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Rapid Evidence Searches

Scottish Government Review of Maternity and Neonatal Services

THE EVIDENCE RELATING TO PLACE OF MATERNITY CARE, INCLUDING PLACE OF BIRTH

DR MARY ROSS-DAVIE, NHS Education for Scotland

on behalf of the Models of care Sub-Group

Summary and recommendations The aim of this rapid review was to inform high quality maternity care provision for all women across Scotland, through distilling core principles and practice recommendations from good quality current evidence. We aimed to identify any relevant systematic reviews, high quality population based and cohort studies and guidelines. The Evidence: From the evidence identified and explored, a range of recommendations relating to location of maternity care and place of birth can be made. In order to provide guidance on core principles and practice recommendations, the recommendations have been framed in accordance with the Framework for Quality Neonatal and Newborn Care (Renfrew et al., 2014). Some evidence that relates to place of care and birth is explored in evidence focussing on midwifery- led care and continuity of carer. This evidence has been explored in the parallel rapid review undertaken on Continuity of carer (Ross-Davie, 2016) and is not examined again in this review. There is a lack of systematic reviews or randomised controlled trials on the topic of place of birth. The majority of evidence is derived from large population-based studies to compare outcomes from planned home, midwifery- led care settings and obstetric led settings. Core Principles: Practices

Options for place of care and care provider will be discussed in partnership with women, drawing on the best available evidence. This discussion should include the risks of interventions and comparison of outcomes in different settings, in the context of the woman’s particular individual needs.

All health boards will review their current provision to ensure that women booking for maternity care in their area are offered a real choice of the most suitable setting for them: home, midwifery care settings including alongside and freestanding midwifery units and consultant units. Healthy women at low risk of complications should be offered the choice of labouring and giving birth in a midwifery care setting. That is, at home, in an alongside or freestanding midwifery unit.

Values and Philosophies

Maternity care in Scotland has as its foundation the principle of person-centred care, with services and systems wrapped around the woman and her family.

Midwifery care settings offer a safe alternative to consultant hospital settings for many women.

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Organisation of Care

Most women will have the majority of care in local ‘community hubs’, with more specialised services provided on a health board, regional or national basis. This universal maternity care will be developed according to local population and geographical requirement, where women can access a range of services from the multi-disciplinary and multi-agency team including midwifery care, obstetric input, primary care, health visiting, ultrasound, physiotherapy and lifestyle advice, access to social support services including financial and social work services.

Community hubs will have extended hours and may be open 24/7 depending on local need. Some hubs may offer care during labour and birth.

Where women require a considerable proportion of their care to be provided by the multi-disciplinary maternity team including obstetricians, anaesthetists and neonatologists, this care will be provided in appropriately staffed and resourced obstetric units.

Where needs develop during pregnancy, women will continue to receive continuity of antenatal care from their named midwife in the community, with the named obstetric team linked to that midwifery team.

Health boards will ensure that women, families, service user organisations and relevant third sector organisations are actively involved in the development and improvement of maternity care in all areas.

Care Providers

The GP and primary care team are key in the care of women with pre-existing medical or mental health conditions and general medical needs arising during pregnancy or the postnatal period.

Health professionals will promote evidence-based discussions about place of care and birth. National information will be developed for women and they will be provided with clear, comprehensible advice and guidance on choice of place of birth through standardised discussion tools to support decision making about place of birth. Consideration should be given to social marketing to ensure that the public are informed about the changes.

1.0 Background and Aim Almost without exception, women in Scotland, regardless of circumstances, experience some of their care in a hospital setting, which for some women may be far from their home. For women identified as being at low risk of complications and suitable for midwife-led ‘green pathway’ care(QIS, 2009) , this is generally to attend for ultrasound scans and, for the great majority of women, for the birth. There is significant variation in the degree of choice that women have in different health boards in terms of options for community based antenatal care and place of birth. The table below provides a summary of options available by health board in terms of place of birth (Consultant Led Unit – CLU, Freestanding Midwife-led Unit – FMU, Alongside Midwife-led Unit – AMU and Home).

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Table 1. Maternity Units in Scotland

Full range of options (CLU, FMU, AMU and home)

Reduced choice

Single Option (CLU or Home)

Tayside – 3 xFMUs, 1 xAMU, 1 xOU

Lothian – 2 x OUs, 1 xAMU Borders – 1 xOU

Ayrshire and Arran – 1 xOU, 1 xAMU and 1 xFMU

Dumfries and Galloway – 1 xOU, 1 xFMU

Forth Valley – 1 xOU

Grampian – 2 x OUs , 1 xAMU and 1 xFMU

Highland – 2x OU, 8 x FMU Lanarkshire – 1 xOU

GGC – 3 x OUs, 1x AMU, 2 x FMUs, + home birth team

Fife – 1 xOU, 1 xAMU Orkney – 1 xOU

Western Isles – 1 xOU, 2 xFMU Shetland – 1 xFMU with GP support

Table 2. Live births by place of delivery to year ending 31 March 2015*. To note: It is not possible

to separate out births in Obstetric- led units from births in Alongside Midwifery Units, as the hospital

is recorded as the place of birth not the unit within the hospital. Some data for FMU births is not

available and is noted as ‘data cannot be verified’.

Health board OU No. Of births FMU No. Of births

Ayrshire and Arran Ayrshire Maternity unit, Crosshouse

3,549 Arran War Memorial, Isle of Arran

Data cannot be verified

Borders Borders General hospital

1,041

Dumfries and Galloway

D&G Royal Infirmary, Cresswell

1,177 Galloway Community Hospital, Stranraer

32

Fife Victoria hospital 3,473

Forth Valley Forth Valley Royal, Larbert

3,130

Grampian Aberdeen Maternity 5,117 Peterhead Cottage Hospital

123

Dr Gray’s Hospital, Elgin

988

Greater Glasgow and Clyde

Princess Royal Maternity Hospital

5,897 Inverclyde Royal Hospital

26

Queen Elizabeth (prev Southern General)

5,721 Vale of Leven District General Hospital

35

Royal Alexandra Paisley

3,485

Highland Raigmore Hospital 2,042 Belford Hospital, Fort William

26

Caithness General Hospital (was OU,

164 Campbeltown Hospital

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Health board OU No. Of births FMU No. Of births

currently MLU)

Mackinnon Memorial Hospital, Skye

12

Dunoon & District General Hospital, Cowal

9

Islay Data cannot be verified

Lorne & Island District General Hospital, Oban

25

Mid-Argyll Community Hospital, Lochgilphead

6

Victoria Hospital, Rothesay

Data cannot be verified

Lanarkshire Wishaw General Hospital

4,651

Lothian New Royal Infirmary of Edinburgh

5,690

St John’s Hospital, Livingston

2,572

Orkney Balfour Hospital, Orkney

139

Shetland Gilbert Bain Memorial Hospital (FMU with GP support)

156

Tayside Ninewells Hospital 3,975 Perth Royal Infirmary, Montrose Royal Infirmary & Arbroath Infirmary

509

Western Isles Stornoway Data cannot be verified

Uist and Barra Data cannot be verified

Totals 52,826 970

* Excludes home births and births at non-NHS hospitals.

* Includes cases where mode of delivery is unknown.

* Includes births where hospital is unknown.

Source: SMR02, ISD Scotland

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Only Greater Glasgow and Clyde currently offer a dedicated home birth team, along with a new pilot home birth service just beginning in Tayside. Home birth rates across Scotland are very low – the average for Scotland is 1.17% compared to 2.21% in England and 3% in Wales. The highest home birth rate in Scotland is in Argyle and Bute at 2.11% (2013) which compares to a high of 10% in Bridgend in Wales and 8.5% in one part of Northamptonshire. The recently published review of maternity services in England reported the 2013 National Federation of Women’s Institutes (NFWI) survey with 5,500 women that identified that around 10% would wish to choose a homebirth and 6% birth in a freestanding midwifery- led unit (p20, Better Births).

In the most recent survey of maternity service users in Scotland, 24% of women said that they were not offered any choice about place of birth (Scottish Government, 2015).

In Scotland, there are 6 health boards that are not currently offering women the option of an alongside midwifery unit: Borders, Dumfries and Galloway, Forth Valley, Glasgow, Highland and Lanarkshire. Around 49% of women surveyed would like to choose an alongside midwife- led unit to give birth in England (p20, Better Births, 2016).

Tayside, which offers a full range of birth place options and well established freestanding midwife led units, stands out in the Scottish picture. In Tayside, 25% of births take place in non consultant- led settings, with 1,150 births in 2015 in the alongside midwife- led unit, three freestanding midwife- led units and at home. This is around 6.5% of births in freestanding or home birth settings. Tayside has also recently begun piloting a home birth team.

2.0 Methods

A rapid evidence review was undertaken by identifying systematic reviews and guidance considering

the evidence on place of care and place of birth. The protocol for the review is detailed in Table 1.

Table 1. Place of Care and Birth Review Protocol

Details Additional Comments

Review question 1. What are the most appropriate settings for universal maternity care? Are there benefits to care being provided in more local community settings or larger obstetric units?

2. What are the risks and benefits of different birth settings including home birth, midwifery units and obstetric units?

A rapid review detailed in boxes below will be conducted to answer the questions.

It is outwith the scope of this review to examine economic implications or approaches to implementation of different care settings or to explore qualitative research in this area.

Objectives To examine the evidence for and against a maternity service that offers women evidence based choice of place of care and place of birth.

Language English

Study design Systematic reviews of Randomised Control Trials (RCTs), cluster-controlled trials, quasi-randomised controlled trials, observational studies.

Large scale recent surveys of maternity service users in the UK.

Professional guidance based on a

If there is a lack of systematic reviews in this subject area then primary studies and then case studies will be sought by contacting experts and examining reference lists of non-systematic reviews and commentaries.

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systematic review of the evidence (National Institute for Clinical Excellence - NICE, Scottish Intercollegiate Guidance Network - SIGN, Royal College of Obstetricians and Gynaecologists - RCOG, Royal College of Midwives - RCM)

Status Papers published in academic journals and reports published by professional governing bodies (i.e. RCOG, RCM, Royal College of Paediatrics and Child Health - RCPH, British Association of Perinatal Medicine - BAPM).

Governing bodies out with the field of health may be included if there is a lack of information from the health field.

Population Maternity care professionals and childbearing women.

Community and home based antenatal and postnatal care

Hospital based antenatal care

Home birth, alongside midwifery units, freestanding midwifery units and obstetric unit births.

Intervention Different care settings

Comparator Outcomes compared between different settings

Outcomes Women’s experiences/satisfaction

Type of birth

Use of analgesia in labour

Medical interventions in labour and childbirth (induction, augmentation, episiotomy)

Premature birth

Fetal loss

Neonatal Apgar scores and admission to NICU

Stillbirth and neonatal loss

Adverse maternal outcomes – mortality and morbidity

Cost of care

Family/partner experiences

Staff experiences and satisfaction

Other criteria for inclusion/exclusion of studies

Date limit 2000

Exclude conference abstracts

Exclude low income countries

Where systematic reviews and RCTs are not available, other quantitative appropriate cohort and population based studies will be examined.

Review Strategies Following databases will be searched: MEDLINE (bibliographic database of life sciences and biomedical information), HMIC (Her Majesty’s Inspectorate of Constabulary), CINAHL (database of journal articles about nursing, allied health, biomedicine and healthcare). The websites of RCOG, RCM and Royal

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College of Nurses - RCN, the National Institute for Health Research Service Delivery and Organisation- NIHR SDO and the Cochrane Effective Practice and Organisation of Care group will all be searched.

Data on all included reviews will be extracted into evidence tables.

If possible, a meta-analytical approach will be used to give an overall summary effect

Critical Appraisal The NICE methodology checklist for systematic reviews and meta-analyses will be used to assess study quality for systematic reviews.

The following sources of systematic reviews were examined for any potentially relevant titles:

National Institute of Clinical Excellence (NICE) guidelines, Scottish Intercollegiate Guidelines Network

(SIGN) guidelines and the Cochrane Pregnancy and Childbirth group. Secondly, the Royal College of

Obstetricians (RCOG) and the Royal Colleges of Midwives (RCM) websites were searched for relevant

guidelines. Thirdly, a database search of MEDLINE (bibliographic database of life sciences and

biomedical information), CINAHL (database of journal articles about nursing, allied health,

biomedicine and healthcare), MIDIRS (midwifery journals and articles database for midwives) and

HMIC (Her Majesty’s Inspectorate of Constabulary) was conducted. Fourthly, the results of the

Scottish Maternity Care Survey 2015 and other recent large scale service user surveys in the UK were

examined. Finally, the report of the English Review of Maternity Services was examined.

3.0 Findings 3.1 Search results This sections provides a description of the records identified by each database or source and the selection process. 3.1.1 NICE All NICE guidelines (n=16) related to maternity care were examined for relevance according to the inclusion/exclusion criteria detailed in table 2.1 at Appendix Two. Two relevant guidelines were identified: CG62 on antenatal care and CG190 on intrapartum care for healthy women and babies. 3.1.2 SIGN Only one current SIGN guideline related to maternity care was identified: ‘127 - Management of Perinatal Mood Disorders’. Although this has information on service configuration, this is in relation to mother and baby units for women with serious mental health problems. This will be considered in the rapid review on services for vulnerable groups.

3.1.3 Cochrane Pregnancy and Childbirth group Titles and abstracts were all screened for relevance to maternity models of care including location of care and place of birth. Three reviews were identified as being relevant for inclusion in this rapid review on place of birth.

