Published 11 June 2009, doi:10.1136/bmj.b2210
Cite this as: BMJ 2009;338:b2210

Editorials

Independent midwifery care versus NHS care in the UK

A need to balance risks, benefits, and choice

A commitment to quality and safety, together with choice and continuity of care, underpins current directions for the reform of maternity services in the United Kingdom and Australia.^{1 2} Recognition that midwifery-led care will be central to these changes, with options for women to give birth at home, has stimulated research about the safest and most effective models of care. Symon and colleagues (doi:10.1136/bmj.b2060) compare clinical outcomes between pregnant women accessing an independent midwife and women using the National Health Service (NHS).³ They found that obstetric risk factors were an important predictor of perinatal outcomes. Unwittingly the authors illustrate pitfalls involved in attempting to match disparate datasets. Nevertheless, they confirm some of what we already know about the benefits of continuity models of midwifery care and the important role of risk selection in achieving good perinatal outcomes.

Symon and colleagues attempted to match two groups of women, which is predictably problematic because women choosing independent midwifery care were a self selected group.³ Unfortunately, the matching process was largely unsuccessful, with numerous important differences remaining, including nutritional status, smoking status, alcohol consumption during pregnancy, geographic location of residence, obstetric risk from previous pregnancy, medical complications during current pregnancy, incidence of breech presentation, differences in preterm birth rates, and incidence of low birth weight.³ These differences should not be present if the matching process was successful in producing comparable groups. Substantial data gaps, including circumstances regarding transfers of women from home to hospital, leaves discussion about perinatal death hazardously speculative. Further, odds ratios relevant to deaths are implausibly large relative to unadjusted counterparts, with unstable estimates produced because of limited variability in the dependent variable (few perinatal deaths), and should be discounted.

Another problem relates to the generalisability of the results. Of the 2.8 million births in the UK between 2002 and 2005, independent midwives attended only 0.0007% of UK births, and only 2.2% of all home births.^{4 5 6 7} Given this tiny percentage, findings of this study should not be applied to the general population of home births, or to the population of midwives who attend home births.

The study shows the difficulties researchers face in trying to compare outcomes between independent midwifery services and NHS care. Currently available data do not capture the important differences between the two groups of women. Moreover, it would be neither feasible nor useful to attempt to conduct a randomised controlled trial, again due to the problem of self selection.

If researchers and policy makers are serious about comparing independent midwifery care with NHS care, they need to recognise that women choosing the former are not typical of the general population of women giving birth, and identify these differences. More comprehensive data from the independent midwifery sector and NHS are required to capture these differences.

Despite methodological flaws, Symon and colleagues’ results are consistent with international literature about benefits of midwifery-led care, including planned home birth for low risk women.^{8 9 10} Women attended by an independent midwife were more likely to go into labour spontaneously, less likely to require pharmacological analgesia, more likely to achieve unassisted vaginal birth, less likely to give birth prematurely, and more likely to breast feed.³ Moreover, for these "low risk" women, as in other studies, no significant differences in perinatal mortality are found to offset these outcomes. However, for women who choose independent midwifery care or home birth in high risk situations (such as twin pregnancy, breech birth), there seems to be a higher risk of perinatal mortality.

An Australian study published in the BMJ over 10 years ago raised similar issues about birth at home for women with breech presentation and twins, finding that higher mortality occurred in these higher risk scenarios.¹¹ It was suggested that women may have felt they had no alternative other than to give birth outside of mainstream services because of lack of choices within hospital settings, limited opportunities for physiological birth, and policies directing birth by caesarean section for breech and twins.¹¹ Similarly in the UK, there is an apparent inability within public maternity services to meet the needs of some women who engage private midwifery services.¹² The question is whether some women who employ independent midwives will ever be able to find what they need within mainstream services and whether independent midwives would feel comfortable working within NHS guidelines if it meant limiting choices for the women they know well as individuals and care for in partnership.

With professional indemnity insurance for independent midwifery care and contracting arrangements with the NHS being explored for independent midwives,³ it will be important to examine strategies for better supporting women who, despite being assessed as high risk, may perceive that they have little choice other than to opt for services independent of the NHS. This lays down the challenge for mainstream services to move beyond the rhetoric of policy documents and provide the type of services that women demand.

Savings that come from promoting physiological childbirth and reducing unnecessary and potentially harmful birth interventions could help fund restructuring of services required to enact new maternity frameworks, as well as making available services more attractive to women who currently opt for independent midwifery care. Documented attributes of such care—including choice, continuity of care, and partnership with a known midwife—should be expected of all maternity services. However, historically women who have been unable to access models of care that can genuinely provide this look to independent midwives to support them in meeting their individual needs.^{3 12}

It is hoped that in the future most women will have the opportunity to be supported throughout their pregnancy, childbirth, and post partum by a known and trusted midwife. 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.

Cite this as: BMJ 2009;338:b2210

¹ School of Nursing, Midwifery and Indigenous Health, Faculty of Health and Behavioural Sciences, University of Wollongong, NSW, Australia 2522, ² Informed Health Choices Trust, NSW, Australia

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Competing interests: AS and BS are co-directors of Informed Health Choices Trust. This is a private trust that provides statistical consulting and a decision-aid booklet about birth after previous caesarean section, but produces nothing related to the subject of the editorial.

References

1. Department of Health. Maternity matters: choice, access and continuity of care in a safe service. London: DoH, 2007. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_073312.
2. Australian Government, Department of Health and Ageing. Improving maternity services in Australia: report of the Maternity Services Review. Barton ACT: Commonwealth of Australia, 2009. www.health.gov.au/internet/main/publishing.nsf/Content/64A5ED5A5432C985CA25756000172578.
3. Symon A, Winter C, Inkster M, Donnan PT. Outcomes for births booked under an independent midwife and births in NHS maternity units: matched comparison study. BMJ 2009;338:b2060[Abstract/Free Full Text]
4. Information Centre for Health and Social Care. NHS maternity statistics, England, 2004-2005. www.ic.nhs.uk/webfiles/publications/maternityeng2005/NHSMaternityStatistics260506_PDF.pdf.
5. Office of National Statistics. Birth statistics: births and patterns of family building England and Wales (FM1) (Nos 31-34). www.statistics.gov.uk/statbase/Product.asp?vlnk=5768.
6. General Registrar Office of Scotland. Births times series data (2002-2005). www.gro-scotland.gov.uk/statistics/births/births-time-series-data.html.
7. Northern Ireland Statistics and Research Agency. Table 1.2: Births, stillbirths, deaths and marriages, numbers and rates, quarterly 1, 1997 to 2007. www.nisra.gov.uk/archive/demography/publications/annual_reports/2007/Table1.2_2007.xls.
8. Olsen O. Meta-analysis on the safety of home birth. Birth 1997;24:4-13.[Web of Science][Medline]
9. Olsen O, Jewell MD. Home versus hospital birth. Cochrane Database Syst Rev 2000;(2):CD000352.
10. Johnson KC, Daviss BA. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ 2005;330:1416-22.[Abstract/Free Full Text]
11. Bastian H, Keirse MJNC, Lancaster P. Perinatal death associated with planned home birth in Australia: population based study. BMJ 1998;317:384-8.[Abstract/Free Full Text]
12. Milan M. Independent midwifery compared with other caseload practice. MIDIRS Midwifery Digest 2005;15:548-54.

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