NICE guidance puts women in control of their care
The updated NICE guideline, Intrapartum care: care of healthy women and their babies during childbirth, is significant for women, midwives and maternity services. Among much else the guidance says that, for women experiencing a straightforward, low risk pregnancy, planning to give birth at home or in midwifery led units is safer for them and as safe for their baby as planning to give birth in an obstetric unit.
For women having their first baby the transfer rate to obstetric units from midwife-led settings is high and from the baby’s perspective, the risk when being born at home is higher than in an obstetric unit. The guidance however emphasises the need for women to be able to make a fully informed choice and to ensure that when a woman does transfer to hospital the transfer is smooth and efficient.
The RCM welcomes this guidance - it puts women firmly at the heart of their care, stresses the need for their own views about how they give birth to be the driver of care and should influence maternity services provision positively.
However all is not completely rosy, the RCM is concerned that it has not been possible to update the entire guideline. Important evidence on team midwifery and continuity of carer, which was available before the guideline was developed, has not been included.
The guidance as it stands suggests that team midwifery may not be the best model of care despite the fact that we now know that a team of three or four midwives can help to ensure the continuity of carer that women prefer while also delivering other high quality outcomes. NICE have acknowledged that some of the remaining 2007 guidance may need rapid updating and we hope to see this specific element updated in the near future.
The fundamental evidence base for the revised guidance is the Birthplace in England Study 2011. This large study of over 70,000 women looked at differences in outcomes for the mother and baby between different planned birth settings. Data was collected on the basis of intention to treat. For example, if the woman received any midwifery care in a setting before being transferred, her outcomes were accounted for as being related to the place she first received care.
It showed that for planned births in midwife-led units (stand alone or alongside) there was no significant difference in adverse perinatal outcomes compared with planned birth in an obstetric unit. For all women there were other benefits including substantially reduced chances of having an intrapartum caesarean section, instrumental delivery or episiotomy.
It did also show that for women having their first baby and planning a home birth, there was a small, but increased risk for the baby. Second-time mothers birthing at home had outcomes as good as a midwife-led unit.
Importantly in these cash strapped times, the study showed that midwife-led births are more cost effective and in the long run will save the NHS money.
The significance of this study and NICE’s use of it cannot be underestimated. The question now is what does this guidance mean for midwives, maternity services and the NHS?
It means there has to be a sea change in how services are organised and delivered. In the UK about 87% of births are in hospital settings with most taking place in obstetric units. This needs to be flipped on its head. Ideally, we need to see more and more births move outside obstetric units into midwife-led settings and at home.
I have been asked about the current midwifery shortage (3,200 in England is the RCM’s latest estimate) and if this will affect the introduction and use of the guidelines.
The answer is that if the NHS embraces these guidelines and commissions services accordingly, we can over time increase the number of women who have a positive outcome of their pregnancy and birth. If this happens then potentially we need fewer midwives than if women need very intensive, medicalised care.
If we organise services with a greater focus on continuity of carer, the community and the home, there is also potentially less need for the enormous overheads associated with hospital-based care. Of course a significant number of women will always need such care but we can potentially design a service that is more efficient and delivers real savings for the NHS. Of primary importance is that the service will be one that ensures high quality for women, their babies and their families.
There are challenges of course. There will be small pockets of resistance to the guidance; people who will question the findings of the Birthplace Study and who will also point to the rare adverse outcomes for mothers and babies in midwifery-led settings. What these people frequently fail to do is mention that things can also go wrong in hospital.
What we need to do is to debunk the default position that hospital birth is both safe and optimum because we have strong evidence that this is not the case for women who are experiencing a very normal pregnancy. We have also got to explain the evidence that midwife-led care is safe to women and enable them to make an informed choice about place of birth.
We also have to acknowledge that changing patterns of service provision may be a challenge for midwives as it will require many of them to work differently. Today a significant number are only familiar with working in medicalised settings. However, with the right training, development and support, midwives can make this transition. I know this because I have seen it in action in many places I have visited around the country.
It can happen. NICE has helped. Policy is in place. It’s over to us now to ensure service change.
About the author
Cathy Warwick is chief executive of the Royal College of Midwives