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3.1.4 Cochrane Effective Practice and Organisation of Care group Reviews within the Cochrane Effective Practice and Organisation of Care group were also examined. One review and two protocols related to pregnancy and childbirth were identified but these were not relevant to continuity of carer. 3.1.5 RCOG The titles of all guidelines (including green top and good practice guidelines) published by the RCOG were examined for relevance to location of care and place of birth. No green top guidelines of relevance were identified. Four good practice and other papers of relevance were identified: ‘Safer Childbirth’, which was developed in collaboration with the Royal College of Anaesthetists (RCA), the Royal College of Paediatrics and Child Health (RCPH) and the RCM (2007), The Standards for Maternity Care, 2008 include some relevant content, Good Practice Guideline no.15 on ‘Reconfiguration of women’s services in the UK’, 2013, RCOG; NHS Cumbria Options Appraisal Final Report, 2015, RCOG. 3.1.6 RCM No relevant reports, guidance or documents were found on this topic. 3.1.7 Database search MEDLINE, CINAHL, MIDIRS and HMIC were searched using a combination of index and free-text terms relevant to home birth, midwifery- led care settings and place of birth. See Appendix 1 for the full search strategy. Using search terms relating to ‘community based and hospital based maternity care’ resulted in the identification of studies comparing continuity models of care with standard models of care. These have been discussed in the Rapid Review on Continuity of Carer undertaken for this review and are therefore not explored here. When using the terms ‘home and hospital birth’, 34 relevant records were identified, with 8 identified for detailed scrutiny after de-duplication and screening. When using the term ‘place of birth’, a total of 162 records were identified. Following title and abstract screening 8 potentially relevant articles were retrieved for full text screening. In total 13 quantitative studies from outside the UK were identified for review. In addition 9 published papers from the Birthplace England study were also identified from the Birthplace England website for detailed review. 3.1.8 Service User Surveys Surveys with maternity service users in Scotland were undertaken in 2013 and 2015, with the aim of identifying women’s experiences of all aspects of their maternity care. A number of other service user surveys were also reviewed (see table A2.7 under Appendix 2). This included the very recent report by the Scottish Health Council seeking women’s views as part of the current Scottish Maternity and Neonatal services review. 3.1.9 English Maternity Services Review reports ‘Better Births: Improving outcomes of maternity services in England. A Five Year Forward View for maternity care ‘ (DoH, March 2016). An extensive consultation process with service users was undertaken as part of the Review.

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The English review process was supplemented through the commissioning of four reports by the National Perinatal Epidemiology Unit into key evidence:

Report 1: Summary of the evidence on safety of place of birth; and implications for policy and practice from the overall evidence review (Kurinczuk et al, 2015)

Report 2: Perinatal and maternal outcomes by parity in midwifery-led settings: secondary analysis of the Birthplace in England cohort comparing outcomes in planned freestanding and alongside midwifery unit births (Hollowell et al, 2015a)

Report 3: Systematic review and case studies to assess models of consultant resident cover and the outcomes of intrapartum care; and two international case studies of the delivery of maternity care (Knight et al, 2015b)

Report 4: A systematic review and narrative synthesis of the quantitative and qualitative literature on women’s birth place preferences and experiences of choosing their intended place of birth in the UK (Hollowell et al, 2015b).

3.2 Narrative Summary A summary of each of the identified documents will now be presented. 3.2.1 NICE NICE develops evidence- based guidelines through a well-established systematic process of review. Evidence is weighted in order to help develop recommendations, written by an expert group. The NICE Antenatal Care for Uncomplicated Pregnancies guideline, 2016 recommends: Antenatal information New Pregnant women should be offered information based on the current available evidence together with support to enable them to make informed decisions about their care. This information should include where they will be seen and who will undertake their care. Where should antenatal appointments take place? Antenatal care should be readily and easily accessible to all pregnant women and should be sensitive to the needs of individual women and the local community. The environment in which antenatal appointments take place should enable women to discuss sensitive issues such as domestic violence, sexual abuse, psychiatric illness and recreational drug use. The NICE Intrapartum Care guideline for Healthy Women and Babies recommends: The 2014 update of the NICE intrapartum guidance significantly revised its guidance in relation to place of birth and advising women about their choices relating to place of birth. This revision was based on the publication of the extensive ‘Birthplace England’ study (Brocklehurst et al., 2011). The change identified that non-obstetric unit care settings may be the most suitable place for many women to give birth, as they have been found to lead to fewer medical interventions without an adverse impact on maternal and neonatal outcomes. The guidance identifies that for women having their first baby, home birth presents some increased risk of adverse neonatal outcomes compared to midwife- led and obstetric- led units and compared to multiparous women. The NICE guidance provides health professionals with detailed guidance and tables to support them in discussing with women the potential risks and benefits of different places of birth in relation to their individual circumstances. These discussions should include availability of services including pain relief, risks of medical interventions and operative births, adverse maternal and neonatal outcomes and risks of transfer between sites.

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The guidance is quoted directly below: It is important that the woman is given information and advice about all available settings when she is deciding where to have her baby, so that she is able to make a fully informed decision. This includes information about outcomes for the different settings. It is also vital to recognise when transfer of care from midwifery-led care to obstetric-led care is indicated because of increased risk to the woman and/or her baby resulting from complications that have developed during labour. The discussion of place of birth and the provision of evidence informed choice of place of birth for women is described in the guideline as a key priority for implementation (National Collaborating Centre for Women’s and Children’s Health, 2014): Explain to both multiparous and nulliparous women that they may choose any birth setting

(home, freestanding midwifery unit, alongside midwifery unit or obstetric unit), and support them in their choice of setting wherever they choose to give birth: o Advise low-risk multiparous women that planning to give birth at home or in a

midwifery-led unit (freestanding or alongside) 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.

o Advise low-risk nulliparous women that planning to give birth in a midwifery-led unit (freestanding or alongside) 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. Explain that if they plan birth at home there is a small increase in the risk of an adverse outcome for the baby. [new 2014]

Commissioners and providers should ensure that all 4 birth settings are available to all women (in the local area or in a neighbouring area). [new 2014]

Providers, senior staff and all healthcare professionals should ensure that in all birth settings there is a culture of respect for each woman as an individual undergoing a significant and emotionally intense life experience, so that the woman is in control, is listened to and is cared for with compassion, and that appropriate informed consent is sought. [new 2014]

Senior staff should demonstrate, through their own words and behaviour, appropriate ways of relating to and talking about women and their birth companion(s), and of talking about birth and the choices to be made when giving birth. [new 2014]

Maternity services should o provide a model of care that supports one-to-one care in labour for all women and o benchmark services and identify overstaffing or understaffing by using workforce

planning models and/or woman-to-midwife ratios. [new 2014] Commissioners and providers should ensure that there are:

o robust protocols in place for transfer of care between settings o clear local pathways for the continued care of women who are transferred from one

setting to another, including: when crossing provider boundaries if the nearest obstetric or neonatal unit is closed to admissions or the local

midwifery-led unit is full. [new 2014] Table 1 below is presented in the NICE guidance on intrapartum care and details the rates of spontaneous vaginal birth, transfer to an obstetric unit and obstetric interventions for planned births in FMUs, AMUs and OUs in the UK(National Collaborating Centre for Women’s and Children’s Health, 2014).

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Table 1. Rates of spontaneous vaginal birth, transfer to an obstetric unit and obstetric interventions for each planned place of birth: low-risk multiparous women (sources: Birthplace 2011; Blix et al. 2012) Taken from National Collaborating Centre for Women’s and Children’s Health (2014).

Number of incidences per 1000 multiparous women giving birth

Home Freestanding midwifery unit

Alongside midwifery unit

Obstetric unit

Spontaneous vaginal birth 984* 980 967 927*

Transfer to an obstetric unit

115* 94 125 10**

Regional analgesia (epidural and/or spinal)***

28* 40 60 121*

Episiotomy 15* 23 35 56*

Caesarean birth 7* 8 10 35*

Instrumental birth (forceps or ventouse)

9* 12 23 38*

Blood transfusion 4 4 5 8

* Figures from Birthplace 2011 and Blix et al. 2012 (all other figures from Birthplace 2011). ** Estimated transfer rate from an obstetric unit to a different obstetric unit owing to lack of capacity or expertise. *** Blix reported epidural analgesia and Birthplace reported spinal or epidural analgesia.

Table 2 which is also presented in the NICE guidance on intrapartum care details the outcomes for

the baby in FMUs, AMUs and OUs in the UK(National Collaborating Centre for Women’s and

Children’s Health, 2014).

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Table 2. Outcomes for the baby for each planned place of birth: low-risk multiparous women (source: Birthplace 2011)

Number of babies per 1000 births

Home Freestanding midwifery unit

Alongside midwifery unit

Obstetric unit

Babies without serious medical problems

997 997 998 997

Babies with serious medical problems*

3 3 2 3

* Serious medical problems were combined in the study: neonatal encephalopathy and meconium aspiration syndrome were the most common adverse events, together accounting for 75% of the total. Stillbirths after the start of care in labour and death of the baby in the first week of life accounted for 13% of the events. Fractured humerus and clavicle were uncommon outcomes (less than 4% of adverse events). For the frequency of these events (how often any of them actually occurred), see appendix A of the NICE guidance.

The guidelines (National Collaborating Centre for Women’s and Children’s Health, 2014) recommend that, using tables 3 and 4 below, healthcare professionals should explain to low-risk nulliparous women that:

planning birth at home or in a freestanding midwifery unit is associated with a higher rate of spontaneous vaginal birth than planning birth in an alongside midwifery unit, and these 3 settings are associated with higher rates of spontaneous vaginal birth than planning birth in an obstetric unit

planning birth in an obstetric unit is associated with a higher rate of interventions, such as instrumental vaginal birth, caesarean section and episiotomy, compared with planning birth in other settings

there are no differences in outcomes for the baby associated with planning birth in an alongside midwifery unit, a freestanding midwifery unit or an obstetric unit

planning birth at home is associated with an overall small increase (about 4 more per 1000 births) in the risk of a baby having a serious medical problem compared with planning birth in other settings. [new 2014]

Table 3. Rates of spontaneous vaginal birth, transfer to an obstetric unit and obstetric interventions for each planned place of birth: low-risk nulliparous women (sources: Birthplace 2011; Blix et al. 2012 ). Taken from National Collaborating Centre for Women’s and Children’s Health (2014).

Number of incidences per 1000 nulliparous women giving birth

Home Freestanding midwifery unit

Alongside midwifery unit

Obstetric unit

Spontaneous vaginal birth 794* 813 765 688*

Transfer to an obstetric unit 450* 363 402 10**

Regional analgesia (epidural and/or spinal)***

218* 200 240 349*

Episiotomy 165* 165 216 242*

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Caesarean birth 80* 69 76 121*

Instrumental birth (forceps or ventouse)

126* 118 159 191*

Blood transfusion 12 8 11 16

* Figures from Birthplace 2011 and Blix et al. 2012 (all other figures from Birthplace 2011). ** Estimated transfer rate from an obstetric unit to a different obstetric unit owing to lack of capacity or expertise. *** Blix reported epidural analgesia and Birthplace reported spinal or epidural analgesia.

Table 4. Outcomes for the baby for each planned place of birth: low-risk nulliparous women (source: Birthplace 2011 ). Taken from National Collaborating Centre for Women’s and Children’s Health (2014).

Number of babies per 1000 births

Home Freestanding midwifery unit

Alongside midwifery unit

Obstetric unit

Babies without serious medical problems

991 995 995 995

Babies with serious medical problems*

9 5 5 5

* Serious medical problems were combined in the study: neonatal encephalopathy and meconium aspiration syndrome were the most common adverse events, together accounting for 75% of the total. Stillbirths after the start of care in labour and death of the baby in the first week of life accounted for 13% of the events. Fractured humerus and clavicle were uncommon outcomes – less than 4% of adverse events. For the frequency of these events (how often any of them actually occurred), see appendix A of the NICE guidance

In addition the NICE guideline on Intrapartum Care makes the following recommendations:

Ensure that all healthcare professionals involved in the care of pregnant women are familiar with the types and frequencies of serious medical problems that can affect babies (…), in order to be able to provide this information to women if they request it. [new 2014]

Commissioners and providers should ensure that all 4 birth settings are available to all women (in the local area or in a neighbouring area). [new 2014]Give the woman the following information, including local statistics, about all local birth settings:

Access to midwives, including: o the likelihood of being cared for in labour by a familiar midwife o the likelihood of receiving one-to-one care throughout labour (not necessarily

being cared for by the same midwife for the whole of labour). Access to medical staff (obstetric, anaesthetic and neonatal). Access to pain relief, including birthing pools, Entonox, other drugs and regional

analgesia. The likelihood of being transferred to an obstetric unit (if this is not the woman's chosen

place of birth), the reasons why this might happen and the time it may take. Refer to table 5 if no local data are available. [new 2014]

If further discussion is wanted by either the midwife or the woman about the choice of planned place of birth, arrange this with a consultant midwife or supervisor of midwives, and/or a consultant obstetrician if there are obstetric issues. [new 2014]

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When discussing the woman's choice of place of birth with her, do not disclose personal views or judgements about her choices. [new 2014]

Table 5. Primary reasons for transfer to an obstetric unit (source: Birthplace 2011). Taken from National Collaborating Centre for Women’s and Children’s Health (2014).

Primary reason for transfer to an obstetric unit*

Number of women transferred (% of total transferred from each setting)

From home (n=3529)

From a freestanding midwifery unit (n=2457)

From an alongside midwifery unit (n=4401)

Delay during first or second stage of labour

1144 (32.4%) 912 (37.1%) 1548 (35.2%)

Abnormal fetal heart rate 246 (7.0%) 259 (10.5%) 477 (10.8%)

Request for regional analgesia

180 (5.1%) 163 (6.6%) 585 (13.3%)

Meconium staining 432 (12.2%) 301 (12.2%) 538 (12.2%)

Retained placenta 250 (7.0%) 179 (7.3%) 203 (4.6%)

Repair of perineal trauma 386 (10.9%) 184 (7.5%) 369 (8.4%)

Neonatal concerns (postpartum)

180 (5.1%) 63 (2.6%) 5 (0.0%)

Other 711 (20.1%) 396 (16.2%) 676 (16.3%)

* Main reason for transfer to an obstetric unit for each woman (there may be more than 1 reason).

