03 December 2014

Midwife-led units safest for straightforward births
By Sanjay Tanday

More women should be encouraged to give birth at midwife-led units rather than traditional labour wards, says NICE.

In updated guidance, the evidence now shows that midwife-led care is safer than hospital care for women having a straightforward, low risk, pregnancy.

This is because the rate of interventions, such as the use of forceps or an epidural, is lower and the outcome for the baby is no different compared with an obstetric unit.

Mid-wife led units can be based at hospital sites next to obstetric units or freestanding and based away from a hospital site.

Around 45 per cent of women have a low risk of developing complications during their pregnancy. 

Factors that can increase the risk of complications during birth include being over 35, being overweight or obese, bleeding after 24 weeks of gestation, and having a high blood pressure. Complications from a previous pregnancy can also increase the risk of complications during birth for pregnant women.

 Outcomes for low-risk pregnant multiparous women for each planned place of birth

 

Number of incidences per 1000 multiparous women giving birth

 

Home

Freestanding midwifery unit

Alongside midwifery unit

Obstetric unit

 

Spontaneous vaginal birth

984*

980

967

927*

Transfer to an obstetric unit

115*

94

125

10**

Regional analgesia (epidural and/or spinal)***

28*

40

60

121*

Episiotomy

15*

23

35

56*

Caesarean birth

7*

8

10

35*

Instrumental birth (forceps or ventouse)

9*

12

23

38*

Blood transfusion

4

4

5

8

(Sources: Birthplace 2011; Blix et al. 2012)

Outcomes for the baby for each planned place of birth: low-risk multiparous women

 

  1. 1.            Number of babies per 1000 births

 

  1.          Home
Freestanding midwifery unit Alongside midwifery unit

Obstetric unit

Babies without serious medical problems

997

997

998

997

Babies with serious medical problems*

3

3

2

3

 ( Source: Birthplace 2011)

Home births safe for baby

The guidance recommends that home births are also equally as safe as a midwife-led unit and traditional labour ward for the babies of low risk pregnant women, except for first-time mothers.

In a midwifery unit or a hospital, a baby born with a serious medical complication might occur in 5 out of every 1,000 births, but this rises to 9 in every 1,000 for home births, for first-time mothers.

Healthcare professionals should inform women of the options available to them and advise that they have the freedom to choose where they give birth.

All women giving birth should have timely access to an obstetric unit if they need to be transferred to hospital for medical reasons or because they request an epidural.

Professor Mark Baker, NICE’s clinical practice director, said: “Where and how a woman gives birth to her baby can be hugely important to her. Although women with complicated pregnancies will still need a doctor, there is no reason why women at low risk of complications during labour should not have their baby in an environment in which they feel most comfortable.

“Our updated guideline will encourage greater choice in these decisions and ensure the best outcomes for both mother and baby.”

Some organisations have voiced concerns that encouraging women to give birth in midwife-led centres or at home would “force” women to give birth without doctors, putting them at greater risk of harm.

But 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.”

Cord-clamping

The update to the 2007 intrapartum care guideline also covers recommendations on cord clamping and advises not to clamp the cord earlier than 1 minute from the birth of the baby unless there is concern about the integrity of the cord or the baby has a heartbeat below 60 beats per minute that is not getting faster.

The cord should be clamped before 5 minutes in order to perform controlled cord traction as part of active management, but women should be supported if they request that the cord is clamped and cut later than 5 minutes.

Co-sleeping

Elsewhere, NICE has also updated postnatal guidance around the association between co-sleeping and Sudden Infant Death Syndrome (SIDS).

Since the launch of the Back to Sleep Campaign which advises parents to place babies on their back to sleep, there has been a drop in the number of deaths from SIDS. However, there were still 221 unexplained infant deaths in England and Wales recorded in 2012.

NICE recommends that parents or carers with a child under the age of 1 are told about the factors associated with co-sleeping and SIDS to allow them to weigh up the possible risks and benefits and decide on sleeping arrangements that best fit their family.

The association between co-sleeping and SIDS may be greater if a parent smokes, drinks alcohol or takes drugs before co-sleeping with their infant.  There is also an association between co-sleeping and SIDS if the child was born prematurely or with a low birthweight.

 

 

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There is no reason why women at low risk of complications during labour should not have their baby in an environment in which they feel most comfortable

Prof Mark Baker, NICE

Giving birth is a highly personal experience and there is no ‘one size fits all’ model that suits all women

Prof Susan Bewley, Kings College London