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3 December 2014

Whose choice in childbirth?

Recommendations by the new NICE guidance on intrapartum care seem to reflect the choices desired by policymakers more than those actually made by women. By Jennie Bristow.

The National Institute for Health and Care Excellence (NICE) on 3 December released its new guidance, following consultation. Its press release, headlined ‘NICE confirms midwife-led care during labour is safest for women with straightforward pregnancies’, begins:

‘Thousands more babies could potentially be born in a midwife-led unit or at home following updated guidance from the National Institute for Health and Care Excellence (NICE).

‘Nearly 700,000 babies were born in England and Wales last year. Nine out of 10 babies are delivered in hospital under the ultimate supervision of obstetricians, but NICE wants women to be given greater freedom to choose where they give birth.

‘According to NICE, the evidence now shows midwife-led care to be safer than hospital for women having a straightforward (low risk) pregnancy [1]. Its updated guidance also confirms that home birth is equally as safe as a midwife-led unit and traditional labour ward for the babies of low risk pregnant women who have already had at least 1 child previously [2].

‘The updated NICE guidance says that women should be given this information to help them think about where they would most like to give birth, but that the final decision should be made by them and supported by healthcare professionals.

‘Professor Mark Baker, NICE’s clinical practice director, said: “Most women are healthy and have straightforward pregnancies and births. Over the years, evidence has emerged which shows that, for this group of women, giving birth in a midwife-led unit instead of a traditional labour ward is a safe option. Research also shows that a home birth is generally safer than hospital for pregnant women at low risk of complications who have given birth before.

‘“Where and how a woman gives birth to her baby can be hugely important to her. Although women with complicated pregnancies will still need a doctor, there is no reason why women at low risk of complications during labour should not have their baby in an environment in which they feel most comfortable. Our updated guideline will encourage greater choice in these decisions and ensure the best outcomes for both mother and baby.”

‘Some organisations have voiced concerns that encouraging women to give birth in midwife-led centres or at home would “force” women to give birth without doctors, putting them at greater risk of harm…’

BPAS’s response to the NICE consultation had voiced a number of concerns about the extent to which the new NICE guidance might constrain women’s choice. This is the article we published back in June.

The National Institute for Health and Care Excellence (NICE) on 12 May published its updated guideline on intrapartum care: the management and delivery of care to women in labour. The document highlights the importance of facilitating and respecting women’s choices.

But looking at the guidelines’ actual recommendations, it appears that the commitment to choice in childbirth is, in practice, somewhat rhetorical.

Choice of birthplace: the principle

The new guidance states that ‘Providers, senior staff and all healthcare professionals should ensure that in all birth settings there is a culture of respect for each woman as an individual undergoing a significant and emotionally intense life experience, so that the woman is in control, is listened to and is cared for with compassion.’

In practical terms, it emphasises that healthy women giving birth at term should have a choice of birthplace: defined by the guidance as an obstetric unit; a freestanding midwifery-led unit; an alongside midwifery unit (midwife-led units on a hospital site with an obstetric unit); or home.

The commitment to ensuring that ‘all 4 birth settings are available to all women (in the local area or in a neighbouring area)’ seems to offer an unprecedented degree of choice to women about where they can deliver their baby. Each individual woman will have her own preference as to whether she prefers to give birth at home, in hospital, or in a midwife-led service with clinical expertise on hand if she should need it.

A first-time mother may be profoundly nervous about the unexpected problems that can arise during labour, and want immediate access to every available obstetric intervention and form of pain relief; or she may be committed to a natural birth and quite sanguine about possible complications. A second- or third-time mother who has had a previously straightforward birth may feel that she knows what she is doing and would prefer to stay at home with her family rather than rushing into hospital; or she may have been shocked by the pain or length of her first labour, or suffered complications resulting in a surgical intervention, which make her determined that the next birth should take place within hospital.

Beyond that, any mother, for any reason, might have a strong attachment to the idea of giving birth in hospital, at home, or in a midwife-led unit – for reasons that might mystify health professionals and her friends alike. The choice of where to give birth is a deeply subjective one; and if a woman’s pregnancy is categorised as ‘low risk’, it is right that the health service makes provision, so far as possible, for her to give birth where she chooses.

However, reality is not perfect, and the maternity services are over-stretched at the best of times. So we know that, with the best will in the world, it is unlikely that women will be simply allowed to choose the place of birth that is best for them; rather, they are likely to find their options limited by what health professionals offer them. And here, the NICE document starts to read more like guidance on how health professionals should persuade women to make a particular kind of choice – namely, to give birth outside of hospital.

‘Advising’ a natural birth

The NICE guidance states that low-risk multiparous women should be advised ‘to plan to give birth at home or in a midwifery-led unit (freestanding or alongside)’, and that low-risk nulliparous women should be advised ‘to plan to give birth in a midwifery-led unit (freestanding or alongside)’.

The use of the word ‘advise’ constitutes a ‘strong’ recommendation: one that is made, in the words of the guidance, ‘when we are confident that, for the vast majority of patients, an intervention will do more good than harm, and be cost effective’. The justification for recommending midwife-led care for all low-risk mothers is that ‘the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit.’

