Select Committee on Health Written Evidence


APPENDIX 22

Memorandum by Alison Macfarlane and Rona Campbell

1.  BACKGROUND

  1.1  This memorandum focuses on the evidence available to support choices about where and with whom to give birth. Decisions about this have a major influence on the pattern of care provided, especially for women with uncomplicated pregnancies. There are, of course, many other factors which can also play a part, but they are outside the scope of the evidence we have reviewed over the years.

  1.2  At the time the House of Commons Health Committee set up its enquiry into Maternity services in 1991, the government's view had long been that every woman should give birth in a district general hospital. This was based on the assumption that the safest place to give birth was a consultant obstetric unit and that the reduction in perinatal mortality in preceding decades was a direct consequence of the increase in the proportion of births taking place in large hospitals with consultant obstetric units.

  1.3  We submitted to the Committee a memorandum1 based on our review of the available evidence published in the British Journal of Obstetrics and Gynaecology2 a fuller review Where to be born?3 published in 1987 and research published subsequently. Among our conclusions were two which contradicted the basis for the government's policies. These were that " ... any statistical relation between the increase in the proportion of hospital deliveries and the fall in the crude perinatal mortality rate seems unlikely to be explained by a cause and effect relation." and that "... there is no evidence to support the claim that the safest policy is for all women to give birth in hospital, or for the policy of closing small obstetric units on the grounds of safety".1

  1.4  In this memorandum, we first outline subsequent policy changes, then discuss the extent to which they have actually been implemented before closing by examining our conclusions in the light of research since 1992, including the second edition of our review4 and subsequent research.

2.  POLICY CHANGES SINCE THE EARLY 1990S

  2.1  In its report on Maternity services, published in 1992,5 the Committee concluded that "On the basis of what we have heard, this Committee must draw the conclusion that the policy of encouraging all women to give birth in hospital cannot be justified on the grounds of safety."5 It went on to comment that "Given the absence of conclusive evidence, it is no longer acceptable that the pattern of maternity care provision should be driven by presumptions about the applicability of a medical model of care based on unproven assertions."5

  2.2  When the government replied to the Committee in July 1992, its position showed little sign of change, but it did recognise a need to provide a choice. "The safety of mother and child must be the prime consideration. It is impossible to predict all the problems which may arise in labour. Women have therefore been encouraged to give birth in hospital where back-up facilities are available in an emergency but the Government recognises that there are women for whom home birth may be an option they would prefer. Health authorities are obliged to recognise a woman's right to choose, and see that a midwifery service is available for a woman to give birth at home, if that is her choice."6

  2.3  The government then appointed the Expert Maternity Group, chaired by Baroness Cumberlege. Its report, Changing childbirth,7 published in August 1993, signalled a considerable change in the direction of policy for maternity care and stressed that the service must be "woman centred". To achieve this, it recommended that midwives should have a more prominent role, with every pregnant woman having a named midwife even if her care was led by a GP or obstetrician. Increasing choice was a key theme of the report, with recommendations that each woman should be provided with accurate and unbiased information about the options available so that she could make informed decisions, for instance about where she received care.

  2.4  In discussing place of birth, the report commented that: "Whether a mother with an uncomplicated pregnancy is putting herself and her child at any greater risk by choosing to have her baby away from a general hospital is a topic that has been argued with vehemence and emotion for decades. The inability to reach agreement after this length of time suggests there is no clear answer. The job of midwives and doctors, therefore, must be to provide the woman with as accurate and objective information as possible, whilst avoiding personal bias or preference."7

  2.5  Changing childbirth contained ten indicators of success to be achieved within five years. It proposed that every woman should have and know a "lead professional" and a named midwife. At least 30% should have a midwife as the "lead professional". Midwives should have direct access to some beds in all maternity units. At least 30% of women should be admitted under the management of a midwife and at least 75% should know the person who cares for them during delivery. It called for the numbers of antenatal visits to be reviewed and for all ambulances to have a paramedic able to support midwives transferring women from home to hospital during delivery. Finally it suggested that all women should be entitled to carry their own case notes and have access to information about local services.7 The 10 indicators of success were also listed in an "Executive letter", entitled "Woman-centred maternity services".8 and a Patient's Charter leaflet.9

  2.6  It was widely believed that there was a legal obligation to provide a home birth service, until the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) took legal advice and published a position statement in 2001.10 While fully supporting "the expectation that choice will be offered to women, and that the option of home birth will be available," this pointed out that "There is no statutory duty to provide any specific aspect of the maternity service."10

