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NICE’s draft guidance, which included a recommendation for all pregnant women to be told of a “trend towards a reduction in perinatal mortality” in hospitals, was submitted to the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

  • mearcatt

    i heard some NCB idiots pushing this story today, about how the uk is finally “doing things right”. gag me. i laughed to myself because these people complain about how the general populous “judges” them for their choice to birth at home because we are “uneducated”, but yet in the next breath, they judge those of us who birth in a hospital and-GASP- might use pain meds. WILLINGLY. the scandal…

  • Ash
    • Young CC Prof

      My expectations for NYT articles on birth are now rock-bottom, so this article actually surpassed them. Probably the worst line in it is: “Doctors are much more likely than midwives to use interventions like forceps deliveries, spinal anesthesia and cesarean sections” without calling out the implicit human rights violation, that of denying women medically appropriate anesthesia on request.

      It also refers to turf wars between OBs and midwives, without mentioning the fact that the USA has a problem with untrained and unqualified midwives running around, in some states enjoying legal protection.

      The conclusion, however, is surprisingly reasonable: The USA should train and employ more CNMs, in part to help deal with a shortage of obstetricians in some areas of the country.

      • Roadstergal

        That was my impression – a bunch of random misleading BS, with a few very reasonable sentences right at the bottom.

        • Anj Fabian

          Half the counties in the United States lack maternity care specialists! Oh noes!

          I’d like to see a map of that. Oh, also – could you tell us what percent of the population this affects?

          (The likely answer is that this affects the areas and populations historically difficult to serve – rural areas that have low population density. It’s not news, it’s olds.)

  • Dr Sarah

    I may be missing something here, but I’m not quite seeing the problem.

    The Birthplace study showed homebirth in the UK to carry no excess risk for babies born to multiparous women with no other risk factors, when compared to hospital birth in the UK. The new guidelines are therefore suggesting that homebirth is offered to that subgroup of women as a suitable option. Where’s the problem?

    Are you querying the Birthplace study findings? If so, on what grounds? (Genuine question – if there are problems with it that I can’t see, I’d be interested to know about them.)

    Also, why are you referring to the Birthplace study as an RCT? Surely it’s a cohort study?

    • Amy Tuteur, MD

      Thanks for the pickup. I did not mean to write that the Birthplace Study is an RCT, but rather that it is a prospective study. I’ve just corrected that in the text.

      As to the problem, the Birthplace Study showed that homebirth might be safe among a subset of multiparous women, but NICE announced that homebirth is safe for mutiparous women in general, which is not true.

      And an even bigger problem is that the Birthplace Study does not tell women the most important information even though that information is acknowledged to be available. What is the perinatal DEATH RATE (not a composite index including relatively minor adverse events) at homebirth as practiced in the UK compared to similar risk women giving birth in the hospital It’s a simple question and the NPEU knows the answer but refused to dislose it. Why?

      It seems to me that the Birthplace Study is just an fig leaf behind which the NHS can hide to it can continue promoting homebirth, a policy that it put in place before it even had a fig leaf to hide behind.

      • Wendy Hinds

        Midwives and doctors in the UK are very clear that only low risk women are suitable candidates for a homebirth and that outcomes for the babies of nulliparous labouring at home, as a group, are poorer than for similar women giving birth in an obstetric unit, alongside unit or freestanding unit.

        Rates of homebirth vary wildly across the uk, from less than 1% to more than 10%.

  • Almost as a deliberate follow-up, the Guardian today has this article:

    http://www.theguardian.com/commentisfree/2014/dec/03/pregnant-women-shun-labour-wards-midwife-care

    But someone ought to note that anecdotes aren’t data. The comments are interesting, however, with the unpredictability of labor outcomes often cited, even for the lowest of low-risk patients. “Russian Roulette” is mentioned.

    But I feel I should point out that this isn’t the first time that NHS bureaucrats, who usually know nothing about obstetrics try to push home birth. The reality is that the public generally doesn’t want home birth , for a variety of reasons. Some do, of course, often for the wrong reasons but, after all, expectant parents aren’t obstetric experts either.

