APPENDIX 11
Memorandum by Birth Centre Network UK
The system of maternity care in this country
is derived from historical accident not rational evidence-based
planning. It is being changed by irrational, finance driven closures
of midwife-led units not by coherent strategic planning and respect
for women's informed choice. There is clear evidence that the
Birth centre model offers better outcomes and higher levels of
satisfaction for women who can safely choose it. There is inequity
in the availability of this choice for women currently, which
can and should be addressed.
CONCLUSIONS
1. It is clear that the debate needs to
move from how to eradicate risk, to how to maximise choice and
normal birth.
2. This will improve outcomes, user satisfaction
and cost effectiveness by taking an evidence based approach to
risk management.
3. Such progress can only be achieved by
focusing on the needs of the mother and baby not the needs of
the NHS to intervene as if childbirth were an illness needing
treatment.
4. Targeting resources to meet their needs
would mean that women who face possible complications can receive
a service designed to meet their needs in the same way as low
risk women with a need for normal birth.
5. This shift would produce a more rational
service than the current model where every woman is treated as
a ticking time bomb of risk. We must move from a litigation-centred
service to a woman-centred.
RECOMMENDATIONS
12.1 Moratorium on birth centres closures—Until
the NSF is published setting standards, there should be a moratorium
on all Birth Centre closures.
12.2 Standards on Choice—The
Children's NSF Maternity Module should address the issue of place
of birth setting clear standards for choice in maternity care.
12.3 Normal birth as the norm—"Normal
birth as often as possible" should be promoted as an objective
for the NHS and performance indicators developed for PCTs on the
numbers of births which take place with "a spontaneous labour
and delivery, without induction, the use of instruments or caesarean
section." This is the indicator derived from the NHS Maternity
Statistics England 2001-02, and only occurs currently in 53% of
cases nationally. This would follow the precedent set by the PCT
target to increase breastfeeding initiation rates by 2% per year,
as set out in the National Planning and Priorities Framework1.
12.4 Agreeing what needs to be monitored
and monitoring it—A common birth centre dataset needs
to be developed including transfer rates, reason for transfers
according to a common code, postcode of women booking, ethnic
origin etc. This will lay the foundation for aggregating individual
Centre's users to provide an aggregate national sample of women
using this model of care, to assist the evidence-based development
this option nationally.
12.5 Auditing informed choice—The
wider dissemination of Informed Choice leaflets, in English and
ethnic minority languages and other media, is an urgent priority
in the facilitation of informed choice for women. This should
be government funded as part of information standards in the Children's
NSF.
1. THE BIRTH
CENTRE NETWORK
1.1 The Network was established in November
2000 and now has 329 members across the UK, including users, midwives,
GPs and obstetricians. It is based on an electronic network and
offers its members an opportunity both to share good practice
and new ideas and access to documents developed and used successfully
in individual Centres, such as the job specifications for midwifery
assistants, selection criteria and user involvement tools. The
Network has held two national conferences. It is led by a multi-disciplinary
Steering Group (members listed in the Appendix). The Network's
Patron is Baroness Cumberlege and Vice Patrons include the President
of the Royal College of Obstetricians an Gynaecologists, Professor
Bill Dunlop, the General Secretary of the Royal College of Midwives,
Dame Karlene Davis and Ms Poonan Pradham (research fellow in obstetrics).
1.2 The aim of the Network is to "advantage
public education and the protection and promotion of the mental
and physical health of mothers and their families in matters of
childbirth by ensuring that modern maternity care includes the
provision of birth centres as real choice for women."
2. WHAT IS
A BIRTH
CENTRE?
2.1 The Birth Centre Network has defined
Birth Centres as "homely, community-based facilities which
provide maternity care for women who want and can safely choose
a low-tech, midwife-led approach to birth. They are managed, staffed
and run by midwives skilled in supporting women through normal
birth; providing friendly, individualised woman and family-centred
maternity care. Women's needs are at the heart of the organisation
and their influence on care is apparent. Birth Centres can be
freestanding, or part of a community hospital or other NHS facility.
