Speeding through the streets in an ambulance, with the piercing wail of a siren filling your ears is a scary experience. But to cope with this scenario while in labour, experiencing complications and being rushed to an obstetric unit, must be petrifying.
Transfer is a topic that has received little attention. However, new research has been released – with more in the pipeline – on the back of which claims have emerged that the process needs to be improved and new guidelines drawn up and rolled out.
The pioneering
Birthplace study (University of Oxford, 2011), revealed that giving birth at home or a midwife-led unit (MLU) is as safe as giving birth at an obstetric unit. The study of 64,500 births also confirmed that planned births outside hospitals have a far lower rate of medical intervention, with 11% of hospital births being caesareans, compared to just 2.8% of home births.
But one thing that can’t be avoided with MLUs and home births is the possibility of transfer. It’s the elephant in the room – the unspoken threat looming large over labour, but often not given much consideration until the moment 999 is dialled.
Birthplace shows that almost half (46%) of first-time mothers planning a home birth were transferred to an obstetric unit, with 16% of women from all settings transferred. Although, the home birth figure drops to 12% for a second or subsequent birth.
While care is carefully planned out both pre- and post-transfer, research shows that transfer itself can be a period of uncertain limbo, with the mother-to-be uncomfortable, uncertain and speeding towards the unknown.
Birthplace found that possibility of transfer is one of the main worries that stops women from giving birth outside an obstetric unit. It says: ‘The prospect of intrapartum transfer was a major consideration when women made a decision around place of birth, and women often cited concerns about transfer distance as a reason for planning labour in hospital.’
Professor Jane Sandall, who looked at women’s experiences of transfer for the study, is concerned. She tells
Midwives women aren’t given enough information to make educated decisions, and this lack of knowledge can lead to fear and a feeling of loss of control.
‘I think that information is probably one of the most important things that women and their partners want,’ she says. ‘They want guidance and to know that decisions have been considered or agreed.
‘We found that women had concerns about their safety and worries that the professionals did not listen.
‘Women want more certainty, more information – they want to know what the options are where they live; what the transport will be; where they will be transferred. In general, they want more guidance and help.’
Professor Sandall’s concerns are not new – they echo the findings of Jan Walker in a paper from over a decade ago (Walker, 2000). Her research into women’s experiences of transfer showed they felt a great deal of loss when forced to transfer.
‘This related to loss of choice, control, continuity, and support and was associated with anger and resentment,’ the results state.
‘Distress appeared most common when transfer took place late in a healthy pregnancy when the mother recognised no risk to the baby.’
The paper concludes that more attention needs to be paid to the psychological impact that transfer can have, particularly where this involves either a change of location or midwife.
Rachel Rowe, a health services researcher, worked alongside the
Birthplace study for four years, looking at women’s experience of transfer. She interviewed 30 women about their experiences, the results of which are due to be published next year.
She believes with the push for an increase in midwifery-led care, more attention needs to be given to the transfer process.
‘I think there’s a little bit of evidence out there, but generally it’s pretty small studies carried out in single settings,’ she says.
‘I guess the big motivation for my work was the idea that women should be able to choose.
‘An increase in midwifery-led care would mean women transferred more, so it’s a key way to improve the experience for women planning birth at home or an MLU.’
Juliette Astrup, 30, from Bournemouth, was due to give birth at an MLU (see panel overleaf). But, after 16 hours in labour, she had to transfer to an obstetric unit at 3am, as she wasn’t dilating and the baby was in the occiput posterior position.
‘The transfer took a matter of minutes at that time in the morning – maybe 15 – but I was in agony in the back, so it felt like forever,’ she says.
‘Once I knew I was being transferred I wanted to go straight away, but I had to wait some time for the ambulance. The journey was bumpy and felt like it took ages, but the paramedics were lovely.’ She adds that her transfer experience has not put her off giving birth in an MLU, ‘provided that the obstetric unit is accessible in an emergency situation.’
Some trusts have MLUs that offer easy access to obstetric units, but this isn’t always the case, and transfer from home births to hospitals can be a difficult and lengthy process.
