03 December 2014

NICE confirms midwife-led care during labour is safest for women with straightforward pregnancies

Thousands more babies could potentially be born in a midwife-led unit or at home following updated guidance from the National Institute for Health and Care Excellence (NICE).

Nearly 700,000 babies were born in England and Wales last year. Nine out of 10 babies are delivered in hospital under the ultimate supervision of obstetricians, but NICE wants women to be given greater freedom to choose where they give birth.

According to NICE, the evidence now shows midwife-led units to be safer than hospital for women having a straightforward (low risk) pregnancy [1]. Its updated guidance also confirms that home birth is equally as safe as a midwife-led unit and traditional labour ward for the babies of low risk pregnant women who have already had at least 1 child previously [2].

The updated NICE guidance says that women should be given this information to help them think about where they would most like to give birth, but that the final decision should be made by them and supported by healthcare professionals.

Professor Mark Baker, NICE’s clinical practice director, said: “Most women are healthy and have straightforward pregnancies and births. Over the years, evidence has emerged which shows that, for this group of women, giving birth in a midwife-led unit instead of a traditional labour ward is a safe option. Research also shows that a home birth is generally safer than hospital for pregnant women at low risk of complications who have given birth before.

“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 this would not be the case: “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.”

Oxfordshire mother-of-three, Sarah Fishburn, helped to develop the guidance. She said that clear, unbiased information would have benefited her greatly: “When I was first pregnant, the advice I was given by my GP about where I could give birth was limited. As a result, I had a traumatic and stressful birth experience. My second labour was slightly better, but it wasn’t until my third pregnancy when I received the support of an amazing, well-informed midwife and very supportive consultant obstetrician, that I felt confident in my body’s ability to give birth and had a very positive home water birth.”

Sarah, who audits maternity services and supports women who have had difficult pregnancies and births, added: “This guideline, which is based on evidence, facts and figures, will provide the information that was lacking for me during my pregnancies, and support women choosing where to give birth, whatever setting that might be. This will help to make birth safer for mothers and babies in the future.”

Tracey Cooper, Consultant Midwife at Lancashire Teaching Hospitals Trust and a member of the group who developed the updated recommendations, said: “By offering a variety of birth environments this will not only ensure women have more choice and be more likely to be satisfied with their experience, but it also ensures midwives have more choice in the way that they want to work.

“By having midwifery led settings, this increases opportunity for midwives to work in different ways, offering a variety that they can move in and out of depending on what suits them at that particular time in their life. It also supports midwifery led models of care, which can offer more opportunities for not only the woman to know her midwife but for the midwife to have increased job satisfaction by getting to know the woman herself, seeing her through her whole childbirth journey.

“As we currently have a shortage of midwives this will help us to recruit and retain staff and hopefully attract midwives, who have left, back into our profession.”

Other important recommendations for maternity service providers, commissioners and healthcare professionals include:

  • Maternity services supporting 1-to-1 care for all women during childbirth by a midwife.
  • All healthcare professionals ensuring that there is a culture of respect for every woman in all birth settings, so that the woman is in control, is listened to and is cared for with compassion, and that appropriate informed consent is sought.
  • Ensuring that women giving birth have timely access to an obstetric unit if they need to be transferred to hospital for medical reasons or because they request an epidural. Service commissioners and providers should ensure that robust protocols are in place for transfer of care between settings.
  • The circumstances in which midwives should consider transferring a woman in labour from her home or midwife-led unit to hospital. These factors are set out fully in the guideline, but include high blood pressure in the mother, concerns about the baby’s heartbeat or presence of significant meconium (a baby’s first faeces) in the mother’s waters when they break.
  • Minimising separation of the baby and mother, taking into account the individual clinical circumstances.

NICE has also updated its recommendations to midwives about how long after birth to leave a baby’s umbilical cord before clamping and cutting it. It says:

  • Do not 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.
  • Clamp the cord before 5 minutes in order to perform controlled cord traction as part of active management.
  • Support a woman if she requests that the cord is clamped and cut later than 5 minutes.

