Where is the ‘right’ place for a woman to give birth?
Every birth is different – different experiences, fears and need. So where, therefore, is the ‘right’ place for a woman to give birth? It’s a much-debated point but at the Birth Trauma Association we believe the answer is simple: where she feels most comfortable about having her baby after she has considered all the risks and benefits of different places of birth.
However, risk in itself is subjective. For example, evidence published by the Birthplace in England Research Programme in 2011 shows a tripling in risk for first time mothers giving birth at home. Advocates of home birth will say that the risk is still very small, and those who are opposed will say this tripling of risk makes it hugely dangerous. So is it ‘wrong’ for a first time mother to have a home birth? Absolutely not – as long as she has had accurate information about the risks and has made an autonomous, informed choice, based on her assessment of what risk is.
The problem, of course, is the quality of advice women are being given. Giving women accurate information about objective risks - severe adverse outcomes, operative deliveries, emergency caesareans, and so on – is absolutely fundamental to informed choice. If you mislead women about evidence, you take away choice. This is where we are most worried about the NICE guidance when it advises first time mothers that giving birth in a free-standing midwifery unit is safe.
Let us explore some of this evidence, starting with the Birthplace study. The women who chose hospital birth were higher risk. Even when the 20 per cent of women in the obstetric group who had complications at the start of labour were removed, the hospital group women were still riskier.
However, the closer you match the cohorts, the more you see the risks for first time mothers increase in freestanding midwife units. The best quality Birthplace data – around three quarter of the total from units who returned 85 per cent or more of birth records – shows that serious outcomes more than doubled for first-time mothers in freestanding midwifery units. A doubling of catastrophic risks on the best data does not warrant an assertion of safety.
Other studies that NICE used, such as the 2011 Davis study and the 1999 David study, had exactly the same flaw: the midwifery cohort and the hospital cohort were not adequately matched.
This is not just a concern of researchers, either. Law firms say that they are seeing a hugely disproportionate number of first time mums who had a bad experience in birth centres being awarded claims. As medical negligence solicitor Rebecca Day points out on the perils of transfer to hospital: ‘Our clients recount stories of frantic searches for wheelchairs and difficulties in elevators which have cost precious time during a period where every minute can be critical for the safety of mothers and their babies.’
The consequences of delay during transfer can, of course, be catastrophic and are often understated by advocates of home birth, including death, serious brain injury and lifelong disabilities.
So what should NICE have recommended? The Birth Trauma Association believes that there should have been a research recommendation that we obtain better evidence on the safety of midwife units. However, this would still not solve our big problem: what many women want is the calm, peaceful environment of a birth centre but within a hospital environment, where they have easier access to epidurals and don’t have to be transferred if things go wrong.
To many women this would be perfect – but it is the one choice women don’t have. We must remember many women do not make their choices on the basis of data and NICE guidance but through life experiences, which is why the word ‘advised’ in the NICE guidelines is so inappropriate.
Yes, a woman may be low risk and ‘advised’ to give birth in a freestanding midwifery unit – but what if her sister or friend had a horrific experience in one of these units, and therefore she prefers to give birth in a hospital? Her choice is no less valid. Yet she will not be listened to. There needs to be much less advising - and much more listening.
About the authors
Maureen Treadwell and Lucy Jolin are members of the Birth Trauma Association management committee