3.2.3 Cochrane Reviews

Alternative v conventional institutional settings for birth, Cochrane Review, 2012, Hodnett E, Downe S and Walsh D. The study comprised of 10 trials, including 11,795 women. The RCTs included compared being cared

for in a ‘home from home’ and compared to ‘usual’ labour ward hospital setting. There was variation

between studies as to whether the rooms were located in in midwife-led or a consultant-led unit.

Trials were of variable quality, with only three classed as low risk of bias across all domains.

There were a number of statistically significant positive results relating to giving birth in an

‘alternative’ (more homely) setting:

A lower rate of epidural use (8 trials, 10,931 women) RR0.80

Oxytocin augmentation (8 trials, 11,131 women) RR 0.77

Instrumental birth (8 trials, 11,202 women) RR 0.89

Episiotomy (8 trials, 11,055 women) RR 0.83

More positive views of the birth from women (2 trials, 1207 women) RR 1.96

No adverse outcomes were identified.

Antenatal day care unit v hospital admission for women with complicated pregnancy, Cochrane

review, 2009, Dowswell T et al.

Included 3 trials with 504 women. Compared outcomes for women cared for in the two different

settings when requiring additional care for raised blood pressure or premature rupture of

membranes. Study quality was variable with one study being graded as high or unclear risk of bias

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across the domains. The other studies were generally graded at low risk of bias, except for domains

related to blinding where they were considered high risk due to the difficulties in blinding such a

study.

Women cared for in a day care setting were less likely to be admitted overnight (RR0.461), their

average length of admission was shorter, though they had a higher number of outpatient visits to

hospital. In one study, women in the day care unit were less likely to experience induction of labour.

There were no differences in other outcomes.

Planned Hospital v planned home birth, Cochrane Review, 2012, Olsen and Clausen

Identifies the difficulties in exploring this topic through randomised controlled trials rather than

observational studies. Only one RCT was able to be included (only two identified overall) and this

had only 11 women included. This study was too small to draw any conclusions from the results.

3.2.4 The Royal College of Obstetricians and Gynaecologists (RCOG)

Safer Childbirth: Minimum standards for the organisation and delivery of care in labour, RCOG, RCM et al, 2007 The Safer Childbirth report made recommendations about midwifery and medical staffing levels for all intrapartum care settings. This identifies that midwives will provide care for women across a variety of settings and that women have the right to choose where to give birth. The report:

States that all places of birth should operate within a clinical network with robust clinical

governance structures and systems including risk management and audit, guidelines,

appropriate personnel and equipment, training and education and transfer arrangements.

Endorses the transfer arrangements from out of hospital birth settings from the Confidential

Enquiry into Stillbirths and Deaths in Infancy (CESDI) 5th Report. These arrangements include

timely early transfer as soon as problems are identified, the need for the woman’s consent,

a clear handover from the transferring staff to receiving staff, agreements with local

ambulance service and if the baby is requiring transfer to hospital, wherever possible the

mother should accompany the baby.

Sets out midwifery staffing levels for different birth settings. For home and midwife- led

settings a ration of 1 whole time midwife per woman during labour, with 1 maternity

support worker for a team of six midwives. For women in obstetric units, this ratio rises to

1.4 wte midwives to 1 woman with rising need levels, with 1 support worker for four

midwives.

Standards for Maternity Care, RCOG, RCM, RCoA (Royal College of Anaesthetists), RCPCH, 2008 These standards, developed by a working group from all four colleges, were drawn from a review of all available published standards, with the aim of creating an agreed full set of maternity care standards for all aspects of care.

In relation to access to antenatal care, the standards state:

Antenatal care should be provided in a variety of local settings and at times that take account of the demands of the woman’s working life and family (p14, RCOG, 2008).

1 Relative Risk that women would be admitted overnight, which was about 54% less likely in this study.

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In relation to choice of birth place, the standards indicate: All midwives, obstetricians and GPs must be competent to assist women in considering their options for antenatal, birth and postnatal care and the clinical risks and benefits involved (p16 RCOG 2008). Good Practice Guideline no.15 on Reconfiguration of Women’s Services in the UK, 2013, RCOG This guideline estimated that around 1/3 of women are suitable to give birth in a freestanding midwifery unit or at home – as they are ‘known’ low risk on the basis that they are having a 2nd or subsequent baby with no previous problems. Only around 5% of this group of women will require transfer to higher level care during labour. The guideline estimated around 1/6 are clearly ‘high risk’ and require birth in a consultant- led unit. They defined the remaining 50% as ‘unknown’ risk, largely as they are giving birth to their first baby. They identified that up to 40% of this group may require transfer to higher risk care during labour, and so suggest that the most suitable care setting might be an alongside midwifery unit. The guideline argues for the need to assess whether so many obstetric units are necessary and

feasible. The guideline acknowledges that there is no published evidence on the ideal size for a

maternity unit. Rather than size, the report identified the need to reflect on the population needs

and the characteristics of care that are required. The RCOG guideline stated ‘increasing the provision

of community based midwifery- led services would allow for the centralisation of obstetric services’

(p3). Such obstetric services should have 24 hour cover from an experienced obstetric anaesthetist

with appropriate operating department assistant support and should have high level neonatal

services.

NHS Cumbria Options Appraisal Final Report, 2015, RCOG In October/November 2014 the RCOG were commissioned by the Cumbrian and North Lancashire Health Trusts to undertake a review of the configuration of maternity services there in the wake of the Morecambe Bay enquiry findings. The review was published in March 20152. The review addresses some of the issues relevant in parts of Scotland in relation to the existence of

small consultant-led units. The review identified significant problems with recruitment of

anaesthetists and appropriate neonatal cover.

As part of this review, a literature review was undertaken to explore the safety of smaller and more

remote maternity units:

The review found most studies relating to numbers of births were from the USA and Scandinavia.

These studies found that hospitals with a lower number of births are associated with:

- A higher proportion of operative deliveries (than units with more births)

- Higher rates of peri-operative maternal mortality from haemorrhage at caesarean section

- Higher rates of postpartum haemorrhage

Smaller units were found to have a neutral impact on:

- No difference in infection rates

- No difference in episiotomy rates

- No difference in uterine rupture

2

http://www.cumbriaccg.nhs.uk/about-us/2015-03-23--rcog-options-appraisal-final-report-(nopword).pdf

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Smaller units had a positive impact on:

- Lower rates of postnatal anaemia. The literature review into distance of nearest maternity unit and safety, found studies mainly from theUK and Europe. Two of these studies found no overall association between travel time/distance and overall neonatal mortality and stillbirths. One study found an overall association between travel time/distance and increased neonatal death. Other studies found a positive but not significant gradient between travel time and perinatal mortality (for neonatal death rather than stillbirth). The RCOG review in Cumbria is also of interest in the options it identifies and the process to ensure appropriate implementation of those options, which include a whole system wide approach and the use of a ‘hub and spoke’ ‘network’ model to ensure that small units are not isolated. One approach suggested is that medical staff are recruited by the whole Trust, so that there is then an expectation that they will work across different units. The review is also interesting about how women (and staff) can be very wary of freestanding midwife- led units prior to implementation, but if women have experienced care at them, they will then state a preference for them. 3.2.5 Database Search Results The database search identified a lack of systematic reviews of this topic as there are no large randomised controlled trials comparing home and hospital birth. This appears to be due to the difficulties of gaining consent from women to be randomised to a place of birth (Olsen and Clausen, 2012). Abstracts of the 12 identified primary quantitative studies from outside the UK are discussed below and a summary of the studies is detailed in table A 2.4 in Appendix Two. The Birthplace England study has led to the publication of nine papers so far from 2011-2016. The abstracts of these are discussed below and detailed further in Appendix Three of this paper. The reviewed studies from outside the UK included large population based studies or cohort studies. Nine of the thirteen identified studies compared a range of clinical outcomes of planned home and hospital births (Lindgrenz et al 2008, Janssen et al 2009, Wax et al 2010, Davis et al 2011, Van der Kooy 2011, Overgaard et al 2012, Cheyney et al 2014, De Jonge 2015, Halfdansdottir et al 2015). Of these nine, eight found that planned home birth for low risk women was associated with fewer interventions and no significant differences in adverse outcomes. One study found a significantly higher risk of adverse neonatal outcomes with home birth (Wax et al 2010). Four of the identified thirteen studies focussed on a particular outcome such as transfer rates (Blix et al 2016), Postpartum haemorrhage rates (Davis et al 2012) or cost (Janssen et al 2015, Hendrix 2009). Studies that specifically explored transfers found that the most common reason for transfer from home to hospital during labour was failure to progress (Cheyney et al 2014). Nulliparous women were transferred during labour or up to 72 hours postnatally in about one third of cases, multiparous women in 8%. 3.8% of transfers were described as ‘potentially urgent’ (Blix et al 2016). It should also be cautioned that as all of these studies are observational in nature, they are at a high risk of bias. The Birthplace England study set out to compare perinatal outcomes, maternal outcomes, and interventions in labour by planned place of birth at the start of care in labour for women with low risk pregnancies. The prospective cohort study included all NHS trusts in England providing intrapartum care at home, all freestanding midwifery units, all alongside midwifery units (midwife- led units on a hospital site with an obstetric unit), and a stratified random sample of obstetric units.

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64,538 eligible women with a singleton, term (≥37 weeks gestation), and “booked” pregnancy who gave birth between April 2008 and April 2010 were included. Planned caesarean sections and caesarean sections before the onset of labour and unplanned home births were excluded. A composite primary outcome of perinatal mortality and intrapartum related neonatal morbidities (stillbirth after start of care in labour, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus, or fractured clavicle) was used to compare outcomes by planned place of birth at the start of care in labour (at home, freestanding midwifery units, alongside midwifery units, and obstetric units). The study published its initial findings in the British Medical Journal in 2011 and has subsequently undertaken and published a range of sub-group analyses of the findings. The main results of the overall study are described on the website and in the comprehensive question and answer document3. The key findings below are quoted from the Birthplace website4 :

Giving birth is generally very safe

For 'low risk' women the incidence of adverse perinatal outcomes (intrapartum stillbirth, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, and specified birth related injuries including brachial plexus injury) was low (4.3 events per 1,000 births).

Midwifery units appear to be safe for the baby and offer benefits for the mother

For planned births in freestanding midwifery units and alongside midwifery there were no significant difference in adverse perinatal outcomes compared with planned birth in an obstetric unit.

Women who planned birth in a midwifery unit (AMU or FMU) had significantly fewer interventions, including substantially fewer intrapartum caesarean sections, and more 'normal births' than women who planned birth in an obstetric unit.

For women having a second or subsequent baby, home births and midwifery unit births appear to be safe for the baby and offer benefits for the mother

For multiparous women, there were no significant differences in adverse perinatal outcomes between planned home births or midwifery unit births and planned births in obstetric units.

For multiparous women, birth in a non-obstetric unit setting significantly and substantially reduced the odds of having an intrapartum caesarean section, instrumental delivery or episiotomy.

For women having a first baby, a planned home birth increases the risk for the baby

For nulliparous women, there were 9.3 adverse perinatal outcome events per 1,000 planned home births compared with 5.3 per 1,000 births for births planned in obstetric units, and this finding was statistically significant.

3 https://www.npeu.ox.ac.uk/downloads/files/birthplace/Birthplace-Q-A.pdf

4 https://www.npeu.ox.ac.uk/birthplace/results

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For women having a first baby, there is a fairly high probability of transferring to an obstetric unit during labour or immediately after the birth

For nulliparous women, the peri-partum transfer rate was 45% for planned home births, 36% for planned FMU births and 40% for planned AMU births.

For women having a second or subsequent baby, the transfer rate is around 10%

For women having a second or subsequent baby, the proportion of women transferred to an obstetric unit during labour or immediately after the birth was 12% for planned home births, 9% for planned FMU births and 13% for planned AMU births.

A number of other studies have been undertaken to undertake secondary and subgroup analysis of the Birthplace England data. These have included exploration of the outcomes for obese women with no other medical or obstetric risk. This identified that the risks of adverse outcomes and increased risks of intervention for healthy multiparous obese women are lower than previously appreciated and that BMI should be considered alongside parity in determining individual risks and informing decisions about place of birth (Hollowell et al 2014). Further analysis of the data has also found that interventions and adverse maternal outcomes increase incrementally with maternal age, particularly for nulliparous women (Li et al 2014), that immersion in water during labour in home and midwifery settings reduces the risk of transfer for nulliparous women (Lukasse et al 2014) and that costs for home and midwifery care settings are significantly lower than in obstetric settings (Schroeder et al 2012).

