Study shows the way to improve safety in midwifery-led settings

Published on Thursday, 11 June 2020 Post

Researchers in the NIHR Policy Research Unit in Maternal Health and Care in the NPEU, in collaboration with others from the Universities of Leicester and Birmingham, Bradford Royal Infirmary and the Royal College of Midwives, have published new research investigating deaths of babies in births planned in midwifery-led settings, which has found that improvements in care may have made a difference to the outcome in 75% of the deaths.

A midwifery-led setting is a midwifery unit or planned birth at home, where the care during labour and birth is provided by midwives, with transfer to a hospital labour ward should the woman or baby need medical care. Deaths in births planned in these settings are rare, occurring in around 6 in every 10,000 births, and the authors caution that their findings do not challenge the evidence that planned birth in a midwifery-led setting is safe and has many benefits for women who are healthy with straightforward pregnancies.

The Enhancing the Safety of Midwifery-led Birth Enquiry (ESMiE), published in BJOG, reviewed the quality of care relating to 64 deaths of babies in England, Scotland and Wales between 2013 and 2016. In 75% of the deaths, improvements in care may have made a difference to the outcome for the baby. Improvements which may have made a difference to the future health and wellbeing of the mother were also identified in 75% of the deaths.

Many of the issues with care identified in the ESMiE study were the same as those identified in an earlier similar study carried out by the Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) collaboration, published in 2017, which investigated 78 similar baby deaths, but where, in most cases, the woman had planned to have her baby in a hospital consultant-led maternity unit or labour ward.

Areas identified in the ESMiE study where potential improvements in care could be made, with specific relevance to midwifery-led settings included:

• Discussing and documenting planned place of birth and conducting risk assessments during pregnancy and at the start of labour to ensure that the chosen setting is an appropriate planned place of birth for the mother;
• Ensuring prompt transfer during labour when required, with appropriate urgency, including ensuring timely care after transfer;
• Monitoring progress during labour and appropriate use of intermittent monitoring of the baby's heart rate;
• Resuscitation and transfer of an unwell baby when no specialised newborn baby doctors (neonatologists) are on site;
• Involvement of midwives with experience of providing care in midwifery-led setting in follow up and local reviews of care.

Dr Rachel Rowe, Senior Health Services Researcher in the National Perinatal Epidemiology Unit said,

The death of a baby is a tragedy for the parents and wider family, and has lasting impact on all involved. Fortunately, deaths such as those investigated by the ESMiE team are extremely uncommon. There is good evidence about the safety and benefits of planned birth in midwifery-led settings for women who are healthy with straightforward pregnancies. The ESMiE findings do not challenge that evidence or national policy and guidance, but they should be used to identify areas where care for women planning birth in midwifery-led settings can be improved and made even safer.

Read more about the study, which is published in BJOG: An International Journal of Obstetrics & Gynaecology - Wiley Online