They are often a further development of what previously were called
GP or midwife led maternity units and often attached to community
(cottage) hospitals. Freestanding Birth Centres do not provide
epidurals or caesareans as they have no doctors on site. Some
provide pethidine and other forms of pain relief. All operate
a screening process and only accept women who fit their selection
criteria which assess suitability for this model of care and most
community-based Birth Centres allow for the majority of out-patient
antenatal care (routine visits, antenatal classes) to increasingly
be provided close to women's homes.
3. CHOICE—MAKING
IT REAL
3.1 Choice is not a reality for any service
user unless they have:
(a) A service which actually offers different
options from which they can choose.
(b) The information to make their choice
of options informed.
3.2 Options for place of birth in the UK
are (1) District General Hospital (2) Home birth (3) Birth Centre.
3.3 To make choice a reality the Birth Centre
Network UK is working to facilitate an expansion in the number
of Birth Centres across the UK, to raise the standards they are
working to and to disseminate information about them to inform
the public. We are uniquely placed to drive forward this work
because of our multidisciplinary pedigree and strong support and
participation from the Royal Colleges.
4. WHEN IS
CHOICE NOT
A CHOICE—WHERE
ARE BIRTH
CENTRES ACTUALLY
AN OPTION?
4.1 Currently, there are 90 freestanding
Birth Centres in the UK: 57 in England, 13 in Wales and 20 in
Scotland. In Northern Ireland, there are proposals for two Birth
Centres to be created in spring 2003, to be called "Community
Midwifery Centres". The location of these Centres is indicated
on the Map overleaf. Some 10,000 births per year take place in
freestanding birth centres out of over 550,000 birth nationally
(1.8%). There are also a number of Birth Centres alongside consultant
units for which no data is collated centrally. These units vary
greatly in the model of care and the care environment.
4.2 The scattered incidence of Birth Centres
is the result of historical accident and of a pattern of closers
of GP and midwife-led units which lacks coherence, evidence-base
or accountability. The failure to develop and implement an integrated
maternity strategy to meet need, has led to a post code lottery
of choice. The map and chart overleaf demonstrate clearly the
geographical inequality of choice in relation to the Birth Centre
option.
4.3 The lack of a rational plan for the
maternity infrastructure is leading to irrational closers of Birth
Centres even as a consensus is developing at national level about
their role as the only sustainable way forward for maternity care
in this country. The Malmesbury Unit in Wiltshire is under threat
of closure, even though it is part of a clinical network. Three
other units in around the Scarborough consultant unit are also
under threat: Malton, Bridlington and Whitby. Some hold the view
that such closures are at best short sighted, at worst negligent.
4.4 The vast majority of women in the UK
do not have access to Birth Centres as a choice within easy reach
of where they live. The Choice they have is between birth in one
or more consultant units or, if they find a midwife to attend
them, a home birth. Home birth services are under increasing threat
as midwife shortages restrict services across the country. Nationally,
home birth accounts for less than 2% of all birth.
4.5 Where Birth Centres do exist there is
evidence that they are attracting an increasing number of women.
(a) In Crowborough, numbers increased from
179 per year in 1997 (when it became a midwife led unit instead
of GP unit) to 326 in 2002, which is 50% of local births in a
town with a population of 24,000 plus perhaps the same again in
the surrounding rural catchment area.
(b) The Edgeware Birth Centre, the only centrally
funded national demonstrator pilot of this model of care, attracted
an average of 350 bookings per year in its first two years rising
to 658 in 2002-03.
(c) Lichfield Victoria Maternity Unit in
Staffordshire provides for about 300 births per year, which includes
about 20% of all Lichfield births. Being the only Birth Centre
in South Staffordshire, women travel from many surrounding towns
to use its facilities for childbirth.
These figures are by no means typical of Birth
Centres nationally but they do demonstrate that where birth centres
are available and actively promoted, large numbers of women exercise
their choice and their use increase dramatically.