3.2.6 Service User surveys Having a Baby in Scotland 2015: Listening to Mothers’, Cheyne et al, 2015; Office of National Statistics, Edinburgh. The most recent maternity service user survey in Scotland was undertaken in 2015, including 2,300 women. The survey included questions on two specific aspects of choice; these were choice of location of antenatal check-ups and choice of place of birth. The results suggest that relatively few women currently feel that they have these choices. Overall 80% said that they had no choice about where their antenatal check-ups would take place. Considering place of birth, just over half of women said that they were given enough information to help them decide where to have their baby. Only 36% were offered a choice of hospitals (a decrease from 41% in 2013), 25% were offered a choice of giving birth at home and almost one quarter of women said that they were not offered any choice. However, despite the evident lack of choices in these areas the large majority of women (81%) said that they had enough involvement in care decisions, a significant increase from 78% in 2013(p21, Cheyne et al 2015). NATIONAL REVIEW OF MATERNITY AND NEONATAL SERVICES: Patient Views and Experience of Maternity and Neonatal Services, Report by Scottish Health Council, May 2016 The Scottish Health Council sought views from a wide range of service users and community groups, using various methods, such as focus group discussions, one-to-one discussions with people who were unable to attend a group, and completed questionnaires from individuals. Using all these methods a total of 581 people – 105 of whom had experience of both maternity and neonatal services - took part in the engagement across Scotland. The report identified that for ‘those in more remote and rural areas identified particular challenges and generally supported the provision of maternity care as close to home as possible…Where

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pregnancy scans and routine clinic appointments were available locally in rural, areas this was felt to be very helpful’ (SHC, 2016). Safely delivered: a national survey of women’s experience of maternity care, 2014, National Perinatal Epidemiology Unit (NPEU) This survey was undertaken in 2014, with questionnaires sent to a random sample of 10,000 women, with 4,571 responses. In relation to choice and place of birth, 25% described being aware of all four options, 40% were aware of 2 or 3 options and 33% had only one choice of place of birth. Most women (70%) felt they had been given enough information to decide where to have their baby and most (60%) made their choice in early pregnancy. Support Overdue: Women’s Experiences of Maternity Services, 2013, NFWI and National Childbirth Trust (NCT) This report examines the experiences of 5,500 women who gave birth in the past five years (three quarters of them in 2012) in England and Wales. Key findings: choice remains an aspiration rather an a reality for many women; maternity care is fragmented; women face a postcode lottery of postnatal care. Dignity in Childbirth: The Dignity Survey 2013: Women’s and Midwives’ Experiences of dignity in UK Maternity Care, 2013, Birthrights Organisation UK This online survey, via Mumsnet, was completed by 1,100 women who had given birth within the previous two years. A higher proportion of women who gave birth in consultant- led settings had negative experiences in relation to feelings of choice, control, respect and dignity, compared to home or midwifery settings. 3.2.7 The English Maternity Service Review – ‘Better Births’, 2016 The Review of English Maternity services suggests the development of managed clinical networks for maternity care on a regional basis. Most care would be provided in ‘community hubs’ that then have clear and speedy referral pathways to more specialist regional services. This reflects the guidance from the RCOG best practice guideline. This model would enable choice to be provided to women on a regional basis. The English Maternity Service Review commissioned four further evidence reviews from NPEU (Oxford) based on further analysis of the Birthplace study and a review of other literature relating to consultant cover of labour wards and women’s preference s in maternity care. The first of these, ‘Summary of the evidence on safety of place of birth and implications for policy and practice from the overall evidence review’ (Kurinczuk et al 2015) identified that the risks and benefits of the four different birth settings are different for low risk women having their first baby and those having their second or subsequent baby; the risks and benefits for women having their first baby vary with the woman’s age, but do not appear to differ according to the woman’s ethnicity or level of deprivation. This identifies the need for local evaluation and monitoring to ensure that the services offered reflect local need and to ensure that expansion of freestanding units should be targeted to areas where there is sufficient demand for them to be viable. The report highlighted that for women with some risk factors who are clear they do not wish to have an obstetric unit birth, consideration should be given to offering them an ‘outwith guideline’ pathway for a planned alongside midwifery unit birth rather than the current default position of a homebirth.

The second report ‘Perinatal and maternal outcomes by parity in midwifery-led settings: secondary analysis of the Birthplace in England cohort comparing outcomes in planned freestanding and alongside midwifery unit births’ (Hollowell et al 2015) identified that there was no difference in

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adverse perinatal outcomes between planned AMU (alongside midwifery units) and FMU (freestanding midwifery units) births. The overall pattern suggested a trend toward lower intervention rates and fewer maternal adverse events in planned FMU births compared with planned AMU births. The report acknowledges that a significant proportion of women may have a preference for a setting with ready access to medical staff, even if they are considered to be suitable for a home or midwife- led setting. Maternity services need to ensure that women are still able to choose an obstetric unit rather than out of hospital care.

The third report ‘Systematic review and case studies to assess models of consultant resident cover and the outcomes of intrapartum care and two international case studies of the delivery of maternity care’ (Knight et al, 2015) indicated that there is little evidence to support the expectation of 24 hour residential consultant presence in labour wards and highlights the potential of the clinical network model to enable a maternity system based on clear ‘risk tiering’ of provision.

The fourth report ‘A systematic review and narrative synthesis of the quantitative and qualitative literature on women’s birth place preferences and experiences of choosing their intended place of birth in the UK’ (Hollowell et al, 2015b) identified that studies suggest that midwives are the most important source of information for women when making decisions about place of birth and the influence of health professionals can lead to women feeling they have no choice. The evidence reviewed in the report suggested that only a small minority (<10%) of women would consider a home birth.

4.0 Conclusions High quality large scale observational studies of place of birth have demonstrated that midwifery

care settings including home birth, freestanding midwifery units and alongside midwifery units, are a

safe option for the majority of healthy women with uncomplicated pregnancies. There appears to

be a significant difference between the proportion of women who indicate in surveys that they

would like to give birth at home or in midwifery units, compared to the very low proportion of

women who currently give birth in these settings across Scotland. Systems should be developed to

support the provision of real choice in relation to place of care and birth, including evidence based

accessible information and decision aids for women, families and health professionals, appropriate

physical settings to act as ‘community hubs’, the relocation of maternity professionals to reflect the

shift from hospital centred to a greater proportion of community centred care, and the

implementation of team systems that support the provision of community based maternity care

including intrapartum care.

There is strong high quality evidence to support the promotion of real choice to women about the

location of their maternity care: through the antenatal, intrapartum and postnatal period.

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Appendix One - Search Strategies

MEDLINE, HMIC and MIDIRS, EBSCO

Searches undertaken on 25.05.16, 27.05.16 and 29.05.16

Limits – 2000-2016, in English, Journal articles,

Search terms used:

1. Place of birth – 162 initial results – 8 for more detailed

2. Home + Hospital + Birth – 122 results – 8 for more detailed

Results were sifted to remove qualitative research, repetition and research undertaken in

developing or low income countries. This led to the more detailed review of 12 studies.

These 12 studies are summarised in a table in Appendix Two.

The Abstracts of these studies are included in Appendix Three.

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Appendix Two – Detailed Study Selection Tables

Table A2.1 NICE Guideline Search.

Guideline Details Relevant to rapid review

Guideline CG62 on antenatal care, 2016.

Focused on uncomplicated pregnancies. Includes recommendations about provision and organisation of care, which includes continuity of care.

Yes

Guideline CG190 Intrapartum care for healthy women and babies, 2014.

Focused on uncomplicated births. Includes recommendation for one to one care and support from a midwife throughout labour and advice about midwife-led care settings for women during labour.

Yes

Guideline NG3 on diabetes in pregnancy.

No information on organisation of care other than a joint diabetes in pregnancy clinic.

No

Guideline CG107 on hypertension in pregnancy.

No recommendations relating to organisation or model of care, other than identifying the need for ‘an integrated package of care’.

No

Guideline PH11 on maternal and child nutrition.

No recommendation relating to organisation or model of care. No

Guideline CG110 on pregnancy and complex social factors.

Guidance identifies the need for ease of access, multi-agency communication but does not identify the model of maternity care or the need for continuity of care(r).

No

Guideline PH26 on smoking in pregnancy.

No reference to organisation of care, model of care or continuity of care(r).

No

Guideline PH27 on weight management before, during and after pregnancy.

No reference to organisation of care, model of care or continuity of care(r).

No

Guideline CG192 on antenatal and postnatal mental health.

Reference to need for continuity of mental health care between CAMHs and adult mental health services, no reference to continuity of maternity care(r).

No

Guideline NG4 on safe midwifery staffing for maternity settings.

Identifies evidence and requirement for one to one midwifery care through labour and childbirth. No reference to model of care including continuity of care(r).

No

Guideline CG37 on postnatal care.

No reference to organisation of care, model of care or continuity of care(r).

No

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Table A2.2 Cochrane Pregnancy and Childbirth Group Search. 561 results relating to pregnancy and

childbirth

Title Exclude/ Include

Reason

Hodnett et al, 2012, Alternative versus conventional institutional settings for birth.

Include Found a range of improved outcomes for women giving birth in ‘alternative’ settings v hospital (home from home rooms).

Dowswell et al. 2009. Antenatal day care units versus hospital admission for women with pregnancy complications.

Include Small number of trials and women. Results showed fewer admissions and shorter stays for women attending day care units, with no impact on other outcome.

Olsen & Clausen, 2012, ‘Planned hospital v planned home birth’.

Include Only one very small RCT with 11 women included.

Sandall et al 2016, Midwife-led continuity models versus other models of care for childbearing women (updated 2012, 2015) (replaced Hodnett 2008 on continuity of caregiver through pregnancy and childbirth).

Exclude Was explored in depth in rapid review on continuity of carer.

Hodnett et al 2015 Continuous support for women during childbirth

Exclude Was explore in depth in rapid review on continuity of carer.

Dowswell et al 2015, Alternative versus standard packages of antenatal care for low-risk pregnancy

Exclude Compared standard number of visits (8-12) with reduced number (4-5) – found negative impact on perinatal mortality and maternal satisfaction; did not explore model of care in terms of provider.

Catling et al 2015, Group versus conventional antenatal care for women

Exclude Not related to provider. Improved maternal satisfaction , but no impact on any other outcomes including preterm birth, birthweight, type of birth.

Hodnett et al 2010, Support during pregnancy for women at increased risk of low birthweight babies

Exclude Additional social support by multi-disciplinary teams and layworkers– not found to reduce preterm or lbw birth, though reduced number of admissions.

Dodd et al 2015, Specialised antenatal clinics for women with a multiple pregnancy for improving maternal and infant outcomes

Exclude Found higher CS rates among women attending specialist clinic but no other differences in outcomes.

Turnbull and Osborn 2012, Home visits during pregnancy and after birth for women with an alcohol or drug problem

Exclude Home visiting from a range of professionals and community workers. Insufficient evidence, only 800+ women, but no benefits found in terms of cessation of drug and alcohol use.

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Lavender et al 2013, Telephone support for women during pregnancy and the first six weeks postpartum

Exclude Telephone support for a range of issues including anxiety, depression, smoking cessation and clinical birth outcomes. No significant effect.

Khunpradit 2011, Non-clinical interventions for reducing unnecessary caesarean section

Exclude Implementation of guidelines with mandatory second opinion can lead to a small reduction in caesarean section rates, predominately in intrapartum sections. Peer review, including pre-caesarean consultation, mandatory secondary opinion and post caesarean surveillance can lead to a reduction in repeat caesarean section rates. Guidelines disseminated with endorsement and support from local opinion leaders may increase the proportion of women with previous caesarean sections being offered VBAC in certain settings. Nurse-led relaxation classes and birth preparation classes may reduce caesarean section rates in low-risk pregnancies.

Khianman 2012, Relaxation therapy for preventing and treating preterm labour

Exclude According to the results of this review, there is some evidence that relaxation during pregnancy reduces stress and anxiety. However, there was no effect on Preterm labour or birth.

Chamberlain et al 2013, Psychosocial interventions for supporting women to stop smoking in pregnancy

Exclude Psychosocial interventions included counselling, combined with incentive, most effective in terms of smoking cessation. Not about organisation of maternity care – other than smoking cessation sometimes provided by mainstream maternity services.

Bond et al., 2015. Immediate delivery or expectant management of the term baby with suspected fetal compromise for improving pregnancy outcomes.

Exclude Not on organisation of care

Stock et al., 2012. Immediate or deferred delivery of the preterm baby with suspected fetal compromise for improving outcomes

Exclude Not on organisation of care

Churchill et al., 2013. Interventionist versus expectant care for severe pre-eclampsia before term.

Exclude Not on organisation of care

Bain et al., 2014. Interventions for managing asthma in pregnancy.

Exclude Not on organisation of care

El Senoun et al., 2014. Planned home versus hospital care for rupture of the membranes before 37 weeks' gestation.

Exclude Inadequate number and size of studies to draw conclusions

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Table A 2.3 Other Systematic Reviews

No other systematic reviews on the topic of place of birth identified.

Table A 2.4 Summary of 11 Quantitative Studies on Birth Place Outside the UK

Author Title Publication + Year

Population Key outcomes

Blix et al ‘Transfer to hospital in planned home birth in four Nordic countries – a prospective cohort study.

Acta OBstet. Gyn, Scand, 95,4

2016

Norway, Sweden, Denmark and Iceland home birth at the onset of labor, Data from 3,068 women, 572 nulliparas and 2,446 multiparas.

One-third of all nulliparous and 8.0% of multiparous women were transferred during labor or within 72 h of the birth. The proportion of potentially urgent transfers was 3.8%.

Cheyney et al

‘Outcomes of care for 16,924 planned home births in the US…2004-2009’.

Journal of Midwifery and Women’s health, 2014.

16,924 women planning home birth at start of labour.

Most transfers for failure to progress. Low risk women had high rates of physiological birth, low rates of intervention without an increase in adverse outcomes.

Davis et al ‘Risk of severe PPH in low-risk childbearing women in New Zealand; exploring the effect of place of birth and comparing third stage management of labor’.

Birth, 2012 16,210 low risk women giving birth 2006-7.

Planned place of birth was not found to influence the risk of blood loss greater than 1000ml. Active management showed a twofold increase in blood loss >1000ml compared to physiological.

De Jonge et al

‘Perinatal mortality and morbidity…among 743,070 low risk planned home and hospital births…’.

BJOG, 2015 Netherlands, nationwide cohort study.

No increase in adverse perinatal outcomes for planned home births among low-risk women.

Halfdansdottir et al

‘Outcome of planned home and hospital births among low-risk women in Iceland, 2005-2009’.

Birth, 2015 307 planned home births v matched sample of 921 planned hospital births.

Lower rates of whole range of interventions for planned home birth. Apgar scores <7 same in home and hospital birth groups. Home birth had higher NICU admission. Hospital birth had higher obstetric anal sphincter injury and operative birth.

Hendrix et al 2009

Cost analysis of the Dutch obstetric system: low-risk

BMC Health Services Research.

Netherlands The total costs associated with pregnancy, delivery, and postpartum care are

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nulliparous women preferring home or short-stay hospital birth--a prospective non-randomised controlled study.

9:211, 2009.

comparable for home birth and short-stay hospital birth. The most important differences in costs between the home birth group and the short-stay hospital birth group are associated with maternity care assistance, hospitalisation, and travelling costs.

Janssen et al

‘Outcomes of planned home birth…v planned hospital birth’.

