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National Maternity and Perinatal Audit Clinical report 2017

Sheena Byrom

Screen Shot 2017-11-18 at 17.30.19.png


On 6th November 2017, a maternity audit report was published, based on births in NHS maternity services in England, Scotland and Wales over two years (1st April 2015 - 31st March 2016).

This blog summarises some of the key findings and methodological details of relevance for Midwifery Unit Network. We hope this will encourage you to take a look at the full report for further information. 

NMP Audit Finding:

‘Increasing access to midwife-led birth settings is a national priority and although the majority of obstetric units are co-located with an alongside midwifery unit in England, only around 13% of women give birth in a midwife-led setting.’


Jane Sandall and colleagues showed 45% of women were eligible for midwifery-led care at the end of pregnancy, and a mapping study by Denis Walsh and colleagues suggests that ‘a pragmatic calculation of the percentage of women that potentially could birth in midwifery units after obstetric referrals in pregnancy and during labour is 36%’ (Sandall et al, 2014; Walsh et al, 2018)

Relevance for midwifery unit managers and support groups

The main points of interest are:

·       The explicit call to action ‘Increasing access to midwife-led birth settings is a national priority’ – see above.

·       Reporting that routinely collected alongside midwifery unit data can often not be separated from the obstetric unit data. This has been reported repeatedly before, but it is a serious impediment to ongoing comparisons of outcomes for selected groups of women, and for sites with different proportions of women receiving midwifery-led care and using midwifery units.

·       The recommendations to ‘individual clinicians’, to services and commissioners, reproduced below.

Overall key findings

The key findings are helpfully summarised at the start of the report, they include reports on BMI, maternal age, smoking, access to midwifery units, 3rd and 4th degree perineal tears, heavy blood loss, low Apgar scores, and small for gestational age babies born at term and post 40 weeks. Missing data are also highlighted for planned caesarean births carried out at 37 and 38 weeks, when babies are more at risk of illness than after 39 weeks.

Aims of the audit

The overarching aim of the NMPA is to produce high-quality information about NHS maternity and neonatal services which can be used by providers, commissioners and users of the services to benchmark against national standards and recommendations where these exist, and to identify good practice and areas for improvement in the care of women and babies. The NMPA consists of three separate but related elements:

• an organisational survey of maternity and neonatal care in England, Scotland and Wales providing an up-to-date overview of care provision, and services and options available to women

• a continuous clinical audit of a number of key measures to identify unexpected variation between service providers or regions

• a programme of periodic ‘sprint’ audits on specific topics.


 ‘The project is estimated to have captured 92% of births in England, Scotland and Wales during the (two year) time period, based on comparisons with hospital administrative and birth registration data for the reporting period.

‘The measures in this report were arrived at using an iterative process with consultation from external stakeholders through a Clinical Reference Group and members of the public through our Women and Families Involvement Group. They were evaluated for feasibility, data quality and statistical power, given the data that the NMPA has been able to collect and access in its first year.

‘In order to compare like with like, the majority of measures are restricted to singleton, term births.’

‘As a general principle, the denominator for each measure is restricted to women or babies to whom the outcome or intervention of interest is applicable. For example, the measure of the ‘proportion of women with a third or fourth degree tear’ is restricted to women who gave birth vaginally.

‘Rates of measures are also adjusted for risk factors which are beyond the control of the maternity service, such as age, ethnicity, level of socio-economic deprivation and clinical risk factors that may explain variation in results between organisations.’

It should, however, be remembered that the data are not complete, and there are known data quality issues. The authors state elsewhere ‘rates that appear to be ‘positive’ outliers … may be due to under-diagnosis or data quality issues’.


These, selected, recommendations of specific relevance for midwifery units have been quoted verbatim. Comments in bold have been added by the author. Recommendations that have been highlighted are of particular importance to Midwifery Unit Network.

…for individual clinicians

 • Clinicians involved in maternity care should, in multidisciplinary teams, familiarise themselves with the findings for their own service and how these compare to national averages in order to determine the focus of quality improvement activity required.  How many women in YOUR trust or board give birth in a midwifery unit or at home?

…for services

• Services should examine their own findings and data quality and compare these to internal audits where available, both to evaluate their data quality and to consider how they compare with national rates, and to determine action plans for quality improvement.

• Results for individual measures should not be interpreted in isolation. Rather, services should examine all measures together, attempting to understand possible relationships between them, and use this analysis to improve services as a whole, not just to one particular target. Measures in this report should also be considered together with perinatal mortality results from MBRRACE and measures of neonatal care from the National Neonatal Audit Programme (NNAP).

• Where the rate for a service differs substantially from the overall rates, the service should identify reasons for this. This includes rates that appear to be ‘positive’ outliers as this may be due to under-diagnosis or data quality issues. Where true positive outliers are identified, services should consider ways of sharing best practice with their peers (emphasis added) and with the NMPA so that these can be shared with other services.

• Services should ensure that local information about the rates of care processes and outcomes in labour is made available to women using their services. This should be by planned or actual place of birth, eg home birth, freestanding midwifery unit, alongside midwifery unit and/or obstetric unit.

• Audit departments should facilitate dissemination of these findings among all relevant staff and services and commissioners should share and discuss the findings as part of their Maternity Voices Partnerships (formerly Maternity Services Liaison Committees).

• Further work is needed to understand the potential for increased use of midwife-led settings. This includes gaining a better understanding of the proportion of women considered suitable to use these settings and the criteria applied by different services through local review by providers and commissioners, inclusion of relevant questions in national surveys of women, and further research.

…for commissioners

• Commissioners should facilitate the dissemination of these results to GPs and local authorities.

• Commissioners, together with clinicians, services and policymakers should strongly prioritise the provision of resources to support breastfeeding, both in maternity units and in the community, to reduce the variation in the proportion of babies receiving breast milk at their first feed and at discharge from the maternity unit.

• Commissioners should support services to collect information on planned and actual place of birth, distinguishing between obstetric units, alongside midwifery units, freestanding midwifery units and home, and to collect information on transfers in utero, and during labour and the postnatal period.