The knowledge that the babies born outside of hospital are likely to fare just as well as those born in high-tech obstetric units is of course really important. It makes a big difference to mothers-to-be, whose main concern is usually that their baby will be born healthy, and allows them peace if mind if they do not want to give birth in an obstetric unit. It is also important in underlining the advances that have been made in detecting problems with pregnancies, which allow women to be classified as ‘low risk’ and ‘high risk’ in advance of labour; and in paying testament to the quality of care offered by midwives, who use their knowledge and expertise to deliver hundreds of thousands of healthy babies every year.

But the health of the baby is not the only thing that matters to a woman in labour. The pain and physical trauma undergone by the pregnant woman, the time she spends in labour, and the anxiety she experiences if something goes wrong are also crucial features of childbirth. The NICE guidance appears to brush over many of these things. Its consideration of maternal factors amounts to the statement that ‘the rate of interventions’, such as instrumental vaginal birth, caesarean section and episiotomy, is lower for women who plan to undergo midwife-led care than for those who labour in an obstetric unit.

Undergoing fewer interventions in childbirth could well be a good thing – if we assume that this means that the baby has been delivered easily and without excruciating pain. But labour, for most women – even those who are clinically ‘low risk – is not like that. Stories of emergency C-sections, forceps or ventouse delivery, episiotomies, and epidural anaesthesia are commonplace; and although some claim that these interventions are often performed unnecessarily, it seems reasonable to assume that many are done to save the woman from pain, or the baby from the effects of a prolonged or complicated labour. So a hospital offering a ‘high rate of interventions’ might be providing very good care for mothers and babies.

A survey of women’s experiences of maternity care, published by the Care Quality Commission in 2013, found that 23% of women planned to use epidural pain relief in childbirth. The most recent NHS maternity statistics found that in 2012-13, two thirds of hospital deliveries required some anaesthetic; 16.5% (93,974) of deliveries required an epidural or caudal anaesthetic before or during delivery, and 14.4% (82,161) used a spinal anaesthetic, which were mostly for caesarean deliveries. Furthermore, over one third of women (35.6%, 44,812) aged 35 years or older required a C-section. This is in line with the fact that the age of childbirth is rising, and women over the age of 35 are more likely to require C-sections than younger women.

The blunt fact about midwife-led care is that surgical interventions, or epidural pain relief, are not available in these settings. So we might expect women who undergo labour in midwife-led units to have fewer interventions, because they are simply not available. Yet the statistics about how women give birth now indicate that interventions and epidurals are what a large proportion of them want and need.

The extent to which ‘advising’ women where they should plan to give birth might gloss over some of the harsher realities of labour is particularly an issue for first-time mothers, who are far less likely to be aware of the degree of labour pain they might experience; how their body will respond to labour; and how they will feel about it all.

What if birth doesn’t go to plan?

The NICE guidance states that the maternity service should: ‘Ensure that all women giving birth have prompt access to an obstetric unit in case they need transfer of care for medical reasons or because they request epidural analgesia’. Clearly, however, transferring a woman midway though labour is time-consuming and unpleasant for her, and carries an additional logistical complication for services.

It seems rather far-fetched to assume that women who need ‘a bit of help’ in speeding up the final stages of labour, or who are begging for an epidural a few hours into labour, will be put in an ambulance and transported to the nearest hospital – which, in provincial or rural areas, may be several miles away.

It is unclear from the guidance whether the rate of interventions at home or in midwife-led units is lower because women are less likely to need and/or request interventions in these settings, or whether they cannot access them. And if it is the case that women are being denied the interventions that they want because they have been advised to give birth in a midwife-led unit or at home, then this does the very opposite of facilitating women’s choices.

Most strikingly of all, the guidance runs contrary to the choices that women already seem to be making about where to have their babies. The Birthplace study of 2011, upon which much of the NICE guidance is based, noted that: ‘Births outside an obstetric unit are relatively uncommon. Of women giving birth in 2007, around 8% gave birth outside an obstetric unit—2.8% at home, around 3% in alongside midwifery units, and just under 2% in freestanding midwifery units.’

Given that choice of birthplace has been an option for many years, is it not possible to conclude from this that women making an informed choice about where to give birth opted for an obstetric unit – and with very good reason?

The problem of cost-effectiveness

The NICE guidance has attracted some concerns. The Birth Trauma Association has criticised the guidance for over-stating the relative safety of births in midwife-led units, and accused the Department of Health of manipulating women’s choices to suit a policy agenda to ‘centralise maternity care for high risk women in large superunits and to downgrade many regional obstetric units to midwife led’ – a claim that the DH has ‘strongly denied’.

Criticisms of the policy push to promote midwife-led units over hospital births, which has been going on for several years now, are often based on the suspicion that this is driven by a cost-cutting agenda. Midwives’ wages are far lower than those of doctors, and it seems common sense that births involving fewer surgical interventions will be cheaper than those involving more complex equipment and procedures.