The
Birthplace team looked at four case study locations across England: one coastal urban, one inner city, one hillside and one countryside. They were selected as they represent the different birthing options and configurations of maternity services across the country.
Figures for location of birth varied, depending on factors including birthing facilities, geography and population. For example, in the city setting, 80% gave birth in an obstetric unit, while the figure rose to 98% in the rural hillside setting. This is attributed to the hillside area having ‘potentially long travel times’ for women being transferred and midwives attending home births.
But it is not just the birthing options that varied – it is also the way that transfer was handled. ‘Each area that we looked at handled transfer differently. I think it’s something that should be considered in NICE guidelines,’ says Professor Sandall. ‘It’s hard because we found the decisions were being made on a case-by-case basis.
‘But if we had clear national guidelines around this, at least women and partners would know where they stand. Then there would be greater certainty for everyone involved.
‘One of the case studies had good systems – they had agreements in place. But in others there’s a lot of variation in practice and the way that home births are covered across the country is hugely variable.’
NICE issued guidance in 2007 on indications for intrapartum transfer, which aimed to improve women’s experiences in labour. However, while the guidance tells midwives what to look out for – such as uncertainty of the presence of a fetal heartbeat – it doesn’t state exactly when or how transfer should take place.
The Department of Health is responsible for requesting that guidelines are created by NICE.
Asked by
Midwives whether there are any plans to develop more specific transfer guidelines, a spokesman says transfers should take place ‘in accordance with best clinical practice and guidance that is already available’. But adds there are currently no plans in the pipeline to tighten up the guidelines.
Speaking about the results of
Birthplace, Cathy Warwick, RCM chief executive, says: ‘Rates of birth without medical intervention are significantly increased in planned home births or those in MLUs.
‘Women expecting their first baby should be advised that they are as safe planning to give birth at an MLU as a consultant-led unit. They will experience less medical intervention in labour, such as caesarean section, forceps delivery, and blood transfusion.
‘They are also more likely to use water for birth and avoid an episiotomy. Most of these women will actually give birth in an MLU. For those who will require transfer during labour, it is vital that there are excellent systems of communication and transport for their safe and swift transfer.’
With the
Birthplace study having proven the safety of home and MLU births, and choice for women high on the agenda, transfer is an issue that should also be high on the agenda.
And, with Rachel Rowe’s findings on women’s experiences of transfer due for publication in about 12 months, hopefully some more light will be shed on what can be an incredibly traumatic time for women in labour and ensure that they are not travelling into the unknown.
Juliette Astrup: a first-time mother’s transfer experience
‘I was due to give birth at an MLU and was hoping for a lovely waterbirth, but after eight hours labouring there – 16 hours in total by then – the midwife was concerned.
‘I wasn’t dilating and my baby’s head was at the wrong angle and getting swollen from hitting my pelvis.
‘I was put in an ambulance and blue lighted to hospital at about 3am, so that I could be given an epidural and drugs to bring on stronger contractions. I ended up with a forceps delivery in theatre.
‘I knew that the unit only dealt with straightforward vaginal deliveries and had no ability to deal with any complications whatsoever. I was quite prepared to make the transfer if anything happened.
‘The midwife came with me to do the handover to the midwives at the hospital. I was quite out of it, but they did their best to keep me informed.
‘The midwives at the hospital were outstanding on the delivery suite but, unfortunately, had little time for aftercare, which was crucial to me starting out as a new mother.
‘After one night in hospital, I was transferred back to the MLU where the team was fantastic and helped me through what was a very tricky start to breastfeeding.
‘I’m not in the least put off MLUs from the experiences of my first birth. I would certainly go back and try for a waterbirth next time. Given the choice, I would always choose midwife-led care - provided that the obstetric unit is accessible in an emergency situation.’
To view the Birthplace reports, please visit:
www.npeu.ox.ac.uk/birthplace
References
Birthplace in England Collaborative Group. (2011) Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study.
BMJ 343: d7400.
Walker J. (2000) Women's experiences of transfer from a midwife-led to a consultant-led maternity unit in the UK during late pregnancy and labor.
Journal of Midwifery and Women's Health 45(2): 161-8.
