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The new NICE guidance on intrapartum care published today recommends that healthy women with straightforward pregnancies should be advised to give birth in midwifery-led units or at home rather than in a consultant-led obstetric unit. Key evidence for these recommendations comes from the Birthplace in England national cohort study, carried out by researchers in the National Perinatal Epidemiology Unit (NPEU) , Nuffield Department of Population Health and published in the BMJ in 2011.

The Birthplace cohort study compared the safety of births planned in four settings: home, freestanding midwifery units, alongside midwifery units and obstetric units. The main findings relate to healthy women with straightforward pregnancies who meet the NICE intrapartum care guideline criteria for a ‘low risk’ birth.

The study collected data on care in labour, delivery and birth outcomes for the mother and baby for over 64,000 ‘low risk’ births in England including nearly 17,000 planned births planned at home, 28,000 planned in midwifery units and nearly 20,000 planned  in obstetric units.

Safety for the baby was assessed by examining  how often babies had any of the following adverse outcomes: stillbirth during labour, death of the baby in the first week after birth ,neonatal encephalopathy (disordered brain function caused by oxygen deprivation before or during birth), meconium aspiration syndrome (where the baby breathes meconium into their lungs) , and physical  birth injuries such as brachial plexus injury, and bone fractures. These outcomes were chosen because differences in how often these events occurred might reflect differences in the quality of care received during the birth.

Safety for the mother was measured by looking both at poor medical outcomes, such as serious perineal tears or need for a blood transfusion, and also at whether the woman received obstetric interventions, such as an emergency caesarean section or a forceps or ventouse delivery.

The key Birthplace findings that have led to a change in the guidance given to women at low risk of complications are:

  • For planned births in freestanding midwifery units and alongside midwifery units there are no significant differences in adverse perinatal outcomes compared with planned birth in an obstetric unit.
  • Women who plan birth in a midwifery unit have significantly fewer interventions, including substantially fewer intrapartum caesarean sections, and more ‘normal births’ than women who plan birth in an obstetric unit.
  • For women having a second or subsequent baby, there are no significant differences in adverse perinatal outcomes between planned home births or midwifery unit births and planned births in obstetric units.
  • For women having a first baby, there is a significant increase in the risk of an adverse perinatal outcome, although the absolute risk is still low (9.3 adverse perinatal outcome events per 1000 planned home births compared with 5.3 per 1000 births for births planned in obstetric units)

Dr Jennifer Hollowell, one of the epidemiologists who ran the study, commented: “Before the Birthplace study, it was known that midwifery-led care reduced the risk of interventions during labour and birth, but there was insufficient evidence about the safety of different birth settings for the baby. Birthplace filled that gap in the evidence. Since we published the findings there has been a steady increase in the number of midwifery units around the country and I would expect the NICE guidance to accelerate this expansion. I would also expect more women having a second or subsequent baby to feel more confident about requesting a home birth. At the moment, less than 3% of births take place at home.”