Revised clinical guidance has been issued today from NICE on intrapartum care.
I may seem cynical when I say that I am sceptical about the reasoning and motivation behind this Guidance which purports to rely on research findings to support the view that giving birth in a free standing midwifery or home birth setting is better and at least as safe as it is in a hospital for low risk first time mothers.
Is this view point really supported by reasoned analysis of the facts? Or simply yet another example of the drive to reduce expenditure within the NHS, or to justify the reallocation of resources away from the expensive hospital setting to cheaper alternatives?
It has long been recognised that home births are the cheapest option, requiring fewer midwives but can it really be said that childbirth at home or in a midwife only unit is safer for low risk women and their babies?
Certain risk factors can of course be identified during the antenatal period; diabetic mothers, maternal age, obesity, high blood pressure to name but a few. But what of those women who do not present as high risk from the outset and may, as a result of the new Guidance, be steered away from the more costly hospital based service to other alternatives?
The research upon which the Guidance is based did not include all-important data on outcomes for the number of women who were transferred from the midwife only setting to hospital when complications arose after the labour had started. Surely a fair and accurate analysis should have taken these women into account and the outcomes in order to give a full picture of what it means to be in the “midwife only or home birth setting” and to suddenly and unexpectedly face problems with the labour.
No two births are the same. The fundamental principle must be that women should be given accurate facts and appropriate and fair guidance in order to make an educated and informed choice about the safest place for them to have a baby. No woman should be lulled into a false sense of security from misleading guidance.
An apparently “low risk” mother, even when supported at home by the best midwife, can suddenly find that something is not going right with the labour. These women and their unborn child need urgent hospital based care, and intervention may be required with the minimum of delay. Can this specialist intervention be guaranteed to all women in the out of hospital setting, particularly if the numbers of home births are set to increase as a result of this Guidance? I for one do not think so.
The Guidance states that: “Commissioners and providers should ensure that all 4 birth settings are available to all women (in the local area or in a neighbouring area)” meaning that women should have a choice of birth at home, birth in a stand-alone midwifery unit, an alongside hospital setting, or a hospital. Can already stretched NHS resources really offer women the choice of four possible settings or will this just result in a postcode lottery of care facilities being available or the downgrading of hospital maternity care in some areas?
Another extremely worrying aspect of the new Guidance is the direction that low risk women in suspected or established labour should not have cardiotocography or CTG monitoring performed at the initial assessment and that decisions about a woman’s care in labour should not be based on the findings of CTG traces alone. Surely directions such as this will only serve to reduce the opportunity for staff to identify and act upon potential life threatening abnormalities in the fetal heart rate and potential indicators of stress in the unborn child?
As a lawyer who acts for parents of injured and brain damaged babies the CTG trace can be a helpful tool in the armoury of evidence to piece together retrospectively what went wrong during a birth and to assess whether the injuries could have been avoided by better care and earlier intervention. If this Guidance encourages less use of modern technology, designed to help make the process of childbirth safer, then are we not at risk of returning to the dark days when stillbirths, and brain injured children were simply accepted as inevitable acts of God or fate? Surely technologies such as CTG should be used to their full advantage, to inform and to guide? Surely experienced midwives should only be asked to care for labouring mothers if they can be fully satisfied that the back-up of the hospital setting, modern technology and surgical intervention is available at short notice and as and when required?
I for one am very concerned that the revised NICE Guidance could be potentially dangerous for mothers and babies in the future.