Tuesday, 13 May 2014

What is the right place to give birth?


The Daily Mail has led with a story that NICE are now recommending that more women should give birth at home or in Midwife led units. http://www.dailymail.co.uk/health/article-2626670/NHS-push-home-births-Second-time-mums-told-need-hospital-high-risk.html

In Stafford this is a major current issue as our consultant led unit, which has a very good safety record, is threatened with being downgraded to a MLU as part of the reorganisation of the deficit hit health service in our region

The reaction of the people of Stafford to the TSA proposals for our hospital was pretty clear. People want to give birth in a Hospital that is close by. They want a hospital that can treat birth as is should be for most people –a normal natural occurrence. They also want a hospital that will be able to cope with the complications that may develop for a small number of people during the delivery some of which can have serious and expensive outcomes.

In the case of Stafford the TSA initially proposed that there should be no more births in Stafford.  They then (possibly as a response to public opinion, or possibly because it was what they always intended) took the advice of the Health Equalities Impact Assessment group that there should be  a choice for women, and that therefore there should be a Midwife led unit in Stafford, and that there should also be more provision for home births.

The NICE recommendations are making the point that MLUs are as safe as consultant led units for the majority of births.  There recommendations are I think based on this report. https://t.co/RaMdTdLmZn

Whilst most people can accept the principle that Midwife led units are as safe as Consultant led units for the majority of low risk births, the argument against accepting an MLU is based on the experience that they do not tend to attract public support, they are therefore expensive to run and  tend to fail after a short time.

The people of Stafford pointed out that the argument to down grade the maternity unit from Consultant led to Midwife led was based primarily on numbers. There is a recommendation that units with less than 2,500 should not be consultant led. If the logic were to be applied nationally then these numbers would mean that a very large number of consultant led maternity units throughout the country would be under threat.

It is clear that the Prime Minister took this point. Many of the maternity units in marginal constituencies would be affected if the bulk of births began to be shifted to the super maternity units that are being proposed in a handful of big hospitals.  We can presume that it is because he understood this threat that he chose to called at the last possible minute for a review of the possibility of having a consultant led maternity unit in Stafford.

The timing of the NICE recommendations may be purely coincidental, but NICE does what arguably needed to be done before trying to use Stafford as a back door route to reconfiguration of the health service. NICE has put forward recommendations that would radically reshape the provision of maternity services.

The trend towards super maternity units has been driven largely by the cost and availability of consultants. (It is suggested that the EU working time directive is a factor in this). Closing small maternity units and asking people to travel long distances in labour is politically difficult, and it may not be the best option for many women. What NICE is doing is asking us to think differently about Midwife led units, seeing these not as simply an additional choice, but as the normal option for most women.

It is clear that currently there are not enough midwives in employment to give the one to one service that is advocated, but it does appear that there are substantial numbers of trained midwives who could, with the required funding, be employed to do the job.

Adequate numbers of midwives would allow for much better assessment of the risk levels for individual women, and could therefore ensure that the small numbers of those identified as high risk could be directed to the distant consultant led units that would be an essential part of networks of Midwife led units.   

I would also hope that detailed thought is being given to the best way to make consultant support available to Midwife led units and to home births.

MLUs – if they become the normal choice – can give us a safe and good place to give birth. We are told that this may help to prevent the over medicalization that can occur in consultant led units, and can give women a better experience 

Perhaps the major barrier to this as a solution is our attitude to risk. The last few years have focused so heavily on the risks associated with medical treatments that the public may find it difficult to think of birth as a normal and natural process for the majority of women.

So now people throughout the country are being asked the question – What is the right place to give birth?

Where does that leave us here in Stafford? Your guess is as good as mine.

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