  2.7  This came at a time when the NHS Plan and related government policy documents were emphasising the need to reduce geographical variations in the availability of services.11 In parallel with this, the Maternity Care Working Party, set up by professional and voluntary organisations, published a toolkit for primary care trusts in 2001. In this, it recommended that "All women should be given an even-handed explanation of the options for location, ie home, hospital or community unit. A 24 hour midwifery service should be available for birth at home."12

  2.8  These policies have been reiterated in the Emerging findings of the Children's National Service Framework which emphasise the need to promote normality and offer greater choice.13

3.  TO WHAT EXTENT HAVE POLICIES BEEN IMPLEMENTED?

  3.1  No formal system was set up to monitor progress towards the targets in Changing childbirth. A survey undertaken in 1997 of NHS trusts in England with maternity units found that between a third and two fifths reported that they collected data about easily quantifiable Changing childbirth indicators of success, with only 18 collecting all of them.14

  3.2  Data from routine systems give some insight about the extent of births in different settings, although there are problems in interpreting them. No data are collected at a national level about lead professionals but the Hospital Episode Statistics record the person conducting the delivery and the type of ward in which the woman gives the birth. The address at which birth takes place is recorded at birth registration. A code is allocated to denote the institution in which the birth took place. Births outside hospitals or other institutions are subdivided into those at the woman's usual place of residence and those elsewhere.

Place of birth

  3.3  Most women give birth in large maternity units. According to data from birth registration, nearly a quarter or 22.8% of women who gave birth England and Wales in 2002 did so in institutions with 4,000 or more registrable maternities and a further 22.8% did so in institutions with 3,000-3999 maternities.15 Only 12.8% of maternities took place in institutions with 1,000-1999 maternities and 3.0% on sites with under 1,000 maternities.

  3.4  The impact of the European Working Time Directive and the implementation of neonatal networks is likely to lead to further closures and mergers, increasing the proportions of women who deliver in large units and the distances they will need to travel to do so, even for uncomplicated deliveries. The alternative to this is to keep maternity units open as midwife-led units when consultant obstetrics services are withdrawn and to open new midwife-led units in areas when none currently exist. This would be in line with the government's wider policy of increasing the extent to which care is given outside secondary and tertiary centres.

  3.5  The percentage of births taking place at home remains low. At the time of the Committee's previous enquiry into maternity services, the percentage of maternities at home in England and Wales had risen slowly but steadily from an all time low of 0.89% in 1987 to 1.13% in 1991.16 This rise continued to 2.26% in 1997, after which it levelled off around 2.1%, as Figure 1 shows.16,17

  3.6  There are considerable variations throughout the country, as Figure 2 shows . This was based on pre-April 2002 health authorities,18 but variations at a more local level are even wider.18 The highest figure was 6.1% of all maternities in the former South and West Devon Health Authority area, but within that, 8.3% of maternities to residents within the Torbay Unitary Authority occurred at home.19 Within the area served by the West Herts Hospitals Trust, the proportion of maternities at home in 2001 ranged from 0.7% for residents of the Watford local authority district and 1.2% in Three Rivers to 3.5% in Dacorum and 3.7% in St Albans. A survey undertaken by the National Childbirth Trust which asked for data by trust giving care rather than area of residence found similarly wide variations.20

Lead professional and type of care

  3.5  In England as a whole, the percentage of hospital deliveries conducted by midwives declined from 75.6 in the financial year 1989-90 to 66.2% in 2001-02, while the percentage conducted by hospital doctors rose from 23.7 to 33.8%.21 This mirrors almost exactly the rise in caesarean sections and the decline in spontaneous delivery. Regional differences in 2001-02 showed the same association. The marked differences between units within the same region are likely to be a sign of corresponding differences in the proportion of women delivering with a midwife.

  3.6  Relatively few women appear to have midwife-led care. In 1996-97, when the category was first used, 1% of women in England gave birth in a midwife or other ward. This rose to reach 3% in 2001-02.21 This coding covers both freestanding midwife-led units and birth centres as well as midwife led units in hospitals with consultant units. Deliveries coded in this way varied markedly by region. They accounted for 15% of women delivering in the South West Region, 11% of those in the Yorkshire and Humber Region, 4% of those in the London Region and well under 3% of those in the other regions.21

  3.7  Deliveries coded as occurring in GP wards declined from 5% in 1989-90 to 2% 1996-97 and 1% in 2001-02.21 This is not surprising as "isolated GP units" had been closing for many years. Most of the care in the units was given by midwives and during the 1990s many of the remaining GP units changed their designation to midwife-led units.

