Every woman and baby deserves the safest birth experience possible, no matter the place of birth. This means ensuring that all professionals have the equipment and training to feel confident, competent and valued. Nowhere is this truer than in the community.
Overall, 1 in 50 women in England and Wales will give birth at home (NHS, 2018). Births in the community are gaining more attention as a better option for some low-risk women (Birthplace in England Collaborative Group, 2011; National Institute of Health and Care Excellence, 2014; National Maternity Review, 2016).
For nulliparous women planning to give birth at home, there is an increased risk of adverse perinatal outcomes (9.3 per 1000, compared with 5.3 per 1000 in an obstetric unit) (Birthplace in England Collaborative Group, 2011). Nearly half of nulliparous women giving birth at home (45%), and over 1 in 10 multiparous women (12%) are transferred to the obstetric unit (Birthplace in England Collaborative Group, 2011). Training with ambulance practitioners is vital to optimum transfer and outcomes.
Unmet training needs
As part of the national ambition to halve stillbirths, neonatal deaths, and brain injuries by 2025, a Maternity Safety Training Fund of £8.1 million was awarded to 136 NHS Trusts in England in 2016—each receiving a minimum of £40 000. Although welcome, the fund highlighted an unmet need nationally.
Demand for Baby Lifeline's Childbirth Emergencies in the Community training course increased by 1504% after the Fund was awarded. In addition, the Mind the Gap report (Ledger et al, 2018) showed that, despite this increase, 1 in 4 Trusts did not provide pre-hospital specific emergency skills and drills training.
‘Even though we are community-based, our training is always hospital-orientated and can feel like we are outsiders or a bit of an anomaly because of this. The training was completely relevant to my daily work. I feel more empowered to react to situations where things deviate from the norm or are truly an emergency (eg shoulder dystocia, resuscitating a baby), because we were practising skills as though we were in someone's house, not a hospital ward with all the immediate backup.’
Impact of high-quality training
The Fund enabled Baby Lifeline to provide more than 1000 midwives, paramedics and multidisciplinary colleagues with community-specific maternity training on how to manage obstetric emergencies in low-resource settings according to evidence-based best practice.
Of over 1500 professionals, 94% stated that they would modify their practice after training, and half of these stated that they would modify practice in a major way.
Knowledge in managing obstetric emergencies also improved after training (Figure 1). There was a highly significant difference between delegate knowledge immediately pre- and post-training (P<0.001), which was until at least 3 months post-training (P<0.001). The drop-off in knowledge after 3 months suggests that training would need to be repeated.
#HowDoYouCarryYours? Standardising home birth bags
Cross-organisational training creates conversations about variation in practice; on training days community midwives frequently reported that there was no standardisation in the equipment carried to community births. To investigate, Baby Lifeline conducted a survey and social media campaign ‘#HowDoYouCarryYours’ with the Royal College of Midwives.
Results showed that around 1 in 3 midwives reported issues. These included:
‘Unfortunately, we have had to source our own bags … this has the potential to be unsafe in an emergency. Previous Trusts I have worked for provided the bag and it was packed exactly the same way for all community midwives which meant that in an emergency we knew where everything was.’
In response, Baby Lifeline assembled an expert panel, including midwives, paramedics, obstetricians, pharmacists and neonatologists, to develop a gold standard for equipment and how it should be carried. The group was also guided by a survey of community midwives.
The rucksack-style bag, with optional wheels, was designed with human factors principles in mind. The bag has been compartmentalised and colour-coded to make it easier to identify equipment, and includes everything from scissors and towels to equipment for use in emergencies.
The trial—interim results
Currently, 69 bags are being trialled in 10 sites in the UK and Jersey. The trial is ongoing as some compartments have yet to be piloted; however, the interim results based on 26 births have been reported here.
Most of the births have been planned (n=24; 92%) with no obstetric emergencies or complications (n=19; 73%). Of the complications or emergencies reported, the majority were related to the mother requiring perineal sutures (n=5; 19%) or transfer to hospital (n=2; 8%). One mother had a postpartum haemorrhage. Most of the births (n=20; 77%) required no interventions; the most common type of intervention was IV cannulation of the mother (n=4; 15%).
The majority of midwives reported that the bag was organised to allow them to find items easily (n=24; 92%). A few midwives (n=5; 19%) reported that the bag still required adjustments to how it was carried and how equipment was accessed—qualitative data suggest that this is due to the size of some compartments. There are some items that midwives have requested, such as more sterile gloves, a sterile bowl and a speculum.
Overall, 25 of 26 midwives said that they would recommend the bag to fellow community midwives. Any suggestions to improve the bag will be considered in the next phase of the project.
‘Other than the two items mentioned, I think the bag is really incredible, it makes me feel safer at a home birth. It is really well organised and amazingly light considering.’
‘I like the idea that if this was standardised across our community team that when I arrive as a second midwife I would know exactly where to find anything I may need […] because we all pack our kits up differently, I feel I need to spend time on arrival familiarising myself as to where everything is in my colleagues’ kit. This is clearly of benefit in the case of an emergency.’
Conclusion
Although 1 in 50 women will give birth at home, appropriate equipment and specific training for community practitioners is still not prioritised. Results from Baby Lifeline's Childbirth Emergencies in the Community training has shown a highly significant increase in knowledge post-training, which is sustained until 3 months. Nearly half of professionals who attended training reported that they would modify their practice in a major way after training.
The training also revealed a lack of standardisation in what is carried to births in the community. Baby Lifeline convened an expert panel to design a gold standard for equipment and the way it is carried. Interim results have shown minor adjustments for the next phase of the project; however, the bag has mostly been successful. To improve knowledge and confidence, and to ensure that practitioners feel valued and prepared, standardisation in equipment and training must be prioritised.