By: 15 June 2020
Improvements in care could make birth in midwifery-led settings even safer

An investigation into deaths of babies in births planned in midwifery-led settings has found that improvements in care may have made a difference to the outcome in 75% of the deaths.

Such deaths are rare, occurring in around six in every 10,000 births, and the authors caution that their findings do not challenge the evidence that planned birth in a midwifery-led setting is safe and has many benefits for women who are healthy with straightforward pregnancies. 

A midwifery-led setting is a midwifery unit or planned birth at home, where the care during labour and birth is provided by midwives, with transfer to a hospital labour ward should the woman or baby need medical care.

The investigation reviewed the quality of care relating to 64 deaths of babies in England, Scotland and Wales between 2013 and 2016. In 75% of deaths, improvements in care may have made a difference to the outcome for the baby. Improvements which may have made a difference to the future health and wellbeing of the mother were also identified in 75% of the deaths.

The Enhancing the Safety of Midwifery-led Birth Enquiry (ESMiE) study, led by researchers in the National Institute for Health Research (NIHR) Policy Research Unit in Maternal Health and Care at the National Perinatal Epidemiology Unit, University of Oxford, used the same approach as a study carried out by the Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) collaboration.

The MBRRACE-UK enquiry, published in 2017, investigated 78 similar baby deaths. In most cases, the woman had planned to have her baby in a hospital consultant-led maternity unit or labour ward. The enquiry found that, in 78% of those deaths, improvements in care may have made a difference to the outcome for the baby.

Both studies used a confidential enquiry approach, which involves expert panels of midwives, obstetric and specialist baby (neonatal) doctors, and pathologists, reviewing anonymised medical records in cases where the baby died, and comparing the care provided against national standards and guidelines.

Dr Rachel Rowe, senior health services researcher in the National Perinatal Epidemiology Unit, said: “The death of a baby is a tragedy for the parents and wider family, and has lasting impact on all involved. Fortunately, deaths such as those investigated by the ESMiE team are extremely uncommon.”

“There is good evidence about the safety and benefits of planned birth in midwifery-led settings for women who are healthy with straightforward pregnancies. The ESMiE findings do not challenge that evidence or national policy and guidance, but they should be used to identify areas where care for women planning birth in midwifery-led settings can be improved and made even safer.”

The ESMiE study, published in BJOG, found that many of the issues identified when babies died after planned birth in a midwifery-led setting were the same as those identified in the MBRRACE-UK enquiry. Areas where potential improvements in care could be made with specific relevance to midwifery-led settings included:

  • Discussing and documenting planned place of birth and conducting risk assessments during pregnancy and at the start of labour to ensure that the chosen setting is an appropriate planned place of birth for the mother;
  • Ensuring prompt transfer during labour when required, with appropriate urgency, including ensuring timely care after transfer;
  • Monitoring progress during labour and appropriate use of intermittent monitoring of the baby’s heart rate;
  • Resuscitation and transfer of an unwell baby when no specialised newborn baby doctors (neonatologists) are on site; and
  • Involvement of midwives with experience of providing care in midwifery-led setting in follow up and local reviews of care.

Source: Nuffield Department of Population Health, University of Oxford