Dear Anna
Can I suggest that you look at the current evidence arising from the BIrthplace study regarding maternal and perinatal outcomes from home, FMU and AMU. You can see a summary of this evidence on this website. In addition, further analyses of the birthplace
cohort regarding transfer outcomes are below.
https://www.npeu.ox.ac.uk/birthplace
It is important to note that
a) NICE guidelines already exist regarding what clinical conditions and complications indicate planning an OU birth.
b) Outcomes in the birthplace study are by intention to treat in this low risk population, and it is of concern that more women
who planned to give birth in an OU experienced more
interventions during childbirth.
c) Current NICE guidance is that women should be provided with up to date evidence about risk and benefits of choosing different birth settings in order to make an informed choice.
d) Midwives in all settings are trained and have the equipment
to provide first line emergency obstetric care.
In terms of planning, reconfiguration is a separate issue. Using the NICE guidelines about 45% of women at the end of pregnancy would be eligible to choose to give birth in an out of obstetric unit setting in England, and the % in London is probably lower than this due to clinical complexity. There are a few trusts in London, where around 25% of women already give birth in out of OU settings, but there is a lack of capacity. Each locality will need to be able to provide a mix of settings where there are no barriers to referral and transfer.
FMUs are not intended to replace OUs and should not be seen as second class provision. They are part of a mixed economy of provision within a locality for women at low risk. Women with complications would be advised to plan to give birth in an OU. This raises questions about how local such provision is for women who may need to travel further, how big is a too big OU and of course cost-effectiveness.
regards
Dear Anna,
I am copying this to the midwifery-research jiscmail, which includes midwives who work in freestanding units and at home births. They can tell you better than a statistician how they deal with postpartum haemorrhage.
Alison
Dear Anna,
That may have been written before publication of the Birthplace study, a large prospective study which didn’t show that ‘alongside’ midwifery units are safer than freestanding units. https://www.npeu.ox.ac.uk/birthplace The point is that that freestanding units are set up with arrangements for transfer when needed and the consultant unit has to be still open for them to transfer to. Also, midwives who have always worked in consultant units may not have the confidence and skills to work in a freestanding unit, let alone develop the type of care they can offer. It isn’t difficult to find examples where so-called freestanding midwifery units have been set up as a sop in the aftermath of the closure of an obstetric unit and have failed. Kidderminster is a prime example.
At the other end of the scale, recent research from Epicure shows that the tiny minority of extremely preterm babies do better if they are transferred antenatally to units with a level 3 neonatal unit, but that doesn’t mean that all babies should be delivered in maternity units with such a high level of neonatal intensive care. http://fn.bmj.com/content/early/2014/03/06/archdischild-2013-305555.full.pdf+html
Maternity and neonatal services have been trying to develop networks in order to offer appropriate care with good arrangements for transfer if needed. This involves collaboration between a range of units rather than competition between a small number of huge units, so it is completely undermined by current government policy under the HSC Act.
Alison Macfarlane
From: Anna Athow [mailto:[log in to unmask]]
Sent: 26 March 2014 18:56
To: Macfarlane, Alison
Cc: [log in to unmask]
Subject: Re: blog by john lister on 'London's NHS at a Crossroads' report
Dear Alison,
When they came to remove the consultant led obstetric unit at Chase Farm, which has about 4000 deliveries a year and an excellent record, there was the sop of the possibiity of a midwife led unit, to salve the blow.
( The same sop is being suggested at Mid Staffs incidentally as it is being dismantled. )
The Chase Farm midwives themselves wrote a critique of this proposal and said it was not safe. The problem is that even with the best antenatal sifting, every now and then the expected normal delivery is not normal and requires emergency obstetric care.
In their view, these midwife led units should only exist within running distance of a proper consultant led obstetric unit. I think they are right.
bW
Anna
On 21 Mar 2014, at 11:45, Macfarlane, Alison wrote:
It was unfortunate that the article in the Evening Standard article on this report led on maternity services with an unsubstantiated claim that midwife-led maternity units are unsafe. In particular, it claimed that freestanding units were unsafe compared to midwifery unit on the same site as obstetric units. This is what the RCOG wants to believe, contrary to evidence from the Birthplace Programme https://www.npeu.ox.ac.uk/birthplace This showed that, for women without complications, planning to give birth in a midwifery unit is as safe for the baby as giving birth in an obstetric unit, and has lower rates of intervention for the mother and is more cost effective. Most midwifery units have a different philosophy of care from obstetric units This has been shown in a considerable body of recent research on midwifery units, including a freestanding midwifery unit in Tower Hamlets. It is completely wrong to describe them as ‘downgraded’ maternity units.
While we could do with more midwifery units, they are obviously not for women with complications who need obstetric care. Plans to withdraw and centralise obstetric care are a separate issue. There has been no research to compare obstetric units by size and no evidence that larger obstetric units are better or safer than smaller ones. Given a series of enquiries about problems in huge centralised units, surely it is time some research was done, given threats of centralisation. It is a pity the report didn’t call for this research, instead of attacking free-standing midwifery units.
Alison Macfarlane
From: Caroline Molloy [mailto:[log in to unmask]]
Sent: 21 March 2014 08:51
To: [log in to unmask]
Subject: blog by john lister on 'London's NHS at a Crossroads' report
Of interest even to non-Londoners!
yours
Caroline
(ex-Londoner)
--
mobile 07931 302507 / tel 01453 753700@carolinejmolloy