Where to Be Born? Evidence about the quality and safety of birth in different settings to support optimal outcomes and women’s choice about place of birth
Submitting InstitutionCity University, London
Unit of AssessmentAllied Health Professions, Dentistry, Nursing and Pharmacy
Summary Impact TypePolitical
Research Subject Area(s)
Medical and Health Sciences: Nursing, Public Health and Health Services
Summary of the impact
This case study is based on a series of major studies by academic staff
at City University London relating to quality, safety, choice and
organisation of birth in different settings. Their research has been
widely cited and debated by policy, professional and user groups,
nationally and internationally. The key impact has been on national and
international guidelines for commissioning and on reconfiguration of
services to include Midwife Units, to tackle the rising rates of
intervention in childbirth and to underpin informed choice for patients.
The research is being used by policy-makers, commissioners and managers to
plan future services and by midwives to support informed choice
A series of research projects and reviews undertaken over a long period
at City University London culminated in a major programme of research to
evaluate the quality and safety of birth in different settings:
1) Research by Macfarlane from the late 1970s to the 1990s using routine
data and reviews of small studies to investigate safety of different birth
settings, with major policy impact, forms the background and foundation of
this case study.
2) The Birthplace in England Programme, commissioned by the Department of
Health Policy Research Programme and the National Institute for Health
Research (NIHR), investigated the quality and safety of different birth
settings to provide internationally-robust evidence to inform government
policy (2007 to 2011). The Programme included five research projects
conducted by a large collaborative team from the University of Oxford,
City University London and King's College London, plus key stakeholders.
Christine McCourt (Professor at City since 2010) was lead researcher for
the organisational case study component of the programme and
co-investigator on the whole programme. Alison Macfarlane (Professor at
City since 2001) was a co-investigator on the whole programme. Dr Juliet
Rayment was a member of research staff (at City since 2010) working on the
3) The Barkantine Birth Centre Evaluation (2009 to 2011). This study,
funded by NIHR Research for Patient Benefit and led by Alison Macfarlane
with a team at City, included a survey of women's experiences of birth in
midwifery or obstetric units, cost-effectiveness and clinical evaluations.
4) The Organisational Study of Alongside Midwifery Units (AMUs) (2010 to
2012): This study, funded by the NIHR Service Delivery and Organisation
(SDO) was led by Christine McCourt. It investigated emerging issues
relating to provision of care in AMUs including professional deployment,
training and experiences of working in midwifery or obstetric units, user
experiences of the service and organisational challenges to development
5) A follow up study funded by the NIHR SDO programme is analysing
further the Birthplace Cohort Study data (2012 to 2013). Professors
McCourt and Macfarlane are co-investigators. This analysis is addressing
key questions concerning the impact of organisational, contextual or
patient characteristics on outcomes and the patterns and implications of
transfer from out-of-hospital settings during labour.
The Birthplace Programme examined clinical outcomes of birth planned at
home, midwifery or obstetric units; cost-effectiveness; organisational and
professional factors impacting on quality and safety; and user and
provider experiences of care; and also mapped provision for choice
nationally. Comparisons for a sample of 65,000 low-risk women found no
overall difference in adverse neonatal outcomes, but a higher rate of
adverse outcomes for first births planned at home, along with higher rates
of positive maternal outcomes and of cost-effectiveness in midwifery units
and home. The Organisational Case Studies highlighted women's positive
experiences of birth in out-of-hospital settings, but identified staffing,
training and organisational challenges to quality of care, inequalities
and deficiencies in information and choice.
The Barkantine study identified that planning birth in an inner-city
freestanding birth centre offered women more choice in the care given and
greater continuity of carer compared with hospital care, higher levels of
cost-effectiveness and satisfaction with care.
The AMU study identified challenges to quality and safety, sustainability
and scaling-up of this rapidly growing model of care. They included
professional tensions, resource conflicts, poor quality of information for
women, training, management and staff deployment issues.
References to the research
Birthplace in England Collaborative Group (2007). 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 10.1136/bmj.d7400
McCourt C., Rance S., Rayment J. & Sandall J. (2012). Organisational
Strategies And Midwives' Readiness To Provide Care For Out Of Hospital
Births. Midwifery, 28(5), 636-645 10.1016/j.midw.2012.07.004
Birthplace in England Collaborative Group (2012). The Cost-Effectiveness
Of Alternative Planned Places Of Birth In `Low Risk' Women BMJ,
2012(344), e2292 10.1136/bmj.e2292
Rance, S. McCourt, C. Rayment, J. Mackintosh, N. Carter, W. Watson, K.
& Sandall, J. (2013). Women´s safety alerts in maternity care: is
speaking up enough? BMJ Qual. Saf. 2013(22) 348-355 10.1136/bmjqs-2012-001295
Indication of quality of the research: The British Medical Journal
is ranked in fourth place in the international rankings of the most
influential general medical journals in the world, (http://tinyurl.com/kfze8n2)
(2012). Midwifery is a leading international journal in midwifery
and maternal studies, published by Elsevier and employing a double-blind
peer review process.