Specific outcomes

For this, the first NMPA report, three measures were selected as indicators for ‘outlier reporting’.  These indicators are:

• proportion of vaginal births with a severe (3rd or 4th degree) perineal tear

• proportion of women with an obstetric haemorrhage of 1500ml or more

• proportion of singleton, term, liveborn babies with a 5-minute Apgar score of less than 7.

The report includes ‘site level’ findings for these outcomes (p76) and for other measures of clinical importance (see list below), and reports those that are statistically higher or lower than the mean (average). Unfortunately, there are no published results for births in midwifery units, but these should be available locally.

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Some ‘sites’ (usually a trust/board, obstetric unit or a combined obstetric unit and alongside midwifery unit) have no findings listed, as their data were either not submitted, or were woefully incomplete. Check out the results for your trust/board, obstetric unit or a combined obstetric unit and alongside midwifery unit. If your local site is not listed find out about the problem and ask your LMS Board (in England) to sort it out. 

The National Maternity and Perinatal Audit is led by the Royal College of Obstetricians and Gynaecologists (RCOG) in partnership with the Royal College of Midwives (RCM), the Royal College of Paediatrics and Child Health (RCPCH) and the London School of Hygiene and Tropical Medicine (LSHTM)

Summary written by Mary Newburn for MUNet.


Sandall, J., Murrells, T., Dodwell, M., et al., 2014. The efficient use of the maternity

workforce and the implications for safety and quality in maternity care: a population based,

cross-sectional study. Health Services and Delivery Research 2, 1–289.

Walsh D., Spiby H., Grigg C., et al 2018 Mapping midwifery and obstetric units in England. Midwifery 56, 9-16. Available online at


My Birthplace: shared decision making at it's best!

Sheena Byrom


By Gill Walton Director of Midwifery Portsmouth Hospitals Trust

The My Birthplace app gives evidence based information and is used as part of a shared decision making pathway to help women express their preference for place of birth. It was developed by a group of local mothers, midwives and web designers (the technical team!) following a successful bid for the Health Foundation Shine awards

After the Birthplace study was published it became clear that mothers and midwives did not use  the evidence in a way that was useful to them.

The app was tested locally in Portsmouth.   The initial feed back from mothers and midwives was that it was simple to use, presented the evidence in away they could understand and the number of women expressing a preference for place of birth increased at 36 weeks!

There is a PhD student now in her final year of her research digging deeper into women’s experiences of using the app.

The service can monitor the use of the app and there are approximately 500 new users every month. At least we can say that women are accessing the information and the evidence!

The most important thing about implementing the My Birthplace app was actually the Shared Decision Making training programme (see below) for place of birth. This is based on a simple model and the training has helped midwives talk to women in a different way about their values and preferences in order to support their final decision.

We have also tested an ‘Ask 3 Questions’ card which also supports women to take the lead in asking questions about Place of Birth. This has increased women-led conversation about place of birth.

The My Birthplace app. has now been rolled out across Wessex and has been bought by Tayside. There is a clincial reference group that meets three times per year to implement any changes and ensure new evidence is added to the app.  For example, when the NICE guideline for place of birth was published we added information about transfers.

The number of births off the labour ward in Portsmouth is now between 20-25%. The most important thing is that women feel confident in their decision and understand both the benefits and risks of each place of birth. The app is used by partners and family members too-always helpful for influence and support! 

Midwifery Unit Network 1st European Meeting

Sheena Byrom

By Lucia Rocca-Ihenacho

Around 4.7 million European women give birth each year. Despite the strong evidence for midwifery-led care and midwifery units, most EU countries still offer women very limited choice regarding place of birth and lead practitioner, with referral to an obstetric unit being the mainstream option. In many EU countries obstetric units are in fact the only available birthing setting.

Against this background the UK has been leading research on midwifery-led settings and we have remarkable capacity to collaborate internationally to share best practices as well as benefit by widening our horizons. At City University of London, led by Prof McCourt, we have been co-investigators in the Birthplace in England Programme, which underpinned the choice of place of birth recommendation in the NICE intrapartum guideline (2014). More recently we have been co-investigators on a NIHR project on MUs led by Associate Professor Denis Walsh. Lucia Rocca-Ihenacho is also currently conducting an NIHR Knowledge Mobilisation Fellowship in order to develop strategies for increasing the number of births in midwifery-led settings.

At EU level, a project led by Professor Soo Downe called ‘Childbirth Cultures, Concerns, and Consequences: Creating a dynamic EU framework for optimal maternity care’ is already laying some foundations for the improvement of outcomes and experiences for women having straightforward pregnancies.

Our vision is to improve women’s health by ensuring that midwifery units become mainstream rather then an alternative.

The MUNet will build bridges between researchers, service users and providers, organisational managers and commissioners, engaging all those who are implementing or improving the performance of a Midwifery Unit or lobby for the existence of MUs in first place. 

The Midwifery Unit Network (MUNet) aims at building on existing research evidence, philosophy, leadership, knowledge and skills in order to share and grow stronger together.

The MUNet Europe has already had an impact by developing groups in Spain, Italy and the Czech Republic and planning to expand its network of European network gradually. We have supported events in England, Italy and Spain and currently undertaking a staff development need assessment.

The First European Meeting which took place in London on April the 28th 2016 had the following objectives:

  1. Agree an European definition of Midwifery Unit.
  2. Start a consensus exercise on Midwifery Unit operational procedures, which can be used in all EU countries.
  3. Identify key partners and lead organisations for the EU applications.
  4. Identify potential pilot Midwifery Units to be implemented in the partner countries.
  5. Start developing country-specific strategies to overcome the challenges.

Check out our short film of the successful event...

Following the very successful event in London we co-hosted an event in Genoa (Italy) in April 2016 and one in Tarragona (Spain) as part of the ICM Southern Europe conference in May 2016.

