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Feature: The maternity maze

23 September, 2011

Feature: The maternity maze

Standalone MLUs seem the ideal solution in a move towards more midwife-led births, yet some trusts seem reluctant to invest in them. With report findings into different birth settings imminent, Alison Moore speculates about the future of these units. Midwives magazine: Issue 6 :: 2011

Standalone MLUs seem the ideal solution in a move towards more midwife-led births, yet some trusts seem reluctant to invest in them. With report findings into different birth settings imminent, Alison Moore speculates about the future of these units.

Standalone midwifery-led units (MLUs) or birth centres often seem to embody good midwifery care. They provide minimum intervention in the natural process of birth with a woman-centred approach and one-to-one care in established labour. But the popularity of such units among health service professionals and mothers-to-be has fluctuated, and they now appear to be at a crossroads.

On one side, a recent report called for fewer medically-led maternity units and more midwife-led births (RCOG, 2011) in line with current reconfigurations of services that often set up a standalone MLU as higher-risk births are concentrated in fewer consultant-led units. But on the other side, several existing MLUs are under threat with staffing issues, cost and low birth numbers cited as reasons for closure. A long-awaited government-commissioned report into outcomes in different birth settings – Birthplace in England – is due out imminently. It is expected to be favourable towards MLUs.

The RCOG’s report into women’s health care (RCOG, 2011) called for fewer units to be staffed by doctors and said ‘it is likely that there will be an increase in the number of midwife-led births’. Of the UK’s 220 consultant-led units, 56 delivered fewer than 2500 babies a year and five delivered fewer than 500. Change was needed to ensure a safe service, the report concluded.

National Childbirth Trust (NCT) senior policy adviser Elizabeth Duff says it represented ‘very positive moves, including what looks like more of an ‘endorsement’ of out-of-hospital birth settings’.

Standalone units dealing with low-risk births could help achieve this, and have often been promoted when consultant-led services have been withdrawn as part of the centralisation of services. Maidstone and Salford are just two of the areas that will get MLUs as consultant-led services move away.

RCM education and professional development adviser Gail Johnson says this should not be seen as a downgrading or loss of services. ‘It’s an opportunity to support women in the most appropriate environment,’ she says. ‘Not all women need a medic but they all need a midwife.’

But some areas have shied away from this solution. NHS Bury decided not to set up a such a unit, despite political and public pressure around the closure of maternity services. It cited additional costs of between £450,000 to £700,000 a year above tariff if deliveries were 300 a year and the unit was staffed round the clock. This reduced to £70,000 if it was only staffed for deliveries.

But some units are currently under threat. In East Kent, the Canterbury Birthing Unit has been closed to births since January while a review of safety and efficiency of maternity services across the area was carried out. Closure of both Canterbury and the MLU at Dover – which was temporarily closed for several months last year – has now been put forward as the recommended option in a consultation about to be launched by the primary care trust (PCT). And the MLU at Bishop Auckland Hospital in County Durham was closed for two months over the summer.

Two standalone MLUs in Derbyshire – at Buxton and Matlock – are under threat, as is the Andover Birth Centre in Hampshire, which could close to births if two of three options from a recent consultation document are followed. In addition, at the end of July, the Jubilee Birth Centre at Castle Hill Hospital in East Yorkshire was closed after the Care Quality Commission raised issues over compliance; a decision on its future is expected this autumn.

Research by the Health Service Journal in March (HSJ, 2011) found that the number of births had dropped over the past three years in around half the MLUs it could get data for.

A number of factors seem to be causing this decline. Some units have seen temporary and sometimes sudden closures – such as the Bishop Auckland unit where women in the late stages of pregnancy found they could not give birth there. This not only reduces the number of births in the short term, but may also affect women’s decisions about where to give birth in the future.

In many cases, the closures have been put down to staff shortages or midwives being needed at larger consultant-led units to cope with higher than expected numbers of births. Standalone MLUs in Gosport and Petersfield were closed to births for several months last year as midwives were pulled into the major consultant-led unit in Portsmouth, which was dealing with an increased number of births.

Cost often seems to be an issue as well. On paper, MLUs have the potential to provide a tailored service to women at a relatively low cost: no expensive doctors or complex technology. But staffing a unit with a low number of births round the clock is expensive, although some alternative models have been developed, such as only staffing units when a woman is in labour. When women are transferred to a distant consultant-led unit in labour, this also adds to the total cost.

Winchester and Eastleigh Healthcare Trust, which runs the Andover Birth Centre, has suggested that births there cost twice as much as those in the Royal Hampshire County Hospital. It says the number of births would need to triple before costs were similar.

And in Derbyshire, the PCT says keeping open the Buxton and Matlock MLUs would cost £2m over five years, with births costing between £1100 and £3000 more than those at home or in a consultant-led unit.  
There is no definitive break-even point for a standalone unit and it can sometimes be difficult to work out exactly how much they cost in comparison with those that are consultant-led. RCM policy manager Sean O’Sullivan says research suggests that under Payment by Results, around 300 births a year are needed to break even. Relatively few MLUs have that number of births and those experiencing falling numbers are likely to see costs per birth increasing.

Mr O’Sullivan says there is a need for proper comparisons on costs. ‘Where the favoured option is to close a birth centre, then the data tends to be used in a way which supports that case,’ he says.
But looking at just the costs of the birth may be the wrong approach. In the long term, more midwife-led births reduce the total demand for staff, compared with more women giving birth in a high-tech environment, he says.
Many midwives would also point to improved outcomes from more normal births – including less medical intervention and increased breastfeeding rates. The NCT cites evidence that standalone MLUs have lower rates of intervention, higher rates of normal birth – with less perineal trauma – and higher maternal satisfaction. Babies born in them have lower rates of admission to neonatal units (NCT, 2008).

‘Midwife-led units (and home birth services) should not be regarded as a kind of luxury add-on to ‘normal’ services, but a serious and sustainable alternative with lower overheads that, once the initial investment is covered, will reduce levels of intervention and therefore reduce costs of the whole service,’ says Elizabeth Duff.

‘The evidence suggests that low-risk women do better when given midwife-led care. Put her in an obstetric unit then the risk of intervention increases,’ says the RCM’s Gail Johnson.

But, in the end, the future of standalone MLUs may depend on persuading low-risk mothers-to-be that the units are both a safe and attractive option for their births. With the birthplace report expected shortly, Mr O’Sullivan says decisions on a unit’s future should be delayed until it has been digested. 

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Moore A. (2011) Midwife-led units threatened by falling birth rates. See: www.hsj.co.uk/news/acute-care/midwife-led-units-threatened-by-falling-birth-rates5026963.article (accessed 21 September 2011).

NCT. (2008) Midwife-led units, community maternity units and birth centres. See: www.nct.org.uk/sites/default/files/related_documents/MS2Midwife-ledunits-1.pdf (accessed 21 September 2011).

RCOG. (2011) High quality women’s health care. See: www.rcog.org.uk/high-quality-womens-health-care (accessed 21 September 2011).

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