CMAJ, 2009 All planned home births in British Columbia, Canada 2000-2004 n=2,889 v planned hospital births meeting home birth eligibility requirements attended by same cohort of midwives n=4,752 and a matched sample of physician-attend planned hospital birth n=5,331.

Home birth significantly lower intervention rates, no difference in perinatal mortality rates. Homebirth group less likely to have meconium aspiration.

Lindgrenz et al

‘Outcome of planned home births compared to hospital births in Sweden between 1992 and 2004. A population based register study’.

Acta Obstetrica et Gynecologica, 2008.

897 planned home births v 11,341 planned hospital.

Lower intervention rates, higher rate of neonatal mortality in home births, though didn’t reach statistical significance.

Overgaard et al

‘Freestanding midwifery units versus obstetric units: does the effect of place of birth differ with level of social disadvantage’.

BMC Public Health 2012, 12:478

The study was designed as a cohort study with a matched control group. It included 839 low-risk women intending to give birth in an FMU, who were prospectively and individually matched on nine selected obstetric/socio-economic factors to 839 low-risk women intending OU birth. Educational level was chosen as a proxy for social position.

Both for women with and without post-secondary education, intending to give birth in an FMU significantly increased the likelihood of a spontaneous, uncomplicated birth with good outcomes for mother and infant compared to women intending to give birth in an OU.

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Van der

Kooy et al

‘Planned home compared with planned hospital birth in the Netherlands: Intrapartum and early neonatal death in low-risk pregnancies’.

Obstetrics and Gynecology, 2011.

679,952 low risk births 2000-2007 in the Netherlands.

No higher risk of increased mortality in home birth in ‘routine conditions’, though for certain sub-groups the risk of intrapartum death and neonatal death may be higher.

Wax et al ‘Maternal and newborn outcomes in planned home birth v planned hospital births: a meta-analysis’.

AMJOG, 2010 Meta analysis of a range of studies in English language developed Western countries.

Lower intervention rates at home, similar perinatal mortality rates, found elevated neonatal mortality rates.

Table A2.5 RCOG Guideline Search

Guideline Details Relevant to rapid review

Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour, 2007 (joint with RCM and other colleges)

Details standards for the organisation and Delivery of Care in Labour. Provides some information on critical care provision, although mainly just statements.

Yes

Standards for Maternity Care, 2008 (joint with RCM and other colleges)

Standards relating to named midwife for all women regardless of risk, one to one care in labour, named midwife to continue coordination of care postnatally.

Yes

Good practice guidance on the reconfiguration of women’s services, Good practice guide 15, 2013.

Explores some of the issues relating to choice of place of birth and size of obstetric unit

Yes

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Table A2.6 RCM Guidance

Document Group/ Author/ Organisation

Details Relevant to rapid review

State of Maternity Services Report, 2015.

RCM Details number of women requiring maternity care number of midwives needed to provide this. Identifies that Scotland does not have a midwife shortage at present.

No

Evidence based guidelines for midwifery-led care in labour, 2012.

RCM Identifies need for one to one midwifery support in established labour.

No

The contribution of continuity of midwifery care to high quality maternity care, 2015.

Jane Sandall for the RCM

Summarises the policies, evidence and guidelines relating to continuity of midwifery care and its contribution to the improvement of a range of outcomes.

No

Position statement on safe midwifery staffing, 2015.

RCM RCM recommends the use of the Birthrate plus workforce modelling tool to plan workforce based on local need.

No

Joint statement on multi-disciplinary working and continuity of carer, 2016.

RCM & RCOG

Strongly supports the NHS England Maternity review report on multi-disciplinary collaboration and continuity of carer. Identifies need for adequate staffing levels to support.

No

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Table A2.7 Large Scale Reviews of Women’s Experiences of Maternity Care

Document Group/ Author/ Organisation

Details Relevant to rapid review

NPEU Safely Delivered: a national survey of women’s experience of maternity care, 2014.

National Perinatal epidemiology unit, Oxford.

Asked women about their perceptions of choice and knowledge of different birth place options.

Yes

Support Overdue: Women’s experiences of maternity services, 2013.

The National Federation of Women’s Institutes (NFWI) & NCT.

Report which explored women and their families’ experiences of pregnancy and childbirth.

Yes

Dignity in Childbirth: The Dignity Survey 2013: Women’s and midwives’ experiences of dignity in UK maternity care.

Birthrights organisation.

Relationship between place of birth and how much respect, dignity, choice and control women felt they had.

Yes

Having a Baby in Scotland 2015: Women’s Experiences of Maternity Care - National Report, Cheyne et al.

NHS Scotland Results of 2015 survey on women’s experiences of maternity services.

Yes

Care Quality Commission survey into maternity service user satisfaction in England.

CQC, England Very similar results to Scottish survey. No

Patient Views and Experience of Maternity and Neonatal Services, Scottish Review of Maternity and Neonatal services, 2016.

Scottish Health Council

One of the key themes from this report was the particular

challenges faced by people living in remote and rural areas,

mainly around travel and the amount of time spent away

from home. They supported the provision of maternity care

– particularly routine clinic and scan appointments – as close

to home as possible.

Yes

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Appendix Three – Publications from the Birthplace England Study

Birthplace in England Collaborative Group, Brocklehurst P, Hardy P, Hollowell J, Linsell L, Macfarlane

A, Mccourt C, Marlow N, Miller A, Newburn M, Petrou S, Puddicombe D, Redshaw M, Rowe R,

Sandall J, Silverton L, Stewart M. Perinatal and maternal outcomes by planned place of birth for

healthy women with low risk pregnancies: the Birthplace in England national prospective cohort

study. British Medical Journal. 2011;343. Fulltext link

Objective To compare perinatal outcomes, maternal outcomes, and interventions in labour by planned place of birth at the start of care in labour for women with low risk pregnancies. Design Prospective cohort study. Setting England: all NHS trusts providing intrapartum care at home, all freestanding midwifery units, all alongside midwifery units (midwife- led units on a hospital site with an obstetric unit), and a stratified random sample of obstetric units. Participants 64 538 eligible women with a singleton, term (≥37 weeks gestation), and “booked” pregnancy who gave birth between April 2008 and April 2010. Planned caesarean sections and caesarean sections before the onset of labour and unplanned home births were excluded. Main outcome measure A composite primary outcome of perinatal mortality and intrapartum related neonatal morbidities (stillbirth after start of care in labour, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus, or fractured clavicle) was used to compare outcomes by planned place of birth at the start of care in labour (at home, freestanding midwifery units, alongside midwifery units, and obstetric units). Results There were 250 primary outcome events and an overall weighted incidence of 4.3 per 1000 births (95% CI 3.3 to 5.5). Overall, there were no significant differences in the adjusted odds of the primary outcome for any of the non-obstetric unit settings compared with obstetric units. For nulliparous women, the odds of the primary outcome were higher for planned home births (adjusted odds ratio 1.75, 95% CI 1.07 to 2.86) but not for either midwifery unit setting. For multiparous women, there were no significant differences in the incidence of the primary outcome by planned place of birth. Interventions during labour were substantially lower in all non-obstetric unit settings. Transfers from non-obstetric unit settings were more frequent for nulliparous women (36% to 45%) than for multiparous women (9% to 13%). Conclusions The results support a policy of offering healthy women with low risk pregnancies a choice of birth setting. Women planning birth in a midwifery unit and multiparous women planning birth at home experience fewer interventions than those planning birth in an obstetric unit with no impact on perinatal outcomes. For nulliparous women, planned home births also have fewer interventions but have poorer perinatal outcomes.

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Appendix Four: Nine Published Studies, including subgroup analyses, of Birthplace England study Hollowell J, Pillas D, Rowe R, Linsell L, Knight M, Brocklehurst P. The impact of maternal obesity on intrapartum outcomes in otherwise low risk women: secondary analysis of the Birthplace national prospective cohort study. Br Journal Obstet Gynaecol. 2014;121:343-55. Fulltext link Objectives To evaluate the impact of maternal BMI on intrapartum interventions and adverse outcomes that may influence choice of planned birth setting in healthy women without additional risk factors. Design Prospective cohort study. Setting Stratified random sample of English obstetric units. Sample 17,230 women without medical or obstetric risk factors other than obesity. Methods Multivariable log Poisson regression was used to evaluate the effect of BMI on risk of intrapartum interventions and adverse maternal and perinatal outcomes adjusted for maternal characteristics. Main outcome measures Maternal intervention or adverse outcomes requiring obstetric care (composite of: augmentation, instrumental delivery, intrapartum caesarean section, general anaesthesia, blood transfusion, 3rd/4th degree perineal tear); neonatal unit admission or perinatal death. Results In otherwise healthy women, obesity was associated with an increased risk of augmentation, intrapartum caesarean section and some adverse maternal outcomes but when interventions and outcomes requiring obstetric care were considered together, the magnitude of the increased risk was modest (adjusted RR 1.12, 95% CI 1.02–1.23, for BMI > 35 kg/m2 relative to low risk women of normal weight). Nulliparous low risk women of normal weight had higher absolute risks and were more likely to require obstetric intervention or care than otherwise healthy multiparous women with BMI > 35 kg/m2 (maternal composite outcome: 53% versus 21%). The perinatal composite outcome exhibited a similar pattern. Conclusions Otherwise healthy multiparous obese women may have lower intrapartum risks than previously appreciated. BMI should be considered in conjunction with parity when assessing the potential risks associated with birth in non-obstetric unit settings. Li Y, Townend J, Rowe R, Knight M, Brocklehurst P, Hollowell J. The effect of maternal age and planned place of birth on intrapartum outcomes in healthy women with straightforward pregnancies: secondary analysis of the Birthplace national prospective cohort study. BMJ Open. 2014;4(1):e004026. Fulltext link Objectives To describe the relationship between maternal age and intrapartum outcomes in ‘low-risk’ women; and to evaluate whether the relationship between maternal age and intrapartum interventions and adverse outcomes differs by planned place of birth. Design Prospective cohort study. Setting Obstetric units (OUs), midwifery units and planned home births in England. Participants 63,371 women aged over 16 without known medical or obstetric risk factors, with singleton pregnancies, planning vaginal birth. Methods Log Poisson regression was used to evaluate the association between maternal age, modelled as a continuous and categorical variable, and risk of intrapartum interventions and adverse maternal and perinatal outcomes. Main outcome measures Intrapartum caesarean section, instrumental delivery, syntocinon augmentation and a composite measure of maternal interventions/adverse outcomes requiring obstetric care encompassing augmentation, instrumental delivery, intrapartum caesarean section,

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general anaesthesia, blood transfusion, third-degree/fourth-degree tear, maternal admission; adverse perinatal outcome (encompassing neonatal unit admission or perinatal death). Results Interventions and adverse maternal outcomes requiring obstetric care generally increased with age, particularly in nulliparous women. For nulliparous women aged 16–40, the risk of experiencing an intervention or adverse outcome requiring obstetric care increased more steeply with age in planned non-OU births than in planned OU births (adjusted RR 1.21 per 5-year increase in age, 95% CI 1.18 to 1.25 vs adjusted RR 1.12, 95% CI 1.10 to 1.15) but absolute risks were lower in planned non-OU births at all ages. The risk of neonatal unit admission or perinatal death was significantly raised in nulliparous women aged 40+ relative to women aged 25–29 (adjusted RR 2.29, 95% CI 1.28 to 4.09). Conclusions At all ages, ‘low-risk’ women who plan birth in a non-OU setting tend to experience lower intervention rates than comparable women who plan birth in an OU. Younger nulliparous women appear to benefit more from this reduction than older nulliparous women. Li Y, Townend J, Rowe R, Brocklehurst P, Knight M, Linsell L, Macfarlane A, McCourt C, Newburn M, Marlow N, Pasupathy D, Redshaw M, Sandall J, Silverton L, Hollowell J. Perinatal and maternal outcomes in planned home and obstetric unit births in women at 'higher risk' of complications: secondary analysis of the Birthplace national prospective cohort study. BJOG. 2015;Epub:1-13. Fulltext link Objective To explore and compare perinatal and maternal outcomes in women at 'higher risk' of complications planning home versus obstetric unit (OU) birth. Design Prospective cohort study. Setting OUs and planned home births in England. Population 8,180 'higher risk' women in the Birthplace cohort. Methods We used Poisson regression to calculate relative risks adjusted for maternal characteristics. Sensitivity analyses explored possible effects of differences in risk between groups and alternative outcome measures. Main outcome measures Composite perinatal outcome measure encompassing 'intrapartum related mortality and morbidity' (intrapartum stillbirth, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus or clavicle) and neonatal admission within 48 hours for more than 48 hours. Two composite maternal outcome measures capturing intrapartum interventions/adverse maternal outcomes and straightforward birth.Results The risk of 'intrapartum related mortality and morbidity' or neonatal admission for more than 48 hours was lower in planned home births than planned OU births [adjusted relative risks (RR) 0.50, 95% CI 0.31-0.81]. Adjustment for clinical risk factors did not materially affect this finding. The direction of effect was reversed for the more restricted outcome measure 'intrapartum related mortality and morbidity' (RR adjusted for parity 1.92, 95% CI 0.97-3.80). Maternal interventions were lower in planned home births.Conclusions The babies of 'higher risk' women who plan birth in an OU appear more likely to be admitted to neonatal care than those whose mothers plan birth at home, but it is unclear if this reflects a real difference in morbidity. Rates of intrapartum related morbidity and mortality did not differ statistically significantly between settings at the 5% level but a larger study would be required to rule out a clinically important difference between the groups.