As part of our European strategy we plan to apply for EU funding in order to build on existing expertise and develop leadership and research capacity. The funding will help expanding the existing network and provide vital resources to support travel expenses and the facilitation of training across Europe. 

Objectives of the MUNet:

  1. NETWORKING-Create an European community of practice to support existing MUs, lobby for the creation of new ones and influence policy.
  2. TRAINING-Philosophy, Knowledge And Skills development via the MUNet Academy.
  3. LEADERSHIP- Developing leadership capacity within MUs.
  4. RESEARCH- Developing research capacity on MUs.
  5. CONSULTANCY- Supporting teams establishing MUs or improving existing ones in the field. 

Enormous gratitude to City University London, and Active Birth Pools for sponsoring this event. 

A new UK Midwifery Study System

Sheena Byrom

What is UKMidSS?  Why is it exciting that all alongside midwifery units (AMUs ) in Scotland, England, Wales and Northern Ireland are involved? How can you find out more, and stay in touch? Dr Rachel Rowe, who leads UKMidSS, and Catherine Williams, Vice Chair of the UKMidSS Steering Group, explain.......

The Birthplace study showed the importance of carrying out high quality research in midwifery-led settings.  It also showed that there is an appetite amongst midwives for getting involved in research that relates directly to their practice.  Building on this, UKMidSS has been set up as a new national system for carrying out research studies in midwifery units.  Funded by the National Institute for Health Research (NIHR) and co-ordinated by a research team at the National Perinatal Epidemiology Unit (NPEU) in Oxford, UKMidSS is a national collaboration currently involving over 200 midwives from 122 units across the UK. 

For Catherine, as a service user representative on the UKMidSS Steering Group, the exciting thing about UKMidSS is that midwifery units are now well-enough established as part of the maternity landscape to be the subject of research in their own right.  As more new midwifery units open, and more women have the option of planning birth in an alongside (AMU) or freestanding midwifery unit (FMU), research carried out in these settings will be increasingly important so that women can make informed decisions about planned place of birth and other aspects of their care. 

So how does UKMidSS work?

If you’re really research-minded you can read the details in the UKMidSS protocol, but in simple terms UKMidSS is a platform for carrying out research.  And the easiest way to explain how it works is to consider the kinds of questions that can and are being answered by UKMidSS studies. 

Researching uncommon events and outcomes

The best available evidence shows that healthy women at low risk of complications who plan birth in a midwifery unit are more likely to have a straightforward birth without medical intervention, with no difference in safety for their baby, compared with planning birth in a consultant-led hospital unit. 

Of course the key national guideline here is NICE CG190 Intrapartum Care for healthy women and their babies (2014).  Catherine was a lay member of the guideline development group, and you can read more about the guideline (and the various versions – plain English, flowcharts, recommendations, and full evidence and text) on her blog here.

Coming back to UKMidSS, we know that midwifery units, and possibly AMUs in particular, are also used by some women who may be at a ‘higher risk’ of complications during birth, that is they may have one or more of the medical conditions or other factors listed in the NICE CG190 planning place of birth recommendation as factors which may affect planned place of birth.  There is very little evidence on the numbers of women planning birth in midwifery units “outside the guidelines” in this way or on outcomes for these women and their babies.  Using UKMidSS we can carry out studies to investigate questions like these and the first UKMidSS study is doing just that by focusing on women who are severely obese (with a BMI>35kg/m2 at booking) and admitted to an alongside midwifery unit for labour care. 

UKMidSS Severe Obesity Study

We know that maternal obesity is a recognised risk factor for a range of complications and poor outcomes and as a consequence NICE CG190 recommends that women with BMI>35kg/m2 are advised to plan birth in a consultant-led obstetric unit.  In the Birthplace study relatively small numbers of severely obese women planned birth in midwifery units so it was not possible to investigate their outcomes.  However based on further analyses of Birthplace data on women planning birth in obstetric units we know that ‘otherwise healthy’ obese women having a second or subsequent baby may have lower risks than was previously thought.  Since Birthplace there has been a rapid increase in the number of alongside midwifery units, obesity continues to rise, and anecdotally we hear of increasing demand for midwifery unit birth from obese women.  Midwives are keen to be able to provide evidence-based information on risks and benefits to the women they care for, so the first UKMidSS study is aiming to answer these questions:

·       What proportion of women starting labour care in AMUs are severely obese?

·       What are the socio-demographic and clinical characteristics of these severely obese women?

·       How do the outcomes for severely obese women (and their babies) starting labour care in AMUs compare with outcomes for women of normal weight starting labour care in AMUs?

Since January of this year, midwives who are our ‘UKMidSS reporters’ in all 122 AMUs across the UK have been collecting data to answer these questions and will continue to do so until the end of December.  Every month they tell us how many ‘cases’ of severe obesity they have seen in their unit.  They also tell us about the number of admissions and births in their unit so we have a ‘denominator’ to work out what proportion of admissions are severely obese.  Then when they report a ‘case’ they follow up by sending more detailed data on that woman and two comparison women or ‘controls’.  The idea is that these ‘controls’ are representative of the general population of women admitted to AMUs so we have a good comparison group. 

All UKMidSS studies use anonymised data routinely recorded in women’s notes which is reported to the UKMidSS team using specially designed secure web-based systems.  We also aim to focus on relatively uncommon events, conditions or outcomes so that the burden of data collection shouldn’t be too great. 

But why is it important to focus on uncommon events?  Just because an event or outcome is uncommon this doesn’t mean it isn’t significant and of interest to women and their families.  Our first study is evidence of this, but it also clear that some uncommon outcomes in particular may have a disproportionate impact.  We know from Birthplace that serious poor outcomes are uncommon in midwifery units, but we also know how big an impact these can have on women and their families, so it is important to continue to investigate uncommon poor outcomes in midwifery-led settings.  Because these outcomes are uncommon, UKMidSS can provide an infrastructure for this kind of research. 