4.6 In some cases the integration of Birth
Centres into "clinical networks" is well advanced. Grouped
together in Wiltshire there are seven freestanding units: Malmesbury,
Chippenham, Trowbridge, Devizes, Paulton, Frome and Shepton Mallet.
The consultant unit at Bath (Wiltshire and Swindon Healthcare
NHS Trust) supports this clinical network of midwife-led small
units that are local community providers of high quality maternity
care. The units act as a gateway and pathways to specialist consultant-led
care when required, providing real partnership working across
the primary and secondary care. Between them these units between
them covered 1,529 births in 2000, which is 50% of all births
that take place from the area the seven units cover. A similar
model operates from the Royal Shrewsbury Healthcare NHS Trust
with five freestanding units. This network has the highest normal
birth rate and the lowest caesarean rate in the country.
5. ARE BIRTH
CENTRES A
SAFE CHOICE?
5.1 Any discussion about evidence on Birth
Centres or any other model of care is hampered by the poor data
the NHS has on services. It is a shameful fact that English data
collection is so poor in the NHS that the regular Bulletins of
Maternity Statistics issued by the Department of Health have to
be based on estimates. Some hospitals do not even record all births
in the Hospital Episode Statistics (HES) system. London is the
worst offender with 8% of births unrecorded in 2001-022. With
each HES recorded delivery is an extra set of information (the
"maternity tail") which records such details as interventions.
The level of recording of the maternity tail is even worse than
the recording of births, with a third of births in the England
occurring without any national tracking of how they were conducted.
The Couth West region is the worst offender as it only records
just over half (56%) of maternity tails.
5.2 From the HES data provided DH has estimated
figures on types of delivery and interventions, such as caesareans,
inductions and breech births across English hospitals for 2000-01.
given this background of poor data collection, it is no wonder
that the organisation of maternity services is so haphazard. What
cannot be seen cannot be managed.
5.3 Over the past twenty years a large body
of research evidence has accumulated which consistently demonstrates
the safety of community-based intrapartum care for healthy women
with a normal pregnancy3,4 studies have consistently demonstrated
maternal and infant outcomes (mortality and morbidity) associated
with birth centre care to be equal to or better than those achieved
with women of similar low risk status cared for on traditional
labour wards5.
5.4.1 Outcomes from the five well-established
Wiltshire birth centres which surround Bath provide further evidence
that small, midwife-led birth centres work safely and effectively,
and are highly regarded by both women and health professional
alike.6 These outcomes are confirmed by similar birth centres
research in the United States. A published review found that these
free-standing birth centres present "advantages for low risk
women as compared with traditional hospital settings: lower cost
of maternity care and lower use of maternity procedures without
significant differences in perinatal mortality".7
5.4.2 The largest published study, of over
12,000 women giving birth in 84 birth centres, found that women
who gave birth in birth centres had fewer medical interventions
in labour, and maternal and neonatal mortality and morbidity rates
were no different from those of large conventional hospitals.8
This is supported by similar findings from birth centres in Germany,
Australia and Scandinavia. This finding has recently been confirmed
in this country in a systematic review of "home-like versus
conventional institutional settings for birth,9 which found that
continuous support from a female support person is associated
with
(a) lower use of pharmacological analgesia;
(b) a very slight reduction in the length
of labour;
(c) fewer operative deliveries;
(d) fewer caesarean section;
(e) more five minute APGAR scores greater
than 7.2;
(f) women feeling in control of their labour;
(g) labour being better than expected;
(h) a more positive overall experience for
the women.
As the MIDIRS leaflet on Support in Labour (see
below paragraph 6) concludes; "Research over the past 25
years has shown that the constant presence of a supportive birth
companion is one of the most effective forms of care that women
can receive during childbirth." Models of care need to facilitate
this so that women are connected to human support rather than
treated as the objects of medical intervention.
5.5 None of the many published evaluations
has ever found any significant differences in mortality or life-threatening
morbidity for either mother or baby when born in midwife-led birth
centres. The reasons for these findings centre on the fact that
women are more relaxed and able to give birth normally in a low-key,
intimate environment with one-to-one care from familiar midwives.
