Rapid Responses to:

FEATURE: Lesley Page Is there enough evidence to judge midwife led units safe? Yes BMJ 2007; 335: 642 [Full text]

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Rapid Responses published:

missing the point?

Bob Bury   (28 September 2007)

Lack of quality evidence

Bob Sheridan   (28 September 2007)

Single measure of safety

A Sajayan   (30 September 2007)

Safety and Quality of care really matter

Sally K Tracy   (30 September 2007)

Damaged babies

Lydia M Stevens   (30 September 2007)

NO, midwifery-led care is a risky business.

Olakunle Fajemirokun-Odudeyi   (1 October 2007)

Place of Birth

Melvyn F Docker   (2 October 2007)

Places of birth- Satisfaction or Safety?

Bode Williams   (2 October 2007)

'From cradle to grave'

Anna E Livingstone   (2 October 2007)

Midwife led unit’s needs more evidence prior to independent practice

Chelliah R Selvasekar   (2 October 2007)

Risk to babies with home delivery and midwife led units

Philip Murray   (3 October 2007)

midwifery led-units: choice and safety

Fatima A Husain, Phillip W. Reginald   (3 October 2007)

Author's Response

Lesley Page   (3 October 2007)

No

Ian A L Treharne   (3 October 2007)

Are midwife-led maternity units safe?

Dr Mike Bull   (3 October 2007)

Midwifery down the drain

Anne Savage   (4 October 2007)

5 year survey in Isles of Scilly

Toby Dalton   (4 October 2007)

Ongoing research on planned place of birth and safety

David M Puddicombe, Mary Stewart and Rachel Rowe   (4 October 2007)

Hospital delivery was a negative experience

Elizabeth L. Saltmarsh   (15 October 2007)