Neonatal Admission Study

In 2017 we will be investigating cases where a baby is admitted to neonatal care following birth in an AMU.  Admission of full-term babies to neonatal care is a key indicator for the safety of maternity care.  NICE CG190 recommends transfer to an obstetric unit when certain complications arise during labour in a midwifery unit, but we know from Birthplace that around 40% of poor outcomes in babies occurred in births which took place in the original planned birth setting, i.e. where no transfer took place.  Admission to neonatal care following birth in an AMU is therefore a potential marker for an event where different care might have made a difference to outcome. 

This study aims to identify maternal characteristics and aspects of care during labour, birth and the immediate postnatal period which may be associated with neonatal admission. 


As with all UKMidSS studies the research questions for these studies have been developed with input from the multidisciplinary Steering Group which includes women, midwives, doctors and research experts from across the UK.   

Developing midwifery research capacity

We are looking to expand the involvement of the midwifery community in UKMidSS.  UKMidSS is already creating a community of practice in midwifery research, beginning with AMUs.  UKMidSS reporters – one or more in each AMU - and the managers and colleagues supporting their participation, are facilitating research that matters to women and that has the potential to develop research capacity in midwifery.  We are very excited to be holding our first Study Day for UKMidSS reporters in November, where we will be getting together to hear some preliminary findings from our first study, to network, share experiences and to generate ideas for future studies.  Then, dependent on further funding, we will be looking to expanding UKMidSS to include FMUs as well.

We are particularly keen to hear from midwives who have ideas for future UKMidSS studies or who would like to work with us to develop a study idea. 

Montrose Birth Centre, Scotland 

Montrose Birth Centre, Scotland 

Staying in touch

Rachel is delighted to be connected with MUNet through her involvement as a member of MUNet’s advisory board.  You can catch up with both Rachel and Catherine at the RCM’s Annual Conference in October 2016.  Look out for further conference appearances and blogs when we have news of our first study results. 

In the meantime you can stay in touch with us by following us on Twitter @NPEU_UKMidSS @RachelRowe3 @BerksMaternity, or by reading the UKMidSS newsletters (sign up to be notified about newsletters by emailing 

Rachel Rowe is funded by a National Institute for Health Research (NIHR) Post Doctoral Fellowship (PDF-2014-07-006).  This article presents independent research funded by the NIHR.  The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

We have a new logo!

Sheena Byrom

Logo design by Jamel Darling Logos for the Low Low

Logo design by Jamel Darling Logos for the Low Low

We had an encouraging response to our competition for a logo for the Network, and the winning design was chosen by our Advisory Group, against set criteria. Jamel Darling who created the design, said with his entry:

'The message I tried to convey with this design is networking & growth. Midwives play a large role when it comes to the birthing process, and play a part in the healthy growth of a newborn or still developing child. The roots symbolized the network aspect, connecting midwives from many different areas. The sprout symbolizes new growth, and the colors of pink & light blue represent newborn babies'.  [We changed the pink and blue colours to the ones now used in the logo]. 

When Jamel heard the news he said: 'I am excited to have my design chosen as the winner'.  You can see Jamel's work here, and find him on Twitter via @Logos4theLowLow

The MUNetwork leads would like to thanks all those who entered the competition, for sharing their ideas and creations. 

The competition was generously sponsored by Pinter and Martin.

Midwifery Units in Northern Ireland

Sheena Byrom

Photo: Lagan Valley Freestanding Maternity Unit

Photo: Lagan Valley Freestanding Maternity Unit

Midwifery Units in Northern Ireland

By Seána Talbot

There were 24,394 live births in NI during 2014 (NISRA, 2015) with the total number of MLU births being 2,960 - equating to 12% of births. The home birth rate is stubbornly bottoming along at less than 1% (n=67).

NICE guidelines advise health care professionals working with low-risk women to:

  • Explain to both multiparous and nulliparous women that they may choose any birth setting (home, freestanding midwifery unit, alongside midwifery unit or obstetric unit), and support them in their choice of setting wherever they choose to give birth:
  • Advise low-risk multiparous women that planning to give birth at home or in a midwifery-led unit (freestanding or alongside) is particularly suitable for them because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit.
  • Advise low-risk nulliparous women that planning to give birth in a midwifery-led unit (freestanding or alongside) is particularly suitable for them because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit.

NICE Guideline CG190, Intrapartum Care for Healthy Women and Babies, December 2014

 Despite this, a quick glance at the NI Midwifery Unit map shows that, unless a woman lives in greater Belfast, her choices are currently limited.


Currently, there are three freestanding and five alongside units, with a further alongside unit in development in Belfast. The units are geographically clustered in the east, and (apart from the Downe and the South Western units) in areas of higher population density, so women living on the north coast, west of Lough Neagh, or in rural areas have limited options.

Our maternity strategy commits the Health & Social Care system in N Ireland to ensuring that women have access to midwifery-led options as part of a wider culture change. Units are also known as MLUs (midwifery led units) in Northern Ireland.

Our midwifery units are highly valued by the women who use them. A quick look at some of the outcomes from one of the units indicates some of the reasons why:

In NI, eligibility criteria are used as a screening tool for admission in line with accepted practice elsewhere. Each MLU in NI had developed their own admission criteria to guide both maternity care professionals and women. In practice, this meant that there was a lack of consistency across NI, as the differences in the criteria and their application impacted on women’s planned place of birth. This led to some women being either inappropriately refused admission to the MLU, incorrectly admitted to a MLU, or transferred unnecessarily to an obstetric unit. 

It was also recognised that the admission criteria varied from one MLU to another, were often not clearly defined, and that midwives in NI had expressed the need for clear evidenced-based guidelines (Healy, 2013).

The Guidelines and Audit Implementation Network (GAIN) is the body which produces official clinical guidelines for use in Northern Ireland. In 2015, the network completed a detailed guideline document for midwife led units. The process was thorough and at times challenging, and involved multidisciplinary and service user guideline development group members reviewing the available evidence and building a consensus about which women should be encouraged to choose midwifery units for their birth. The group included practising midwives, lecturers and researchers as well as obstetricians, GPs, anaesthetists and, importantly, women and women’s advocates. The results of the Ten Thousand Voices listening project, which included maternity care, was also influential in shaping the work.


