New UK homebirth guidelines: midwives win, babies lose

Baby crying

If only babies could vote, the world would be a very different place.

Babies can’t vote, nor can they agitate for political goals; midwives and politicians can. Hence the otherwise inexplicable decision to change the UK homebirth guidelines to promote the economic well being of midwives and the National Health Service (NHS) ahead of babies lives.

Why is it inexplicable? Because homebirth is no safer than it ever was, yet according to the BBC:

The National Institute for Health and Care Excellence (NICE) said home births and midwife-led centres were better for mothers and often as safe for babies…

… [T]he new guidelines state 45% of women are at extremely low risk of complications and may be better off giving birth elsewhere…

It said women should be offered the choice of a home birth, an obstetric unit in hospital, a midwifery unit next to a hospital or a midwifery unit in the community.

That’s not what NICE said back in 2006:

Birth outside a [physician] led unit is consistently associated with an increase in normal vaginal births, an increase in women with an intact perineum and an increase in maternal satisfaction. The quality of evidence available is not as good as it ought to be for such an important health care issue, and most studies have inherent bias. The evidence for standalone midwife led units and home births is of a particularly poor quality.

The only other feature of the studies comparing planned births outside [physician] units is a small difference in perinatal mortality that is very difficult to accurately quantify, but is potentially a clinically important trend. Our best broad estimate of the risk is an excess of between 1 death in a 1000 and 1 death in 5000 births. We would not have expected to see this, given that in some of the studies the planned hospital groups were a higher risk population.

At the time, there was evidence that the government, which had already been promoting midwife led units and homebirth in an effort to save money, tried to pressure NICE to change its report before publication. According to an article in the July 2, 2006 issue of The Sunday Telegraph:

NICE’s draft guidance, which included a recommendation for all pregnant women to be told of a “trend towards a reduction in perinatal mortality” in hospitals, was submitted to the Department of Health nearly a fortnight ago.

Several days later – and ahead of its publication on June 23 – it was altered by Andrew Dillon, chief executive of NICE, after concerns were raised by the Department of Health. To the fury of his own experts, who felt that their message was being diluted, the wording was changed to: “There may be a risk of lower perinatal mortality” in hospital.

A source told The Sunday Telegraph: “There was an angry phone call between Andrew Dillon and representatives of the guideline development group.

“Concern over the safety of mothers and babies in midwife-led units was watered down. Many of the group felt this was totally unacceptable, but, because they are bound by confidentiality clauses, they cannot speak out publicly.”

Even then, it did not stop the government from forging ahead with promoting money saving over the well being of babies.

Five years later, in July 2011, I wrote a piece about the issue for The Times of London after Anthony Falconer, President of the Royal College of Obstetrician Gynecologists claimed that pregnant women “should no longer think of hospital as the default option when giving birth.”

At the time, there was no evidence that homebirth in the UK was as safe as hospital birth, and no evidence that homebirth saved money. There still isn’t, but that hasn’t stopped the political pressure and in the interim, the government came up with a fig leaf, The Birthplace Study.

Did the Birthplace Study show that homebirth in the UK is safe. No, it did not.

… [T]here was a significant excess of the primary outcome in births planned at home compared with those planned in obstetric units in the restricted group of women without complicating conditions at the start of care in labour. In the subgroup analysis stratified by parity, there was an increased incidence of the primary outcome for nulliparous women in the planned home birth group (weighted incidence 9.3 per 1000 births, 95% confidence interval 6.5 to 13.1) compared with the obstetric unit group (weighted incidence 5.3, 3.9 to 7.3).

That’s especially disturbing when you consider that the eligibility requirements for the Birthplace Study were much stricter than the actual eligibility requirements for homebirth as currently practiced in the UK.

Fast forward to yesterday, when a new NICE report was issued. A cynic might imagine that the result was pre-ordained since the chair of the group, obstetrician Susan Bewley, is a long time homebirth advocate.

And, indeed, Bewley concluded what she has concluded before:

Susan Bewley, Professor of Complex Obstetrics at King’s College London, who chaired the group responsible for developing the updated recommendations said: “Midwives are highly capable professionals and can provide amazing one-to-one care to pregnant women in labour, whether that’s in a woman’s own home, a midwife-led unit or a traditional labour ward.

“Some women may prefer to have their baby at home or in a midwife-led unit because they are generally safer – that is their right and they should be supported in that choice. But, if a woman would prefer to have her baby in a hospital because it makes her feel ‘safer’, that is also her right. Giving birth is a highly personal experience and there is no ‘one size fits all’ model that suits all women.

“What’s important is that women and their families are given the most up-to-date information based on the best available evidence so that they can make an informed decision about where the mother gives birth to her child.”

You can find the complete 839 page report here.

On what evidence did Bewley and colleagues rely to declare that homebirth is safe?

Fifteen studies (reported in 16 papers) were included in this review (Ackermann-Liebrich et al., 1996; Birthplace in England Collaborative Group, 2011; Davis et al., 2011 and 2012; de Jonge et al., 2009; de Jonge et al., 2013; Dowswell et al., 1996; Hutton et al., 2009; Janssen et al., 2002; Janssen et al., 2009; Lindgren et al., 2008; Nove et al., 2012; Pang et al., 2002; van der Kooy et al., 2011; Woodcock et al., 1994; Blix et al., 2012).

One of the studies is a pilot randomised controlled trial conducted in England (Dowswell et al., 1996). Three of the included studies are prospective cohort studies; these were conducted in England (Birthplace in England Collaborative Group, 2011), Switzerland (Ackermann-Liebrich et al., 1996) and Canada (Janssen et al., 2002). The remaining 11 studies are retrospective cohorts carried out in 8 different countries: England (Nove et al., 2012), The Netherlands (de Jonge et al., 2009 and 2013; van der Kooy et al., 2011), Sweden (Lindgren et al., 2008), USA (Pang et al., 2002), Canada (Hutton et al., 2009; Janssen et al., 2009), Australia (Woodcock et al., 1994), New Zealand (Davis et al., 2011 and 2012) and Norway (Blix et al., 2012).

How many of these studies involved a prospective trial in the UK? One and ONLY ONE, and by amazing coincidence, it is the Birthplace Study.

All of the above is just a long form version of a simple story. The government of the UK has been promoting homebirth as a cost saving measure since the mid-2000’s when there was no evidence that homebirth in the UK was safe or cost effective. They commissioned the Birthplace Study to slice and dice the data to provide a fig leaf, and lo, and behold, in 2014, with a long time homebirth advocate chairing the group, and relying only on the Birthplace Study, they finally produced the result that dovetailed with the government’s recommendations.

So the bad news is that the well being of babies has been sacrificed to political expediency. There is good news, though.

The good news is that the NICE guidelines appear to have zero practical significance. Despite the fact that the government has been promoting homebirth for nearly 10 years, the homebirth rate has fallen 20% in the past 4 years and now stands at 2.3%.

The new NICE guidelines are penny wise and £ foolish. They provide intellectual cover for the government, and they pander to midwives, but they don’t help babies or mothers, and they won’t save money.

The primary problem that the UK maternity system faces is an appalling level of care that results in a high stillbirth rate and an seemingly endless series of scandals where babies die in hospitals because of midwives’ promotion “normal birth” over babies’ well being. The NICE homebirth recommendations may generate favorable press for homebirth advocates, but they have no practical significance beyond proving, as if further proof were needed, that political power leads to bad healthcare decisions.