5.6 It must be recognised that childbirth
carries some inherent risks wherever it takes place and that these
cannot be removed entirely by prescribing a location for birth,
certainly not by prescribing an obstetric unit as that location.
The Confidential Enquiries into Maternal Death and into Stillbirths
and Deaths in Infancy10 have demonstrated over and over again
that it is the proper deployment of the right staff with the right
skills that can help avoid the mistakes that occur in the care
of pregnant and labouring women. As the recent comprehensive Reference
Report from the External Group on Acute Maternity Services to
the Scottish Executive11 noted:
"furthermore, in assessing and apportioning
levels of risk within maternity services it must be acknowledged
and highlighted to women that there is no such thing as `zero'
risk and that risk cannot be the same for every woman. While maternity
care experts can measure risk and communicate estimated levels
to individuals, this information is filtered and may reflect professional
and social bias . . . One aspect of the increased concern with
risk and safety within the maternity services is the shift from
need to risk."
5.7 It can be seen from the evidence, that
in contrast to the findings cited above on the benefits of support
straying from normal birth can in itself introduce risk for women
who are low risk to start with.
5.7.1 The use of epidurals in labour is
capable of starting a cascade of interventions each bringing their
own risks.
(a) Epidurals are associated with "a
threefold increase in the use of oxytocin in labour".12
(b) "Very occasionally oxytocin can
cause the uterus to contract too much which may affect the pattern
of the baby's heartbeat".13
(c) When oxytocin is used, it is therefore
recommended that continuous electronic fetal monitoring is used.14
(d) Continuous electronic monitoring increases
the caesarean section rate by 160% and the operative vaginal delivery
rate by 30%.15
(e) Risks associated with caesareans include
a five to twenty fold increase in infection rates,16 and an increase
in thromboembolic disease which can be fatal, both of which can
be reduced by prophylactic antibiotics.
5.8 Some women may feel more relaxed knowing
they can have an epidural if they need one. However, they must
be provided with all the available information in choosing a place
of birth for that reason.
5.9 It is clearly crucial that the screening
process applied to women by Birth Centres through their selection
criteria screens out those women who may experience complications
and hence be better suited to birth in hospital where their needs
can be better met. Crucially, it is the woman's choice where she
gives birth and that choice is converted into an informed choice
with unbiased advice and information from healthcare professionals
on the relative benefits and risks of the options available. The
starting point for that discussion must be normality not abnormality
because "pregnancy and birth are normal physiological processes,
in which medical intervention is inappropriate unless it is clinically
indicated and evidence-based."17 To imply to all women that
a panoply of possible interventions must be at their disposal
in case they need them is to misrepresent the position and may
actually be to their disadvantage. Birth Centres offer high quality
evidence based care based on an ethos of normal birth and woman-centred
care. They clearly provide the choice of a safe alternative to
hospital for women who can safely choose them, which is the majority.
6. MAKING CHOICE
INFORMED CHOICE
6.1 Even assuming the existence of a range
of options for place of birth distributed equitably across the
country (which is a big assumption), offering women real choice
can still be a complex process. Information must be offered to
them in an accessible way. This will require both midwife time
to enable them to convey information effectively, and written
materials in English and minority languages which are appropriately
worded. Without this investment, choice is mere political rhetoric.
6.2 It is a great disappointment that, almost
six years after their publication the excellent Informed Choice
Leaflets are still not available in ethnic minority languages.
These Leaflets were commissioned by the NHS from MIDIRs and the
NHS Centre for Reviews and Disseminations on a range of topics,
developed from focus groups with women. Drafts were prepared by
experts, after reviewing the evidence, and then peer reviewed
twice by international experts. The drafts, presented in pairs
with one version for women and another for professionals, have
the Crystal Mark of the Plain English Campaign. The final form
of the leaflets was piloted and amended in the light of feedback.
