Huge variation in midwifery unit provision – Findings from the latest mapping midwifery units in England study
Findings have been published from the midwifery unit mapping study, led by Assistant Professor, Denis Walsh, and a multi-disciplinary team of academics from Nottingham University; City, University of London; De Montfort University; service users; commissioners and clinicians. This is the first study to map provision of midwifery units in England since the Birthplace in England study in 2010 (Brocklehurst et al, 2011; Redshaw et al, 2011). In the intervening period, NICE (2014) has made positive recommendations that women at low risk of pregnancy complications are advised that planning to give birth in a midwifery unit is ‘particularly suitable for them because the rate of interventions is lower and the outcome for the baby is no different compared with (planning to give birth in) an obstetric unit’, and Better Births (NHS England, 2016) has said that women should have personalised care including ‘genuine choice, informed by unbiased information’ about ‘where they would prefer to give birth, whether this is at home, in a midwifery unit or in an obstetric unit’.
The findings tell us the extent to which evidence-based guidance to the NHS on access to midwifery units are being implemented (NICE, 2014). They also provide a baseline from which to measure change in NHS maternity services, in line with national maternity policy in England, the NHS Five Year Forward View (NHS England, 2016).
· Alongside midwifery units have nearly doubled since 2010 (n = 53–97).
· Free-standing midwifery units have increased slightly (n = 58–61).
· There has been a significant reduction in maternity services without either an alongside or free-standing midwifery unit (75–32).
· The percentage of all births in midwifery units has trebled, now representing 14% of all births in England.
· There is wide variation in percentage of all births in midwifery units between different maternity services with a spread of 4% to 31%.
Authors’ key conclusions
In some areas of England, women have no access to a local midwifery unit, despite the National Institute for Health & Clinical Excellence (NICE) recommending them as an important place of birth option for low risk women. The numbers of midwifery units have increased significantly in England since 2010 but this growth is almost exclusively in alongside midwifery units. The percentage of women giving birth in midwifery units varies significantly between maternity services suggesting that many midwifery units are underutilised.
The findings are based on a national survey of heads of midwifery in English maternity services. The response rate was 100%, so the results are very reliable.
· Since 2010, the number of trusts without any kind of midwifery unit has fallen from 75 (50%) to 32 (24%).
· In 2017, a majority of the 134 NHS trusts in England (52.2%) have one obstetric unit and one alongside midwifery unit.
· Over a quarter of trusts, almost 27%, have one OU but no alongside midwifery unit.
· Around one in six trusts (n=23; 17%) have an alongside midwifery unit on the same site as a hospital obstetric unit and at least one FMU.
· Within NHS regions, provision varied widely. For example, in one region a metropolitan area was found to have two alongside midwifery units for a population of 10,000 births per annum, while a nearby city with a similar number of births had no midwifery units.
NICE Intrapartum Guidance (2014), suggests that optimal provision for choice of place of birth involves women having an alongside midwifery unit within their local trust
and the option of a freestanding unit ‘the local area or in a neighbouring area’.
Optimal utilisation of midwifery units
Walsh et al (2018) state, “We were unable to find any robust UK data stating the percentage of women suitable for a midwifery-led pathway after the health assessment in early pregnancy. However, Sandall and colleagues’ (Sandall et al., 2014) population-based cross sectional study, on the maternity workforce and the implications for safety and quality in maternity care in England 2010-11, showed 45% of women were eligible for midwifery-led care at the end of pregnancy. During the intrapartum phase, a transfer rate to obstetric care from midwifery care of 20% can be expected according to the Birthplace in England study (Brocklehurst et al., 2011). This leaves 36% of women remaining in midwifery care. Thus, a pragmatic calculation of the percentage of women that potentially could birth in MUs after obstetric referrals in pregnancy and during labour is 36%.”
The authors conclude that “of midwifery units is extremely variable and shows evidence of underutilisation with the majority providing (midwifery unit) birthing services for less than 20% of their total population. Best available evidence suggests this figure could be as high as 36% with optimal utilisation, but only one Trust in our survey exceeded 30%. The stagnation in the numbers of freestanding midwifery units is also concerning, given their marginally better evidence base, both clinically and in cost effectiveness, compared with alongside midwifery units. … We therefore recommend that providers urgently review their MU provision and utilisation. ” (Walsh et al, 2018).
Walsh D., Spiby H., Grigg C., Dodwell M., McCourt C., Culley L., Bishop S., Wilkinson J., Coleby D., Pacanowski L., Thornton J., Byers S. 2018. Mapping midwifery and obstetric units in England. Midwifery 56, 9-16. Already available online at http://dx.doi.org/10.1016/j.midw.2017.09.009
Brocklehurst P., Hardy P., Hollowell J., et al 2011. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. British Medical Journal 343, d7400.
National Maternity Review. 2016. Better Births: improving outcomes of maternity services in England. A five year forward view for maternity care. London.
NICE, 2014. Intrapartum Care: Care of healthy women and their babies during childbirth (CG190). NICE, London.
Redshaw, M., Rowe, R., Schroeder, L. et al. 2011. Mapping maternity care: the configuration of maternity care in England. Birthplace in England research programme.
Sandall J., Murrells T., Dodwell M., et al 2014. The efficient use of the maternity workforce and the complications for safety and quality in maternity care: a population based, cross-sectional study. Health Services and Delivery Research 2, 1–289.
Action for MUNet members and supporters
Send this summary of findings to local influencers:
· Commissioners - your local clinical commissioning groups (CCGs)
· Service user forums and advocacy bodies - Healthwatch, local charities and community groups
· Multi-disciplinary scrutiny and planning bodies - your local maternity voices partnership,
· Local authority - health overview and scrutiny committee,
· Strategic leaders - the chair of your local maternity system (LMS) board, directors and heads of midwifery in your LMS, the maternity lead on your sustainability and transformation plan (STP) footprint board.
· to use this evidence and to ensure that progress on implementing full choice of place of birth (in line with the NICE recommendation) is a priority in the Transformation Plan and monitoring.
· to go and talk to them about Better Births, NICE recommendations on place of birth, maternity services locally and the mapping study findings.
Consider sending out a press release on access to midwifery unit care in your area, which will be particularly newsworthy if you have:
· above average provision – see our ‘positive’ local media press release template
· new facilities, or have recently reached a milestone, such as 500 or 1,000 births
· new information available for women about choice of place of birth
· below average provision - see our ‘negative’ local media press release template.
If you work for the NHS you will need to work with the communications team of your NHS trust. A local branch of a charity, local Positive Birth Movement group, RCM branch, Friends of a birth centre or maternity voices partnership may want to use the template press release. You may want to inform your local CCG and/or NHS trust communications manager that this is your plan. Working together is usually positive, but independent groups can decide on the action they take.
Further information and support
If you require further information or support, please contact us.