  3.8  In 2001-02, 40% of deliveries were coded as occurring in combined "consultant/GP wards", even though only an estimated 200 women were delivered by GPs.20 This suggests that either the designation of wards or the way in which they are coded had not been changed to reflect the declining involvement of GPs.

4.  ARE EARLIER CONCLUSIONS SUPPORTED BY MORE RECENT EVIDENCE?

  4.1  In this section we summarise the conclusions of research and audit undertaken since the Committee's last report. In doing so, we draw on the second edition of our review Where to be born?, published in 1994.4 Between us, we have summarised more recent research in successive editions of the MIDIRS peer reviewed informed choice leaflet on the subject, the most recent of which was published in 2003.22 As in earlier research, it is impossible to make direct comparisons between the safety of birth in different settings. This is because there are very few deaths among babies born to women who book to give birth in midwife led units or at home.

MIDWIFE LED UNITS IN HOSPITALS WITH CONSULTANT OBSTETRIC UNITS

  4.2  Three randomised trials have compared midwife-led units with consultant obstetric care in the same hospital.23-25 All found a higher rate of electronic fetal monitoring and episiotomy among women receiving consultant care and in two trials more fetal distress was detected. No significant differences were found in mortality or life-threatening morbidity, but much larger trials would be needed to detect any such differences reliably. Two trials found that the women allocated to midwifery units were more satisfied with their care.24,25 One of these found that women allocated to midwifery care reported receiving more consistent advice, saw fewer care providers and experienced greater continuity of intrapartum care.26 The third reported no difference in overall satisfaction.27

Midwife-led units in hospitals without consultant units

  4.3  Women who booked to deliver at the midwife led unit at the Royal Bournemouth Hospital and at the Edgware Birth Centre were compared with women who satisfied the criteria for delivering at the units but booked to deliver in consultant units elsewhere.28,29 Booking for the midwifery units was associated with lower rates of induction of labour and episiotomy and similar rates of perineal tears. One of the studies found higher rates of augmentation of labour and use of anaesthesia among women booked for hospital28 and the other found higher rates of ventouse delivery and elective caesarean sections.29

Home birth

  4.4  A survey of planned and unplanned home births from 1981 to 1994 in the former Northern Region estimated a perinatal mortality rate for women booked for home delivery and delivering there to be 1.7 per 1,000. When women who transferred to hospital were included, the estimated perinatal mortality rate was 4.8 per 1,000.30 This is less than half the rate for the region as a whole, the women booked for home birth did not include those classed as "high risk".

  4.5  A survey by the National Birthday trust fund of 6,044 planned home births in 1994 and 4,724 births in hospital to broadly similar women found no maternal deaths and low perinatal mortality rates were among the women who booked for home birth.31 An economic analysis of the data suggested that the better outcome alongside the lower expected costs per case lead us to conclude that . . . a real option of a home birth for all women who want it would also be a cost effective option.'31

  4.6  Overall perinatal mortality rates for England and Wales continued to fall when percentages of home birth first rose from the late 1980s and then levelled off in the mid to late 1990s. If Figures 1 and 3 are compared, it can be seen that there is no longer any statistical association between them.

  4.7  National statistics do not distinguish between planned and unplanned home births, but the perinatal mortality rate for all births at home in England and Wales fell in the mid 1990s. Since 1994 it has been lower than that for all births in hospital, as Figure 3 shows. This is because the numbers of probably unintentional births of low birthweight babies at home did not increase as overall numbers of home births rose through the 1990s.16,32 This contrasts with the position in 1979, when a national survey showed that a third of births at home were unplanned and they contributed substantially to the high perinatal mortality rates seen in Figure 3.33 It was the high overall rates for 1975-77 which led the Committee's predecessor, the House of Commons Social Services Committee to draw incorrect conclusions about the safety of planned home births.

  4.8  Claims have been made in the British Medical Journal that home birth is no longer safe and that hospital delivery is three to four times safer than home delivery.34 This draws on data from a review of by the Confidential Enquiry into Stillbirths and Deaths in Infancy review of 22 intrapartum deaths among planned home births.35 Closer examination shows that these claims are not supported by the available evidence.36-38

Transfer

  4.9  For a variety of different reasons, women may change their planes during pregnancy or transfer to a consultant obstetric unit during or immediately after labour, if problems arise. The Maternity Hospital Episode Statistics tries to capture data about transfers during labour, but they are incomplete.21 A national survey of maternity units in 2000 found that rates of transfer from planned home births to hospital ranged from zero to over 30% at each stage.20