Initially, the plan was to produce a single list of criteria to guide women and health care professionals. However, as well as agreeing a core list, applicable to both alongside (AMU) and freestanding midwife led units (FMU), the group identified another group of women, with a slightly higher risk profile, who should be encouraged to attend alongside midwifery units only.

In addition, the group identified that more women than expected were transferring out of midwifery units to consultant units while in labour. In order to reduce the numbers of unnecessary transfers out, the group developed a Normal Birth Care Pathway. The pathway focused on confirming that women are in established labour before admission to the unit in labour, as well as identifying best practice in terms of supporting women experiencing straightforward labour.

The guidelines and pathway are available online HERE

In order to encourage implementation of the guidelines, the Chief Nursing Officer has supported the roll-out of awareness sessions for midwives in all Trusts in NI. A detailed evaluation is planned for 2018.

Details of the individual units can be found on the various Trust websites

1. Altnagelvin AMU Check out video which covers obstetric as well as midwifery led options

2. South Western Acute Hospital Check out video which covers obstetric as well as midwifery led options

3. Daisy Hill Hospital AMU Check out video

4. Craigavon Area Hospital AMU  Check out video

5. Lagan Valley FMU 

6. Mater FMU Check out video

7. Ulster Hospital Home from Home AMU Check out video

8. Downe FMU

Photo: Lagan Valley Freestanding Maternity Unit

Photo: Lagan Valley Freestanding Maternity Unit







The Meadow Birth Centre Worcestershire - development to success

Sheena Byrom

Worcestershire Acute Hospitals NHS Trust provides maternity care for around 6,000 women and their families across the largely rural areas in and around Worcestershire. Antenatal care is provided on three main sites, with satellite clinics also running on a further two. Maternity inpatient care is currently provided on one site, at Worcestershire Royal Hospital. I joined the Trust in 2009 when the unit was on the brink of building a new alongside midwifery led unit. Unfortunately, it was not meant to be and plans were put on hold. A subsequent declined bid for Department of Health monies led to further frustration but also revealed the collective hunger of the midwifery team, the women and the Trust as a whole for a midwife led unit to be developed. Third time lucky – funding was secured from the Department of Health which led to an exciting 8 months as plans were activated and the midwifery led unit, named by a new mum as the “Meadow Birth Centre” (in keeping with the nature of the rural location), started to become a reality.

Setting up work streams

Challenges were many however, under the guidance of the Head of Midwifery, work streams were developed to focus on five main areas, distributing the essential work between the senior midwifery team: enabling works; environment; staffing models and preparation and guidelines.

Involving all stakeholders

Service users (past and present), doulas / birth attendants, maternity and obstetric staff, students, university lecturers, infection control, moving and handling team, pharmacy and the estates team engaged with the different work streams making valuable contributions to ensure all views and ideas were incorporated. Inclusion of the many key individuals was later reflected on as having been instrumental to ensure all ideas were achievable within the timeframes, avoiding unnecessary delays which would have been inevitable if different departments had to be contacted for review and approval.

Whilst the building work was, to some extent, limited by the available budget, this did not impact on the end product with large birth pools being the focal point in 4 of the 5 rooms and air flow being individually controlled in each room.  Innovation and inspiration came into play as the collective team worked together to raise additional funds and find alternative ways of achieving the desired outcome. Networking with the University of Worcester led to a connection with the tutor from the graphic design department (who had previously experienced maternity care at the Trust herself). She quickly came on board and ‘got’ the vision and resulting theme for the unit, involving her students to participate as part of their project work and ensuring the women, families and team who would be receiving and providing care in the Meadow were involved every step of the way. The proposed colour schemes were somewhat bolder than we had initially envisaged but striking, homely and calming as a result with suitable names also chosen by the families. The focal quotes on the walls and the designs on the windows and the walls were chosen by the families and staff involved with the project. The Meadow team then chose the furnishings, making sure their practical designs remained comfortable and in keeping with the environment whilst providing opportunity for them to ‘make it their own’.

Focus on calmness and achieving the WOW factor

Lighting was key for all involved and the stubbornness about this was justified when the ‘wow’ factor was achieved (from a member of the estates team) as the longed for ‘twinkly lights’ were turned on and complimented the colour changing pool lights and free standing ‘mood tubes’. We quickly learnt that, having key members of the building team who were new or soon to be fathers certainly helped the desired outcomes to be achieved! The ambiance was further enhanced by the addition of music and aromatherapy diffusers maintaining calmness for the families and staff alike.


Selecting and preparing staff

As the journey progressed, focus turned to the staff selection. Again, the process involved our service users who engaged fully with this and reflected on the evident passion of the resulting team who are a credit to the unit. The importance of investing to prepare the team to care for women in the Meadow was never underestimated – to this point, they had provided care in the hospital’s obstetric units with very limited exposure to intrapartum care in a low risk setting.

This was highlighted when an incidental concern of some members of the team was raised regarding the toilet facilities. The Meadow is fortunate to have a large family room with sofas, dining facilities, kitchenette and bathroom. This is shared between families and staff (as at a homebirth). Whilst the team leader and I had backgrounds as community midwives, where using the family toilet and facilities is the norm, the majority of the team had not experienced this and the thought of sharing their toilet with ‘a man’ was initially a great worry! 

Researching what midwives and maternity support workers needed in terms of preparation revealed a huge gap in evidence to draw upon so we set about discovering their needs, through enquiries and narratives from the team themselves and those who had been through a similar transition at neighbouring Trusts. This led to a bespoke maternity team preparation programme which covered all elements identified by the midwives and maternity support workers to be a potential cause of anxiety or a need, together with the elements of practice and care that MLU teams from neighbouring units reflected would have benefitted them (i.e. physiology refresher for all stages of labour; aromatherapy training; team building activities; conflict resolution; emergency skills drills in the new environment; re-focussing care – programme can be shared if desired). The programme started with a unique opportunity for the midwives to visit one of three neighbouring MLU’s on ‘observational placements’.  This experience proved invaluable, affording them the opportunity to observe midwives, maternity support workers caring for labouring women and their families in established birth centres. They then each shared their reflections with the rest of the team in a facilitated session as part of the programme, providing insight into the importance of communication together with effective, attentive, supportive care.

