The drive for Birmingham Women's hospital to relook at its current service provision and improve choice around place of birth was in direct response to the findings in the Birthplace Study (Birthplace in England Collaborative Group et al, 2011); this research evaluated the relative safety of birth in an obstetric unit compared with birth in an alongside (AMU) or free-standing midwifery unit (FMU) or at home for women who were at low risk of complications at the onset of labour. The results showed that for multiparous women, homebirth was associated with a significant increase in the normal birth rate, and significantly fewer interventions, there were no differences in adverse perinatal outcomes between settings. Although many of the findings have been reported by several researchers over the last few decades (Tew, 1986; Olsen and Jewell, 2000; De Jonge et al, 2009; Overgaard et al, 2011), the study is the largest (n=64 538) to date and was conducted in England. A combination of robust evidence and many maternity services at crisis point due to the 22% increase in births over the last decade, shortage of midwives, limited and over-stretched maternity consultant units, prompted a joint statement on homebirth by the Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (2011). The two colleges recommended that maternity providers need to actively encourage low-risk second-time mothers to birth at home and think creatively about how maternity services could be reconfigured in order to promote homebirth as a real choice, thus improving care, easing pressure on hospitals and reducing costs.
Before the dedicated homebirth service
Prior to the set-up of the dedicated homebirth service, provision for homebirth rested with the hospital's four community midwifery teams which maintained a 24/7 on-call service for women. This proved to be unsatisfactory as these staff were part of the hospital escalation policy and therefore had to work in the hospital when activity level was high. Historically, management of staffing decisions has prioritised resources into the hospital (Walsh et al, 2014). The ramifications of this were twofold; neither women nor midwives had the confidence in the homebirth service being available 24/7 and therefore the midwives did not actively promote the service as they were concerned that women were likely to be disappointed. The midwives also found that the infrequency of homebirths reduced their confidence in their intrapartum skill base; a common finding reported in the RCM (2011) survey of midwives' views around homebirth. The direct impact of this was that few women had their babies at home; only 23 (0.31%) had a planned homebirth in 2013.
Birmingham Women's hospital is one of the largest maternity units in England, with over 8100 births per year; this birth rate is expected to grow approximately 1% year-on-year over the next 10 years (National Statistics Audit Office, 2013). Despite a rebuild, the hospital infrastructure will not sustain the predicted increase. The strategic need to reconfigure maternity services is clear. Moving low-risk women out of the hospital setting and into the community will improve health outcomes and save money. These finances can then be redirected to the areas where they are more needed, such as complex births due to obesity. This predicted redirection of finances from within a limiting tariff certainly contributed to Birmingham Women's hospital's successful funding bid with Birmingham South Central CCG. The evidence suggests that by the end of the 3-year pilot, the service would begin generating an income (Tyler, 2012).
The target agreed with the CCG was to achieve an increase in the homebirth rate from 0.3–3% in 3 years (a total of 240 women per year by the end of year 3). The recruitment of staff for the service started in October 2013. The team consisted of a consultant midwife 1.0 full time equivalent (FTE) (0.5 clinical), 6.8 FTE midwives and 5.8 FTE maternity support workers; who were employed to work as the second birth attendants. The official launch of the service and active recruitment of women commenced April 2014. The data have been collated from December 2013, as a skeleton service was running prior to all staff completing their Trust induction and mandatory training.
Methods and innovation
Before the team was in post, the consultant midwife and other senior managers reviewed other homebirth models used across the country by speaking to midwives and midwifery leaders face-to-face and reviewing the evidence (O'Connell et al, 2012; Brintworth and Sandall, 2013; Yoshida and Sandall, 2013). As a starting point, the King's College Hospital NHS Foundation Trust model was adopted as it has been successful in the past 5 years, achieving a homebirth rate of 5.5%. The decision was made to initially adopt team midwifery rather than a caseloading approach to aid recruitment and minimise staff burnout; research suggests that women value consistency of care, rather than continuity of carer (Yoshida and Sandall, 2013). In addition, Birmingham Women's hospital sought an innovative approach in its staffing design and began in March 2014 to train its maternity support workers to become second birth attendants, a change to skill mix at a homebirth supported by the RCM (2011), provided adequate training is given. Birmingham Women's hospital, in collaboration with its local HEI Birmingham City University, designed a bespoke course at academic level 4 and 5. This has be funded by additional funding from Health Education West Midlands through the widening participation funds. A full report of this initiative will be published at a later date. Further discussion of this innovation can not be made here, due to the word limitation of this article.