    I actually question the monetary factor. I’ve done home births in the UK, and it uses a LOT of staff and resources. Simply the number of midwives needed, should “45%” of births, or even “30%” [the goal announced a few years ago], would skyrocket. However, obstetrics is generally recognized to be a money-losing service no matter how it is handled, since no hospital or regional manager can arrange to have 100% full bed capacity at all times, which most other specialties can organize [nor can midwives be transferred to other wards, like geriatrics or medical, should there be a lull in births, which frequently happens to staff elsewhere] I think it has more to do with the “nostalgia”* factor — home birth seems so nice and cozy, so unregimented, and so extraneous to the whole concept of the NHS, which treats ILLNESS, not a “normal” condition.

    When I was in the UK, only registered nurses could train to be midwives, and the criteria for home birth were so strict that it was not easy for myself and my fellow students to amass the minimum number of home births required for the Central Midwives Board’s certification during the three months we were “on the district”. Now, [1] midwifery training is not restricted to registered nurses, and [2] the criteria have been relaxed, and it is STILL difficult to convince women they should deliver at home!

    *After all, it wasn’t all that long ago when almost EVERYONE delivered at home.

    • Ash

      Exactly, Antigonos ! Imagine how many midwives you’d have to have on-call to guarantee 2 midwives for 20% of the pregnant population! It would be insane, even if maternity services were not already stretched thin.

    • Anj Fabian

      If you are trained as an RN, you could be reassigned to another unit if needed.

      If you are a midwife without the RN training – you are useless anywhere else. Unqualified.

    • Roadstergal

      “Now, [1] midwifery training is not restricted to registered nurses,
      and [2] the criteria have been relaxed, and it is STILL difficult to
      convince women they should deliver at home!”

      Those are two changes that I would certainly think would make it difficult to convince women to birth at home…!

      I didn’t know that UK midwives didn’t require a nursing degree. That explains some things.

      • Phascogale

        I think you still need a recognized university degree to be a midwife. It’s not like America where you can ‘apprentice’ to someone and then call yourself a midwife with little to no real skills. You’re essentially a div 1 nurse with restrictions to midwifery (and associated stuff like working in a SCN). They are properly educated.

        • Roadstergal

          Does it have to be a university degree in a health care field?

          • Michelle

            You do the degree in midwifery, same as doing a degree in nursing but more specialised. There are also postgraduate degrees at masters and above. If a RN already, you can do a shortened course to become a midwife. In any case, all have to meet the requirements to become registered before they can practice.

            Antigonos is right though about how the public doesn’t generally want home birth as there doesn’t seem to be a popular movement for that in the UK, It seems to be pushed outside of what people actually are asking for or what the resources the service has and just for some imaginary money saving. Not a good idea at all.

        • Dr Kitty

          Nope, you can go from high school to a midwifery degree.

  • Guest

    Are you not being somewhat misleading here, Amy?

    First, of course NICE would advice differently in 2006; there has since been new evidence that they consider important (the birthplace study; yes I know you have criticisms of that. But it is not unreasonable for NICE to update advice in light of new evidence. It would be misleading not to).

    Second, NICE is not advising home-births, it is advising midwifery-led units as a first choice. Throughout this post you subtly shift you coverage as if NICE was advising all women to birth at home. But that is not going on here. Please can you explain what your criticism of the midwifery-led units is?

    Third, the birth place study is not a randomised controlled trial – as you well know. Nor is a sufficiently large randomised trial ever likely to happen. when it comes to birth, we are going to have to do the best we can with the non-randomised data we have.

    All in all – not the kind of reporting that lives up to your own standards

  • Stephanie

    I rarely see eye to eye with Dr. Amy on anything, but she is very right with this issue. It is about saving money pure and simple.

    • sdsures

      Saving money at the expense of people’s lives. Yuck.

  • Ash

    This is separate post worthy. Spectrum Health Gerber Memorial Hospital in Michigan notes that about of 18-30% of their OB patients get epidurals, and notes that other hospitals in the area have epidural rates of about 90%ish. An epidural info sheet is given to the woman in her 3rd trimester, which must be signed by the OB provider and the patient. Gems include

    RISKS FOR BABY:1. Reduced blood supply to the placenta may cause fetal distress, brain damage, or death.