This excellent resource is not, however, available to all women
and professionals. Trusts' use of these leaflets has been greatly
circumscribed by cost. The Leaflet on Place of Birth sets out
what is and is not known about the evidence very clearly but the
information is not sufficiently widely disseminated. All the evidence
indicates that we need to move from the largely spurious debate
about choice of intervention (caesarean or not) to the real choice—where
and how to give birth.
7. CHOICE FOR
WHOM?
7.1 Birth outside of an acute unit is only
recommended for healthy women expecting a normal delivery. Depending
on the selection criteria used, delivery in an acute unit is recommended
for between 25-35% of all pregnant women. Preliminary findings
from a recent survey commissioned by the Department of Health18
found that 50% of the 1,805 women surveyed were not offered a
choice about place of birth.
7.2 In addition, there are a number of women
who prefer to deliver in an acute unit, either because they want
to have access to an epidural, or because they feel safer in an
acute unit. There is no reliable data on what proportion of women
come into this category, but "best guesses" are consistently
in the region of 20-30%,19 bringing the total to 45-65%. Therefore,
between a third and a half of the women in England and Wales could
be expected to be both clinically eligible and personally willing
to deliver in a community setting. This amounts to about 200,000-300,000
births per year. This indicates the possibility of a thirty-fold
increase in the numbers of women who might choose Birth Centres
if this option were available to them.
7.3 It is important that the potential of
Birth Centres to care for women, particularly vulnerable women,
in a holistic way is fully exploited. Being based in the community
and staffed by local midwives, care can be more responsive to
local needs, particularly with regard to health inequalities and
social exclusion. The current situation where the great majority
of women giving birth in acute sector hospitals, does not fit
the philosophy of easily accessible, client-led services, that
can contribute to tackling inequalities in health by supporting
women continuously and flexibly.
7.3.1 An important finding of the 5th annual
CESDI Report20 was that the profile of both Sudden Infant Death
and Sudden Unexpected Deaths in Infancy was:
— peak incidence in December,
— lower birth weight and gestational
age,
— mothers younger and more likely to
have smoked,
— parents more likely to be unemployed
and in receipt of income support.
7.3.2 Similarly, the Confidential Enquiry
into Maternal Deaths 1994-96 published 1998, concluded that, although
data is poor, the risk of maternal death in black women may be
higher perhaps by as much as 100%.
These alarming figures demonstrate that women
must have care targeted to support their needs. A service which
takes them in, "delivers" them and sends them home is
not one that can meet their needs.
7.4 Whilst many health inequalities are
created by socio-economic factors, the structure of health services
often contribute to inequalities, particularly in terms of access.
It is widely accepted that those with the poorest health, and
therefore the greatest need for health services, are those least
likely to make use of the services.
7.5 Policy makers and midwives alike have
been impressed by the potential of Birth Centres to provide sensitive,
effective and acceptable care to women and families who have traditionally
had poor access to appropriate services and/or alternatives to
hospital care eg teenage mothers, women from ethnic minorities,
women on low incomes and/or living far from regional units. Crowborough
and Dover Birth Centres have achieved precisely this—with
the units integrating into the community, the midwives are able
to offer particular support to young single mothers and local
"new age" travellers.
7.6 Locally based Birth Centres offer an
excellent opportunity to facilitate "joined up" working
practices between the maternity services, other statutory and
voluntary agencies and the local community. By knowing the local
area well, and by liasing with the relevant agencies and services,
Birth Centre midwives are well placed to target and support women
with pressing social needs, such as those with drug or alcohol
problems, those in violent relationships, teenagers and so on.
7.7 Birth centres can also be an effective
resource to promote healthy lifestyle in relevant and meaningful
ways to the local community. This may be in terms of locally targeted
information, advice and support to tackle specific issues such
as smoking and breastfeeding. The Birth Centre may also adopt
other community-focused strategies such as facilitating social
support within peer groups. Social and emotional support in pregnancy
are known to increase positive outcomes for women21, and Birth
Centres are ideally placed to promote and facilitate this. All
these approaches have great potential for bringing about substantial,
long term health gain to those most at risk of poor health.