missing the point? 28 September 2007
Bob Bury, Consultant Radiologist LS8 2JX Send response to journal: Re: missing the point?	What's a radiologist doing reading this article in the first place? - well, my daughter has just qualified as a midwife and jobs seem to be in short supply, so anything that increases midwife numbers would be welcomed by me. However, my eye was caught by Lesley Page's statement that 'home birth is no less safe than hospital birth for women and babies without complications'. I don't doubt that's true, but it's surely completely irrelevant? The point is that complications are unpredictable, and that if you suffer (e.g.) a post-partum haemorrhage, it's better to be in hospital than at home. The comparison that needs to be made is between the outcomes of all home births, complicated or not, and all hospital births. Unless, of course, I have misunderstood the point she was making. Both Professors indicate that there is no conclusive data as to which venue for delivery is safer (which surprised me, as a non-obstetrician), but it has always been my experience that in the absence of hard evidence, you should trust to common sense. Given that complications will occur, that they are mostly unpredictable, and that they are likely to require urgent medical, surgical (or radiological!) intervention, it seems to me that the conclusion is inescapable. The only other argument in favour of home birth appears to be that women find it a more positive experience. Again, I'm sure that's true, but then they won't have interviewed the ones that died, presumably. Competing interests: Four children delivered in hospitals in the dark ages of the seventies and eighties.
Lack of quality evidence 28 September 2007
Bob Sheridan, member of the public Andover, Hampshire Send response to journal: Re: Lack of quality evidence	That two childbirth professionals can each find evidence to support their opposing views on the safety of midwife-led units versus obstetric units is the clearest indication that the available evidence in this area is equivocal. On this basis alone, it would seem prudent for women in labour to adopt the precautionary approach advocated by Prof. Drife and head straight for the nearest obstetric unit. Competing interests: None declared
Single measure of safety 30 September 2007
A Sajayan, Anaesthetist Hertfordshire Send response to journal: Re: Single measure of safety	The argument that Prof.Page give in favour of midwife lead centres in my opinion is just a reflection of the age old frustration among the midwives against the 'intervening' doctors(includes obstetricians and anaesthetists). She complaints that all the discussions are centred around a single measure of saftey ie,perinatal mortality.Which is the most important end point in a stressful process like pregnancy other than being rewarded with a healthy baby?So it is quite understandable and acceptable that the whole process will be discussed on this outcome and how to make that safer. In her article the doctors are pictured as the monsters who interfere unnencessarily in a natural process waiting for an opportunity to pull the patient in to the theatre for a caesarean section. The cat comes out of the bag in the sentence ''midwifery had been taken from its community base ...and lost its professional autonomy and influence''.I think this fear of losing influence is a basic problem with most if not all midwives and that reflect in their attitude towards doctors. While she rightly suggest that we need both approaches in balance,her definition of the roles of midwives and obstetricians and the lack of positive experience and personal approach in the latter group lacks quality evidence,just like the cochrane studies she quoted. As an anaesthetist who has seen many 'straightforward' pregancies ending up in major complications without much notice,I believe a lot needs to be done in terms of infrastucture like transportation,obstetric unit availabilty at reasonable distance,patient screening mechanisms,understanding of limitations and above all a mutual respect between the two (three including us anaesthetists)professions to make the outcome of the whole exercise better. Given a choice between a holistic,total apporoach with no guarantee of timely 'intervention' and a so called 'fragmented' care with a guaranteed intervention if needed,I know which one I will choose. Competing interests: None declared
Safety and Quality of care really matter 30 September 2007
Sally K Tracy, Professor Women's Health and Midwifery University of Technology, Sydney, NSW, AUSTRALIA Send response to journal: Re: Safety and Quality of care really matter	“Head to Head” this week clearly illustrates the chasm that continues to divide maternity service policy both in the UK and elsewhere. Page correctly identifies that the problem lies in ‘the move to have all women give birth in hospital’ as ‘one of the biggest uncontrolled medical and social experiments of the 20th century’. Drife, on the other hand makes claims that a confidence interval that is ‘only just’ not significant is relevant in the discussion about evidence. (Hopefully the rationale to accept or reject research guiding the newly announced NICE guidelines for intrapartum care was not based on similar opinion!) Clearly the opportunity was missed to judge the effectiveness of hospital birth before all women were advised it was the safest place; however there are important quality signals which we should not continue to ignore. These include for example the amount of pain and suffering associated with increased surgical intervention in birth. Maternal mortality has not improved with rising rates of caesarean section and the increased incidence of life saving hysterectomy following catastrophic post partum haemorrhages is alarming. Every professional concerned with the health of mothers and infants should be eager to find solutions to improve these events. Drife’s claim that ‘safety is never absolute’ signals an opportunity to centre practice changes on sound principles of risk management combined with simultaneous and continuous evaluation of processes of care. Adhering to processes of clinical improvement alongside the introduction of birth centres and midwifery group practices should guarantee the safest possible future maternity care. Advising a woman on the safety of birth in hospital or at home relies on so many more aspects than we have been prepared to acknowledge previously. As Page asserts the domination of a medical view of birth and sole reliance on perinatal mortality measures has blinded us to other equally important factors that drive safety in maternity care. Competing interests: None declared