Our bespoke maternity team preparation programme included a physiology refresher for all stages of labour; aromatherapy training; team building activities; conflict resolution and emergency skills n drills, as well as ‘observational placements’ in established birth centres.

Having previously valued the work of Mary Ross-Davie through academic study, I invited her to support our preparation programme and was delighted that she kindly accepted. The essence and lasting message of her inspirational sessions has greatly influenced the success of the meadow birth centre as is evident through the comments in the visitor’s book. Whilst the families are overwhelmed by the environment, they all comment on the amazing care received from the midwives and maternity support workers – Mary impressed upon them that they are the greatest intervention of all. The environment helps set the scene however how it is the way in which the care is provided that has the greatest impact.

One year on

A year since opening, the number of births has far exceeded the first year’s anticipated target with 650 babies having been born in the Meadow Birth Centre and more student midwives than initially planned having had opportunity to provide the essence of midwifery care in a low risk setting. The tree at the far end of the Meadow Birth Centre marks the births with new parents placing a leaf on the branches with their new baby’s name and date of birth – we have seen it grow and bloom with pride (albeit are now considering the need for an Autumn as the branches are very full!).

We have transitioned from a new birth centre to an established birth centre with ambitions to extend the cautious inclusion criteria to more individualised care planning. The future has to involve sharing the philosophy and re-focussing on the care provided to women in the delivery suite. Already, plans are afoot to improve the birth environment on the delivery suite with funds having been raised and the involvement of the same graphic design department - the aim is for a synergy between the birthing areas so all women experience the same standard of birth environment, whilst being appropriate to their needs.

It is exciting to see all that has been achieved already through the determination of the Meadow Birth Centre team with the support of the wider maternity and obstetric team; reiterated by the comments left from the families who received care, and the students who have worked alongside the team. 

Matron Rachel Carter with mother-to-be

Matron Rachel Carter with mother-to-be

Rachel Carter has been a practising midwife for 21 years, providing all aspects of midwifery care, working in Birmingham and Worcestershire. During her career she has been supported to gain a variety of qualifications, including management, safeguarding, being appointed as a Supervisor of Midwives and achieving a Masters degree. Having been privileged to care for women in the community and maternity inpatients as a team midwife, team leader and matron, her passion is to ensure all women and families receive the highest possible quality of safe and individualised care to enable them to have the optimal pregnancy, birth and postnatal experience and outcome.

Meadow Birth Centre: A Grandad's View!



There are some questions that the Dad of a teenage daughter shouldn’t be expected to answer! Suzy’s water had broken early in the morning, but because of the speed of contractions (and her fear of hospitals) I was now speaking to Ambulance Control. “Is the head of the baby showing?” the person on the other end asked me. “I’m not sure I can answer that!” I said. Undeterred they asked: “Is there any brown liquid?” “Errr…”. By that stage the ambulance crew had arrived, had given Gas & Air, got Suzy into the van and, following on behind, we got to the Meadow Birth Centre.

I had known of the Meadow when it was just an idea. I had heard the vision and excitement of my friend and Midwifery Matron, Rachel Carter, as she talked about it.  I had seen it in various incarnations through the building stage to its completion. I had been delighted that my friend Louise Turbutt was going to lead the team there. I had been impressed with the ethos of the staff team and the careful way in which they were recruited because of their values and temperament. I had been there at its opening and “WOWed” along with everyone else at the facilities, and the birthing pools, and the twinkling lights and the ambience. I had stood by the Tree of Life which, I knew, would soon be full of leaves with the names of babies ‘birthed’ there. I had got to know the team as friends and respected the way they had kept the ethos of tranquillity and choice. And a year on, I attended their 1st Birthday Party after helping more than 650 new lives come into the world.

BUT NOW…IT WAS MY DAUGHTER…arghhh. As soon as we go to the centre all my anxieties were eased. She was welcomed with kind and calm professionalism. Although I joke that I am an “honorary midwife” I left Suzy in the company of my wife Ali and the baby’s dad. I don’t know what went on behind those doors….so my daughter Suzy takes over the story.

On the third of January 2016, I gave birth at the Meadow Birth Centre and I couldn't have asked for a better environment to be welcomed in to. The staff were all absolutely lovely and understanding of my needle and medical phobia. All of the medical equipment was tucked away in to cupboards, away from the viewing of the patients which I completely adored. My labour was assisted by Lucy Laird, who was very polite and friendly. I was later discharged by Allison Collins-Cunneen, who again, was lovely. All of the staff were so warm and loyal to their patients which really made my visit a pleasant one. The actual birth centre itself is a beautiful place to be. The rooms are spacious and very well presented with music, dimmed lights and relaxing aromas. It was wonderful and such an incredible experience so thank you to Meadow Birth Centre for allowing myself and my family to celebrate the birth of my daughter together.”

All I know is that two or three hours later my granddaughter, Emilia Grace, came into the world! It was all so special and beautiful but two things stick in my mind.

Firstly, I know many of the staff well… and they knew me as the Chaplain. But in that Centre on that day they didn’t treat me as anything other than Emilia’s Granddad – which is exactly what I wanted!

Secondly, I will never forget standing by the Tree of Life next to my daughter and granddaughter as we put up the leaf with her name on. Truly special.  So I have seen the Meadow Birth Centre as a colleague and been inspired and impressed. And I have seen it as a Granddad and been humbled by the care, kindness, and love shown.

Emilia continues to grow, bringing us magic day by day. And none of us will forget where she started her days.