7.8 The new public health agenda places
heavy emphasis on local healthy environments and community development,
and Birth Centres can make a significant contribution to this
agenda being taken forward in the maternity services with strong
tradition of community involvement and ownership. User involvement
and representation in the management of established birth centres
has already been shown to increase consumer numbers and satisfaction
by influencing both the philosophy and unit protocols towards
greater inclusion without compromising safety. The Edgware Birth
Centre has a multidisciplinary management committee chaired by
a user with several user members.
8. ARE BIRTH
CENTRES A
CHOICE THE
NHS CAN AFFORD
TO OFFER?
8.1 The capital costs of Birth Centres have
not been formally assessed. The majority consist of a number of
home-like rooms, sitting areas and facilities for staff. Equipment
would include resuscitation equipment. Other than this there are
no "high tech" equipment costs. The cost of converting
the original Edgware Birth Centre22 was just under £90,000.
8.2 There are many opportunities across
the country by the 471 community hospitals to put Birth Centres
in place where they do not currently exist.
8.3 Quite apart from the potential offered
by community hospital sites to increase Birth Centre provision
in a coherent way, the current LIFT capital programmes offers
an unprecedented opportunity to integrate new build/refurbished
Birth Centres as community maternity services.
8.4 This would place maternity services
in primary care with secondary care with secondary care as the
exception for those who need it, which is consistent with the
evidence of need. This would mirror the arrangement of mental
health services where community mental health teams are intended
to be the hub of the service, not the in-patient beds.
8.5 There are two elements to a comparison
of recurrent costs of birth in a Birth Centre and birth in a consultant
unit: comparison of the actual unit costs and assessment of the
opportunity costs of interventions which the same births would
be likely to attract if they took place in a consultant unit.
8.5.1 Actual Unit costs: The NHS Reference
Costs 2002 published by the Department of Health sets out the
average costs of deliveries in the NHS:
— The cost of an Induction is—£1,118
(ranging from £378 to £2461).
— The cost of a Normal Delivery is—£943
(ranging from £220 to £2453).
— The cost of a Caesarean is—£2109
(ranging from £516 to £42513 (!)).
These figures demonstrate the challenge faced
in trying to conclude comparative costs nationally on models of
maternity care. An opportunity exits to cost Birth Centre activity
separately and consistently, so that at least one can be compared
with another. at the same time the Reforming Financial Flows23
policy will require the production of a national tariff for maternity
as for all other healthcare, eventually.
8.5.2 The Edgware Birth Centre evaluation24,
a demonstrator pilot funded by the Department of Health, did a
detailed examination of every item involved in providing care
comparing the unit costs of 35 births at the Birth Centre with
that 33 births at Barnet General. Excluding capital charges which
are variable depending on location, the mean cost at Edgware was
£392.30 per birth compared to a mean cost at Barnet General
of £608.90. Items such as the cost of sutures and Entonox
were included as were the cost of epidurals (not available at
the Birth Centre) at Barnet General.
8.5.3 Excessive costs are often the primary
reason given for the proposed closure of units and this was the
case for the Crowborough Birthing Centre in 1996. The graph demonstrates
that as women increasingly choose midwife led care there are large
cost benefits from small, low-technology birth centres.
8.5.4 As the number of births at Crowborough
rose, so the cost per-birth fell sharply, even allowing for some
additional staffing. Contrary to previous Health Authority predictions,
the cost-per-birth actually fell by over £1,000 per birth,
so that costs were not only well below the national average, but
also significantly below costs at the nearest District General
Hospital at Pembury, Kent.
8.5.6 The cost-per-birth figure does not
indicate all the possible savings, because it understates the
full range of antenatal care, intrapartum and high quality in-patient
postnatal care that is provided by Crowborough Birth Centre. The
centre also acts as a local 24 hour drop-in maternity help-centre,
with over 2,000 attendees per year, including about 800 women
for potential booking and others seeking help or advice whether
antenatally or postnatally.
8.6 Opportunity costs: the National Reference
costs25 include surgical or drug induced in the figure for Normal
Delivery Without Complications (average cost nationally £943)
so this data is of no assistance in determining opportunity costs
of the Birth Centre of care for low risk women.