    OTHER CONSIDERATIONS
    The mother cannot respond naturally to labor cues, and may not feel as much control over the birth process.

    http://birthtools.org/Prenatal-Shared-Decision-Making-Analgesia-Anesthesia-Labor

    • Yikes:

      4. Epidural anesthesia decreases the mother’s ability to push and increases the need for forceps, vacuum, or cesarean section. Forceps or vacuum assisted deliveries have a greater need for an episiotomy and deep tears into the perineal muscle. This can increase the
      pain and healing time after giving birth.

      • Sarah

        Alternatively, women experiencing risk factors for instrumental delivery and EMCS such as poor positioning, lengthy labour, exhaustion and inability to cope with the level of pain being experienced are the ones most likely to feel the need for epidurals. Experiencing these factors without the epidural one needs can also increase the pain and healing time after giving birth. Believe me.

        • Amy M

          And increase risk for PPD too.

        • Dude, totally. Talk about scaring moms. The entire document is wonky….no wonder their epidural rates are so low. I mean, if I didn’t know better and trusted the provider who handed this to me, I’d be like, “Hells bells! No epidural for me!” So sad.

          • Cobalt

            I’m sure some of it is self-selection, though. If the hospital is handing out NCB friendly birth plans, they’re probably attracting all the moms who are into that. That will both lower their epidural rate and raise the epidural rate at surrounding hospitals.

            The hard bit is making sure the difference really IS self-selection.

          • True-dat.

          • Ash

            If all women are given the epidural “Info sheet”, I can definitely see why their epidural rates are lower. The document clearly biases women to not use epidural analgesia. Funny how it says stuff about the risks (and falsehoods about the risks), yet very little information about patient satisfaction rates & how much pain control epidurals can provide.

            re: not discussing pain relief eeffectiveness: this is one of the thing that bugs me about many websites or books that discuss epidurals. If I had no idea what an epidural was/how it provides pain relief, I would have no idea how much pain relief it provides because it’s not discussed. They are happy to discuss that you may not be able to move the lower part of your body effectively, but they are happy to not mention that likely your pain will be SIGNIFICANTLY reduced with a properly functional epidural. If I had no concept of the epidural, perhaps I would think that it’s the equivalent of taking a Tylenol for 9/10 pain–it’s really not going to touch it by very much.

            Their website also cites the Listening to MOthers survey several times. Site says that ~80% of women surveyed used epidural analgesia. Gee, maybe you should LISTEN to women and realize that there is a desire and demand for analgesia!

      • mearcatt

        i was induced and had an epidural, no more pain, just felt pressure when ready to push. baby came out perfect, only a few stitches for light tearing. another girl i know wanted a NCB, baby was distressed and losing oxygen, they were prepping her for a c-section but she pushed the baby out anyway and tore herself to holy heaven and still isn’t right 6 months later. no thanks, i think i’ll stick with my way.

    • Say whhhhhat.

      3. If an epidural is given in early labor, it increases the chance that the baby is in the wrong position as it comes into the pelvis. This may increase the need for a cesarean delivery.

      • Young CC Prof

        There are studies that say that, mostly pretty poorly controlled.

      • Sarah

        Or, you know, women with poorly positioned babies are the ones most likely to be in sufficient pain to need an epidural in early labour. Just a thought.

        • Exactly. This entire document is the work of spin doctors.

      • mearcatt

        nope. i had mine and labored only about 6 hours more and felt pressure to push but almost no pain. wrong.

        • Right. It’s wrong. It’s from the document mentioned above. It’s cra, hence my sarcastic “say whhhhhhat.”

      • sdsures

        How precisely does an epidural cause the baby to change its position?

        • Dunno. You’ll have to view the entire document I’m mocking – er – referring to. The link is above.

    • lawyer jane

      Holy hell, that is totally unconscionable! Even if that information sheet was not riddled with factual errors, it is totally intended to bias women against epidurals. Primarily it makes NO MENTION of the benefits of epidurals: labor hurts! And then it also makes no effort to explain the magnitude & severity of the risks. I can’t believe something like that got approved at that hospital.

      The other more philosophical problem is that women can’t really know in advance how they are going to weigh the risks against the benefits (pain relief) because they don’t know what the reality of the pain is until they experience it. So pretending that they can decide in advance through a yes-no birth plan is just wrong. The popular NCB book “The Birth Partner” actually has a really good approach to this – they have a sort of preferences scale that much better reflects the reality of how people actually think because it lists as a legitimate category “I don’t care” or “I think I’d like to try, but don’t want to be a martyr.” Here is a copy: https://www.childbirthconnection.org/pdfs/PMPS.pdf.

