Women in the UK can choose to give birth in any of four locations: obstetric unit, alongside midwifery led unit, freestanding midwifery-led unit or their own home. Evidence shows how giving birth at home results in good outcomes for mothers and babies, is cost-effective and can enable improved continuity of carer, resulting in higher maternal satisfaction (Birthplace in England Collaborative Group et al, 2011). However, data from 2016 shows that only 2.1% of babies were born at home (Office for National Statistics (ONS), 2017).
A dedicated home birth team was set up in one area of London to increase the local home birth rate, and this article sits alongside a report on the outcomes achieved during the first year of operation (Foley et al, 2019). It seeks to document the lessons learned during this launch phase, which may be useful for others in a similar situation. It also provides some reflection on the achievements of the service, changes made along the way and future plans.
Demand for the service
Tower Hamlets is an East London borough with maternity services offered through a tertiary hospital, alongside birth centre and freestanding midwifery-led unit. Before 2018, home birth had been supported by community midwives, but the lack of a dedicated team meant that the number of home births was low. This was possibly due to a lack of demand, but also poor awareness that home birth was an option. In 2017, 4604 babies were born in Tower Hamlets (ONS, 2019) but just 22 of these were born at home (0.47%). Given this low number, some community midwives had lost confidence in supporting home birth, or indeed had never been exposed to it.
Among women requesting home birth, many felt poorly supported or that they couldn't rely on a midwife attending them at home in labour, since, during busy periods, the on-call community midwives would be required to support other areas of the maternity unit as part of the escalation policy.
The Maternity Voices Partnership (MVP) had lobbied for a dedicated home birth team for many years and with the launch of the Better Births maternity strategy in England (National Maternity Review, 2016), a breakthrough was finally achieved: the Trust included a home birth team in their strategy for improving continuity of carer and started recruiting in 2017.
Lesson learnt
The MVP had received substantial feedback over the years showing demand for a dedicated home birth service. It was involved in interviewing prospective team members and provided invaluable support in the early months of establishing the home birth service. MVPs are fantastic bridges between the community and maternity services, and can help the service focus on what is important to women. In the case of Tower Hamlets, this was continuity of carer and reliability of home birth service provision.
Creating a team
A team of four midwives was deemed the minimum necessary to enable a 24 hours per day, 7 days per week service. The team comprised one Band 7 team leader and three Band 6 midwives. The team leader was recruited from a well-established home birth team and the other midwives from various midwifery roles. The Band 6 midwives were all relatively new to the profession, having worked for an average of 2.5 years since qualifying when starting in the team. While this brought the benefits of enthusiasm and fresh ideas, it also meant they did not have additional skills, such as newborn examination, that would have been useful.
Lesson learnt
When establishing a new home birth team, consider skill mix and qualifications. It is highly desirable for at least one team member to be able to conduct newborn examinations to ensure that as much care can take place in the home as possible.
Protocols, plans and promotions
The Homebirth Team officially started operating on 2 January 2018, having received a small number of referrals from the community midwifery teams. Much of the first month was dedicated to drafting standard operating procedures, organising equipment, creating promotional materials and starting to recruit women into the service. Equipment and supplies were sourced from the community budget and did not always arrive on time. As a result, items were sourced from existing community or labour ward stock, often borrowing items with a promise to return when our own supplies were available. There was also no specific budget for communications, which impacted on our ability to promote the team.
A series of monthly meetings were introdcuced and included: a Homebirth Team meeting, a multidisciplinary team meeting and a ‘meet the midwives’ event for women interested in or planning a home birth. The Homebirth Team meeting was an opportunity for the midwives to discuss operational issues, reflect on experiences, share learning, raise opportunities for personal/team development and make future plans. The multidisciplinary team meeting brought together the Homebirth Team, consultant midwife, consultant obstetrician, matron for low-risk care and others relevant to a particular topic. The meeting included a review of all women in the caseload with complex histories or risk factors; a case review of a woman who had given birth the previous month; and a discussion of any possible developments to guidelines or protocols.
The ‘meet the midwives’ event took place in a children's centre and enabled all women planning a home birth to meet the other midwives in the team who may attend them in labour. They could also meet other women planning home birth and hear from those who have already given birth with the team. The meetings were relaxed, informal events where women and midwives shared stories and advice, engendering an atmosphere of mutual support and encouragement.
Lesson learnt
Although there were a few frustrations and delays due to a lack of a dedicated equipment budget, the team was proactive and flexible in finding solutions. The core operational lesson was how useful it was to establish a series of regular meetings. Not only did the multidisciplinary team enable the Homebirth Team to feel supported and confident, but meetings raised the Homebirth Team's profile in the Trust. In turn, the ‘meet the midwives’ event enabled the women to gain confidence in their ability to give birth at home and in the midwives caring for them.
Generating a caseload
The team was open to receiving referrals from all sources, including GPs, midwives and women themselves. The majority of referrals (64%) were received from community midwives, as was expected, although 20% of women self-referred.
Posters and leaflets were placed in GP surgeries, children's centres, cafés that were popular with parents, libraries, primary schools and other community spaces. Community groups and non-governmental organisations that worked with pregnant women or new mothers were given supplies of leaflets and asked to discuss home birth with their clients, where appropriate. Leaflets were also placed in the pack that women received at their booking appointment. A banner was created to take to community events, which was then established in the antenatal clinic at all other times.
Members of the Homebirth Team regularly looked out for opportunities to promote the service, attending family events, antenatal classes, coffee mornings and council-organised events.
Social media profiles for the team were set up under the handle @THhomebirth. On Twitter, the team posted information about home birth, details about the team or messages from women and families. An Instagram page showed pictures shared by families under the team's care.