Midwifery Unit Network logo competition

Sheena Byrom


We are holding a logo competition! And there is a £50 Pinter and Martin book token for the winner! 


We need your help to create a logo to convey what the Midwifery Unit Network is all about. We'd love to hear from you if you have any creative ideas. Calling out to all graphic artists, birth centre enthusiasts, midwifery students and service user supporters. We got some wonderful ideas from our first appeal before our London Launch, but unfortunately there was no outright winner and we didn't feel we had the right image. 

We would like the logo to:

  • Reflect the values underpinning birth centre care
  • possibly convey a network, and be
  • simple and clear, so easy to reproduce and recognise.

Please submit a photograph or scanned image of your design for a Midwifery Unit Network logo by Sunday 10th July to with your name and address, occupation, email and telephone number(s).  

Also, please provide a short statement (max 200 words) about the message your logo is designed to convey and explain your ideas behind the look and feel of the image.  The co-founders will ask the MUNet advisory group members to select a suitable image from a shortlist of entries to inform the commissioning brief given to a graphic artist for creating the final image. Please make the subject of your email MUNet Logo competition.   If you have any queries please contact us via

Thank you, in anticipation....




Midwifery units – films of birth, virtual tours for parents and antenatal preparation

Sheena Byrom


by Mary Newburn

As one of the leaders of Midwifery Unit Network, I thought it would be useful to find out what there is available online to inform the public, midwives, doctors and commissioners about the care provided, and the environment, in midwifery units (also known as birth centres).

I also wanted to check out useful clips for women, their partners and other birth companions to help them learn about what to expect. 

This is a brief introduction with some links. Let us know what you find useful, or any other comments you may have at the end of this post. 

There are all kinds of birth films on YouTube. But it’s not necessarily easy to find the more relevant ones, such as midwifery units in your country. Often the name or location of the birth centre is not provided. It would also be useful to know which have been filmed in freestanding midwifery units and which are from a midwifery birth centre alongside an obstetric unit.

Currently, few films have an introduction (about the parents, the pregnancy or the unit) or any reflections from the woman or midwives after the birth. I find these additions very helpful as they provide a context and the woman’s perspective about what mattered to her, how her labour and the care provided felt at the time, and what she feels looking back afterwards.

While ‘virtual tours’ of birth centres are usually made by midwives to introduce the service they provide, films of labour and birth tend to be made by parents. In my fairly brief search, I did not find any films of birth where there were observations or reflections by midwives or other staff, edited into the film. If you know of any, please let us know. 

It would be interesting if there were films to introduce birth centres made by women, as well as those made by midwives (see Serenity Birth Centre and Virtual Tours below).  

Also, it would be great if midwives made films of labour and birth in midwifery units, with the informed consent of women and their parents, and edited with a commentary and reflections.  These could be produced as learning resources intended for other professionals or as preparation for pregnant women and partners.  

Labour and Birth

Blackburn, UK

Waterbirth at Blackburn Birthing Centre  Video of a labour in the pool and a water birth at Blackburn Birthing Centre UK on 12.02.2014, when Oscar Joseph Wilson was born. Oscar’s mother (not named) is in the pool throughout, starting as the pool is being filled. She is reclining and uses Entonox. The video has been viewed over 40,000 times. 

Serenity Midwifery Unit, Birmingham, UK

Parents talk about the birth of their baby Hudson, with labour in (I think) the birth centre and birth in the obstetric unit when monitoring the baby’s heatbeat showed fetal distress. It’s good to have the parents talking about the latent phase and reflecting after the birth. 


North America

Natural birth encouragement – pain and joy Katya and Matt made a video of their baby’s birth in water. The voices suggest they are in north America, but no details are provided. A commentary of reflections by Katya have been edited onto the video, plus there are some quotes from writers about labour and women’s power to birth their babies. This beautiful film has been viewed nearly 3 million times. 

 Brisbane, Australia

A natural birth in a birth centre Few details are provided about this dry-land birth but it is possible to see that it took place in an alongside midwifery unit at the Royal Brisbane and Women’s Hospital. The birth room looks very comfortable and the atmosphere is very relaxed. The woman giving birth appears to have her mum or a doula with her as well as her partner. Quality of image is poor in parts. I found the accompanying music rather intrusive. 

 Virtual Tours

There are lots of virtual tour videos available now. I prefer tours that have a voiceover rather than music. The voiceover sets the tone and provides useful information about the philosophy of the unit and facilities available. Lewisham Hospital in London England, has a good one.

The more recent video has a great introduction to the birth centre but feels less woman-centred in its design than the earlier video which had more families shown on screen and fewer health professionals speaking direct to camera.

Lewisham also have online videos of women explaining why they chose to use the birth centre and how it was for them.  

Serenity Birth Centre, Birmingham England:

Blackburn Birth Centre, England:

  And Burnley Birth Centre, England

Lancashire Teaching Hospitals NHS Trust, England

As a service user advocate, I am surprised and dismayed by just how much institutional and clinical kit there is on display in many midwifery units. This disturbs the peaceful, social environment that birth centres aim to achieve. I’m also upset when I hear language being used that isn’t woman-centred or understanding of women’s rights. There should not be talk about what women are ‘allowed’ to do, it sends all the wrong messages. In the UK, discuss your plans early with the local Maternity Forum (MSLC), and engage parents in making the film.

I would like to see some videos made that refer to evidence and provide the references for watchers to follow up, particularly if there are claims being made about any restrictions or limits placed on women’s freedom to decide what feels best for her and her baby.

It’s good to see an online introduction to the birth centre at the Mater Hospital in Belfast. Within the UK, Northern Ireland has had lower levels of midwifery led care and higher rates of interventions than other countries. Promoting midwifery unit care is important for spreading the word about the benefits.

Labour and Birth preparation online

Some midwifery units provide an active birth preparation online. Surprisingly, in these days of promotion and PR, some good videos don’t make it explicit at the start which unit and country they are from. Take a look at this video from Northern Ireland. 

