Making the right choices

Editorial By RCM deputy general secretary Louise Silverton


We have answers to some questions, not least that midwifery care for women at low risk of complications is safe. We also know that these same women are far less likely to experience interventions during their labour care and birth and are more likely to breastfeed following birth in midwifery units and at home.

What makes this study different is that it looked at outcomes by the first place in which the woman received care. Previous studies looked at outcomes by actual place of birth, therefore obstetric units had their figures inflated by the effect of transfers.

For women having their first baby, birth in a midwife-led unit is safe for them and their babies and it reduces their risk of caesarean section. However, for first-time mothers planning a birth at home, there is an increased risk of a poor outcome such as stillbirth, neonatal death, meconium aspiration syndrome, encephalopathy or fractures. The risk of one of these rare outcomes, although tragic for the parents concerned, increases from 5.3 per 1000 births to 9.3; still a low occurrence. When one examines the reasons why women opt for their place of birth, safety is but one factor. As midwives, we know that families often like their baby to be born in their home town, some women are frightened by hospitals and some do not want to be separated from children and other family members. It is important to explain the increased risk to women, but also not to get it out of proportion when considering all the risks that women are exposed to as a result of pregnancy.

What the study does not tell us, however, is almost more important than the answers it provides. Why are women at low risk of complications much more likely to have interventions when they receive all their care in an obstetric unit? Why do first-time mothers planning birth at home have an excess of adverse neonatal outcomes? Are home birth outcomes different where care is given by a dedicated home birth team? How are decisions made to transfer? What can be done to make transfers easier for the women and her partner?

The RCM, together with our obstetric colleagues, will be looking at the results of this study and identifying areas for joint investigation. We will also be reviewing our existing guidelines on home birth and birth centres to see if these need amendments. So watch this space!