Damaged babies 30 September 2007
Lydia M Stevens, GP TW8 8DS Send response to journal: Re: Damaged babies	The articles are short on details regarding perinatal morbidity rather than mortality, which I'm sure reflects the lack of evidence. A case that sticks in my mind from my training was that of a transfer from a midwifery unit some miles away. This child of a "low risk" mother was unexpectedly born "flat." Apparently, there had been no attempt at resuscitation until 20 minutes after birth, when the only anaesthetist in the hospital arrived, having previously been in theatre with a patient he couldn't leave. My understanding is that midwives who only work in low risk units get very little practice in resuscitation, its not the same on a dummy how ever often their "skills" are updated, because nearly all their babies are born screaming. Perinatal mortality is a tragedy but brain damaged babies who could potentially have been saved by timely paediatrician is even more so, and a huge cost in litigation and lifetime care of a quadraplegic child with severe cerebral palsy (as resulted in this case). Every baby is essentially "untested" until born so even "low risk deliveries" sometimes result in unexpectedly sick infants that need expert care immediately. By all means let women come in last minute and go home very soon, but for the unexpected calamity I am sure where I would want to be. Whatever happened to "Domino" deliveries where community midwives helped the labour at home, came in with the mother for the last phase, and quick discharge if all well. Most women were in only 6 hours - perfect compromise? Competing interests: None declared
NO, midwifery-led care is a risky business. 1 October 2007
Olakunle Fajemirokun-Odudeyi, SPR Gynaecological Oncology Leeds St James's University Hospital Leeds LS9 7TF Send response to journal: Re: NO, midwifery-led care is a risky business.	There is no evidence that midwifery-led care is safer compared to consultant-led care and it can in fact have negative impacts on birthing experience. Competing interests: None declared
Place of Birth 2 October 2007
Melvyn F Docker, Retired Medical Physicist ex B'ham Women's Hospital B15 Send response to journal: Re: Place of Birth	Is there enough evidence to judge the safety of midwife led units? I believe that the birth experience is probably better in these. BUT the safety of mother and child must of greater importance. The midwife led unit must be a small one attached to a hospital with full obstetric and theatre facilities! Melvyn Docker Competing interests: None declared
Places of birth- Satisfaction or Safety? 2 October 2007
Bode Williams, Consultant Obstetrician and Gynaecologist Frimley Park Hospital NHS Trust, Surrey, GU16 7UJ Send response to journal: Re: Places of birth- Satisfaction or Safety?	I read with the interest the ongoing debate about the comparative safety of different places of birth for ‘low-risk’ pregnancies. This is based on the misleading notion that pregnant women can be divided into low or high risk groups at the beginning of their pregnancies according to prior history and offered appropriate level of care. Everyone knows that risk assessment is a continuing and dynamic process throughout pregnancy and childbirth. Regrettably, clinical risk scoring systems do not work well in pregnancy. Hence, the vast majority of women who develop life- threatening complications during labour and childbirth including shoulder dystocia and postpartum haemorrhage are so-called ‘low-risk’ pregnancies. The stark reality is that midwives and doctors cannot predict these childbirth complications in advance in any individual pregnancy and current obstetrics management is based on timely intervention when they occur. It seems that the real choice for pregnant women and their supporters is to decide whether to take a chance hoping that nothing will happen and give birth in the ‘plush home from home’ surroundings of the stand-alone midwifery led units in the quest for satisfaction. The alternative is to choose ‘well-resourced’ hospital labour wards with proven safety track records in dealing with relatively uncommon but life threatening childbirth complications. Competing interests: None declared
'From cradle to grave' 2 October 2007
Anna E Livingstone, General practice principal The Limehouse Practice Gill Street Health Centre London E14 8HQ Send response to journal: Re: 'From cradle to grave'	Yes, I agree, birthing centres and home are places of low risk for birth, for women for whom normal deliveries can be expected, and for their babies and I've followed the evidence and arguments across three decades. Here we see Page, midwife, female, with references discretely hidden on the web, pitted against Drife, male, obstetrician, with ostentatious confidence intervals bold on his pages 'not significant but significant'. The age old battle for control of women's bodies continues between midwives and surgeons. However the latter have to bear the responsibility of clinically unjustifiable rises in Caesarian rates,with concomitant maternal complications, and lower breast feeding rates, while in wealthier countries skills have been lost across the board in safely conducting vaginal deliveries that are in the least complex. If you want a safer vaginal breech delivery you need to go to a poor country. But, what of the women ? They don't exist in isolation at a brief period of time spanning pregnancy and the puerperium, but as part of families and a local community, with other influences and aspects to their lives and health which knit in with the childbearing experience. It is shocking that Page doesn't mention general practice at all, and worse than that O'Drife seems to have know idea of the substantial role in maternity care played by many general practitioners and general practices. General practice, can and does bring together local people as patients and families, health visitors, GPs and receptionists who know them all and can identify and support through medical and psychosocial risks. We have been part of such a team in our practice since the early eighties and are not special in this. Local community based services where delivery support is part of ongoing care is what most of the women we see want, whether that delivery be at hospital or outside, and there is great interest in the soon to open birthing centre nearby. Competing interests: I am an NHS GP working in a practice antenatal clinic with midwives and health visitors
