Clinical review

Place of birth

Luke Zander,  Geoffrey Chamberlain. 

The management of childbirth is continuously evolving, reflecting changes in clinical, psychological, and social factors. In the past 50 years there have been dramatic falls in perinatal and maternal mortality, a steady increase in the amount of technological intervention in the management of labour, and a change in the roles of members of the maternity care team.

View larger version (18K): [in this window] [in a new window]   Percentage of women giving birth in United Kingdom in 1890-1990 who gave birth in hospital

Over the past 60 years the proportion of births at home has fallen markedly from 80% in 1930 to 1% in 1990, but in the past eight years the proportion has begun to rise again. Some studies suggest that 10-14% of women would choose this option if given the opportunity. A similar trend has been seen in all Western countries except the Netherlands, where, in 1995, 32% of births still occurred in the home.

View larger version (15K): [in this window] [in a new window]   Percentage of women giving birth in England and Wales in 1980-94 who gave birth at home

When considering how a birth is to be conducted, attention must be given to both risks and benefits. The debate over the place of birth raises many fundamental questions about the general management of labour, patients' satisfaction, and women's rights to choose their form of care. Much professional and lay discussion has taken place on many aspects of pregnancy care, brought into focus by the Department of Health's 1993 report Changing Childbirth, which indicated the way the maternity services may develop. Safety is the foundation of good maternity care but this must take into account the emotional as well as the physical wellbeing of mother and baby.

	Care settings

Top Care settings Dealing with emergencies General practitioners and... Lead professonals Women centred care Conclusions

Home
The home is the place for the practice of midwifery, not obstetrics, and the principal provider of care will be the midwife. The home is therefore appropriate for mothers with a low risk of complications. If any form of intervention is needed the appropriate course of action will almost inevitably be to transfer the woman or baby to the nearest suitable maternity unit. This is irrespective of the competence of the professionals present, for the home is not a suitable setting for undertaking obstetric procedures. It has long been assumed that hospital provides a safer environment for women at low risk as well as the high risk mothers. This assumption, however, is not evidence based.

Free standing general practitioner maternity units
The number of independent general practitioner maternity units has declined markedly over the past 30 years. They are usually much appreciated by women because of their informal approach and accessibility, and attempts at closure often provoke strong opposition. The level of care lies somewhere between home and the specialist unit. If safety is to be maintained, criteria for selection and protocols for care need to be established, ideally by a multidisciplinary group representing all those engaged in the provision of care.

View larger version (15K): [in this window] [in a new window]   Percentage of births in England and Wales in 1975-91 in a freestanding general practitioner unit

Integrated general practitioner units
A major advantage of having a general practitioner unit closely linked to an obstetric unit is the immediate availability of specialist skills if required. Such proximity, however, might discourage the involvement of general practitioners and might also change the ambience of the care provided so that it becomes more like that of the specialist unit.

Midwifery led units
Midwifery led units, either independent from or attached to a specialist obstetric unit, are becoming more common and reflect the fact that midwives provide care at 75% of deliveries. If specialist obstetric or neonatal help is required, the midwife is responsible for seeking it. Giving midwives organisational and clinical responsibility indicates recognition of their professional status and expertise. It is possible that such units will be the models for most delivery units of the future, providing continuity of care throughout pregnancy, labour, and the puerperium.

Consultant led units
Over 90% of labour care is currently provided in consultant led units. Smaller units (under 2500 deliveries a year) may in future have problems with staffing and recognition of their junior obstetric, paediatric, or anaesthetic posts for training purposes. With the expanding role of the midwife and the desire for continuity of care, a large part of a specialist's clinical work will be supervisory and acting as a point of referral for women identified antenatally or during labour as needing specialist services. Hence obstetricians will act in a way that is more like that of specialists in other branches of medicine.

	Dealing with emergencies

Top Care settings Dealing with emergencies General practitioners and... Lead professonals Women centred care Conclusions

Acute, unforeseen emergencies can occur to the mother or fetus at any time during labour or to either after delivery. It is therefore essential that wherever birth takes place adequate arrangements are available to deal with emergencies; midwives and general practitioners must be appropriately trained. In hospital, staff and equipment can speedily be summoned; this is not so at home or in a freestanding unit. The flying squad is no longer a viable option for it removes essential staff from the hospital. It will be the paramedics who help at emergencies away from hospital. They are trained to provide the necessary immediate care for all emergencies (including obstetrics).

	General practitioners and labour care

Top Care settings Dealing with emergencies General practitioners and... Lead professonals Women centred care Conclusions

General practitioners may provide labour care at home or in the general practitioner maternity unit. The number of general practitioners actively involved in labour care has declined markedly over the past 30-40 years. Whereas in 1965 about 50% of all births took place under a general practitioner's care, in 1994 delivery by a general practitioner was reported in only 800 out of 604 300 women. General practitioners are uncertain about their responsibility and role in labour care and how to respond to a woman's request for home birth. To clarify the position, the General Medical Services Committee recently spelt out the duties of general practitioners in labour care.

General practitioners can be involved in labour care at one or more of four levels. Many general practitioners feel reluctant to become involved because of a perceived risk of litigation. Such concern relates not only to their own level of competence but also to the care provided by the midwife.

	Lead professonals

Top Care settings Dealing with emergencies General practitioners and... Lead professonals Women centred care Conclusions

Changing Childbirth recommended that for each pregnant woman there would be a clearly identified lead professional responsible for ensuring that the woman received the appropriate care. This will usually be a midwife. Good communication between the lead professional and other members of the maternity care team is essential so that each can contribute appropriately to the overall care.

	Women centred care

Top Care settings Dealing with emergencies General practitioners and... Lead professonals Women centred care Conclusions

In whatever setting birth takes place, every effort should be made to ensure that the woman is made to feel physically and psychologically as comfortable as possible. She should perceive herself to be in control of what is happening and be able to make decisions about her care, having had full discussions with the professionals involved. If this is to be achieved certain requirements need to be instituted (see box).

	Conclusions

Top Care settings Dealing with emergencies General practitioners and... Lead professonals Women centred care Conclusions

Childbirth is one of life's major events. The way in which it is experienced will have very significant and long term effects on the mother. It is the responsibility of all those involved in the provision of care to achieve a balance between scientific objectivity and a concern for the woman's wishes.

The future lies with an expansion of midwife led delivery units in hospitals with birth pools and birth rooms, with an early return home after delivery. Doctors will still be needed when complications arise.

	Acknowledgments

The graphs showing percentages of hospital and home births are based on data from the Office of Populations, Censuses, and Surveys. Gillian Halksworth-Smith of the University of Glamorgan and staff of the Crowborough birthing centre provided the data for the table on the second page.

Luke Zander is senior lecturer in the department of general practice and primary care at Guy's, King's, and St Thomas's Hospitals Medical Schools.

The ABC of Labour Care is edited by Geoffrey Chamberlain, emeritus professor of obstetrics and gynaecology at the Singleton Hospital, Swansea. It will be published as a book in the summer.