      • Ash

        Parts of the birth plan on birthtools.org are crap, too.

        Option whether you’d like the surgical drape to be lowered or up during a c-section, option whether you’d like the staff to talk about describe what they are doing during the procedure? OK, great.

        But WHY does this birth plan give patients no advice about what’s right for their particular situation without medical guidance?

        As a patient, with no discussion from my healthcare providers about my CURRENT situation, how is it right for me to decide about IV access? I’m just supposed to guess before I go into labor?

        I’m supposed to decide on my own with NO information about vaccinations, Vit K, and eye ointment?

        “I am interested in the option of an abdominal nerve block (TAP block)”

        Parts of this birth plan are NOT giving patients choices, as prospective parents are supposed to “decide” what they want with no information about what is appropriate for the individual.

    • Karen in SC

      Is this a hospital that serves a large percentage of Medicaid and uninsured patients? Because it sure smells that way to me!

    • Ash

      Oh, and check out Spectrum Gerber’s Childbirth World blog. It is a delight (sarcasm).

    • I can’t see why this hospital should be so proud of misinforming patients and why a low epidural rate is anything to brag about.

      If I were expecting, I’d deliberately choose a hospital with a very high rate of epidurals [other factors aside for a moment] for two reasons: [1] I’d know that I would be able to easily get an epidural if I wanted one, and [2] the staff would be highly experienced with them. It is, after all, a highly skilled procedure.

  • I’m frustrated – I’m frustrated because rather than having a guideline that says women must be informed of the risks and benefits of the choices they have available with respect to place of birth and mode of birth and the right to make informed medical decisions for themselves we have governments pushing ideologies in a misguided effort to save money. What happens when a more thoughtful analysis, that’s more complete demonstrates that planned cesarean is more cost effective for all women planning 3 or fewer children? Are we then going to see that “promoted” – doubtful.

    • sdsures

      This frustrates me as well, and I’ve lived in the UK for 6 years.

  • Who?

    I wonder how Ms Bewley feels about rights when it comes to maternal request caesarians? Particularly given that she acknowledges there is no one size fits all approach?

  • yugaya

    “home births and midwife-led centres were… OFTEN AS SAFE (as hospitals) for babies”

    So is unassisted childbirth in the middle of nowhere, or giving birth in the back of the taxi assisted by the taxi driver – quite often these are as safe as hospital birth. The next NICE recommendation ought to acknowledge that as well.

    • Samantha06

      Exactly! And very insulting to UK women..

      • sdsures

        Yep.

    • Beth

      OFTEN as safe….except when it’s not. I mean, what does “often as safe” even mean? If you don’t count the births where mom or baby died or were seriously injured, the homebirths were just as safe?

      Russian roulette is often as safe as checkers. It’s just that those occasional turns when it’s not
      will REALLY get you.

    • Sue

      (To paraphrase Bofa): Driving while drunk is often as safe as driving while sober.

      (Except when it isn’t).

  • LottieS

    I was lucky enough to have fabulous obstetric care when I lived in the US, the delivery of my first baby could not have been better due to the amazing care of OB- an induction at 39 weeks due to reduced movement.

    I have relocated to the UK and, am saddened by the new guidelines. Should I be able to have another baby, I will only be agreeing to having a hospital birth or a midwife led centre which is down the hallway from the OR! I am scared for those who may suffer needlessly due to these guidelines.

    • sdsures

      Me, too.

  • Dr Kitty

    I love how England is treated a a homogenous place.
    As if the risks of Homebirth in central London (ambulance response time less than 10 minutes) and rural Yorkshire (45 minutes from nearest hospital) will be identical.

    • Young CC Prof

      Let’s not forget the folks in Canada, Australia and the USA who will use this to promote home birth 2 hours or more from the nearest hospital.

      • Amazed

        Why so far? I rememer the Irish couple who tried a homebirth 40 miles from a hospital over a mountainous terrain. The baby died.

    • Liz Leyden

      What about rural Scotland, especially the Hebrides, Orkneys, and Shetlands?

      • Anna T

        I have a friend who lives in Orkney and she has told horror stories of appalling medical care, especially obstetric care. She’s an American citizen and plans to fly to the US to get adequate medical care.