Details of the impact
The findings of this body of research support a policy of mother's choice
of place of birth that has been taken up by the UK Department of Health
and internationally. The findings provide evidence that professionals are
now using to inform and advise women with uncomplicated pregnancies on
choice of birth setting. Managers are using the findings to inform
decisions about organisation and delivery of maternity services and
commissioners are using them to inform service planning and
reconfigurations. This is reflected in major recent UK policy documents
which quote the research as a basis for service design and organisation
and the `choice' policy. The UK Government's 2012 White Paper: `Liberating
the NHS: No decision about me, without me' cited the research as
evidence to support the policy of choice of care setting. The NHS
Commissioning Board's 2012 guidance document `Commissioning Maternity
Services' cited the work as supporting evidence for service
improvement to include the policy of offering healthy women with low risk
pregnancies a choice of birth setting.
International impact is reflected in the replication of the Birthplace
Study by a national research team in Australia and in the Brazilian
government's maternity policy. The Rede Cegonhas (Stork Network)
has been set up to improve maternity care across Brazil, including the
development and roll-out of 180 midwifery units nationally. A postdoctoral
fellow was based at City in 2013, funded by the Leverhulme Trust, to work
on replication of our AMU study with a case study in Brazil and McCourt
has been invited to provide expert advice on implementation issues and on
evaluation of the implementation and outcomes of the development. A
petition has been developed citing McCourt et al as evidence to
support the introduction of midwifery-led maternity care in Switzerland.
Locally, the Barkantine Study has been used by commissioners in
decision-making about future service configuration: a second Fetal
Medicine Unit (FMU) has now been opened and new AMUs are being designed. A
NIHR-funded doctoral fellowship is following up the work, investigating
the skills and practices of midwives working in midwifery units and the
potential for transfer to other care settings.
The prior research by Macfarlane raised questions about the evidence base
of previous UK and other national policies that all women should give
birth in hospital. Policies on place of birth had been changed in the past
decade in the UK in line with the `choice' agenda, but this had been
challenged as there had been no previous systematic research on midwifery
units in the UK and there was a lack of robust evidence internationally
comparing safety and quality across different settings. Existing research
had major limitations in terms of sizes of samples, reliance on routine
and retrospective data, controlling for levels of risk, whether the care
setting was planned and on the impact of transfers of care. Earlier
research by McCourt indicated that women wanted choice in maternity care
and that better evidence was needed to inform it.
The first findings from Birthplace in England were published in November
2011. They are already highly cited and have been the subject of
commentaries by the Minister for Health, the Royal College of Midwives,
the Royal College of Obstetricians and Gynaecologists (RCOG) and the
National Childbirth Trust. They have been circulated to NHS managers
through the NHS Confederation Research Digest. The RCOG commentary on the
Birthplace Study states:
`Overall it found that childbirth is generally very safe which is
reassuring, however, it showed that first-time mothers wishing to
deliver at home have an increased risk of poor outcomes for their
babies. The study also showed that first-time mothers have higher
transfer rates from freestanding and adjoining maternity units,
therefore raising questions about the best place for this group of women
to give birth. It is clear to us that for low-risk mothers having their
second or third child, there was no increased risk if they chose to give
birth at home, so an expansion of midwifery-led care would improve
women's choices and ease pressure on hospital units.'
There have been several letters to the British Medical Journal in
response to the clinical and economic study articles and discussions on
user forums and in professional networks debating the implications of the
findings. The implications for design and delivery of future maternity
networks under the new NHS arrangements are currently being discussed, but
early impact is reflected in a very rapid rise in the number of midwifery
units opened in England. An update of the NICE Intrapartum Care Guidelines
was delayed to await the publication of the Birthplace Programme findings.
The updated guidelines are now due to be published in 2014.
The Birthplace Study also received wide press coverage, featuring in a range
of national newspapers including The Guardian, Independent,
Times, Daily Mail, syndicated local newspapers and the Radio
4 Today Programme. The press coverage generated considerable public and
professional responses and discussions on press websites. The economic study
was featured on breakfast television. The findings were also featured as a
summary on the Netmums website, the major consumer maternity discussion
forum in the UK and generated a considerable number of responses and
The study was also covered in a Guardian roundtable debate:
Home or hospital? A Guardian roundtable debate on where to give
birth: `Despite recent research which shows home births can be just as
safe as those in hospitals, many mothers-to-be in England are not
offered a choice' Joanna Moorhead, The Guardian, 11th
Macfarlane, McCourt and Rayment have provided feedback to service
commissioners and managers nationally as well as locally and are being
invited to present the results at major national and international
conferences and workshops. Further research has been commissioned to
investigate questions arising from the research to date on key issues such
as arrangements for transfer of care between settings, professional
training and preparation.
Sources to corroborate the impact
Liberating the NHS: No decision about me, without me — Further
consultation on proposals to secure shared decision-making, London, DoH.
23 May 2012.
- NHS commissioning Board's guidance document `Commissioning
Maternity Services. A Resource Pack to support Clinical Commissioning
Groups' July 2012.
NHS confederation Digest:
NHS choices: Summary of the programme reports.
- Royal College of Obstetricians and Gynaecologists (RCOG) policy
- NIHR SDO Programme digest of the research to aid managers,
professionals and commissioners in decision-making.
- NCT Q&A briefing for NCT practitioners and parents. The Birthplace
in England Research Programme — what have we learned?
- Information on the petition for the introduction of midwifery-led
obstetrics in Swiss Hospitals:
Individual users/beneficiaries who can be contacted by the REF team to
President of the Royal College of Midwives
Head of Research and Policy, National Childbirth Trust
Lead Maternity Commissioner for NHS South of England
United Nations Population Fund (UNFPA) Technical Advisor, Brasilia
Manager, Barkantine & Barking Birth Centres, Bartshealth NHS Trust