Midwife led unit’s needs more evidence prior to independent practice 2 October 2007
Chelliah R Selvasekar, Specialist Registrar in Colorectal Surgery Christie Hospital, Manchester M20 4BX Send response to journal: Re: Midwife led unit’s needs more evidence prior to independent practice	I read with interest the debate on midwife led obstetric care.1 There is currently not much evidence for an independent midwife led unit.2 The aim for this government initiative appears to reduce the cost which will compromise quality. I can comment from my personal experience when my wife was admitted for childbirth in an NHS hospital where I was working and found an appalling practice when my wife was in labour for nearly three days without being seen by a consultant and managed by midwifes without much continuity of care. Finally when my son was born he developed severe sepsis which I believe is due to prolonged labour and was cared by neonatologists at the local hospital and then transferred to a tertiary unit, where it was a consultant led practice. I was able to appreciate the difference in the care, the communication among the health professionals and to the patients was exemplary in the consultant led set up compared to the midwife practice. When I made an official complaint about the lack of adequate obstetric care and lack of communication to improve the quality of the midwife service at the local hospital, the explanation was suboptimal and to my surprise I have noted similar traumatic experience in other midwife led units since then from colleagues and friends. Hence I think before the government introduces the midwife led service, it should assess the available evidence and have an optimal safety plans to ensure midwife care is adequate and not compromise the mother and baby. It is not only important to know the positive side of the mid wife led service, but we as the end users of healthcare should be aware of the negative aspects, near misses, assess the way to prevent mishaps and avoid the ego and tunnelled vision among the midwifes and encourage them to work as a team, audit their work and be more open to ensure welfare of mother and baby. At the end of the day we should understand that the obstetrician has a global approach to patient care as they have gone through a standard medical training whereas the midwife training is limited to a specialty and their overall approach is minimal, hence need to be supervised by an obstetrician for the welfare of the society. Reference List 1. Page, L. Do we have enough evidence to judge midwife led maternity units safe? BMJ 335, 642-643. 29-9-2007. 2. Hodnett ED, Downe S, Edwards N, Walsh D. Home-like versus conventional institutional settings for birth. Cochrane Database Syst Rev 2005; CD000012. Competing interests: None declared
Risk to babies with home delivery and midwife led units 3 October 2007
Philip Murray, Clinical Research Fellow Endocrine Sciences Research Group, Core technology Facility, University of Manchester, M13 9NT Send response to journal: Re: Risk to babies with home delivery and midwife led units	To suggest that there is likely to be no increased risk to a baby from a planned home/midwife centre delivery does not make sense. For those developing signs of fetal distress they will have to be transferred to a consultant led unit. This will inevitably add some time delay prior to delivery and for a very small number of babies this time delay will be significant leading to possible brain damage and death. There will also be babies born unexpectandly flat. Although midwives are well trained in neonatal resuscitaion their skills are not likely to be as good as a middle grade paediatrician present in hospital. I accept that the number of these babies is likely to be very small and that there are high intervention rates in consultant led units but I do feel that all mothes opting for home/midwife led units should be warned of the likely increased risk to their babies. These comments apply only to midwife led units not on the same site as a consultant led unit. Competing interests: None declared
midwifery led-units: choice and safety 3 October 2007
Fatima A Husain, Consultant Obstetrician & Gynaecologist Heatherwood & Wexham Park Hospitals NHS Foundation Trust, SL2 4HL, Phillip W. Reginald Send response to journal: Re: midwifery led-units: choice and safety	Dear Editor, We read with interest the views of both authors and wish to make the following points:- Childbirth is not risk free. Although the process is a natural one, it is not declared safe until the baby is delivered and the third stage is complete. Risk categorisation of a pregnancy is possible, but complications are usually unpredictable needing urgent attention. When this happens in an isolated midwifery led unit (MLMU), transferring the patient to hospital is the only option. Outcome is then variable and depends on the nature of the complication and transfer facilities available. Each patient intending to deliver in a MLMU should be given explicit information emphasizing that this is the only option in the event of a complication. This could reduce the number of deliveries in, and question the viability of, isolated MLMUs. Positive birth experience and safety are important but should not be confused or allowed to compromise each other. Efforts must be made to provide a positive experience in the safety of a hospital maternity unit and possibly in an integrated MLMU. Competing interests: None declared
Author's Response 3 October 2007