Selection criteria

  4.10  Many different selection criteria are in current use and they are based on early epidemiological research and common practice.39 There is no research evidence to indicate which would lead to the best outcomes. As `risk scoring' systems are designed to identify groups of women who are at higher risk of adverse outcome, their ability to identify individual women who may experience problems during labour and delivery has not been demonstrated.40

Women's views

  4.11  Although it is unlikely that many women perceive that they have a choice about were to give birth, this does not necessarily imply a lack of interest. A survey commissioned by the Expert Maternity Group from MORI Health Research asked 1,005 women who had given birth since 1989 whether they would like to have the option of another type of care and delivery if they became pregnant again. Seventy two per cent said they would have liked an option other than delivery in a consultant unit. Of these, 22% said they would have liked the choice of a home birth and 44% a "domino" delivery. These accounted for 16% and 32% of all women questioned, respectively.7

5.  CONCLUSIONS AND RECOMMENDATIONS

The need for better data about the place of birth

  5.1  In order to inform choice, better data are needed about birth in different settings and its outcome, including transfers in labour and after birth. As originally envisaged, data about all registerable births, including those at home and in non-NHS hospitals should be submitted to the Maternity Hospital Statistics. The feedback of Maternity Hospital Statistics to maternity units and its wider dissemination should be improved.

  5.2  A new classification of maternity units and definitions of transfer should be devised to reflect the way care is now given. This should be incorporated into the maternity care data dictionary, into individual computer systems, the Maternity Hospital Episode Statistics and other relevant systems. It should be reviewed and updated on a regular basis.

  5.3  The current proliferation of initiatives relating to the collection of data about maternity care is leading to duplication of effort and inefficient use of resources which are needed to improve data collections systems. The initiatives should be rationalised and the data collection aspects should be brought within the scope of National Statistics and its Code of Practice.

Interpreting the available data and evidence

  5.4  Despite their deficiencies, the available data show marked differences in the types of care available in different parts of the country and that access to midwife led care, whether in midwife led units and birth centres or at home, is limited.

  5.5  There is still no evidence that the safest policy is for all women to give birth in a hospital with a consultant obstetric unit. There is no longer any statistical association between perinatal mortality and the percentage of births at home.

  5.6  These conclusions are based on research undertaken in the United Kingdom. Because of differences in health care systems, findings from other countries cannot be directly applied to the situation here.41 It is notable, however, that research elsewhere has reached broadly similar conclusions.42

  5.7  The policy of concentrating services for women with obstetric complications and sick newborn babies in secondary and tertiary centres has occurred in response to a variety of pressures and is in line with government policy in other areas. In contrast and in addition to the lack of evidence, it is out of line with the emerging findings of the National Service Framework and policies in other areas of health care for women with uncomplicated pregnancies to give birth in such settings, especially when doing so involves journeys of some distance. When consultant obstetric services are withdrawn from maternity units, there are strong arguments for retaining them as midwife led units.

REFERENCES

  1  Campbell R, Macfarlane AJ. Where to be born? Written evidence to the House of Commons Health Committee enquiry into maternity services. In: House of Commons Health Committee. Maternity Services, Volume III, appendices to the minutes of evidence. Second report, session 1991-92, HC 29-III. London: HMSO, 1992.

  2  Campbell R, Macfarlane AJ. Place of delivery: a review. British Journal of Obstetrics and Gynaecology 1986;93:675?83.

  3  Campbell R, Macfarlane AJ. Where to be born? The debate and the evidence. Oxford: NPEU 1987.

  4  Campbell R, Macfarlane AJ. Where to be born? The debate and the evidence. Second edition. Oxford: National Perinatal Epidemiology Unit, 1994.

  5  House of Commons Health Committee, (Chairman N Winterton). Maternity services. Vol I, report. HC 29-I. London: HMSO, 1992.

  6  Department of Health. Maternity services. The Government's response to the second report from the Health Committee, Session 1991-92, Cm 2018. London: HMSO, 1992.

  7  Department of Health. Changing childbirth. Part I. Report of the Expert Maternity Group. London: HMSO, 1993.

  8  NHS Management Executive. Woman-centred maternity services. Executive letter EL(94)9. January 24 1994.

  9  NHS. The patient's charter. Maternity services. Leeds: Department of Health, 1994.

  10  United Kingdom Central Council for Nursing, Midwifery and Health Visiting. Supporting women who intend to give birth at home. London: UKCC, 2001.

  11  Department of Health. The NHS plan. (Cm 4818-I). London: Stationery Office, 2000.

  12  Maternity Care Working Party. Modernising maternity care. London: Maternity Care Working Party, 2001.

  13  Department of Health. Getting the right start: National Service Framework for Children: emerging findings. London: Department of Health, 2003.

