NICE says ‘Midwife-led units safest for straightforward births’

By Professor Vanora Hundley, Professor of Midwifery.

They say that it takes a long time for research to get into practice; so I’m delighted to see that the recently released National Institute for Health and Care Excellence (NICE) guidelines recommend midwife-led care for women having ‘straightforward births’.

Twenty years ago I carried out one of the first studies to evaluate a midwife-led unit (in Aberdeen, Scotland). The study showed that women at low risk of complications had less intervention if they were cared for by midwives in an alongside midwife-led unit rather than a consultant-led labour ward. The NICE guidelines draw on our research, along with other studies from across the globe, to inform their recommendation that ‘More women should be encouraged to give birth at midwife-led units rather than traditional labour wards.’ 

So what is wrong with the ‘traditional labour ward’? 
It is important to clarify here that NICE is not saying that women having a straightforward birth should not be allowed to do so in a traditional, consultant-led labour ward. Women should be able to choose their place of birth and some women may prefer to give birth in an environment where doctors are present. However, it is important that women understand the implications of this decision. 

What are the implications?
The evidence clearly shows that women planning to birth in a midwife-led unit are more likely to have a normal birth and less likely to have intervention than women planning to birth in a traditional labour ward. Outcomes for the baby were similar in both units. Thus choosing to give birth in a traditional labour ward increases your chances of requiring an epidural, having an episiotomy, and needing an assisted birth (forceps birth or caesarean section) without any benefit to the baby.

But isn’t this because traditional labour wards deal with women at greater risk?
No, that cannot explain the findings. All the studies involved looked at women at low risk of complications, and controlled for other factors that could lead to a need for intervention. Thus we can be certain that any differences are due to the place of birth and the caregivers, and not to differences in level of risk.

The reasons behind the greater use of intervention in traditional labour wards are complex, but include staff perceptions of risk, increasing use of technology and fear of litigation. Doctors in traditional labour wards play an important and vital role in supporting women with pregnancy and birth complications. However, the belief that birth can only be normal in retrospect may lead them to intervene earlier in straightforward births and to use interventions when they are not required.

There is strong evidence that using simple interventions like electronic monitoring lead to other interventions such as epidurals and assisted births. In contrast midwives see birth as a normal life event and are less likely to use intervention and more likely to let birth follow a natural course.

Helping women to make the decision about place of birth
A woman’s decision about where to have her baby is a very personal and important one. However, with all the information that is available making this decision can be challenging.

Bournemouth University is working with Portsmouth NHS Hospitals Trust to evaluate a decision app to help women understand the evidence regarding place of birth. Hopefully we won’t have to wait another 20 years until this evidence gets into practice.