Lesley Page, Professor in Midwifery King's College London SE19NH Send response to journal: Re: Author's Response	Dr Bury suggests that women should give birth in hospital in case unpredictable complications such as post-partum haemorrhage occur. The point that I made was that the focus on single indicators of safety has taken our attention away from the real problems facing modern maternity services. These include a steadily rising intervention rate (i.e.caesarean section), and the failure of modern maternity services to close the gap in both perinatal and maternal mortality rates between rich and poor, and between different ethnic groups. Nearly a quarter of women in the UK are delivered of their babies by caesarean section. This high caesarean section rate is associated with significant morbidity for the mother, a higher maternal mortality rate and an increased risk, including the risk of stillbirth, in subsequent pregnancies. The intervention rate should not be considered as a secondary outcome measure, it is a primary outcome measure. The conclusion that planned home birth is no less safe than hospital birth for women without complications was based on the systematic review and meta-analysis referenced in the article. The reviewed studies included all outcomes of both groups including those women and babies who had been transferred to hospital. The analysis revealed no statistical difference in mortality between planned home and planned hospital birth: the confidence interval was not compatible with extreme risks in any of the groups (odds ratio (OR) =0.87, 95%confidence interval (CI)=0.54-1.41). Furthermore there was a lower frequency of low Apgar scores (OR =0.55; 0.41-0.74) in the home birth group. The meta-analysis also showed that fewer interventions occurred in the home birth group. (1). The lower intervention rate may be one of the reasons to choose home birth. Of course the evidence on home birth must be interpreted with caution. In the absence of a large enough randomized controlled trial, despite the matching of groups and controlling for confounding variables in observational studies, there is a possibility of bias. The most likely source of bias being that women who have elected to have their babies at home are motivated to avoid interventions. Women making the choice between home and hospital birth need to know the risks and benefits of all settings, and of any uncertainty in the evidence base. As Olsen commented ‘it cannot be claimed that planned hospital birth is safe for all babies, nor can it be claimed that planned home birth is safe for all babies’. (1) The National Institute for Health and Clinical Excellence (NICE)guidelines for intrapartum care of healthy women and their babies during childbirth state that ‘women should be offered the choice of planning birth at home, in a midwife-led unit or in an obstetric unit’. (2) 1. Olsen O. Meta-analysis of the safety of home birth. Birth 1997; 24:4-13. 2. National Collaborating Centre for Women’s Health.Intrapartum care of healthy women and their babies during childbirth. [Nice Clinical Guidelines]. London: RCOG Press; September 2007. Competing interests: None declared
No 3 October 2007
Ian A L Treharne, Consultant Obstetrician QE 2 hospital al74hq Send response to journal: Re: No	I agree with Prof. DRIFE, that there is no evidence to support Midwifery led units. Working in a unit where there is a proposed merger of two units 13 miles apart I have reservations If cases of major post partum haemorrhage in home births have to travel extra miles for treatment the outcome may not be as good as in cases in hospital. Safety of mother and baby should come before financial restraints. Competing interests: Consultant Obstetrician
Are midwife-led maternity units safe? 3 October 2007
Dr Mike Bull, Retired GP Oxford Send response to journal: Re: Are midwife-led maternity units safe?	I was a GP obstetrician in Oxford from 1956 to 1992 and during that time cared for about 2,000 pregnant women. When I commenced practice some 40% low risk women were booked for home confinement. I was rapidly convinced that no case could be classified as normal until the baby was crying in the cot and the placenta was safely in the bucket. As a consequence I initiated the Oxford GP Maternity Unit, at first situated alongside the Churchill Hospital Consultant Obstetric unit but later fully integrated into the John Radcliffe Hospital. I carefully audited results from this unit for 25 years and, although all cases were selected on the basis of low risk, some 30% required to be transferred to consultant care during pregnancy and another 15% due to complications arising during labour. Whilst we were able to offer a relaxed and supportive style of care to individuals, we were situated physically so that complications could be dealt with promptly due to the proximity of consultant staff and equipment. I have no doubt that maternity care should now in all cases be offered in such a situation. Competing interests: None declared
Midwifery down the drain 4 October 2007
Anne Savage, retired N/A Send response to journal: Re: Midwifery down the drain	Professor Drife's defence of 'hospital is best'will not be well received in this area where our local hospital has been severely censured and a legal case is threatened over an intrapartum death and, last year, a hospital up the road was put under 'special measures' following an unacceptably high number of maternal deaths. I was a GP Obstetrician back in the last century. Four of us in the area provided obstetric care for any woman in the area who was suitable for delivery in a Maternity Hospital, a Mother and Baby Home, where the 'normal' girls were delivered on site ,and for a number of home deliveries. We had all conducted twenty normal deliveries and seen ten 'abnormals' as students and had had post-graduate training. We worked with a team of six midwives, were always available and frequently present during the second stage but never took over the delivery. It was a team effort and included the local hospital where we received excellent back- up and we also could call on two flying squads. An additional safeguard was a system of 'Midwives' Aid' whereby any midwife could summon any doctor on the obstetric list in times of crisis. We had no neonatal deaths, though one very premature baby died in hospital following a prolapsed cord. This excellent service was largely disbanded when consultant obstetricians became frightened that they would be responsible for