Elizabeth Duff, Senior Policy Adviser for the NCT, said: “This guidance is welcome as it should give more women the confidence to plan to give birth in a midwife-led unit or at home.

“These options are safe for most women and can offer benefits such as care from a known midwife and less intervention. Health commissioners should now put these guidelines into practice as soon as possible and make home and community birth a real, not just theoretical, option.”

The updated NICE guidance for the care of women and their babies during labour is published on the same day as NICE updates its recommendations about the association between co-sleeping and Sudden Infant Death Syndrome (SIDS).

Ends

For more information call the NICE press office on 0845 003 7782 or out of hours on 07775 583 813.

Notes to Editors

Explanation of terms

  1. Women are considered to be at low risk of complications if their pregnancy is straightforward, they are in good health and have no serious health conditions (pregnancy-related or otherwise).

Factors that can increase the risk of complications during birth include:

  • women being over the age of 35
  • women who are overweight or obese
  • recreational drug use
  • bleeding after 24 weeks of gestation
  • high blood pressure
  • major gynaecological surgery
  • fetal abnormality
  • the baby lying in a breech position

Complications from a previous pregnancy can also increase the risk of complications during birth for pregnant women. These can include stillbirth, neonatal death, pre-eclampsia, a large baby (weighing more than 4.5kg), serious vaginal, cervical or perineal trauma, or neonatal jaundice requiring exchange transfusion.

Medical conditions that may place women at a higher risk of complications during birth include:

  • cardiac disease
  • anaemia
  • asthma requiring an increase in treatment (or hospital treatment)
  • sickle-cell
  • infectious diseases such as hepatitis B and C and HIV
  • hypertensive disorders
  • risk factors for group B streptococcus
  • spinal abnormalities
  • diabetes
  • epilepsy
  • gastrointestinal problems like Crohn’s disease, ulcerative colitis and liver disease

Tables outlining the full range of medical conditions and factors that raise the risk of complications for mother and baby are included in the updated guideline.

  1. The place of birth recommendations have been developed following an analysis of research, which shows that the rate of medical intervention during birth (for example, forceps or an epidural) is lower for women labouring in a midwifery unit or at home compared with obstetric units. The evidence also shows that there is no difference in any birth setting in the number of babies being born with a serious complication. The exception to this is 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 birth.

About the guidance

  • The updated guidance is available at http://www.nice.org.uk/guidance/CG190.
  • The guideline focuses on the care of pregnant women who are considered to be at low risk of complications while giving birth. A separate guideline is currently in development for pregnant women at high risk of complications.

Facts and Figures

  • 698,512 live births occurred in England and Wales during 2013, according to official statistics.
  • 45% of women giving birth in NHS settings are at low risk of complications, according to a recent study. This means that about 315,000 women are likely to be covered by the NICE guideline each year.
  • In 2013, 2.3% of women giving birth did so at home. This is unchanged from 2012.

About NICE

The National Institute for Health and Care Excellence (NICE) is the independent body responsible for driving improvement and excellence in the health and social care system. We develop guidance, standards and information on high-quality health and social care. We also advise on ways to promote healthy living and prevent ill health.

Our aim is to help practitioners deliver the best possible care and give people the most effective treatments, which are based on the most up-to-date evidence and provide value for money, in order to reduce inequalities and variation.

Our products and resources are produced for the NHS, local authorities, care providers, charities, and anyone who has a responsibility for commissioning or providing healthcare, public health or social care services.

To find out more about what we do, visit our website:www.nice.org.uk and follow us on Twitter: @NICEComms.

"Most women are healthy and have straightforward pregnancies and births. Over the years, evidence has emerged which shows that, for this group of women, giving birth in a midwife-led unit instead of a traditional labour ward is a safe option."

Professor Mark Baker, Director of the NICE Centre for Clinical Practice

“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.”

Susan Bewley, Professor of Complex Obstetrics for King's College London