        • sdsures

          I lived in Scotland for 2 years before moving to Manchester, and having need of a neurologist and/or neurosurgeon necessitated a 1-hour drive to Glasgow each way. Scary.

          • deafgimp

            Shit, man, I wish my neurosurgeon were only a one hour drive each way. And I live in a major metropolitan area. I go for a different doctor that makes me have a 2.5 hour drive one way.

          • sdsures

            Eeek!

        • Dr Kitty

          To be fair, Orkney may as well be Outer Mongolia.
          There is one ferry a day to Aberdeen, and it takes six hours to get there.

          I imagine the healthcare there is similar to what you’d get in rural Alaska or the Australian outback, I.e. The issue is the location, not the system.

          • Christina Maxwell

            Yes, Orkney is at a tremendous geographical disadvantage but maternity care is pretty hit and miss in other parts of Scotland too. In my area (population nearly 450,000) there is ONE OB unit. There are birth centres but 3 out of 4 of them are a minimum 15 miles from the hospital, one is over 30 miles. For people living in the northernmost part of the area the hospital is over 50 miles away down the worst main road in Scotland. Women in this area don’t have ‘choice’ at all. They get what they are ‘given’ and the devil take the hindmost.
            My daughter lives in the middle of a large city, she has just had her first baby. Her birth experience was not great by any means but it was better than some, including one woman who gave birth before she could get to the labour ward because nobody checked her though she begged for help. Another woman ended up with raging sepsis because nobody listened when she told them how ill she was feeling and didn’t check her sufficiently at all after a caesarian.
            I could go on for hours about how my daughter was treated on the post natal ward but I’ll leave that for another time.

      • Dr Kitty

        NICE applies only to England and Wales- Scotland and N.I often implement the guidance, but strictly speaking it doesn’t apply.

  • DiomedesV

    It’s really unfathomable, this continued promotion of homebirth by the NHS. At least women don’t seem to be buying it.

  • araikwao

    Did Birthplace report on risk of low Apgars or of HIE? Just wondering how it compares to the excellent Dr G’s papers, if at all.

    • Sue

      Don;t think it did.

      These studies only seem to report mortality, not avoidable disability.

      • araikwao

        Yet somehow they are used to justify economic decisions about healthcare…

  • Ash

    Isn’t HB in the UK likely more expensive than hospital birth? My understanding is that two midwives must be present for the labor and delivery at homebirth in the UK. But 2 midwives could efficiently care for more than 1 woman in a hospital. True, you don’t have to pay an anesthesiologist at home but a significant # of HBs in the UK transfer to a hospital anyways.

    • Young CC Prof

      NICE keeps throwing around these numbers that supposedly indicate savings, but the whole maternity system is really stretched, and the resource that’s in shortest supply isn’t IVs or forceps or even cash money but trained midwives.

    • Anothergreatpostbydramy

      It’s true. It cannot be cost-effective to have a midwife on-call for 24 hours all the time. I have found that they may be called in if the Labour Ward is busy as the actual number of homebirths as a percentage of total births is extremely low. The cost of the doctors is divided up by many more patients. It’s very simple economies of scale. Also, the exclusion criteria for even in-hospital waterbirths is so robust, that most people will be risked out anyway.

      I’ve said it before and I’ll say it again… Don’t we find it strange that developing countries are encouraging birth in hospitals because it is inherently safer and we are taking it back to the community?!?!? I’m all for patient choice, but patients should also listen to the doctor who is aware of all the risks. You wouldn’t go to a general surgeon and tell them how and when to perform an appendicectomy based on Internet research and with someone trained to hold your hand when you present with rigt iliac fossa pain.

      • sdsures

        But I want my all-natural emergency neurosurgery experience, dammit!!!!! WAAAAH! Meanie doctors. 😉

    • Comrade X

      Yes. It is. 2 midwives is the MINIMUM, by the way – for a singleton pregnancy. The actual regulation is one midwife PER PATIENT. So one for mum, and one for bub. If you have twins, plus mum, that’s 3 fully-qualified midwives who have to be there the entire time, taken out of the system, unable to provide any care to anyone other than you. Even if it were perfectly safe, it would represent an unacceptable waste of resources in a free-at-the-point-of-use public system.

      So it’s massively expensive and patently less safe.