doctors they could not directly control. Some year later, when I was working part of the time in Africa I used to do short locums to 'keep my hand in'. I was shocked at the attitude of midwives in too many places, bored, discontented and unresponsive to women's needs. I sympathised with them, up to a point. Their skills were downgraded, the most junior doctor to arrive in the labour ward could and often did, ignore their advice. In the end it was the women who suffered.Our local paper has been flooded with letters complaining of the poor treatment they experienced and many are now booking with Independent Midwives. This seems to be the worst of both worlds. It is Professor Drife and his colleagues who are responsible for this sad state of affairs but I worry about the government telling women they can have home deliveries but not reestablishing the safeguards. One thing that could be done is to put the midwives in charge of the labour ward, allow them direct contact to the consultant and why not teach the senior staff to intubate and do simple repairs? Competing interests: None declared
5 year survey in Isles of Scilly 4 October 2007
Toby Dalton, General Practitioner The Health Centre, St.Mary's, Isles of Scilly TR21 OHE Send response to journal: Re: 5 year survey in Isles of Scilly	We have recently conducted a five year survey of our midwifery service. And ALTHOUGH we do transfer roughly half of those initially determined as low risk, the satisfaction of the mothers surveyed and the outcomes for all have been good. We, as GPs, do the ALSO course ( advanced life support in obstetrics), and attend every delivery in support of our midwifery service. I am very much in favour of Midwife led care. Toby Dalton. Data AVAILABLE at your request. Competing interests: None declared
Ongoing research on planned place of birth and safety 4 October 2007
David M Puddicombe, Research Assistant National Perinatal Epidemiology Unit, University of Oxford OX4 1AG, Mary Stewart and Rachel Rowe Send response to journal: Re: Ongoing research on planned place of birth and safety	In the most recent issue of the BMJ the Head to Head feature focused on whether or not there is enough evidence to judge midwife led maternity units safe (BMJ 2007;335;642 & 643). This article was of particular interest to us at the National Perinatal Epidemiology Unit (NPEU) because we are currently conducting the Birthplace in England Research Programme (Birthplace) http://www.npeu.ox.ac.uk/birthplace, which incorporates the Evaluation of Maternity Units in England (EMU) cited by Professor Drife. Birthplace is funded by the National Institute for Health Research (NIHR) and the Department of Health (DH) and comprises a series of related studies to compare the safety and cost effectiveness of planned place of birth and describe how provision of maternity services affects women’s experiences. This whole research programme is predicated on the fact that there is currently insufficient evidence to say whether there is a difference in outcomes according to planned place of birth for women at low risk of complications during labour and birth. Birthplace includes a large national prospective cohort study which will compare the safety and cost effectiveness of births planned at home, in midwifery units and in obstetric units irrespective of the actual place of birth. A feasibility study to determine whether births planned at home can be included is ongoing. If it is not possible to include planned birth at home, the national study, which will begin in January 2008, will compare births planned in midwifery units and births planned in obstetric units. Results from the national cohort study will be available by the end of 2009. Competing interests: None declared
Hospital delivery was a negative experience 15 October 2007
Elizabeth L. Saltmarsh, Locum GP Derby, DE21 7FH Send response to journal: Re: Hospital delivery was a negative experience	Dear Dr. Lesley Page, I write as a mother and a doctor who has been through both a hospital delivery and a midwifery- led unit delivery. When I was an SHO in obs & gynae and then paediatrics, I decided that hospitals were the best place for giving birth after seeing all the problems suffered by mother or the baby. Years later when I was in the position of being a maternity patient, I was nervous about going into hospital. The first baby was a hospital delivery and I HATED it. My personal freedom was taken away from me, my natural urge was to walk about but as I was on a drip, I was allowed to either sit in the chair or lie in bed. In the end, I requested an epidural. It was a completely negative experience, and as usual, there was not enough staff around to look after everyone. With the second baby, fortunately there was a midwifery led unit closer to where I was living at that time. It was absolutely fantastic and positive experience, and the midwives were wonderful. I was in control and the midwives always asked ME what I wanted to do. I was allowed to labour in water and I did not need ANY other pain relief. I had one midwife present during the labour, and two for the delivery. Unfortunately I did have a problem and was quickly transferred to the local hospital which was a disappointment. Nevertheless I was pleased that I had coped extremely well with the most important part, the delivery, and the baby was fine. Being a GP, I am well aware of the risks associated with delivery. However, with the medicalisation of the natural process of childbirth has led to women losing control, thus requiring pain relief, leading to further interventions and higher probability of caesarean section. Women should be allowed to make an informed choice of where to deliver; at home, in a midwifery-led unit or hospital. This should be every woman's right, not just for the educated or those who can protest the loudest. I am not surprised by some of the negative feedback you have received as the article was published a medical journal. Mothers who have read your article are possibly too busy looking after their children. I have come across a number of GPs who have chosen not to deliver in hospital. Please continue your important work as a voice for all women. I am sure this debate will continue for many years. Elizabeth Saltmarsh Competing interests: None declared