Evidence-based birthplace choices for women and birthing people

In summary

Since the 1970s, researchers at City St George's, University of London have worked to improve the quality and safety of childbirth.

There is a long-standing assumption about the superiority of hospital births but through a series of studies looking at midwifery units (also called birth centres) and home births, our academics have shown that’s simply not true for straightforward pregnancies.

Now the Centre for Maternal and Child Health Research is focusing on next steps: How can the healthcare system change its mindset and culture? How can the country scale up the number of midwifery units? What’s the best way to make sure these beneficial services get used?

What did we explore and how?

It’s easy for professionals to recommend a hospital birth – that way of thinking is embedded across healthcare services but it’s not based on evidence. In fact, the evidence can point to the opposite: For healthy women with straightforward pregnancies, midwifery units are associated with better outcomes and experiences and are also more cost-effective.

Improving awareness and acceptance of different birth settings among professionals is a major challenge but it will affect pregnant women everywhere. Benefits in these settings include reduced risk of maternal health complications which require admission to higher level of care, blood transfusion and longer postnatal hospital admission.  Service users and staff also have more positive experiences.

City St George's has decades of research to draw on. Back in 1994 Professor Alison Macfarlane published “Where to Be Born?” an important analysis of the statistics on birthplace and safety. In 2011, the Birthplace in England Programme (in collaboration with the University of Oxford and King’s College London) compared outcomes for 65,000 low-risk women.

Professor Macfarlane at City St George's also led a case study of one of the first midwifery units in the UK, showing that it gave women far more positive experiences of care and birth.

Recently, the Alongside Midwifery Unit Study and the NICE BirthPlace Action Study were the first to look at implementation challenges and strategies for scaling up midwifery units. Our researchers have been collaborating even further afield to develop good quality maternity facilities on a more global scale.

There are ongoing projects with the University of São Paulo and a network of birth centres in Brazil and with partners in Afghanistan, India and several African countries.

For two generations, women were told it was safer to have a baby in hospital. We know that stopping things that aren't evidence based is really difficult – they’re embedded in the way institutions and people are organised, the way they think, the way they’re used to operating. We’re identifying what’s happening and why, so we can provide the evidence to trigger a cultural change.

Benefits and influence of this research

By publishing in journals, releasing press statements, and circulating evidence to service managers, the public and practitioners, City St George's researchers have helped change policy and reform maternity services across the world.

The National Institute for Health and Care Excellence’s clinical guidelines were directly influenced by the Birthplace in England programme. And, supported by the ongoing work at the Centre for Maternal and Child Health Research, the number of midwifery units in England rose from 53 in 2010 to 173 in 2019. In that time, the percentage of births in these units increased from 5% to 14%.

More recently, despite an increased interest in out-of-hospital birth, availability of these facilities was reduced as a result of Covid-19 so the work on access continues. Our earlier work highlighted inequities in access too and a new project led by Dr Marina Daniele is also focusing on strategies to improve access for racialised women.

Many countries only offer birth in a hospital obstetric unit and influencing change is challenging. For this reason, in 2016, Dr Rocca-Ihenacho and a small group of midwifery leaders, academics and service users representatives, created the Midwifery Unit Network (MUNet), a community of practice with the aim of making MUs the mainstream birth setting for low-risk women and birthing people.

City St George's, University of London provided support to the network form the beginning and MUNet progressed to support the opening and scaling up of midwifery units in countries like Spain, the Czech Republic and Bulgaria, where birth settings options were almost inexistent previously.

The Network’s Facebook group has over 8,000 members sharing resources and best practices. MUNet has also started the Global Confederation of Birth Centre Networks which will help lead to new maternity units in low- and middle-income countries.

A team at City St George's in collaboration with MUNet developed the first European Midwifery Unit Standards to help all stakeholders implement or improve midwifery units in Europe, using evidence and expert review and wide consultation.

There has already been wide interest from around the world and the network and the Standards have been endorsed by the National Institute for Clinical Excellence (NICE).

The MU Standards have been translated and published in Spanish, Italian, Czech, French, Dutch, Portuguese and Brazilian and Dr Rocca-Ihenacho has collaborated with Saudi Arabia and Afghan to adapt the standards to local contexts.

A Midwifery Units Self-Assessment-tool has been developed to support services in using the Standards for service improvement and pilot studies are in process and in 2022 the Midwifery Units Self-Assessment (MUSA)- Framework was created, which provided a step-by-step guidance for MU quality improvement.

Work is also in process, led by Dr Bradley and Dr Leister, to support implementation in low and middle-income countries and provide evidence of outcomes on a more global scale.

In many countries, hospital care is not affordable for all and it is not always accessible to those with medical complications. Overcrowding and overwork can also lead of care that is not kind or safe.

We are looking at the options for developing more small midwife-led units to address these problems and gather evidence on whether the outcomes are comparable in other contexts.

These projects are working together to shift the focus away from childbirth in hospital as the routine. Women should have a choice – not just for ethical reasons, but because the evidence shows there are real cost and health benefits too.