Summary Tips

If you are making a film:

  • Add the location and type of birth centre!
  • Make sure there’s an introduction and maybe some reflections or comments.
  • Avoid intrusive, repetitive music.
  • Involve parents in the making of virtual tours of midwifery units.
  • If your birth centre is beautiful, please share as many of the details as possible with MUNet, so we can pass on the learning.
  • Use professional architects if you can when creating a new birth centre to ‘design away’ out of sight, or out completely, as much ugly and intrusive institutional furniture and clinical kit as possible.
  • Mind your language. Is it inspiring and enabling? Double check, is it truly woman-centred and evidence informed?  Ask local women and partners their views.

 Please get back to us......

Has your local midwifery unit made a film to introduce what the philosophy of care is all about, to show the facilities and to welcome pregnant women and families? Let us know what’s out there, and what you think is good about it or could be improved on.

Thank you! 

'She can't come here': birth centre criteria and ethics

Sheena Byrom

Guest blog by Dr. Mandie Scamell 

Does your midwifery lead unit welcome all types of women or do you have a list of reasons why some women are automatically turned away?

This was a question  I found myself grappling with while collecting ethnographic data for my PhD on midwives and risk, in England. 

I was researching at the time when the first ever, national Standards for Birth Centres in England were published by the Royal College of Midwives.

The sense of excitement about these standards that emanated from the midwives attending the RCM conference that year was almost palpable.  Eagerly I stood in line (and it was a very, very long line), to collect my own complimentary copy of the RCM standards.  Resisting the uniquely conference inspired ‘Billy no-mates’ sensation, I went off on my own (I am a brave woman!) to paw through my copy of the Standards for Birth Centres in England.  

The trick, it turned out, was ethics.

I was one of those lucky midwives who had managed to win funding to complete my PhD.  As a condition of this funding I completed a number of taught modules, including one on medical ethics.  I went into this module assuming that its relevance would be confined to methodological issues around participation and consent.  How wrong I turned out to be. 

What I learned about he ethics of end of life care turned out to be the analytical key I needed to resolve the bad feeling that had been festering about Birth Centre admission criteria.  I experienced one of those rare but wonderful, epiphany moments where my data suddenly made sense. 

Is it ethical to turn women away from midwifery care offered in a birth centre?

The answer to this question I think should be no!  But are we brave enough as a profession to stand up and say this? Do we have a strong enough professional identity to stand up against the irresistible logic of risk calculation?

A further bit if luck I enjoyed was having the privilege of my analysis of this ethical conundrum published in the British Medical Journal’s, Journal of Medical Ethics. 

Here is the gist of what this paper says:

  • Midwives practise caring (not dissimilar to the caring required for sensitive, warm and supportive end of life care)
  • Midwifery practice should not be confused with medical practice because caring is not the same thing as conducting a medical or surgical procedure
  • The bioethical framework for medical and surgical procedures DOES NOT FIT WHEN APPLIED TO MIDWIFERY CARE
  • Midwives working in Birth Centres have much to gain from the ethical examples set by those providing end of life care
  • If it is not ethical to turn someone away from a hospice just because that individual has refused to accept the recommended treatment for their condition, why is it ethical to turn a mother away from a birth centre just because she has declined to go into the acute hospital setting to have her baby?
  • Shouldn’t Ethics come before Risk in Midwifery practice?

I know what I am suggesting is not easy to hear.  I know what I am saying will make many people angry (I have already had my fare share of hate mail on this one, so no more please!)

But I still feel that it is a point that needs to be made.  If you are interested to learn more the paper is available via this link

Dr Mandie Scamell is a medical anthropologist and midwife specialising in risk and the maternity services in the UK. Mandie joined city in 2013 having previously been part of the Florence Nightingale School of Nursing and Midwifery at Kings College London 

You can contact Mandie via Twitter: @1scamell








A taste of success: two midwifery units in Lancashire!

Sheena Byrom

Tracey Cooper, Consultant Midwife at Lancashire Teaching Hospitals writes about the developments of their two midwifery units (birth centres), with pride! 

Baroness Julia Cumberlege 

Baroness Julia Cumberlege 

Baroness Julia Cumberlege, independent chair of the National Maternity Review opened our alongside birth centre at Preston on the 5th August 2015. It was lovely to spend some time with Julia, to discuss the value of midwifery led settings and show how important this is to women and their families. Lots of families came back to both Preston and Chorley midwifery units (birth centres) to spend some time chatting with her and Tom from NHS England.

Chorley freestanding midwifery unit (birth centre) was refurbished in April 2013, following a successful bid for environment funding from the Department of Health. The findings from the Birthplace study and evidence from local service users provided the evidence for the application to be successful, and the funding also enabled the development of a new alongside birth centre at Preston.

Baroness Cumberlege with staff, including Cathy Atherton, Head of Midwifery 

Baroness Cumberlege with staff, including Cathy Atherton, Head of Midwifery 

The midwives at Lancashire Teaching work in an integrated model between the midwifery units and the community. The intention of this is to provide continuity for midwives, women and their families. The midwives considered different staffing models and chose this way of working, replicating the one at East Lancashire Hospitals Trust, which is very successful. Our midwives are fantastic advocates for promoting physiological birth and woman centred care, I am so proud of them and would like to thank them for their hard work and commitment in making our midwifery led service a great success.

We have had 259 births at Chorley FMU between Apr 2014- end Mar 2015 a 150% increase since being refurbished. 700 births at Preston alongside unit since November 2014. At both units 80% women use water at some point in labour. 60% women birth in water. 75% breastfeeding initiation rate. All babies have optimal cord clamping, unless interventional resuscitation is necessary and all have skin to skin contact immediately at birth. The transfer rate is 20% at Chorley, and 25% for Preston alongside midwifery unit. 

Royal College of Midwives Award Winners! 'Putting Evidence into Practice' 

Royal College of Midwives Award Winners! 'Putting Evidence into Practice' 

Here's what the midwives say about Chorley freestanding birth centre

If you want to contact Tracey, her email is:

Or via Twitter!