The latest Bulletin on Maternity statistics26
states that only 53% of women had a spontaneous labour and delivery,
without induction, the use of instruments or caesarean section.
The NHS does not know what these births cost. The average cost
nationally for an Assisted Delivery Without Complications is £1,118.
This category includes forceps and ventouse so it at least is
possible to conclude that each Assisted Delivery (in Reference
cost terms), costs the NHS 18% more than if there had been no
forceps or ventouse. According to the centrally funded Edgware
evaluation, rates of forceps and ventouse in a midwife-led unit
can be 10% lower fro the risk women than in local district general
hospitals27.
8.7 The cost saving to the NHS of offering
a choice to women of a model of care which allows them to be in
control of their own birth process, would undoubtedly release
savings which could help fund care for high risk women and their
babies where interventions can be lifesaving. The Edgware findings
were based on small numbers and national conclusions cannot be
drawn from them.
8.8 Detailed financial analysis of what
each aspect of childbirth costs the NHS is long overdue. An assessment
is required of the money, which might be saved across the NHS
if normal birth was the norm instead of only happening in just
over half of the cases nationally.
9. MATERNITY
NETWORKS
9.1 The integration of neonatal intensive
care units into networks presents an opportunity to include Birth
Centres into a parallel network of maternity care. This can be
integrated with clinical governance links to obstetric units and
management accountability to PCTs, making maternity care community-based
and responsive following the Wiltshire and Shrewsbury models.
9.3 Just as protocols for transfers of babies
between different levels of unit are being developed for neonatal
intensive care, so protocols and monitoring mechanism need to
be developed for transfers antenatally and intrapartum where this
proves necessary. Birth centres must be integrated into clinical
networks so that transfers can be managed and monitored.
10. WOMEN'S
VOICES
10.1 In the DOH funded evaluation of the
Edgeware Birth Centre, when answering a question about the potential
benefits of the birth centre, over 90% of women cited as prime
attractions, (i) the relaxed and homely atmosphere, (ii) the freedom
to do what felt right for them during labour and delivery and,
(iii) having their own room from the time of arrival until the
time of leaving. Over 70% saw not being attached to any monitors
of "high tech" equipment and being looked after by midwives
with no doctors involved as an attraction.
10.2 When asked, during pregnancy, about
the attractions of the birth centre compared to home birth, nearly
90% of women said that more facilities and midwives always on
the premises were a great attraction. 60% of women said getting
a break from domestic responsibilities was an attraction.
10.2.1 Ms K Said: "I have got a six
year old. I do not want him walking in".
10.2.2 Mrs C said: "We can hear everything
that happens next door, so I just imagined that it might make
me feel really self conscious if I imagined all our neighbours
could hear me in labour and it wouldn't feel private".
10.3 During interviews after their babies
were born, 100% of "Birth Centre" women were very satisfied
or satisfied with their experience, commenting on it in very positive
terms.
10.3.1 Mrs R said: "They let you do
what you want to do, I had no-one saying to me I couldn't do that".
10.3.2 Mrs M said: "I would rate it
that high because of the support I had, the surroundings, the
aftercare. "Other answers given postnatally were very similar
to those given antenatally. However, a even higher proportion
identified not being attached to monitors or high tech equipment
as an attraction.
10.4 Women were asked what they had found
to be the important benefits of the birth centre compared with
a hospital birth.
10.4.1 "At the birth centre I had more
freedom to do what felt right for me" and "The birth
centre had a homely and relaxed atmosphere" were typical
responses.
10.4.2 Mrs J said: "I think in a place
like the birth centre you're not rushed, you're put under any
pressure".
10.4.3 Mrs S Said: "I didn't have any
interventions as such. I didn't have any pain relief, just the
pool" 30% of women rated the fact that at the Birth Centre
they had their own room from the time they arrived until they
were ready to leave as one of the two most important attractions.
