The Birthplace Study, 2011

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I wanted to give you all a summary of the Birthplace Study, which was published towards the end of 2011. It was a major study undertaken to assess the provision of services to women in labour. On the whole it was extremely positive. The media, of course, were rather sensationalist about the home birth statistics, which showed an increase in adverse perinatal outcomes for the baby in first time mothers. However, it is worth noting, having spoken to several midwives about this now, that all perinatal outcomes were listed together, from the very mild to the very serious. And, the other thing that midwives wanted to point out is that transferring to hospital from a home birth does not necessarily indicate a major problem requiring blue-lit ambulances, it can just be a decision by the mother that she requires more pain relief, or a concern that Mum is “failing to progress” satisfactorily. Anyway, I will let you read the summary (which I have adapted from a presentation by Julie Frohlich, the midwife in charge of “normalising birth” at St Thomas’s Hospital, where I sit on the Maternity Services Liaison Committee) and come to your own conclusions.

The Birthplace in England Research Programme was a multi-disciplinary research programme, jointly funded by the National Institute for Health Research (NIHR) Service Delivery and Organisation programme and the Department of Health Policy Research Programme.

It was conducted to fill important gaps in the evidence relating to the availability, safety, organisation and costs of maternity services provided for women in labour in four birth settings: in hospital obstetric units, inmidwifery units situated alongside obstetric units in hospital (AMUs), in freestanding midwifery units (FMUs), and at home.

The questions the research addressed were:

  • Are there differences in outcomes for the mother and baby between the different birth settings?
  • Are there differences between birth settings in costs and cost-effectiveness?
  • How is maternity care currently organised and is this changing?
  • What are the organisational features of the maternity care system that may affect quality and safety of care in different settings?

The study included births in NHS hospitals and trusts in England between 1 April 2008 and 30 April 2010. The study collected data on care in labour, delivery and birth outcomes for the mother and baby for over 64,000 ‘low risk’ births in England including nearly 17,000 planned ‘low risk’ home births, 28,000 planned ‘low risk’ midwifery unit births (AMUs and FMUs) and nearly 20,000 planned ‘low risk’ obstetric unit births.

What is “low risk”?

A woman was considered at ‘low risk’ of complications if she was healthy and the pregnancy was straightforward. The definition of ‘low risk’ was based on the National Institute for Health and Clinical Excellence (NICE) Intrapartum Care Guideline

Outcomes in the planned home and midwifery unit births were compared with planned births in the obstetric unit. To ensure that the groups were comparable, the main analysis looked only at women who, at the start of labour, were healthy and did not have known risk factors for complications, such as high blood pressure, diabetes, problems in a previous pregnancy or birth, or complications in the current pregnancy.

Safety for the baby was measured by looking at how often any baby had any of the following adverse outcomes: stillbirth during labour, death of the baby in the first week after birth, neonatal encephalopathy (disordered brain function caused by oxygen deprivation before or during birth), meconium aspiration syndrome (where the baby breathes meconium into their lungs), and physical birth injuries such as brachial plexus injury, and bone fractures.

Why did the study group together serious and less serious outcomes for the baby?

The individual outcomes are all uncommon so if they had been considered individually the numbers would have been too small to see clearly if there were any difference in outcome between the birth settings.

How were the benefits and risks for the mother assessed?

By looking both at poor medical outcomes, such as serious perineal tears or need for a blood transfusion, and also at whether the woman received obstetric interventions, such as an emergency caesarean section or a forceps or ventouse delivery.

The study also measured ‘positive’ outcomes for the mother, such as having a birth without any medical interventions – sometimes referred to as a ‘normal birth’ – and whether the mother breastfed her baby at least once.

Key findings

1. Giving birth is generally very safe

For ‘low risk’ women the incidence of adverse perinatal outcomes (intrapartum stillbirth, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, and specified birth related injuries including brachial plexus injury) was low (4.3 events per 1000 births).

2. Midwifery units appear to be safe for the baby and offer benefits for the mother

For planned births in freestanding midwifery units and alongside midwifery units there were no significant differences in adverse perinatal outcomes compared with planned birth in an obstetric unit.

Women who planned birth in a midwifery unit (AMU or FMU) had significantly fewer interventions, including substantially fewer intrapartum caesarean sections, and more ‘normal births’ than women who planned birth in an obstetric unit.

3. For women having a second or subsequent baby, home births and midwifery unit births appear to be safe for the baby and offer benefits for the mother

For women having a second or subsequent baby, there were no significant differences in adverse perinatal outcomes between planned home births or midwifery unit births and planned births in obstetric units.

4. For women having a first baby, a planned home birth increases the risk for the baby

For women having a first baby, there were 9.3 adverse perinatal outcome events per 1000 planned home births compared with 5.3 per 1000 births for births planned in obstetric units, and this finding was statistically significant.

5. For women having a first baby, there is a fairly high probability of being transferred

to an obstetric unit during labour or immediately after the birth

For women having a first baby, the transfer rate during labour or immediately after the birth was 45% for planned home births, 36% for planned FMU births and 40% for planned AMU births.

6. For women having a second or subsequent baby, the transfer rate is around 10%

For women having a second or subsequent baby, the proportion of women transferred to an obstetric unit during labour or immediately after the birth was 12% for planned home births, 9% for planned FMU births and 13% for planned AMU births.