12 June 2009

Study calls for urgent review of NHS and independent birth care

Research: Outcomes for births booked under an independent midwife and births in NHS maternity units: matched comparison study Editorial: Independent midwifery care versus NHS care in the UK, BMJ online

There is an urgent need to review certain aspects of care for women giving birth using an independent midwife and those using NHS services, concludes a study published on bmj.com today (Friday June 12th).

Patient choice is a key aspect of government health policy in the UK and hospitals are urged to support low risk women who want to give birth at home.

Currently, around 2.5% of births occur in the home, most with NHS personnel in attendance, but a small number of women opt to employ an independent midwife, a self-employed qualified practitioner working outside the NHS.

Studies have consistently shown that, for low risk women, giving birth at home is as safe as giving birth in hospital, yet no studies have compared likely outcomes for women using an independent midwife and those using NHS services.

So a research team at the University of Dundee identified records for 8,676 women who had given birth between 2002 and 2005. Of these, 7,214 women had used NHS services and 1,462 had employed a member of the Independent Midwives Association (IMA).

Data on socio-economic status, medical history, and previous obstetric complications were collated for each mother. Clinical outcomes, such as onset and duration of labour, delivery, use of pain relieving drugs, and infant deaths, were then compared.

There were important differences between the two groups of women. For example, IMA group mothers were more likely to have a pre-existing medical condition and previous obstetric complications than NHS group mothers. IMA mothers were also more likely to have a twin pregnancy and breech presentation.

IMA mothers were significantly more likely to start labour spontaneously and have an unassisted vaginal birth than NHS mothers. IMA mothers also used fewer pain relieving drugs and were much more likely to breastfeed successfully than NHS mothers.

IMA mothers were also more likely to experience a stillbirth or a neonatal death than NHS mothers (1.7% in the IMA group compared with 0.6% in the NHS group).

However, when `high risk' cases were excluded from both groups, the difference was not statistically significant (0.5% in the IMA group and 0.3% in the NHS group). This suggests that it is these higher risk situations (breech birth and twin pregnancies) that account for the higher death rate, say the authors.

Although the average gestational age was very similar between the groups, birth weights in the IMA group were significantly higher than in the NHS group. NHS babies were also far more likely to be premature and admitted to a neonatal intensive care unit.

While clinical outcomes across a range of variables are much better for women using an independent midwife, the significantly higher perinatal mortality rate, particularly in higher risk women, indicates an urgent need for a full review of these cases, say the authors. The significantly higher premature birth rates and admissions to intensive care units in the NHS group also indicate an urgent need for review.

This would provide women with further evidence on which to base their decisions about pregnancy care and delivery, they conclude.

This study shows the difficulties researchers face in trying to compare outcomes between independent midwifery services and NHS care, say experts in an accompanying editorial.

Allison and Brett Shorten from the University of Wollongong and the Informed Health Choices Trust in Australia believe that mainstream maternity services `need to move beyond the rhetoric of policy documents and provide the type of services that women demand.'

They conclude: `Health systems will need to cultivate models that foster open referral and consultation between professional groups and most importantly make genuine efforts to include women in decision making. Collaboration within and between disciplines will increase the likelihood of providing higher quality, safe services for women and families.'

Contacts:
Research: Andrew Symon, Senior Lecturer, School of Nursing & Midwifery, University of Dundee, Scotland, UK
Mobile (Wed and Thurs): +44 (0)7954 436 269; Fri: +44 (0)1382 388 553 Email: a.g.symon@dundee.ac.uk.

or

Professor Peter Donnan (Thurs afternoon): +44 (0)1382 420 019

Editorial: Allison Shorten, Senior Lecturer, School of Nursing, Midwifery and Indigenous Health, Faculty of Health and Behavioural Sciences, University of Wollongong, NSW, Australia
Tel (Please note, Wollongong is 9hrs ahead of UK time): +61 2 42 213964;
Mobile: +61 2 0409 226415
Email: ashorten@uow.edu.au.

Click here to view paper under embargo: http://press.psprings.co.uk/bmj/june/midwife.pdf
URL for readers to click on once embargo lifted: http://www.bmj.com/cgi/doi/10.1136/bmj.b2060.

Click here to view editorial under embargo: http://press.psprings.co.uk/bmj/june/midwifeedit.doc
URL for readers to click on once embargo lifted: http://www.bmj.com/cgi/doi/10.1136/bmj.b2210.

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