      It is driven entirely by ideology on the midwife side (pregnancy and birth aren’t illnesses, woman-to-woman care, all natural etc etc) and, frankly, largely by Spoiled Middle-Class Brat syndrome on the parental side (the overwhelming majority of women in the UK who homebirth on the NHS are rich white chicks who somehow fantasize that they and their precious spawn are getting a “better” start to it all than the hoi polloi).

  • Young CC Prof

    I don’t get this “home birth saves money” narrative. It only saves money if you don’t bother trying to rescue people when things go wrong.

    • Dr Kitty

      Any you don’t count the million £ lawsuits for birth injuries…

  • GiddyUpGo123

    Did you notice Bewley’s subtle way of interjecting her opinion into that statement about respecting women’s choices: “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”

    Midwife-led units are generally safer. But hospitals only make women feel “safer.” Putting one in quotes and leaving the other one out is a pretty strong indication of how she really feels about this. She might as well have phrased it, “Women should be supported in choosing homebirth or midwife-led units, and those ignorant women who think they’ll be safer in hospitals, well, just let the poor dumb things make whatever stupid choices they want to.”

    • Sarah

      ‘Generally’ is very unhelpful here. There’s considerable variation between outcomes for first and second timers, for example, or high and low risk women in the UK.

  • MLE

    The paragraph about feeling safer (in quotes!) in the hospital – how muh more patronizing can you get?

    • Amy M

      I guess they think women in the UK are stupid? One doesn’t have to be a rocket scientist to figure out that if an emergency arises, it is safer to be where that emergency can be dealt with. That’s the crux of the argument. If there is no access to emergency resources, its not the safest place, full stop.

      Certainly many women can have home births just fine, or all natural births in the hospital or a MLU and never need any medical resources. But most people, recognizing that sometimes, things don’t go to plan, want to be able to get help ASAP if necessary. The fact that only 2.3% of UK women are choosing homebirth shows this. So who do they (the govt, Susan Bewley, etc) think they are fooling? Do they just need to fool the people who allocate the health care money (evidently successfully?) And what happens when the number of women choosing homebirth doesn’t increase, or continues to decrease? How long, how many disasters, until its clear that this is not a money saver and they change practice so it is based on actual evidence?

      • Roadstergal

        They are successfully fooling at least one smart, sweet, good-hearted, college-educated (in a science field) woman who is very dear to me, and it makes me so mad I want to go punch Susan Bewley. Repeatedly.

      • sdsures

        They’re obsessed with women having “choice”.

        • Amy M

          In order to make a fully informed choice, one must have ALL the (unbiased) information. And anyway, how much choice is it, when a woman asks for an epidural and is either refused, or stalled to the point of no return? We’ve heard plenty of those stories from the UK. (not aimed at you sdsures, at the authorities in this situation saying “Women should have the choice—to make the choice we want them to make–’cause we don’t want to spend the money on the other choice.’

          • sdsures

            Oh yeah, no offense taken. That attitude grates on me as well.

        • misha

          It’s horrifying you think women should be denied choice. Yes in that case I’m obsessed with women having choice… because they should! Or are we back in the dark ages?

          Where I work women are given the epidural sheet with the risks on and they’re presented in a neutral way to avoid bias. The anaesthetists are clear that there are risks but the woman has a higher chance of having effective relief than a poor outcome. What’s the point in scaring a woman at the point of having an epidural administered?! Who would do that?! No midwives or anaesthetist I know.

          In an obstetric led unit women have 24/7 access to an epidural unless the anaesthetist is already carrying out a procedure on someone else/in an emergency situation, or if the woman’s labour has progressed to a point where an epidural is pointless. Show me an anaesthetist who would do an epidural on a woman where vertex was visible and advancing.

          • sdsures

            You have missed the point. The choice to get adequate pain relief should not be taken away. The Royal College of Midwives doesn’t care about women getting pain relief (if they choose it); they are instead pushing the ideology that a woman need not be forced into getting hospital care during her kid’s birth. The RCOM cares about its woo ideology, not the women it is supposed to serve.

          • sdsures

            I’ll rephrase: the choice to have an epidural or to birth in the hospital is conveniently downplayed by NICE, because they are promoting the idea that many women can birth “safely” at home.