Rotas
At the outset, the planned structure for the midwifery on calls was from 08:00–20:00, ON and ON* switching phones on at 07:00 to be able to take over at 08:00. The ON* are the midwives who coordinate the day and would be the first to attend a labouring woman. The ON would be the second, attending in second stage and is free to do visits or clinic. The night on-call runs from 20:00–08:00, with the same principle of switching phones on at 19:00, OC1—first on call and OC2—second on call to attend in second stage. Although this structure has been followed, the model is proving to be unrelenting on staff. The main reason for this has been that there have been delays in training the maternity support workers. It is expected that once the maternity support workers are no longer supernumerary on the rota, the call system will be less onerous.
Results and evaluation
From December 2013 to October 2014 the homebirth team received 212 referrals, of which 173 (82%) were accepted have a homebirth (Table 1). Of these, 139 received care until they were in labour, and 61 of 79 resulted in a homebirth—18 women had to transfer to hospital during labour. The remaining women had not given birth by the time of writing the report. Water was the most commonly used analgesia with a 48% waterbirth rate, 34% of women did not use any analgesia in labour.
| Month | Referrals | Decision/suitability to book with homebirth team | Number of antenatal transfers to consultant-led care | Number of women cared for by homebirth team up until labour |
|---|---|---|---|---|
| December | 10 | 10 | 2 | 8 |
| January | 19 | 19 | 8 | 11 |
| February | 16 | 14 | 3 | 11 |
| March | 28 | 17 | 4 | 13 |
| April | 20 | 18 | 3 | 15 |
| May | 16 | 12 | 3 | 9 |
| June | 18 | 16 | 2 | 14 |
| July | 19 | 18 | 5 | 13 |
| August | 20 | 17 | 2 | 15 |
| September | 26 | 19 | 2 | 17 |
| October | 11 | 11 | 0 | 11 |
| Unrecorded | 9 | 2 | 0 | 2 |
| Total | 212 | 173 | 34 | 139 |
Bookings
Thirteen women (33%) changed their mind about having a homebirth, most of whom opted to go to the birth centre instead (Figure 1).
Antenatal transfer of care
Developing high-risk conditions was the main reason for transferring in pregnancy to hospital-based care (Figure 2): 26 (76%) women were transferred to hospital care for developing obstetric risk factors and 3 women (9%) were transferred for post-term induction of labour.
Analgesia used at home
Figure 3 demonstrates which analgesia was used at home in labour:
Intrapartum homebirths
In addition to the 61 women who were under the care of the homebirth team, a further 12 women received care from the team unexpectedly as they found themselves in labour at home. In five cases, the midwife arrived in time to provide care for the birth. Paramedics were also present at some of these births (Table 2).
| Month | Planned homebirths | Unplanned homebirths | Total homebirths with midwifery input | |
|---|---|---|---|---|
| Midwife present for birth | Midwife not present for birth but 3rd stage | |||
| December | 1 | 0 | 0 | 1 |
| January | 3 | 0 | 0 | 3 |
| February | 3 | 0 | 0 | 3 |
| March | 2 | 0 | 0 | 2 |
| April | 2 | 0 | 2 | 4 |
| May | 8 | 0 | 1 | 9 |
| June | 6 | 0 | 0 | 6 |
| July | 7 | 2 | 2 | 11 |
| August | 11 | 2 | 0 | 13 |
| September | 9 | 1 | 2 | 12 |
| October | 9 | 0 | 0 | 9 |
| Total | 61 | 5 | 7 | 73 |
Key learning points of the project thus far
Planning
Team building
Change management
Winning hearts and minds is key to changing the culture. The perception over the last 50 years has been that all mothers and babies do better if they birth in hospital. One of our biggest challenges, therefore, is to market homebirth as a safe option for low-risk pregnancies. The team approached this in numerous ways:
One innovation that is currently under review as there are difficulties maintaining sustainability is the approach of sharing the cost of the pools with the families. A very successful marketing strategy has been our pilot birthing pool project. Women booking with the homebirth team are entitled to receive a birth pool voucher which entitles them to 75% discount off the cost of a birthing pool. This has proved to be popular and the homebirth team waterbirth rate is 48%.
Planning ahead
Conclusion
This project, as with all new services has not been without its difficulties; however, the early success should be celebrated as the homebirth rate has increased by over 300% within the time of reporting. Parents have positively evaluated the service and their care received through numerous cards and emails, written stories and the willingness to share their experiences with other parents through local groups, that promote homebirth. The homebirth team and community midwives have been assiduous throughout this last year. They have overcome challenges, been innovative and creative and all share a passion for promoting choice around place of birth and through dialogue promoted place of birth based on risk and choice to ensure that all maternity users are in the best place at the best time to receive optimal care.