Julie says:

    thankyou Hacney doula. I’m hosting the first meeting of a homebirth support group in Newcastle this week, and I’ll print off your post to refer to and to let folk read, as it’s really very excellent…

  7. Why don’t you write a rapid response to the British Medical Journal? I think your opinion is valuable in this debate. http://www.bmj.com/content/343/bmj.d7400?tab=responses

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