10.4.4 Mrs M Said: "Afterwards you
are not put on a crowded ward, you are in a nice little room of
your own, you can get to know the baby and the baby can get to
know you, the father can get to know the baby, the father could
stay there".
10.4.5 Speaking of the attitudes of the
midwives and type of care she received, Ms C said: "I was
listened to, I had consistent care, I was treated like a human
being and also had a lot of one-to-one help".
10.5 Perhaps the last word should go to
a woman who was transferred to the acute unit during labour: "The
birth centre provides an invaluable service to women. The care
is truly woman-centred, it seems to be the only place that treats
women as intelligent human beings. My experience there is so at
odds with what I experienced during hospital care, it is hard
to believe it is part of the NHS".
11. REAL CHOICE—MOVING
FROM DEBATE
TO ACTION
11.1 The debate about Birth Centres has
been taken over by events with publication of the Report to the
Department of Health Children's Taskforce from the Maternity and
Neonatal Workforce Group in January of this year28. This Report
noted that "current patterns of working and service provision,
based on currently forecast level of supply, are not sustainable,
due in part to the European Working Time Directive and the NHS
Plan commitment to a consultant delivered service where medical
intervention is required. Some change is therefore inevitable".
11.2 There is a window of opportunity now
to grasp the Birth Centre issue, producing a coherent national
plan and addressing remaining concerns instead of just debating
them. The variability of data and data collection between units,
which mirrors the positions across the NHS, needs to be addressed
with a core data set addressing what must be monitored within
the Birth Centre and within its network.
11.3 In addition an Accreditation Framework
is needed built on multi-disciplinary consensus incorporating
user involvement standards. The Birth Centre Network UK is taking
this work forward in collaboration with the Royal Colleges of
Midwives and the Royal College of Obstetricians and Gynaecologists.
To make choice a reality for women, a range of options is needed
spread equitably across the country and a greater understanding
of selection criteria for both Birth Centres and obstetric units
needs to be developed.
12. CONCLUSIONS
AND RECOMMENDATIONS
Conclusions
1. It is clear that the debate needs to
move from how to eradicate risk, to how to maximise choice and
normal birth.
2. This will improve outcomes, user satisfaction
and cost effectiveness by taking an evidence based approach to
risk management.
3. Such progress can only be achieved by
focusing on the needs of the mother and baby not the needs of
the NHS to intervene as if childbirth were an illness needing
treatment.
4. Targeting resources to meet need would
mean that women who face possible complications can receive a
service designed to meet their needs in the same way as low risk
women with a need for normal birth.
5. This shift would produce a more rational
service than the current model where every woman is treated as
a ticking time bomb of risk. We must move from a litigation-centred
service to a women-centred service.
Recommendations
12.1 Moratorium on birth centre closures—Until
the NSF is published setting out standards on maternity care,
there should be a moratorium on all birth centre closures.
12.2 Standards on Choice—The children's
NSF Maternity Module should address the issue of place of birth,
setting clear standards for choice in maternity care.
12.3 Normal birth as the norm—"Normal
birth as often as possible" should be promoted as an objective
for the NHS and performance indicators developed for PCTs on the
numbers of births which take place with "a spontaneous labour
and delivery, without induction, the use of instruments or caesarean
section". This is the indicator derived from the NHS Maternity
Statistics England 2001-02, and only occurs currently in 53% of
cases nationally. This would follow the precedent set by the PCT
target to increase breastfeeding initiation rates by 2% per year,
as set out in the National Planning and Priorities Framework.29
12.4 Agreeing what needs to be monitored
and monitoring it—A common birth centre dataset needs to
be developed including transfer rates, reason for transfers according
to a common code, postcode of women booking, ethnic origin etc.
This will lay the foundation for aggregating individual Centre's
users to provide an aggregate national sample of women using this
model of care, to assist the evidence-based development this option
nationally.
12.5 Auditing informed choice—The
wider dissemination of Informed Choice leaflets, in English and
ethnic minority languages and other media, is an urgent priority
in the facilitation of informed choice for women. This should
be government funded as part of information standards in the Children's
NSF.
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