By Andrea Nove
This study is a follow-up to a large-scale UK study published in 2009 which found a significantly higher risk of perinatal mor tality among the babies of women who had booked with an independent midwife (most of which were planned home births) than among women who had received NHS maternity care (most of which were planned hospital births). However, the raised risk of a baby dying was due entirely to 'high-risk' pregnancies; among women with low-risk pregnancies, the risk of a baby dying around the time of birth was not significantly different whether the woman received care from an independent midwife (IM) or from the NHS.
This study set out to establish whether the 15 perinatal deaths in the IM group which occurred at or after 36 weeks of pregnancy were attributable to care provided by the IMs. This was done by reviewing the (anonymised) case notes and conducting one-to-one inter views with the relevant IMs. The study was limited by the fact that only the IMs were interviewed and the views of the mothers/their partners were not sought. The views of other health professionals were included via case notes but they were not interviewed as part of the study.
Among the 15 perinatal deaths, just one of the pregnancies was classed as 'low-risk' at the start of labour - the group included four women expecting twins, three women planning VBACs and three women with babies presenting by the breech. Eight of the women had refused at least some antenatal screening, so may not have been fully aware of their pregnancy risk status. Several were fearful of accessing NHS care: two women who wanted a home birth declined the IM's advice to transfer to hospital during labour, and the IMs felt that six would 'definitely or probably' have birthed their babies unattended if they could not have had an IM. For seven of the fifteen perinatal deaths, all the professionals involved were in agreement that the death would have occurred regardless of the way in which labour was managed. In the other eight cases, it was felt that an elective caesarean may have resulted in a live birth. Seven of these eight women had been offered an elective caesarean but had refused, several because of traumatic experiences in previous births. In the eighth case, there had been no clinical indication for an elective caesarean.
In two cases, the IM was referred to the Nursing and Midwifery Council. In four cases, the IMs were of the view that problems in communication on transfer of care from home to hospital may have contributed to the outcome. IMs perceived that hospital staff had no sense of urgency when labouring women transferred from home to hospital and acted as though the woman's labour had just started.
The results of the 2009 study elicited a predictable response, with questions being raised about whether pregnant women should be 'allowed' to make choices that go against medical advice. In their discussion, the authors highlight this dilemma, making the point that, in the UK, the fetus has no legal status, so a mentally competent pregnant woman has a legal right to make choices that may increase the risk to the fetus from a medical viewpoint (bearing in mind that it is impossible to predict exactly which pregnancies will have a negative outcome). To keep matters in perspective, they also point out that the vast majority of so-called 'high-risk' pregnancies under the care of IMs had a positive outcome.
The authors' final discussion point is that the NHS should seek to understand why some women are so traumatised by their pregnancy and birth experience that they completely reject 'standard' NHS care in subsequent pregnancies. Fur thermore, they state that, if informed choice in health care is to become a reality, clinicians must accept that sometimes pregnant women will make choices that take the clinicians out of their comfort zones.
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