Louise Silverton (Royal College of Midwives), Jane Sandall (King's College, London), Mary Newburn (NCT), Alison Miller (CEMACH), Chris McCourt (Thames Valley University), Neil Marlow (University College London), Alison Macfarlane (City University, London), Stavros Petrou (NPEU (Former member)), Maggie Redshaw (NPEU (Former member))
Labour and delivery, Organisation and delivery of maternity and neonatal care
Department of Health, National Institute for Health Research Service and Delivery Organisation
In England women are offered NHS care for labour and birth at home, in obstetric units (OUs) in hospitals, "free-standing" midwifery units (FMUs) which are not in the same place as any OU, and 'alongside' midwifery units (AMUs) which are on the same site as OUs.
High quality evidence has been lacking about the risks and benefits associated with planning to give birth in these different locations.
The Birthplace in England Research Programme combined the Evaluation of Maternity Units in England study, funded by the National Institute for Health Research Service Delivery and Organisation (NIHR SDO) programme, and the Birth at Home in England study funded by the Department of Health Policy Research Programme (DH PRP).
The programme was designed to answer the following questions:
How is intrapartum care organised in England?
Are there differences in maternal and child outcomes between the various birth settings and, in particular, are there differences in safety for the babies of women at 'low risk' of complications according to current clinical guideline?
What is the comparative cost-effectiveness of the planned settings for birth?
What are the features of maternity care systems that affect the quality and safety of care?
The programme included the following component studies:
Birthplace terms and definitions: consensus process
Mapping maternity care: the configuration of maternity care in England
The Birthplace national prospective cohort study: perinatal and maternal outcomes by planned place of birth
Birthplace cost-effectiveness analysis of planned place of birth
Birthplace qualitative organisational case studies
There is wide variation in the provision of different settings for births in England, by trust and by region, and this provision changed during the three years of the project.
For 'low risk' women having their second or subsequent baby there was no evidence of any increased risk of adverse perinatal outcomes, but there was a substantial decrease in instrumental deliveries and caesarean section for births planned outside of an obstetric unit.
For 'low risk' women having their first baby there was a modest increase in the risk of an adverse perinatal outcome for women planning a birth at home compared with an obstetric unit, but no increase in risk for woman planning births in either type of midwifery unit.
For 'low risk' women having their first baby, all planned places of birth outside an obstetric unit were associated with a lower risk of instrumental delivery and caesarean section.
For 'low risk' women having a first baby, there is a fairly high probability of transferring to an obstetric unit during labour or immediately after the birth.
Analysis of the short term NHS costs associated with the birth itself shows that planned birth at home or in a midwifery unit is cost saving.
There is insufficient evidence in the literature on longer-term outcomes to enable longer term costs and cost-effectiveness to be modelled.
The case studies highlight organisational features associated with well-functioning midwifery led and obstetric services and identify staffing, training and other issues that may affect the quality and safety of care.
A further programme of analysis using data from the Birthplace national prospective cohort study is now ongoing.