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Lukasse M, Rowe R, Townend J, Knight M, Hollowell J. Immersion in water for pain relief and the risk of intrapartum transfer among low risk nulliparous women: secondary analysis of the birthplace national prospective cohort study. BMC Pregnancy and Childbirth. 2014;14(1):60. Fulltext link Background Immersion in water during labour is an important non-pharmacological method to manage labour pain, particularly in midwifery-led care settings where pharmacological methods are limited. This study investigates the association between immersion for pain relief and transfer before birth and other maternal outcomes. Methods A prospective cohort study of 16,577 low risk nulliparous women planning birth at home, in a freestanding midwifery unit (FMU) or in an alongside midwifery unit (AMU) in England between April 2008 and April 2010. Results Immersion in water for pain relief was common; 50% in planned home births, 54% in FMUs and 38% in AMUs. Immersion in water was associated with a lower risk of transfer before birth for births planned at home (adjusted RR 0.88; 95% CI 0.79–0.99), in FMUs (adjusted RR 0.59; 95% CI 0.50–0.70) and in AMUs (adjusted RR 0.78; 95% CI 0.69–0.88). For births planned in FMUs, immersion in water was associated with a lower risk of intrapartum caesarean section (RR 0.61; 95% CI 0.44–0.84) and a higher chance of a straightforward vaginal birth (RR 1.09; 95% CI 1.04–1.15). These beneficial effects were not seen in births planned at home or AMUs. Conclusions Immersion of water for pain relief was associated with a significant reduction in risk of transfer before birth for nulliparous women. Overall, immersion in water was associated with fewer interventions during labour. The effect varied across birth settings with least effect in planned home births and a larger effect observed for planned FMU births. McCourt C, Rayment J, Rance S, Sandall J. Organisational strategies and midwives' readiness to provide care for out of hospital births: An analysis from the Birthplace organisational case studies. Midwifery. 2012;28(5):636-45. Fulltext link Objective The objective of the Birthplace in England Case Studies was to explore the organisational and professional issues that may impact on the quality and safety of labour and birth care in different birth settings: Home, Freestanding Midwifery Unit, Alongside Midwifery Unit or Obstetric Unit. This analysis examines the factors affecting the readiness of community midwives to provide women with choice of out of hospital birth, using the findings from the Birthplace in England Case Studies. Design Organisational ethnographic case studies, including interviews with professionals, key stakeholders, women and partners, observations of service processes and document review. Setting A maximum variation sample of four maternity services in terms of configuration, region and population characteristics. All were selected from the Birthplace cohort study sample as services scoring ‘best’ or ‘better’ performing in the Health Care Commission survey of maternity services (HCC 2008). Participants Professionals and stakeholders (n=86), women (64), partners (6), plus 50 observations and 200 service documents. Findings Each service experienced challenges in providing an integrated service to support choice of place of birth. Deployment of community midwives was a particular concern. Community midwives and managers expressed lack of confidence in availability to cover home birth care in particular, with the exception of caseload midwifery and a ‘hub and spoke’ model of care. Community midwives and women's interviews indicated that many lacked home birth experience and confidence. Those in midwifery units expressed higher levels of support and confidence. Key conclusions and implications for practice Maternity services need to consider and develop models for provision of a more integrated model of staffing across hospital and community boundaries.

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Rowe RE, Townend J, Brocklehurst P, Knight M, Macfarlane A, McCourt C, Newburn M, Redshaw M, Sandall J, Silverton L, Hollowell J. Service configuration, unit characteristics and variation in intervention rates in a national sample of obstetric units in England: an exploratory analysis. BMJ Open. 2014;4(5):e005551. Fulltext link Objectives To explore whether service configuration and obstetric unit (OU) characteristics explain variation in OU intervention rates in ‘low-risk’ women. Design Ecological study using funnel plots to explore unit-level variations in adjusted intervention rates and simple linear regression, stratified by parity, to investigate possible associations between unit characteristics/configuration and adjusted intervention rates in planned OU births. Characteristics considered: OU size, presence of an alongside midwifery unit (AMU), proportion of births in the National Health Service (NHS) trust planned in midwifery units or at home and midwifery ‘under’ staffing. Setting 36 OUs in England. Participants ‘Low-risk’ women with a ‘term’ pregnancy planning vaginal birth in a stratified, random sample of 36 OUs. Main outcome measures Adjusted rates of intrapartum caesarean section, instrumental delivery and two composite measures capturing birth without intervention (‘straightforward’ and ‘normal’ birth). Results Funnel plots showed unexplained variation in adjusted intervention rates. In NHS trusts where proportionately more non-OU births were planned, adjusted intrapartum caesarean section rates in the planned OU births were significantly higher (nulliparous: R2=31.8%, coefficient=0.31, p=0.02; multiparous: R2=43.2%, coefficient=0.23, p=0.01), and for multiparous women, rates of ‘straightforward’ (R2=26.3%, coefficient=−0.22, p=0.01) and ‘normal’ birth (R2=17.5%, coefficient=0.24, p=0.01) were lower. The size of the OU (number of births), midwifery ‘under’ staffing levels (the proportion of shifts where there were more women than midwives) and the presence of an AMU were associated with significant variation in some interventions. Conclusions Trusts with greater provision of non-OU intrapartum care may have higher intervention rates in planned ‘low-risk’ OU births, but at a trust level this is likely to be more than offset by lower intervention rates in planned non-OU births. Further research using high quality data on unit characteristics and outcomes in a larger sample of OUs and trusts is required. Rowe RE, Townend J, Brocklehurst P, Knight M, Macfarlane A, Mc Court C, Newburn M, Redshaw M, Sandall J, Silverton L, Hollowell J. Duration and urgency of transfer in births planned at home and in freestanding midwifery units in England: secondary analysis of the birthplace national prospective cohort study. BMC Pregnancy and Childbirth. 2013;13(1):224. Fulltext link Background In England, there is a policy of offering healthy women with straightforward pregnancies a choice of birth setting. Options may include home or a freestanding midwifery unit (FMU). Transfer rates from these settings are around 20%, and higher for nulliparous women. The duration of transfer is of interest because of the potential for delay in access to specialist care and is also of concern to women. We aimed to estimate the duration of transfer in births planned at home and in FMUs and explore the effects of distance and urgency on duration. Methods This was a secondary analysis of data collected in a national prospective cohort study including 27,842 ‘low risk’ women with singleton, term, ‘booked’ pregnancies, planning birth in FMUs or at home in England from April 2008 to April 2010. We described transfer duration using the median and interquartile range, for all transfers and those for reasons defined as potentially urgent or non-urgent, and used cumulative distribution curves to compare transfer duration by urgency. We explored the effect of distance for transfers from FMUs and described outcomes in women giving birth within 60 minutes of transfer.

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Results The median overall transfer time, from decision to transfer to first OU assessment, was shorter in transfers from home compared with transfers from FMUs (49 vs 60 minutes; p < 0.001). The median duration of transfers before birth for potentially urgent reasons (home 42 minutes, FMU 50 minutes) was 8–10 minutes shorter compared with transfers for non-urgent reasons. In transfers for potentially urgent reasons, the median overall transfer time from FMUs within 20 km of an OU was 47 minutes, increasing to 55 minutes from FMUs 20-40 km away and 61 minutes in more remote FMUs. In women who gave birth within 60 minutes after transfer, adverse neonatal outcomes occurred in 1-2% of transfers. Conclusions Transfers from home or FMU commonly take up to 60 minutes from decision to transfer, to first assessment in an OU, even for transfers for potentially urgent reasons. Most transfers are not urgent and emergencies and adverse outcomes are uncommon, but urgent transfer is more likely for nulliparous women. Rowe RE, Fitzpatrick R, Hollowell J, Kurinczuk JJ. Transfers of women planning birth in midwifery units: data from the Birthplace prospective cohort study. British Journal of Obstetrics and Gynaecology. 2012;119(9):1081-90. Fulltext link Objective To examine the percentage of women transferred, reasons for transfer and factors associated with the transfer of women planning birth in midwifery units (MUs). Design Prospective cohort study. Setting All freestanding midwifery units (FMUs) and alongside midwifery units (AMUs) in England. Participants Twenty-nine thousand, two hundred and forty-eight eligible women with a singleton, term and ‘booked’ pregnancy, planning birth in an MU between April 2008 and April 2010. Methods Multivariable logistic regression was used to explore the sociodemographic and clinical characteristics associated with transfer. Main outcome measures Transfer during labour or within 24 hours of birth. Results Over one in four women were transferred from AMUs and over one in five from FMUs. In both types of MU, compared with multiparous women aged 25–29 years, nulliparous women aged <20 years had higher odds of transfer (FMU-adjusted odds ratio [OR], 4.5; 95% confidence interval [CI], 3.10–6.57; AMU-adjusted OR, 2.6; 95% CI, 2.18–2.06), and the odds of transfer increased with increasing age. Nulliparous women aged ≥35 years in FMUs had 7.4 times the odds of transfer (95% CI, 5.43–10.10) and, in AMUs, 6.0 times the odds of transfer (95% CI, 4.81–7.41). Starting labour care after 40 weeks of gestation and the presence of complicating conditions at the start of labour care were also independently associated with a higher risk of transfer. Conclusions Transfer from MUs is common, especially for first-time mothers. This study provides evidence on the maternal characteristics associated with an increased risk of transfer, which can be used to inform women’s choices about place of birth. Schroeder E, Petrou S, Patel N, Hollowell J, Puddicombe D, Redshaw M, Brocklehurst P. Cost effectiveness of alternative planned places of birth in woman at low risk of complications: evidence from the Birthplace in England national prospective cohort study. British Medical Journal. 2012;344. Fulltext link Objectives To estimate the cost effectiveness of alternative planned places of birth. Design Economic evaluation with individual level data from the Birthplace national prospective cohort study. Setting 142 of 147 trusts providing home birth services, 53 of 56 freestanding midwifery units, 43 of 51 alongside midwifery units, and a random sample of 36 of 180 obstetric units, stratified by unit size and geographical region, in England, over varying periods of time within the study period 1 April 2008 to 30 April 2010. Participants 64 538 women at low risk of complications before the onset of labour.

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Interventions Planned birth in four alternative settings: at home, in freestanding midwifery units, in alongside midwifery units, and in obstetric units. Main outcome measures Incremental cost per adverse perinatal outcome avoided, adverse maternal morbidity avoided, and additional normal birth. The non-parametric bootstrap method was used to generate net monetary benefits and construct cost effectiveness acceptability curves at alternative thresholds for cost effectiveness. Results The total unadjusted mean costs were £1,066, £1,435, £1,461, and £1,631 for births planned at home, in freestanding midwifery units, in alongside midwifery units, and in obstetric units, respectively (equivalent to about €1,274, $1,701; €1,715, $2,290; €1,747, $2,332; and €1,950, $2,603). Overall, and for multiparous women, planned birth at home generated the greatest mean net benefit with a 100% probability of being the optimal setting across all thresholds of cost effectiveness when perinatal outcomes were considered. There was, however, an increased incidence of adverse perinatal outcome associated with planned birth at home in nulliparous low risk women, resulting in the probability of it being the most cost effective option at a cost effectiveness threshold of £20,000 declining to 0.63. With regards to maternal outcomes in nulliparous and multiparous women, planned birth at home generated the greatest mean net benefit with a 100% probability of being the optimal setting across all thresholds of cost effectiveness. Conclusions For multiparous women at low risk of complications, planned birth at home was the most cost effective option. For nulliparous low risk women, planned birth at home is still likely to be

the most cost effective option but is associated with an increase in adverse perinatal outcomes.

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Appendix Four: Abstracts of Quantitative Studies Relating to Place of Birth

from Outside of the UK Blix et al, 2016, ‘Transfer to hospital in planned home birth in four Nordic countries – A Prospective Cohort Study, Acta OBstet. Gyn, Scand, 95,4 Introduction Women planning a home birth are transferred to hospital in case of complications or elevated risk for adverse outcomes. The aim of the present study was to describe the indications for transfer to hospital in planned home births, and the proportion of cases in which this occurs. Material and Methods Women in Norway, Sweden, Denmark and Iceland who had opted for, and were accepted for, home birth at the onset of labor, were included in the study. Data from 3068 women, 572 nulliparas and 2,446 multiparas, were analyzed for proportion of transfers during labor and within 72 h after birth, indications for transfer, how long before or after birth the transfer started, time from birth to start of transfer, duration and mode of transfer, and whether the transfer was classified as potentially urgent. Analyses were stratified for nulliparity and multiparity. Results One-third (186/572) of the nulliparas were transferred to hospital, 137 (24.0%) during labor and 49 (8.6%) after the birth. Of the multiparas, 195/2,446 (8.0%) were transferred, 118 (4.8%) during labor and 77 (3.2%) after birth. The most common indication for transfers during labor was slow progress. In transfers after birth, postpartum hemorrhage, tears and neonatal respiratory problems were the most common indications. A total of 116 of the 3068 women had transfers classified as potentially urgent. Conclusions One-third of all nulliparous and 8.0% of multiparous women were transferred during labor or within 72 h of the birth. The proportion of potentially urgent transfers was 3.8%. Cheyney et al, 2014, Outcomes of care for 16,924 planned home births in the United States: the Midwives Alliance of North America Statistics Project, 2004 to 2009, J Midwifery Womens Health. 59(1):17-27, 2014 Jan-Feb Introduction Between 2004 and 2010, the number of home births in the United States rose by 41%, increasing the need for accurate assessment of the safety of planned home birth. This study examines outcomes of planned home births in the United States between 2004 and 2009. Methods We calculated descriptive statistics for maternal demographics, antenatal risk profiles, procedures, and outcomes of planned home births in the Midwives Alliance of North American Statistics Project (MANA Stats) 2.0 data registry. Data were analyzed according to intended and actual place of birth. Results Among 16,924 women who planned home births at the onset of labor, 89.1% gave birth at home. The majority of intrapartum transfers were for failure to progress, and only 4.5% of the total sample required oxytocin augmentation and/or epidural analgesia. The rates of spontaneous vaginal birth, assisted vaginal birth, and cesarean were 93.6%, 1.2%, and 5.2%, respectively. Of the 1054 women who attempted a vaginal birth after cesarean, 87% were successful. Low Apgar scores (< 7) occurred in 1.5% of newborns. Postpartum maternal (1.5%) and neonatal (0.9%) transfers were infrequent. The majority (86%) of newborns were exclusively breastfeeding at 6 weeks of age. Excluding lethal anomalies, the intrapartum, early neonatal, and late neonatal mortality rates were 1.30, 0.41, and 0.35 per 1,000, respectively. Discussion For this large cohort of women who planned midwife-led home births in the United States, outcomes are congruent with the best available data from population-based, observational studies that evaluated outcomes by intended place of birth and perinatal risk factors. Low-risk women in this cohort experienced high rates of physiologic birth and low rates of intervention without an increase in adverse outcomes.

