RCOG statement on the results of the NPEU Birthplace study

The Birthplace study, conducted by the National Perinatal Epidemiology Unit (NPEU) at the University of Oxford, examined the impact of intended place of birth on maternal and perinatal outcomes for mothers with no complications in pregnancy. It compared four birth settings: birth in hospital obstetric units, free standing (FMU) and alongside (AMU) midwifery units and home birth.

The study looked at 65,000 births, which included nearly 17,000 planned home births and 28,000 planned midwifery unit births from 2008 – 2010.

It found that for women with no complications in pregnancy, childbirth is generally very safe. The outcome for mothers was good in all birth locations. In 250 births however, the baby had a poor outcome (4.3 events per 1000 births) across the four birth locations.

Key findings include:

• For first-time mothers planning to have a home birth, there was an increased risk of poor outcomes for the baby (9.3 per 1000 births compared with 5.3 per 1000 births in obstetric units). There was no increased risk for babies delivered at home in women who were in their second or subsequent pregnancy.
• There was a 45% transfer rate to obstetric units for first-time mothers planning to deliver at home. The transfer rate for midwifery units was 36.3% (FMU) and 40.2% (AMU).
• The transfer rate for mothers who were in their second or subsequent pregnancy to obstetric units was 12% (home birth), 9.4% (FMU) and 12.5% (AMU).
• Lower intervention rates were reported in both types of midwifery units.
• There are wide differences across the country in the availability of midwifery units, and in the way maternity services are organised and staffed with 50% of trusts having no midwifery units in 2010.

Dr Tony Falconer, President of the Royal College of Obstetricians & Gynaecologists (RCOG) said:

“The Birthplace study looks at a large number of women with no complications in pregnancy and provides us with robust data on the safety of births across four different settings. We now have good evidence on the risks and benefits of each birth setting, information that is important to help women and healthcare professionals make informed choices on the place of birth.

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“The RCOG has always supported appropriately selected home birth but this study has shown that first-time mothers wishing to deliver at home have an increased risk of poor

outcomes for their babies thus raising questions about the right birth location for this group of women. In addition, the high transfer rates from FMU and AMUs for first-time mothers pose serious logistical problems. The potential of having to transfer 36% of mothers from FMU to obstetric units raises many issues. In contrast, the close proximity of AMUs provides easier transfer thereby reducing stress and anxiety.

“The case is different for mothers with no complications in their subsequent pregnancies delivering at home or in a midwifery unit. There is therefore a need to expand these facilities with appropriate midwifery staffing to improve women’s choices.

“Following from our High Quality Women’s Health Care report, we recommend that services should be provided in managed clinical networks which link primary, community, secondary and tertiary services. This study supports the concept of configuring maternity services differently and the expansion of midwifery units should occur.

“Within an obstetric unit, care is provided in a multidisciplinary, multi-professional manner, involving midwives and specialist doctors. Midwifery and obstetric units both work to standard clinical guidelines and medical help is provided only when indicated. This study identified the need for further work on the adverse outcomes of home birth for first-time mothers and to examine why intervention rates are higher in obstetric units. The RCOG agrees that better information systems in maternity, through the implementation of the national maternity data set would be beneficial for delivering higher quality care.

“In order for our maternity services to work better, there is the need to concentrate obstetric care for the expanding numbers of complex pregnancies and also for the women bring transferred from other birth locations. These units should provide continuous senior medical staff presence on the labour ward, achieved by expanding the numbers of consultants in O&G.”

Staff Writer