  14  Kenney N, Macfarlane A. Identifying problems with data collection at a local level: survey of maternity units in England. BMJ 1999; 319(7210) :619-22.

  15  Office for National Statistics. Unpublished analysis of birth registration data for 2002.

  16  Macfarlane AJ, Mugford M, Henderson J, Furtado A, Stevens J, Dunn A. Birth counts: statistics of pregnancy and childbirth. Volume 2,Tables. Second edition. London: The Stationery Office, 2000.

  17  Office for National Statistics. Birth and patterns of family building, England and Wales. Series FM1. Published annually.

  18  Office for National Statistics. Birth and patterns of family building, England and Wales, 2001. Series FM1, No 30. London: TSO, 2002; Table 8.2.

  19  Office for National Statistics, VS1 tables, 2001. Titchfield: Office for National Statistics, 2002.

  20  National Childbirth Trust. Home birth in the United Kingdom. London: NCT, 2001.

  21  Department of Health. NHS maternity statistics, England: 2001-02. Statistical bulletin 2003/09. London: Department of Health, 2003.

  22  MIDIRS. Place of birth. In: MIDIRS informed choice information pack. Bristol: MIDIRS, 2003.

  23  Hundley VA, Cruickshank FM; Lang GD et al. Midwife managed delivery unit: a randomised controlled comparison with consultant led care. Br Med J 1994;309:1400-4.

  24  Macvicar J, Dobbie G, Owen-Johnstone L et al. Simulated home delivery in hospital: a randomised controlled trial. Br J Obstet Gynaecol 1993;100:316-23.

  25  Turnbull D, Holmes A, Shields N et al. Randomised, controlled trial of efficacy of midwife-managed care. Lancet 1996;348:213-8.

  26  Turnbull D, Shields N, McGinley M et al. Can midwife-managed units improve continuity of care? Br J Midwifery 1999;7:499-503.

  27  Hundley VA, Milne JM, Glazener CMA et al. Satisfaction and the three C's: continuity, choice and control. Women's views from a randomised controlled trial of midwife-led care. Br J Obstet Gynaecol 1997;104:1273-80.

  28  Campbell R, Macfarlane A, Hempsall V et al. Evaluation of midwife-led care provided at the Royal Bournemouth Hospital. Midwifery 1999;15:183-93.

  29  Saunders D, Boulton M, Chapple J et al. Evaluation of the Edgware Birth Centre. Harrow: Northwick Park Hospital, North Thames Perinatal Public Health, 2000.

  30  Northern Region Perinatal Mortality Survey Coordinating Group. Collaborative survey of perinatal loss in planned and unplanned home births. Br Med J 1996;313:1306-9.

  31  Chamberlain G, Wraight A, Crowley P eds. Home births: the report of the 1994 confidential enquiry by the National Birthday Trust Fund. Carnforth: Parthenon, 1997.

  32  Office for National Statistics. Mortality statistics: childhood, infant and perinatal. Series DH3. London: TSO, published annually.

  33  Campbell R, Davies IM, Macfarlane A, Beral V. Home births in England and Wales, 1979: Perinatal mortality according to intended place of delivery. Br Med J 1984;289:721-4.

  34  Drife J. Data on babies' safety during hospital births are being ignored. Br Med J 1999;319:1008.

  35  Maternal and Child Health Research Consortium. Confidential Enquiry into Stillbirths and Deaths in Infancy [CESDI]. 5th annual report. London: Maternal and Child Health Research Consortium, 1998.

  36  Young G, Hey E. Choosing between home and hospital delivery. Home birth in Britain can be safe. Br Med J 1999;320:798.

  37  Macfarlane A, McCandlish R, Campbell R. Choosing between home and hospital delivery. There is no evidence that hospital is the safest place to give birth. Br Med J 2000;320;798.

  38  Chamberlain G. Choosing between home and hospital delivery. Risk of home birth in Britain cannot be compared with data from other countries. Br Med J 2000;320:798-9.

  39  Campbell R. Review and assessment of selection criteria used when booking pregnant women at different places of birth. Br J Obstet Gynaecol 1999;106:550-6.

  40  Reynolds JL, Yudkin P, Bull MJV. General practitioner obstetrics: does risk prediction work? J R Coll Gen Pract 1988;38:307-10.

  41  Macfarlane A. The safest place of birth—is there a better analysis than meta-analysis? [commentary]. Birth 1997;24 :14-6.

  42  Olsen O. Meta-analysis of the safety of home birth. Birth 1997. 24(1):4-13.











 
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