It's never been more crucial to move maternity services into the community
“COVID-19 presents the NHS with arguably the greatest challenge it has faced since its creation”
(Sir Simon Stevens Amanda Pritchard and NHS Chief Executive NHS Chief Operating Officer)
An alternate means of providing care must be devised moving care into the community as hospitals become swamped. In the UK, beds have been emptied, hospital appointments have been either dramatically reduced or moved to the community or replaced with Skype appointments and Telemedecine. A&E units are empty for the first time in years as people stay clear of the hospital
Matt Hancock, the health secretary said “empty hotels across the country would help ease the pressure on hospitals that are filling up with patients”. It makes sense to use as many resources as possible to make way for the ‘tsunami’ of Covid19 sufferers requiring hospitalisation.
How are Maternity Services managing the problem of providing care when there are staff shortages and overcrowded hospitals? Some trusts are attempting to maintain home birth services in response to increased demand, others are temporarily closing down or reducing service. A number of Birth Centres lie empty or have become isolation units for pregnant women who have suspected or confirmed Covid19
So where do healthy women go to have their baby?
Currently, the majority have little option but to go to hospital, the place which has been described by clinicians in Italy as "possibly the main Covid-19 carriers" (sic), as they are rapidly populated by infected patients, facilitating transmission to uninfected patients’. It's not hard to understand why many women are concerned and anxious about this grim picture. Some have been told they can’t bring their birth partner to the birth room, some can’t bring their partners because, due to social distancing, there’s no one at home to look after the other children. And, seriously, who would want to go to hospital during a pandemic unless they really needed to?
Certainly if you have health and medical issues going to hospital will be the safest place. There are teams of experienced obstetricians and midwives ready to take care of you. But what happens to healthy women who are expecting their birth to be straightforward, who don’t need doctors or drugs or hospital equipment?
How many women will take the situation into their own hands by giving birth at home without trained professional assistance, perhaps unsafely, due to lack of knowledge and preparation?
Freebirth Facebook groups are erupting, some with as many as 3500 members. Enquiries for home birth have, at the very least, doubled. Birth Activist Michelle Quashie describes her concerns:
... women are not making an informed decision to free birth. Most are doing so as they feel it’s the safer option in the current climate as they don’t want to enter hospitals and/ or it is the only way they can guarantee who is with them at birth.
My experience is that women who freebirth are usually extremely informed, prepared and have spent much time educating themselves for all eventualities. They are mentally prepared… ...I’m not sure the women who are choosing to freebirth at present are as prepared. Women are making decisions whilst in a state of panic as the rug has been pulled from underneath them. Such a horrible place to be.
What would it take for Hospital Trusts to ease the burden on hospitals and staff by transferring some of the services where they are safest - into the community? Can the issues be addressed in a more optimal way by looking for solutions with a different perspective?
Writing about their experiences clinicians from Bergamo hospital conclude:
“Western health care systems have been built around the concept of patient-centered care, but an epidemic requires a change of perspective toward a concept of community-centered care.”
There has never been a more crucial time to build community services than now
The reasons for withdrawing home birth services include staffing shortages and potential delays if transferring from home to hospital in an emergency. How can a home birth service be provided in the current circumstances? Maternity Services were already overstretched with a significant shortage of midwives before the viral outbreak. Now with high sickness rates, the problem has escalated.
Despite this dismal situation there are ways of releasing skills and expertise to meet demands for home births. There are several groups of midwives that are available to support and supplement the existing workforce. Independent Midwives are desperate to help and experienced retired community midwives who have returned to help during the pandemic are an excellent resource and often have experience of home births and can act as primary carers. Indeed, I believe a lot more would return if they knew they didn’t have to work in the hospital environment.
One myth to dispel right away is that there is a legal requirement to have two midwives at a home birth. Most midwives enjoy the reassurance another pair of expert hands brings in an unexpected emergency - but doulas and student midwives and Maternity Support Workers can fill the role of “second pair of hands” in rare emergencies.
When is "an emergency" an emergency?
The other reason for stopping home births is pressure on ambulance services but in the vast majority of transfers to hospital an ambulance is not necessary, a private car or taxi can be more effective in optimising transfer times in the majority of cases.
What is the likelihood of needing an ambulance in a home birth? The number of emergency transfers a day in the UK that require a medical vehicle are very low - 2 to 3 a day. If the number of home births double numbers would still remain very low.
Please note there is a difference between an emergency and urgency and how these terms are defined is not standard. In the rare event of a life threatening emergency, midwives are trained in and use lifesaving skills, carry drugs and most can commence intravenous therapy.
We can learn how rural midwives manage delays safely. Transfers in rural areas like the highlands of Scotland can take several hours. These midwives employ strategies such as good communication with the hospital, using enhanced skills in risk assessment and make early decisions for transfer depending on weather and traffic conditions.
What can be learned from Hospital Trusts who continue to offer community services? Can neighbouring Trusts join forces?
We need to prepare to do the best under the circumstances for those who decide home birth is safest for them rather than limiting that choice and potentially increasing the risk of harm.
Limiting birth environments that have the greatest capacity to reduce the chance of transmission is counterintuitive. Birth Centres and the home environment are exactly the right places to help reduce fear and anxiety, minimise infection transmission and increase safety during a serious public health crisis. Lessening the load on hospital based Maternity services will benefit women who have complex health needs and require extra attention from the team and also for those who choose that environment.
‘In a pandemic, patient-centered care is inadequate and must be replaced by community-centered care. Solutions for Covid-19 are required for the entire population, not only for hospitals’
Appendix: Calculations for emergency transfers
In 2018, there were 731,213 live births in the UK. The home birth rate is approx 2.1% That’s 15,355 women giving birth at home. Overall transfer rates vary 9.1%-31.9% depending on parity, first timers have a higher chance of transfer (a,b) This comprises mainly non urgent transfers which can be made using a car or taxi.
Urgent emergencies requiring a medical vehicle and rapid transfer, mainly postpartum haemorrhage and fetal distress and, more rarely, cord prolapse or retained placenta can be extrapolated using national stats and other studies (b). The table provided by Cathy Williams of Chilled Mama (c) based on the Birthplace Study 2015, removing non urgent reasons, I calculated, for first timers, the rate of urgent transfer is around 3.8% and for second timers around 1.5% (a) giving an average urgent transfer rate of under 6%. Nationally that’s 921 emergency transfers a year, 2-3 urgent transfers a day in the UK. My rough calculation matches the conclusion in a study by Blix et al (b).
“The most common indication for transfer was labour dystocia, occurring in 5.1% to 9.8% of all women planning for home births. Transfer for indication for foetal distress varied from 1.0% to 3.6%, postpartum haemorrhage from 0% to 0.2% and respiratory problems in the infant from 0.3% to 1.4%. The proportion of emergency transfers varied from 0% to 5.4%”
- Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study BMJ 2011;343:d7400 https://www.bmj.com/content/343/bmj.d7400?fbclid=IwAR3ZrWfBVj35RfOCbAqLftXKfHDTp17C_YI_dJEyE5owEw-80I74tdFO0Hc
- Transfer to hospital in planned home births: a systematic review
prize winning birth image "Galactic Baby" used under licence from cat fancote - https://birthphotographyperth.com.au/ - this image is copyright - all rights reserved