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Davis et al, 2011, Planned Place of Birth in New Zealand: Does it Affect Mode of Birth and Intervention Rates Among Low-Risk Women? Birth, 38:2,2011 Background Midwives providing care as lead maternity caregivers in New Zealand provide continuity of care to women who may give birth in a variety of settings, including home, primary units, and secondary and tertiary level hospitals. The purpose of this study was to compare mode of birth and intrapartum intervention rates for low-risk women planning to give birth in these settings under the care of midwives. Methods Data for a cohort of low risk women giving birth in 2006 and 2007 were extracted from the Midwifery Maternity Provider Organisation database. Mode of birth, intrapartum interventions, and neonatal outcomes were compared with results adjusted for age, parity, ethnicity, and smoking. Results Women planning to give birth in secondary and tertiary hospitals had a higher risk of cesarean section, assisted modes of birth, and intrapartum interventions than similar women planning to give birth at home and in primary units. The risk of emergency cesarean section for women planning to give birth in a tertiary unit was 4.62 (95% CI: 3.66–5.84) times that of a woman planning to give birth in a primary unit. Newborns of women planning to give birth in secondary and tertiary hospitals also had a higher risk of admission to a neonatal intensive care unit (RR: 1.40, 95% CI: 1.05–1.87; RR: 1.78, 95% CI: 1.31–2.42) than women planning to give birth in a primary unit. Conclusions Planned place of birth has a significant influence on mode of birth and rates of intrapartum intervention in childbirth. Davis et al, 2012, Risk of Severe Postpartum Hemorrhage in Low-Risk Childbearing Women in New Zealand: Exploring the Effect of Place of Birth and Comparing Third Stage Management of Labor, BIRTH 39:2 June 2012 Background Primary postpartum hemorrhage is a leading cause of maternal mortality and morbidity internationally. Research comparing physiological (expectant) and active management of the third stage of labor favors active management, although studies to date have focused on childbirth within hospital settings, and the skill levels of birth attendants in facilitating physiological third stage of labor have been questioned. The aim of this study was to investigate the effect of place of birth on the risk of postpartum hemorrhage and the effect of mode of management of the third stage of labor on severe postpartum hemorrhage. Methods Data for 16,210 low-risk women giving birth in 2006 and 2007 were extracted from the New Zealand College of Midwives research database. Modes of third stage management and volume of blood lost were compared with results adjusted for age, parity, ethnicity, smoking, length of labor, mode of birth, episiotomy, perineal trauma, and newborn birthweight greater than 4,000 g. Results: In total, 1.32 percent of this low-risk cohort experienced an estimated blood loss greater than 1,000 mL. Place of birth was not found to be associated with risk of blood loss greater than 1,000 mL. More women experienced blood loss greater than 1,000 mL in the active management of labor group for all planned birth places. In this low risk cohort, those women receiving active management of third stage of labor had a twofold risk (RR: 2.12, 95% CI: 1.39–3.22) of losing more than 1,000 mL blood compared with those expelling their placenta physiologically. Conclusions Planned place of birth does not influence the risk of blood loss greater than 1,000 mL. In this low-risk group active management of labor was associated with a twofold increase in blood loss greater than 1,000 mL compared with physiological management.

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De Jonge et al, 2015, ‘Perinatal mortality and morbidity up to 28 days after birth among 743 070

low-risk planned home and hospital births: a cohort study based on three merged national perinatal

databases’, BJOG: An International Journal of Obstetrics & Gynaecology. 122(5):720-8, 2015 Apr

Objective To compare rates of adverse perinatal outcomes between planned home births versus planned hospital births. Design A nationwide cohort study. Setting The Netherlands. Population Low-risk women in midwife-led care at the onset of labour. Methods Analysis of national registration data. Main outcome measures Intrapartum and neonatal death, Apgar scores, and admission to a neonatal intensive care unit (NICU) within 28 days of birth. Results Of the total of 814,979 women, 466,112 had a planned home birth and 276,958 had a planned hospital birth. For 71,909 women, their planned place of birth was unknown. The combined intrapartum and neonatal death rates up to 28 days after birth, including cases with discrepancies in the registration of the moment of death, were: for nulliparous women, 1.02 for planned home births versus 1.09 for planned hospital births, adjusted odds ratio (aOR) 0.99, 95% confidence interval (95% CI) 0.79-1.24; and for parous women, 0.59 versus 0.58, aOR 1.16, 95% CI 0.87-1.55. The rates of NICU admissions and low Apgar scores did not significantly differ among nulliparous women (NICU admissions up to 28 days, 3.41 versus 3.61, aOR 1.05, 95% CI 0.92-1.18). Among parous women the rates of Apgar scores below seven and NICU admissions were significantly lower among planned home births (NICU admissions up to 28 days, 1.36 versus 1.95, aOR 0.79, 95% CI 0.66-0.93). Conclusions We found no increased risk of adverse perinatal outcomes for planned home births among low-risk women. Our results may only apply to regions where home births are well integrated into the maternity care system. Halfdansdottir et al, 2015, Outcome of Planned Home and Hospital Births among Low-Risk Women in Iceland in 2005–2009: A Retrospective Cohort Study, BIRTH 42:1 March 2015 Background At 2.2 percent in 2012, the home birth rate in Iceland is the highest in the Nordic countries and has been rising rapidly in the new millennium. The objective of this study was to compare the outcomes of planned home births and planned hospital births in comparable low-risk groups in Iceland. Methods The study is a retrospective cohort study comparing the total population of 307 planned home births in Iceland in 2005–2009 to a matched 1:3 sample of 921 planned hospital births. Regression analysis, adjusted for confounding variables, was performed for the primary outcome variables. Results The rate of oxytocin augmentation, epidural analgesia, and postpartum hemorrhage was significantly lower when labor started as a planned home birth. Differences in the rates of other primary outcome variables were not significant. The home birth group had lower rates of operative birth and obstetric anal sphincter injury. The rate of 5-minute Apgar score < 7 was the same in the home and hospital birth groups, but the home birth group had a higher rate of neonatal intensive care unit admission. Intervention and adverse outcome rates in both study groups, including transfer rates, were higher among primiparas than multiparas. Oxytocin augmentation, epidural analgesia, and postpartum hemorrhage rates were significantly interrelated. Conclusions This study adds to the growing body of evidence that suggests that planned home birth for low-risk women is as safe as planned hospital birth.

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Hendrix et al, 2009, Cost analysis of the Dutch obstetric system: low-risk nulliparous women preferring home or short-stay hospital birth--a prospective non-randomised controlled study.,BMC Health Services Research. 9:211, 2009. Background In the Netherlands, pregnant women without medical complications can decide where they want to give birth, at home or in a short-stay hospital setting with a midwife. However, a decrease in the home birth rate during the last decennium may have raised the societal costs of giving birth. The objective of this study is to compare the societal costs of home births with those of births in a short-stay hospital setting. Methods This study is a cost analysis based on the findings of a multicenter prospective non-randomised study comparing two groups of nulliparous women with different preferences for where to give birth, at home or in a short-stay hospital setting. Data were collected using cost diaries, questionnaires and birth registration forms. Analysis of the data is divided into a base case analysis and a sensitivity analysis. Results In the group of home births, the total societal costs associated with giving birth at home were euro 3,695 (per birth), compared with euro 3,950 per birth in the group for short-stay hospital births. Statistically significant differences between both groups were found regarding the following cost categories 'Cost of contacts with health care professionals during delivery' (euro138.38 vs. euro87.94, -50 (2.5-97.5 percentile range (PR)-76;-25), p < 0.05), 'cost of maternity care at home' (euro1,551.69 vs. euro1,240.69, -311 (PR -485; -150), p < 0.05) and 'cost of hospitalisation mother' (euro707.77 vs. 959.06, 251 (PR 69;433), p < 0.05). The highest costs are for hospitalisation (41% of all costs). Because there is a relatively high amount of (partly) missing data, a sensitivity analysis was performed, in which all missing data were included in the analysis by means of general mean substitution. In the sensitivity analysis, the total costs associated with home birth are euro4,364 per birth, and euro4,541 per birth for short-stay hospital births. Conclusion The total costs associated with pregnancy, delivery, and postpartum care are comparable for home birth and short-stay hospital birth. The most important differences in costs between the home birth group and the short-stay hospital birth group are associated with maternity care assistance, hospitalisation, and travelling costs. Janssen et al , 2009, ‘ Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician’, CMAJ Canadian Medical Association Journal. 181(6-7):377-83, 2009 Sep 15. Background Studies of planned home births attended by registered midwives have been limited by incomplete data, non representative sampling, inadequate statistical power and the inability to exclude unplanned home births. We compared the outcomes of planned home births attended by midwives with those of planned hospital births attended by midwives or physicians. Methods We included all planned home births attended by registered midwives from Jan. 1, 2000, to Dec. 31, 2004, in British Columbia, Canada (n = 2,889), and all planned hospital births meeting the eligibility requirements for home birth that were attended by the same cohort of midwives (n = 4,752). We also included a matched sample of physician-attended planned hospital births (n = 5,331). The primary outcome measure was perinatal mortality; secondary outcomes were obstetric interventions and adverse maternal and neonatal outcomes. Results The rate of perinatal death per 1,000 births was 0.35 (95% confidence interval [CI] 0.00–1.03) in the group of planned home births; the rate in the group of planned hospital births was 0.57 (95% CI 0.00–1.43) among women attended by a midwife and 0.64 (95% CI 0.00–1.56) among those attended by a physician. Women in the planned home-birth group were significantly less likely than those who planned a midwife-attended hospital birth to have obstetric interventions (e.g., electronic fetal monitoring, relative risk [RR] 0.32, 95% CI 0.29–0.36; assisted vaginal delivery, RR 0.41, 95% 0.33–0.52) or adverse maternal outcomes (e.g., third- or fourth-degree perineal tear, RR

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0.41, 95% CI 0.28–0.59; postpartum hemorrhage, RR 0.62, 95% CI 0.49–0.77). The findings were similar in the comparison with physician-assisted hospital births. Newborns in the home-birth group were less likely than those in the midwife-attended hospital-birth group to require resuscitation at birth (RR 0.23, 95% CI 0.14–0.37) or oxygen therapy beyond 24 hours (RR 0.37, 95% CI 0.24–0.59). The findings were similar in the comparison with newborns in the physician-assisted hospital births; in addition, newborns in the home-birth group were less likely to have meconium aspiration (RR 0.45, 95% CI 0.21–0.93) and more likely to be admitted to hospital or readmitted if born in hospital (RR 1.39, 95% CI 1.09–1.85). Interpretation Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician. Janssen P et al, 2015, ‘Costs of Planned Home vs. Hospital Birth in British Columbia Attended by Registered Midwives and Physicians’, PLoS ONE [Electronic Resource]. 10(7):e0133524, 2015 Background Home birth is available to women in Canada who meet eligibility requirements for low risk status after assessment by regulated midwives. While UK researchers have reported lower costs associated with planned home birth, there have been no published studies of the costs of home versus hospital birth in Canada. Methods Costs for all women planning home birth with a regulated midwife in British Columbia, Canada were compared with those of all women who met eligibility requirements for home birth and were planning to deliver in hospital with a registered midwife, and with a sample of women of similar low risk status planning birth in the hospital with a physician. We calculated costs of physician service billings, midwifery fees, hospital in-patient costs, pharmaceuticals, home birth supplies, and transport. We compared costs among study groups using the Kruskall Wallis test for independent groups. Population A total of 9,864 women were included in the study. The total number of planned home births was 2,243, the total number of planned hospital births with a midwife for women meeting the eligibility criteria for home birth was 3610. 4011 women had planned hospital birth with a physician and met the eligibility criteria for home birth. Women were both primiparous and multiparous. The results included the costs of emergency transport from a home birth setting for mother and baby – including air transport. Results In the first 28 days postpartum, we report a $2,338 average savings per birth among women planning home birth compared to hospital birth with a midwife and $2,541 compared to hospital birth planned with a physician. In longer term outcomes, similar reductions were observed, with cost savings per birth at $1,683 compared to the planned hospital birth with a midwife, and $1,100 compared to the physician group during the first eight weeks postpartum. During the first year of life, costs for infants of mothers planning home birth were reduced overall. Cost savings compared to planned hospital births with a midwife were $810 and with a physician $1,146. Costs were similarly reduced when findings were stratified by parity. Conclusions Planned home birth in British Columbia with a registered midwife compared to planned hospital birth is less expensive for our health care system up to 8 weeks postpartum and to one year of age for the infant.

