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. 2011; 343

London: NICE; 2014

Choice of place of birth: Is it really that simple?

02 January 2015
Volume 23 · Issue 1

On 3rd December 2014, the much awaited updated National Institute for Health and Care Excellence guidelines on intrapartum care were published (NICE, 2014). The guidelines focus on the care of healthy pregnant women in labour who have had a straightforward pregnancy.

New recommendations have been added in a number of areas, including choice of place of birth, care during the latent first stage of labour, transfer of care, fetal assessment and monitoring during labour (particularly cardiotocography compared with intermittent auscultation) and management of the third stage of labour.

Some of the key priorities regarding choice of place of birth include advising ‘low-risk multiparous women that planning to give birth at home or in a midwifery-led unit is particularly suitable for them because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit.’ The advice for nulliparous women is slightly different regarding homebirth as the guidelines state there is a ‘small increase in the risk of an adverse outcome for the baby’.

Much of the advice on place of birth comes from the 2011 Birthplace Study (Birthplace in England Collaborative Group, 2011), which found that for low-risk women giving birth is generally very safe. It also endorsed a woman's right to chose where she has her baby. Women must know that they have a choice in their care and be able to access and understand the evidence-base in order to make an informed decision. However, as Cathy Rogers et al (page 42) point out, changing current perceptions around the safety of giving birth in midwifery-led settings is challenging. This is apparent as 4 years after the Birthplace Study was published, only 10% of women give birth in a midwife-led setting. The authors set about changing this and their paper discusses new initiatives focusing on improving informed choice and the knowledge and confidence of midwives in one large maternity unit. The strategies have been successful with approximately 30% of local women planning to give birth in a midwifery-led setting. This is great news and something that could be implemented in other Trusts. The authors do acknowledge that these initiatives need to be supported by a national strategy for a cultural shift in birthplace to take place.

On page 22 Soltani et al explored the local impact of a Cochrane review that demonstrated that midwifery-led continuity models of care provide explicit benefits for mothers and babies compared with other models of maternity care alongside other midwifery-led care evidence and guidelines. Again, neither the women nor the health professionals had much of an awareness of the supporting evidence. How are women expected to make informed decisions if those caring for them are unaware of all the options and evidence available to them?