But while policymakers clearly do have an agenda to increase the use of midwife-led units, their motivation seems to be something less crass than an attempt to save money. Guidance issued by NICE in 2011 on C-sections stated that the cost of a planned C-section is only £700 more than a vaginal birth, and recommended, contrary to its previous guidance, that women should be allowed to plan to have a C-section even if there were no medical indications for doing so.

The 2011 C-section guidance also drew attention to the costs accrued by problematic vaginal births, particularly when there was a delay in delivering a ‘compromised fetus’, which may result in ‘major and long-term harm including cerebral palsy and other major long-term disability’. The guidance stated:

‘A large amount of NHS and other state funding is used to provide continuing care for infants who are disabled as a result of delay in delivery and in providing lifelong support for the child and their family. In addition, large sums of public money are spent on litigation and compensation in some of these cases through the Clinical Negligence Scheme for Trusts (CNST).’

Indeed, in recommending that all women be offered a choice of four places of birth – home, hospital, or midwife-led care either in a freestanding or alongside unit, this recent guidance on intrapartum care – the NICE guidance on intrapartum care seems to be promoting a rather costly scenario.

Rather, what lies behind the promotion of a more natural, de-medicalised childbirth is a particular view of the kind of birth that women should want, which has been promoted and supported by those who see themselves as champions of women’s rights and mothers’ choices.

Value judgements

The NICE guidance on intrapartum care states that: ‘Healthcare professionals should think about how their own values and beliefs inform their attitude to coping with pain in labour and ensure their care supports the woman’s choice.’ Postnatal groups abound with stories from women who feel that their desire for an epidural in labour was disapproved of by the midwives caring from them. Many other women feel that their treatment by midwives was kind and respectful; yet they felt they were denied access to certain forms of pain relief (in particular, epidural anaesthesia) because of practical barriers.

There is no conspiracy to prevent women from accessing effective pain relief. But there is presumption, particularly among those who promote home births or midwife-led units, that women should want as ‘natural’ a birth as possible. This goes back to the campaigns against the ‘medicalisation’ of childbirth in the 1970s, which were supported by many feminists, in the interests of giving women more choice and control over their bodies in childbirth.

While these campaigns succeeded in reducing some of the clinically unnecessary, paternalistic practices employed by obstetric services at this time, they also had the unfortunate effect of endorsing a romanticised, traditionalist notion of childbirth as a natural pain that should be embraced, as part of a mother’s destiny.

In a recent discussion organised by the University of Cambridge Department of Sociology and the Reproductive Sociology Research Group (ReproSoc), the editors of two classic feminist texts published in the 1980s reflected on their impact at the time, and how things have moved on now. Michelle Stanworth, editor of the 1987 book Reproductive Technologies: Gender, motherhood and medicine, discussed some of the problems within the feminist critique of reproductive technologies, which included ideas about nature and the natural.

Back then, Stanworth argued, this was the form taken by many arguments against medicalisation – but it was a ‘risky tactic to use nature to defend we wanted to do’. The idea that there is an opposition between technology and nature has, Stanworth argued, now gone among academics, but is still very much alive in the natural childbirth movement.

It is precisely this ‘risky tactic’, of eliding women’s choices with what is ‘natural’, that has brought about the policy presumption that women will want to choose to give birth outside of hospital, with minimal interventions or pain relief. And here, feminist arguments against ‘medicalisation’ have had a paradoxical effect. Rather than finding a range of choices in childbirth respected and facilitated, women can often find themselves pushed into making the kind of choice that others see as a marker of a good mother. This is every bit as paternalistic as the obstetric practices of the past.

Why choice of birthplace, not choice of birth?

One major issue here seems to be a decision by policymakers as to which body of healthcare professionals is best placed to manage childbirth. There is, rightly, a view that midwives play an invaluable role on childbirth, and that for low-risk multiparous women, they are often best placed to manage a woman’s labour.

However, there are surely questions about whether midwife-led care for the women who choose this is best achieved by a policy to create a division between midwife-led and obstetric units. Would not this imperative be better supported by having midwives play an active role within obstetric units, where they can manage women’s labours but with easy access to obstetric interventions if and when required? Midwives provide excellent care. But however excellent they are, they cannot provide epidurals, perform C-sections, or call on a surgical team in an immediate crisis. These are the reasons why women are likely to choose to give birth in an obstetric unit.

A far better policy designed to improve the care of women in childbirth would focus, not on women’s choice of birthplace, but on her choice of birth. Women should be given greater access to the interventions and pain relief that they may need, and have their choices in requesting these interventions – or not - genuinely respected. At the same time, they should be cared for by midwives, who can bring to bear their knowledge and expertise, without feeling that their role is to cajole women through a self-consciously ‘natural’ birth.

Also read:

Event: Childbirth and the New Dad. An evening seminar in London on 1 July 2014, discussing how expectations of fathers’ involvement in childbirth have changed. Organised by BPAS with speakers from the History and Policy Forum on Parenting.

The politics of childbirth. Jennie Bristow reviews the historical controversy surrounding the decision over where, and how, it is best to give birth. Reproductive Review, 2 April 2013.