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Just to add a few points to the already excellent responses:

- in the Birthplace study, transfer rates were highest in alongside midwife units, where transfer time is very short and usually just a lift or corridor. 
- as Laura has said, when you look at the rates from Birthplace, they are different for multips and from different settings but also a large proportion are not emergency
- we also had evidence in the Birthplace organisational case studies that a range of professional and organisational issues could be affecting transfer rates so attention is needed to skills, confidence (so training) but also integration and relationships within a service (so that transfers are based on good professional jdgement of clinical needs/women's wishes not on territorialism or professional conflicts or organisational imperatives such as crowding or lack of staffing)
- the economic evaluation included the costs of transfers in a very comprehensive way
- the analysis was designed to take into account all transfers when considering the clinical outcomes - this means that any such risks were included in the analysis - the findings represent the outcomes of the full continuum of care according to where women planned the setting, defined at the start of care in labour
- the work done on experiences of transfers showed that from the women's viewpoint (and their birth partner's) it is how you manage the transfer that really matters: they could have a positive experience but it did need to be well managed and supported and with appropriately tailored good quality information. Professional conflict or poorly developed transfer arrangements will not support a positive experience. Women ideally want some continuity too, with the midwife able to transfer with them, and good care and attention on arrival, not judgement - of them or of the professional who provided their care to that point. 

Other studies such as Overgaard's in Denmark and the Canadian studies and the Australian study have used similar methodology to ensure these kind of issues are taken into account.

It seems at times that people in quite senior roles feel entitled to speak on an issue without reading the research in detail, to check the methods and what is covered, so then draw misleading conclusions such as 'it is all very well to say it is cost effective but what about the cost of transfers' and convey them to others with an air of authority. 


 
 
 

On 14/11/2018, 13:24, "A forum for discussion on midwifery and reproductive health research. on behalf of MacVane Phipps Fiona" <[log in to unmask] on behalf of [log in to unmask]> wrote:

    Keep up the good work, Laura! I agree with previous comments but where is the 40% transfer rate coming from? I think it is important to also talk about education, education for midwives, for women and for doctors about physiological birth. A lecture from a vet always goes down well. Imagine you are breeding horses, what conditions would a veterinarian say would be optimal for a safe birth? Vets usually say, a known, warm, safe, quiet, dark environment. No intrusions, let the mother do it herself (no tugging, pulling etc.) but know how to help if and when it becomes necessary, . The physiology of birth works for all mammals (and human babies don't have those long awkward legs with sharp elbows)! If physiology is respected and women and midwives both understand this and have developed a trusting relationship then transfers will go down.
    
    -----Original Message-----
    From: A forum for discussion on midwifery and reproductive health research. <[log in to unmask]> On Behalf Of Billie Hunter
    Sent: 14 November 2018 09:50
    To: [log in to unmask]
    Subject: Re: Debates on the ‘uselessness’ and costs of having MLU and homebirth in ongoing Italian Congress
    
    Great answers Soo and Laura! It's so important to turn these arguments on their head and point out the flaws in the 'logic'! 
    Good luck with the presentation Laura & congratulations on the important work you are doing in Italy Very best Billie 
    
    Billie Hunter, RCM Professor of Midwifery & Director, WHO Collaborating Centre for Midwifery Development, School of Healthcare Sciences, Cardiff University. 
    
    Sent from my iPhone - apologies for any typos 
    
    > On 14 Nov 2018, at 09:38, Soo Downe <[log in to unmask]> wrote:
    > 
    > I would say:
    > 
    > 1. all women in hospital have had to transfer from home to hospital, 
    > often in strong labour, but no-one seems to worry about this - if we wanted minimum transfers in labour, we would have 100% home birth, with women only being transferred when they really needed the hospital 2. there are units with much lower transfer rates, still with safe outcomes, so if we want to reduce transfers lets look at these units, and use their guidelines - lets not work on the basis of units where the guidelines are so restrictive, without any benefit to mothers and babies.
    > 3. If there really is a need for 40% transfer (which is unlikely) this 
    > still means that 60% of women are able to have their baby as they want 
    > to in a BC. This is much higher than the % of healthy women who manage 
    > to have the kind of birth they originally wanted in hospital - so what 
    > is the problem? Indeed, if we want to maximise the chance for women to 
    > have physiological births, even with a 40% transfer rate, BCs beat 
    > hospitals every time
    > 
    > All the best
    > 
    > Soo
    > 
    > 
    > -----Original Message-----
    > From: A forum for discussion on midwifery and reproductive health 
    > research. <[log in to unmask]> On Behalf Of Laura 
    > Iannuzzi
    > Sent: 14 November 2018 09:07
    > To: [log in to unmask]
    > Subject: Debates on the ‘uselessness’ and costs of having MLU and 
    > homebirth in ongoing Italian Congress
    > 
    > Dear all
    > I am attending the pre congress courses of the BIRTH Congress in 
    > Venice and I ll be speaking this afternoon of our experience in the 
    > Margherita birth centre in The Italian context The doctor who was 
    > chairing the course this morning in his presentation posed the 
    > question of what is the benefit of having MLUs if women in large part 
    > need to be transferred (he mentioned the 40% transfer rate for 
    > nulliparous in the birthplace study) and access to obstetric led unit 
    > with consequent trauma for women and costs for the system and ‘risks’ 
    > related to emergency  (homebirth was not even considered to be an 
    > option being ‘risky’ - and he used US based literature ) So he was 
    > posing question on the issue of transfers
    > 
    > I am trying to slightly change my presentation trying to address this 
    > question (that express a very common cultural standpoint in some 
    > context, that encourages midwife led care in labour ward but not 
    > midwife led care in midwife led units or home)
    > 
    > For sure in my mind are coming reflection such as ;
    > - yes it might be quite a challenge the theme of transfer for both 
    > women/ family and midwives
    > - what is provided is not only intrapartum care
    > - the more you protect physiology the less u need to transfer
    > - the theme of women’s choice
    > - the fact that transfers are mainly not due to emergency reason but 
    > more ‘tranquil’ situation such as slow progress of labour
    > - what about the costs of unnecessary interventions ? Are we sure that 
    > they are lower than the costs of transfers
    > - health is more than a intact Perineum and so on
    > 
    > 
    > But as even if thoughly posed this is an interesting are of debate, I d like to know if possibile from you what would you argue, what points would you make to answer ?
    > This could be of massive help
    > Thanks!
    > Laura
    > 
    > Laura Iannuzzi
    > PhD, MSc, PgCert, BMId, RM
    > Lead midwife physiological pregnancy path and Margherita birth centre 
    > Careggi university hospital Italy
    > 
    > 
    > 
    > Inviato da iPhone
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