Place of birth
BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7185.721 (Published 13 March 1999) Cite this as: BMJ 1999;318:721
- 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.
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.
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
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.
Objectives of good labour care
To provide a safe outcome for the mother and baby with the minimum of avoidable complications
To make the birth experience as satisfying as possible for the mother and her family
To make optimal use of the available resources
“The woman must be the focus of maternity care. She should be able to feel she is in control of what is happening to her and able to make decisions about her care based on her needs, having discussed matters fully with the professionals involved.” From Changing Childbirth
Reasons that women choose home birth*
To avoid unnecessary intervention 31%
To be on familiar territory so as to be more relaxed and in control 25%
Previous home birth 11%
Wish to be in a familiar setting in which they feel relaxed 10%
Fear of hospital setting 10%
To have a continuing relationship with midwife 4%
*Data from National Birthday Trust's 1994 home births survey (see Home Births in key references box)
Is hospital really the safest place to deliver?*
A statistical association between the increase in the proportion of hospital births and the fall in crude perinatal mortality seems unlikely to be the result of cause and effect
No evidence exists to support the claim that a hospital is the safest place for women to have normal births
The policy of closing small obstetric units on the grounds of safety is unsupported by available evidence
*Conclusions from Where to be Born, published by the National Perinatal Epidemiology Unit, 1994
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.
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.
Deliveries in freestanding general practitioner units, England and Wales
Most general practice units report low perinatal mortality and low rates of intervention compared with the national rates derived from total populations. This is partly because the women delivering at these units will have a low risk of complications.
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.
Recent data from two freestanding midwifery delivery units
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.
Reasons that women choose a hospital birth*
Safety 84%
Previous hospital birth 6%
*Data from National Birthday Trust's 1994 home births survey (see Home Births in key references box)
Dealing with emergencies
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).
Special tertiary care centres will always be needed for particular obstetric and neonatal problems. Consideration is being given to how these centres can best be integrated into the overall provision of services
Reasons for changes in general practitioners‘ involvement in labour care
Perceived lack of expertise
Fear of litigation
Changes in the organisation of out of hours cover
Unacceptable encroachment on off duty hours
Inadequate remuneration
General practitioners and labour care
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.
Duties of general practitioners in labour care*
To provide impartial advice regarding the availability of local services
To discuss the available options in a way that the woman can make an informed choice
To arrange for the provision of care
*As defined by the General Medical Services Committee
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.
Four levels of potential general practitioner involvement in labour care
Providing the necessary information and advice
Referring women for further care to the appropriate professional (midwife, obstetrician, or another general practitioner)
Being present during labour to provide psychosocial support for the woman and non-specialist support for the midwife
Providing practical labour care in a general practitioner maternity unit. This would require a higher level of training (only general practitioners undertaking this type of work can be called “general practitioner obstetrician”)
Legal responsibilities of general practitioners in labour care*
General practitioners are responsible only for their own acts or omissions
Midwives are accountable for their actions and decisions regardless of where they work
General practitioners do not have to attend a birth at home unless requested to do so by the midwife (regardless of whether they have agreed to provide maternity care for that woman)
If a general practitioner undertakes labour care and a mishap occurs, at litigation the general practitioner would be judged by the standards of a colleague of similar skills and training, not those of a specialist obstetrician
*According to Maternity Task Group of the Royal College of General Practitioners, 1995
Lead professonals
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.
The lead professional is responsible for ensuring that the woman receives appropriate care and that all the services provided by her different carers are fully coordinated. The lead professional will usually be a midwife
Requirements of women centred care*
An appropriate range of options of care need to be provided
Women need to be informed of the options available
Women need to be able to establish a relationship with their care providers so that their views and preferences can be discussed
A woman's preferences need to be recorded in her records so that they can be acted on appropriately by those providing her care even if they have not met her before
Attention needs to be given to the physical design of the surroundings and the availability of relevant facilities, such as water pools or birth aids
*According to Changing Childbirth
Women centred care
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
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.
Key references
Campbell R, MacFarlane A. Where to be born? Oxford: National Perinatal Epidemiology Unit, 1994.
Chamberlain G, Wraight A, Crowley P. Home births. Carnford: Pergamon Press, 1997.
Department of Health. Changing childbirth. London: HMSO, 1993, 1994.
General Services Medical Council. General practitioners and intrapartum care—interim guidance. London: BMJ Publishing, 1997.
Statistical bulletin. NHS maternity statistics England 1989–1995. London: Stationery Office, 1997.
Maternity Task Group of the Royal College of General Practitioners. The role of the general practitioner in maternity care. London: RCGP, 1995. (Occasional paper No 72.)
Welsh Office. Health evidence bulletin. Maternal and child health. Cardiff: NHS Wales, 1998.
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.