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Lindgrenz et al, 2008, ‘Outcome of planned home births compared to hospital births in Sweden between 1992 and 2004. A population-based register study’, Acta Obstetricia et Gynecologica. 2008; 87: 751_759 Objective The aim of this population-based study was to measure the risk of adverse outcome for mother and child in planned home births in a Swedish population irrespective of where the birth actually occurred, at home or in hospital after transfer. Design A population-based study using data from the Swedish Medical Birth Register. Setting. Sweden 1992_2004. Participants A total of 897 planned home births were compared with a randomly selected group of 11,341 planned hospital births. Main outcome measures Prevalence of mortality and morbidity among mothers and children, emergency conditions, instrumental and operative delivery and perineal lacerations were compared. Results During this period in Sweden the neonatal mortality rate was 2.2 per thousand in the home birth group and 0.7 in the hospital group (RR 3.6, 95% CI 0.2_14.7). No cases of emergency complications were found in the home birth group. The risk of having a sphincter rupture was lower in the planned home birth group (RR 0.2, 95% CI 0.0_0.7). The risk of having a cesarean section (RR 0.4, 95% CI0.2_0.7) or instrumental delivery (RR 0.3, 95% CI 0.2_0.5) was significantly lower in the planned home birth group. Conclusion In Sweden, between 1992 and 2004, the intrapartum and neonatal mortality in planned home births was 2.2 per thousand. The proportion is higher compared to hospital births but no statistically significant difference was found. Women in the home birth group more often experienced a spontaneous birth without medical intervention and were less likely to sustain pelvic floor injuries. Overgaard et al, 2012, ‘Freestanding midwifery units versus obstetric units: does the effect of place of birth differ with level of social disadvantage’, BMC Public Health 2012, 12:478 Background Social inequity in perinatal and maternal health is a well-documented health problem even in countries with a high level of social equality. We aimed to study whether the effect of birthplace on perinatal and maternal morbidity, birth interventions and use of pain relief among low risk women intending to give birth in two freestanding midwifery units (FMU) versus two obstetric units in Denmark differed by level of social disadvantage. Methods The study was designed as a cohort study with a matched control group. It included 839 low-risk women intending to give birth in an FMU, who were prospectively and individually matched on nine selected obstetric/socio-economic factors to 839 low-risk women intending OU birth. Educational level was chosen as a proxy for social position. Analysis was by intention-to-treat. Results Women intending to give birth in an FMU had a significantly higher likelihood of uncomplicated, spontaneous birth with good outcomes for mother and infant compared to women intending to give birth in an OU. The likelihood of intact perineum, use of upright position for birth and water birth was also higher. No difference was found in perinatal morbidity or third/fourth degree tears, while birth interventions including caesarean section and epidural analgesia were significantly less frequent among women intending to give birth in an FMU. In our sample of healthy low-risk women with spontaneous onset of labour at term after an uncomplicated pregnancy, the positive results of intending to give birth in an FMU as compared to an OU were found to hold for both women with post-secondary education and the potentially vulnerable group of FMU women without post-secondary education. In all cases, women without post-secondary education intending to give birth in an FMU had comparable and, in some respects, more favourable outcomes when compared to women with the same level of education intending to give birth in an OU. In this sample of low-risk women, we found that the effect of intended place on birth outcomes did not differ with women’s level of education.

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Conclusion FMU care appears to offer important benefits for birthing women with no additional risk to the infant. Both for women with and without post-secondary education, intending to give birth in an FMU significantly increased the likelihood of a spontaneous, uncomplicated birth with good outcomes for mother and infant compared to women intending to give birth in an OU. All women should be provided with adequate information about different care models and supported in making an informed decision about the place of birth. Van der Kooy et al, 2011, Planned Home Compared With Planned Hospital Births in The Netherlands: Intrapartum and Early Neonatal Death in Low-Risk Pregnancies’, Obstetrics & Gynecology, Volume 118(5), November 2011, p 1037–1046

Objective The purpose of our study was to compare the intrapartum and early neonatal mortality rate of planned home birth with planned hospital birth in community midwife-led deliveries after case mix adjustment. Methods The perinatal outcome of 679,952 low-risk women was obtained from the Netherlands Perinatal Registry (2000–2007). This group represents all women who had a choice between home and hospital birth. Two different analyses were performed: natural prospective approach (intention-to-treat–like analysis) and perfect guideline approach (per-protocol–like analysis). Unadjusted and adjusted odds ratios (ORs) were calculated. Case mix was based on the presence of at least one of the following: congenital abnormalities, small for gestational age, preterm birth, or low Apgar score. We also investigated the potential risk role of intended place of birth. Multivariate stepwise logistic regression was used to investigate the potential risk role of intended place of birth. Results Intrapartum and neonatal death at 0–7 days was observed in 0.15% of planned home compared with 0.18% in planned hospital births (crude relative risk 0.80, 95% confidence interval [CI] 0.71–0.91). After case mix adjustment, the relation is reversed, showing non significant increased mortality risk of home birth (OR 1.05, 95% CI 0.91–1.21). In certain subgroups, additional mortality may arise at home if risk conditions emerge at birth (up to 20% increase). Conclusion Home birth, under routine conditions, is generally not associated with increased intrapartum and early neonatal death, yet in subgroups, additional risk cannot be excluded.

Wax et al, 2010, Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis, Am J Obstet Gynecol. 203(3):243.e1-8, 2010 Sep. Objective We sought to systematically review the medical literature on the maternal and newborn safety of planned home vs planned hospital birth. Study design We included English-language peer-reviewed publications from developed Western nations reporting maternal and newborn outcomes by planned delivery location. Outcomes' summary odds ratios with 95% confidence intervals were calculated. Results Planned home births were associated with fewer maternal interventions including epidural analgesia, electronic fetal heart rate monitoring, episiotomy, and operative delivery. These women were less likely to experience lacerations, hemorrhage, and infections. Neonatal outcomes of planned home births revealed less frequent prematurity, low birthweight, and assisted newborn ventilation. Although planned home and hospital births exhibited similar perinatal mortality rates, planned home births were associated with significantly elevated neonatal mortality rates. Conclusion Less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate. The Wax meta-analysis did not follow the standards set out for meta analysis by the Cochrane library or PRISMA. It is worthy of note that following the publication of the Wax meta analysis there was considerable robust contention of the findings. Criticisms cited of the Wax analysis are that it

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included unplanned and unattended home births and high risk home births in its analysis. The Wax review also included some very old studies, dating back to the 1970s. Some of the articles refuting the conclusions of the Wax analysis can be read here: http://www.nature.com/news/2011/110318/full/news.2011.162.html https://www.midwiferytoday.com/articles/ajog_response.asp

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References, Bibliography Birthrights Organisation, 2013, Dignity in Childbirth: the dignity survey 2013: women and midwives experiences of dignity in UK maternity care’, http://www.birthrights.org.uk/wordpress/wp-content/uploads/2013/10/Birthrights-Dignity-Survey.pdf Blix et al, 2016, Transfer to hospital in planned home birth in four Nordic countries – a prospective cohort study, Acta OBstet. Gyn, Scand, 95,4 Care Quality Commission, 2016, Maternity services survey 2015, CQC London http://www.cqc.org.uk/content/maternity-services-survey-2015 Cheyne et al, 2015, Having a baby in Scotland 2015: listening to mothers; Office of National Statistics, Edinburgh. http://www.gov.scot/Resource/0049/00490953.pdf Cheyney et al, 2014, Outcomes of care for 16,924 planned home births in the United States: the Midwives Alliance of North America Statistics Project, 2004 to 2009, J Midwifery Womens Health. 59(1):17-27, 2014 Jan-Feb Davis et al, 2011, Planned Place of Birth in New Zealand: Does it Affect Mode of Birth and Intervention Rates Among Low-Risk Women? Birth, 38:2,2011 Davis et al, 2012, Risk of Severe Postpartum Hemorrhage in Low-Risk Childbearing Women in New Zealand: Exploring the Effect of Place of Birth and Comparing Third Stage Management of Labor, BIRTH 39:2 June 2012 De Jonge et al, 2015, Perinatal mortality and morbidity up to 28 days after birth among 743 070 low-risk planned home and hospital births: a cohort study based on three merged national perinatal databases, BJOG: An International Journal of Obstetrics & Gynaecology. 122(5):720-8, 2015 Apr Halfdansdottir et al, 2015, Outcome of Planned Home and Hospital Births among Low-Risk Women in Iceland in 2005–2009: A Retrospective Cohort Study, BIRTH 42:1 March 2015 Hendrix et al, 2009, Cost analysis of the Dutch obstetric system: low-risk nulliparous women preferring home or short-stay hospital birth--a prospective non-randomised controlled study.,BMC Health Services Research. 9:211, 2009. Hollowell J, Pillas D, Rowe R, Linsell L, Knight M, Brocklehurst P, The impact of maternal obesity on intrapartum outcomes in otherwise low risk women: secondary analysis of the Birthplace national prospective cohort study. Br Journal Obstet Gynaecol. 2014;121:343-55. Fulltext link Hollowell et al, 2015 a, Review of Maternity Services, NHS England. Report 2: Perinatal and maternal outcomes by parity in midwifery-led settings: secondary analysis of the Birthplace in England cohort comparing outcomes in planned freestanding and alongside midwifery unit births, NPEU, Oxford Hollowell et al, 2015b, Review of Maternity Services England. Report 4: A systematic review and narrative synthesis of the quantitative and qualitative literature on women’s birth place preferences and experiences of choosing their intended place of birth in the UK, NPEU, Oxford. Janssen et al , 2009, Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician, CMAJ Canadian Medical Association Journal. 181(6-7):377-83, 2009 Sep 15.

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Janssen P et al, 2015, Costs of Planned Home vs. Hospital Birth in British Columbia Attended by Registered Midwives and Physicians, PLoS ONE [Electronic Resource]. 10(7):e0133524, 2015 Knight et al, 2015b, Review of Maternity Services, England. Report 3: Systematic review and case studies to assess models of consultant resident cover and the outcomes of intrapartum care; and two international case studies of the delivery of maternity care, NPEU, Oxofrd. Kurinczuk et al, 2015, Review of Maternity Services England. Report 1: Summary of the evidence on safety of place of birth; and implications for policy and practice from the overall evidence review, NPEU, Oxford Li Y, Townend J, Rowe R, Knight M, Brocklehurst P, Hollowell J. The effect of maternal age and planned place of birth on intrapartum outcomes in healthy women with straightforward pregnancies: secondary analysis of the Birthplace national prospective cohort study. BMJ Open. 2014;4(1):e004026. Fulltext link Li Y, Townend J, Rowe R, Brocklehurst P, Knight M, Linsell L, Macfarlane A, McCourt C, Newburn M, Marlow N, Pasupathy D, Redshaw M, Sandall J, Silverton L, Hollowell J, Perinatal and maternal outcomes in planned home and obstetric unit births in women at 'higher risk' of complications: secondary analysis of the Birthplace national prospective cohort study. BJOG. 2015;Epub:1-13. Fulltext link Lindgrenz et al, 2008, Outcome of planned home births compared to hospital births in Sweden between 1992 and 2004. A population-based register study, Acta Obstetricia et Gynecologica. 2008; 87: 751_759 Mccourt C, Rayment J, Rance S, Sandall J. Organisational strategies and midwives' readiness to provide care for out of hospital births: An analysis from the Birthplace organisational case studies. Midwifery. 2012;28(5):636-45. Fulltext link National perinatal epidemiology unit, 2014, Safely delivered: a national survey of women’s experience of maternity care, https://www.npeu.ox.ac.uk/downloads/files/reports/Safely%20delivered%20NMS%202014.pdf NFWi and NCT, 2013, Support overdue: Women’s experiences of maternity services https://www.thewi.org.uk/__data/assets/pdf_file/0006/49857/support-overdue-final-15-may-2013.pdf NICE, 2014, Intrapartum care of healthy women and babies, Clinical guideline 190 https://www.nice.org.uk/guidance/cg190 NICE 2016, Antenatal care for uncomplicated pregnancies https://www.nice.org.uk/guidance/cg62 Overgaard et al, 2012, Freestanding midwifery units versus obstetric units: does the effect of place of birth differ with level of social disadvantage, BMC Public Health 2012, 12:478 RCOG, RCM et al, 2007, Safer Childbirth: Minimum standards for the organisation and delivery of care in labour, https://www.rcog.org.uk/globalassets/documents/guidelines/wprsaferchildbirthreport2007.pdf RCOG, RCM, RCoA, RCPCH, 2008,Standards for maternity care, https://www.rcog.org.uk/globalassets/documents/guidelines/wprmaternitystandards2008.pdf

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RCOG, 2013, Reconfiguration of women’s services. Good Practice no.15, https://www.rcog.org.uk/globalassets/documents/guidelines/reconfiguration_good_practice_no.15_corrected_february_2014.pdf RCOG, 2015, NHS Cumbria Options Appraisal Final Report http://www.cumbriaccg.nhs.uk/about-us/2015-03-23--rcog-options-appraisal-final-report-(nopword).pdf Renfrew et al, 2014, Midwifery and quality care: findings from a new evidence informed framework for maternal and newborn care, The Lancet Rowe RE, Fitzpatrick R, Hollowell J, Kurinczuk JJ, Transfers of women planning birth in midwifery units: data from the Birthplace prospective cohort study. British Journal of Obstetrics and Gynaecology. 2012;119(9):1081-90. Fulltext link Rowe RE, Townend J, Brocklehurst P, Knight M, Macfarlane A, Mc Court C, Newburn M, Redshaw M, Sandall J, Silverton L, Hollowell J, Duration and urgency of transfer in births planned at home and in freestanding midwifery units in England: secondary analysis of the birthplace national prospective cohort study. BMC Pregnancy and Childbirth. 2013;13(1):224. Fulltext link Rowe RE, Townend J, Brocklehurst P, Knight M, Macfarlane A, McCourt C, Newburn M, Redshaw M, Sandall J, Silverton L, Hollowell J, Service configuration, unit characteristics and variation in intervention rates in a national sample of obstetric units in England: an exploratory analysis. BMJ Open. 2014;4(5):e005551.Fulltext link Schroeder E, Petrou S, Patel N, Hollowell J, Puddicombe D, Redshaw M, Brocklehurst P, Cost effectiveness of alternative planned places of birth in woman at low risk of complications: evidence from the Birthplace in England national prospective cohort study. British Medical Journal. 2012;344. Fulltext link

Scottish Government, Having a baby in Scotland 2015: listening to mothers, http://www.gov.scot/Resource/0049/00490953.pdf Scottish Health Council, 2016, NATIONAL REVIEW OF MATERNITY AND NEONATAL SERVICES : Patient Views and Experience of Maternity and Neonatal Services Van der Kooy et al, 2011, Planned Home Compared With Planned Hospital Births in The Netherlands: Intrapartum and Early Neonatal Death in Low-Risk Pregnancies’, Obstetrics & Gynecology, Volume 118(5), November 2011, p 1037–1046 Wax et al, 2010, Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis, Am J Obstet Gynecol. 203(3):243.e1-8, 2010 Sep.