Community midwives were a core source of referrals so strong links were built with the teams. Home birth midwives regularly attended community midwife meetings to answer questions, provide updates and encourage promotion of the service. Community midwives were the second midwife at the home births, so it was important to understand their concerns and get feedback on their experiences.
On referral to the home birth team, women were allocated a case midwife, who would then visit the woman at home to arrange care at mutually convenient dates and times. This proved very popular with women, who were often able to opt for appointments to suit their working day and were relieved not to have to wait in a GP surgery.
To help build up the caseload, the Homebirth Team looked at taking several bookings each month from the antenatal clinic, with the aim of targeting low-risk multiparous women. By offering home-based antenatal care throughout the pregnancy, it was hoped these women would be favourable to giving birth at home. However, only one of the 22 women booked actually planned a home birth, with four miscarrying after their booking appointment. Given the lack of success with this approach, it was scaled back towards the end of the year.
A second approach was to offer a caseloading service to women who were referred to the specialist team who cared for vulnerable women, but did not meet this team's criteria. Mostly these women had previous or low-level mental health concerns or were very anxious about their pregnancy. To date, eight women have been offered care by the Homebirth Team and six have accepted. None have yet reached full term, but several are considering home birth. A further eight women under the care of this team have also given birth at home or plan to, suggesting that home birth may be an attractive option for women requiring extra support during pregnancy.
Lesson learnt
The average gestation a woman was referred to us was 25 weeks. While not a problem per se, it meant the women missed out on having extended continuity of care and the convenience of home appointments earlier in their pregnancy. The team received very few referrals from GPs, as it proved difficult to persuade them to refer directly to the team. If GP referrals were increased, it would enable the Homebirth Team to book women and offer care throughout the pregnancy. This highlighted the importance for close liaison and collaboration between the two services to benefit women and enable choice.
Auditing the outcomes
The team was keen to ensure a detailed audit of the women cared for and their outcomes. A Microsoft Excel database was created to enable data capture. A mid-year review was presented to the Trust maternity board. The full year review of outcomes is reported in the report that accompanies this article (Foley et al, 2019).
It was important to regularly communicate outcomes, in order to create a profile in the hospital, which would ensure continued support and encourage referrals. A monthly dashboard was created to show the number of births, place of birth, mode of birth and other core outcomes. It also showed trends over time, caseload growth and continuity of carer. This was circulated to maternity managers.
Lesson learnt
Raising the profile of the team was crucial to keeping home birth in people's minds so they would make referrals. The monthly dashboard was useful for maternity managers but did not reach community midwives, which may have been beneficial.
Keeping women at the centre
A core reason for establishing the Homebirth Team was to meet demand from women, and it was crucial that their needs and preferences were kept at the centre of all the team did. Each woman was asked to complete a feedback form about their experience. This enabled continued improvements and motivated the team, who could see the impact of their work in the comments.
The team opted not to produce a list of who could and could not give birth at home, preferring to assess each woman individually. When risk factors were identified, they were discussed with the woman and appropriate professionals, such as the consultant midwife or obstetrician. Women appreciated this approach, feeling able to make fully informed decisions on, for example, induction of labour for a postdates pregnancy, or giving birth at home after a previous caesarean section.
Lesson learnt
Having open and supportive conversations about risk avoided problems, built strong relationships and resulted in good outcomes. Some women were recommended not to give birth at home, due to the risks, but nevertheless chose to do so. Individual care plans were written with these women to support them, and midwives remained alert to changes in the clinical picture, communicating with women and making safe decisions jointly.
Future plans
One midwife in the team was due to qualify as newborn and infant physical examination (NIPE) practitioner by early 2019 and two others will undertake the training during the year. This will enable the Homebirth Team to offer newborn examinations at home, improving the postnatal experience for women and maintaining high levels of continuity of care.
The team is also investigating administering anti-D at home for Rhesus-negative women. Although this occurs elsewhere, Trust policy prohibits administration, even in the alongside birth centre. With fetal DNA Rhesus testing becoming standard for Rhesus-negative women in the Trust, fewer women should require anti-D, but it remains a frustration for women who are required to attend hospital solely for this purpose.
Student midwives have been a core group supporting choice of birthplace, often talking to women during antenatal appointments while the midwife completed other tasks. The Homebirth Team plans to run regular place of birth sessions to ensure that students have the evidence and tools for their discussions. Student placements with the team will continue to be provided, enabling them to experience home birth first-hand.
An increasing caseload may require additional staff. As maternity support workers take on more roles in maternity services, and with increased training available, it may be desirable to consider how this role would fit within the team.
A final area of focus for the team will be to look at how home birth can be encouraged among minority ethnic groups. Bengali women make up 30% of the population of Tower Hamlets (Barts Health, 2017), but constituted just 15% of the caseload in 2018. Finding advocates of home birth in the community who can have open discussions with families may be a way of dispelling myths and promoting the benefits.
A successful first year
Outcomes for the women and babies cared for by the team are detailed in a separate article (Foley et al, 2019) and show encouraging result for normal births, minimal intervention and continuity of carer. Over the year, 67 women were cared for and discharged by the team. Six women chose to give birth on the labour ward due to change in circumstances but remained under the care of their home birth midwife. Two women miscarried. Of the 59 remaining women, 46 started their labours at home, with 37 giving birth at home, a 68% increase on 2017 rates. Eight women gave birth on the obstetric unit, with one in the freestanding midwifery-led unit.
In December, the team was proud to receive an award for teamwork at the end-of-year Trust celebration event. The citation noted:
‘The team supports one another in ensuring 24/7 365 [days per year] cover is available to all women who have chosen to have their babies at home and lead by example showing great flexibility and dedication to their chosen roles to provide high quality care and personalised choice to local women.’
The team plans to build on its initial success and make progress in helping women consider home as a natural place to give birth.