          • sdsures

            The Internet ate my reply a few times, so I’ll repost:

            There is also the choice given to get adequate pain relief. That is a choice in and of itself. But NICE downplays it because their goal is to save the NHS money.

      • Alex

        Midwives SAY they are obsessed with women having choice but actually, that’s only choices that midwives approve of. NICE came out with another guideline in 2012 which said that women should have the right to choose a caesarean birth if they really want one, but that hasn’t been greeted with nearly such enthusiasm from the RCM. Midwives hate elective caesareans (because it puts them out of work) and if you dare ask a midwife if one could be arranged, you’ll get everything from sudden deafness and stonewalling to outright hostility. One leading teaching hospital in central London even had a notice on the maternity services page of its website which said (in slightly more words) “Don’t bother asking for an ELCS because refusal offends. I contacted them to ask how that was consistent with NICE guidelines, and the notice was hastily taken down by a press officer worried that I was a journalist. But the hospital hasn’t actually changed its attitude. It’s about a) money and b) midwives job security.

        • pinky

          midwives aren’t affected by the number of women having Caesareans; they still need to be cared for antenatally, perinatally & postnatally & that is done by Midwives. In fact women having Caesareans need MORE midwifery input.

    • Young CC Prof

      Your own blankets in your own house are what really makes you and your baby safe. Every 2-year-old knows that! Of course, if some foolish doctors and women think that machines and drugs and an operating room immediately available will make birth safer, they’re free to do it that way.

  • A.P.

    I am a anesthesia resident and was shocked to see the sensationalist, media articles like “Low risk women urged to avoid hospital births” on my newsfeed today. It only takes reading the original homebirth studies to see how manipulative the media reporting is. As you mentioned, there is clearly a huge rate of transfer to obstetrical care for nulliparous women and significantly increased perinatal complications for the same group.

    However, beyond this, the Birthplace study does not even report maternal outcomes. I do not see any statistics for important outcomes like mortality, antenatal hemorrhage, infection rate etc. We are also missing long term outcomes for both mom and baby.

    It is so distressing to me that the NICE guidelines have been changed with incomplete evidence, and in fact, evidence that contradicts its message of equivalence in safety. Furthermore, I am outraged that the media has used this to further demonize medical care, without any understanding of the complex nature of labour and delivery, or any understanding of how to interpret the primary literature.

    I am frightened that under this change, more women and/or babies will face complications, and they will accept this because they believe that they actually made the right choice.

  • Dr Kitty

    Amen.
    Thank you.
    This is exactly the same conclusion I came to.

    Of course is women are to be informed of all their options, which means that I can inform them that epidurals aren’t available in birth centres or at home, that if there is an emergency a baby needs to be delivered within 10 minutes, and it might take an ambulance 8 minutes to arrive at your home plus however long it takes to get you to the OR, but that they may be less likely to have a CS or an episiotomy if they stay home.

    • Roadstergal

      “they may be less likely to have a CS”

      This is the point I keep falling over myself about. If you don’t need (or want) a CS, you won’t have one at the hospital or at home. If you do need a CS, you’ll have a live baby at the hospital and a dead or compromised one at home. How on earth does this context of ‘reduced rates of CS’ come across as a good thing?

      • Vg2010

        because baaaaabies that are born by c-section are draaaaged through life by the whims of drs who want to go play a golf game….
        women’s bodies are strong and powerful, and never fail (otherwise we wouldnt be here after 1000 years because EVOLUTION has gotten rid of small pelvis and big babies) and if you let them do its thing on their own time THEY WILL BIRTH the damn baby!

        • Cobalt

          The midwife gave Colombe Chatri 28 years to deliver her baby. In the end, it was a post-mortem cesarean.

          http://lithopedionbaby.wordpress.com/cases-and-diagnosis-2/

          • Siri

            That’s a heck of a lot of knitting.

          • Ob in OZ

            sad story, but Siri, you are funny.

          • Seattle Mom

            How is that possible? Was the baby etoptic and somehow survived?

          • Cobalt

            No, the baby did not survive the pregnancy. The mother went into labor (unknown if the baby was alive at this point but she had felt movement and expected a live baby), had contractions, water breaking, excessive bleeding. She just never delivered. The baby died at some point, and her (it was a baby girl) body calcified, becoming a lithopedion, or ‘stone baby’. The mother died 28 years later, autopsy revealed the baby in the abdominal cavity.