Home birth: putting evidence into practice and promoting choice

This blog is linked to Life lesson 1 How to prepare a conference talk  – living and learning also published yesterday, 8th June 2016.

Having come from a wonderful conference on home birth organised by the University of Bradford Midwifery Society, which I enjoyed enormously and was privileged to be invited to speak at, my key messages about Home birth: putting evidence into practice and promoting choice are these:

Why does the issue matter?

How women give birth is a political and human rights issue. From a feminist perspective, it is a women’s rights issue. Individuals and organisations have lobbied to raise awareness about home birth and the need for home birth services to be offered to women routinely. Choice of place of birth has been official policy since the early 1990s, yet the rate of home births remains low at around 2-3% for England overall. There seem to be obstacles in the way. We need to understand what they are.

Who stands to benefit?

Birth place decisionsThe Birthplace in England study, a large, prospective cohort study of direct relevance to our maternity services, showed that pregnant women at low risk of complications (generally, women who are healthy with a straightforward pregnancy, and no previous obstetric complications) are more likely to have their whole labour and birth without the need for medical procedures (epidural, episiotomy, forceps, ventouse or an emergency Caesarean section) if they plan for a home birth rather than book for care in an obstetric unit. For ‘low-risk’ women who have previously had a baby, planned home birth is very safe. For ‘low-risk’ first-time mothers, there is a small additional chance of an ‘adverse’ outcome, but the absolute risk is still very small.

What are women saying?

Women responding to NCT surveys told researchers what they found helped them have the kind of birth they wanted. The things they rated most important in descending order were:  a birthing pool or a large bath; en suite toilet / bathroom; a comfortable, adjustable bed; low lights or adjustable lighting; privacy and quiet. Women who had a home birth reported having access to these things more often than women who had their labour and birth in other settings.(See NCT report on Better birth Environment accessible at: http://www.arquitecturadematernidades.com/sites/default/files/nct2003_bbe_report.pdf

How might clinical outcomes, experiences and wellbeing be enhanced?

There is evidence that clinical outcomes, women’s experiences, start in life for babies and long-term wellbeing can all be enhanced if women are offered the opportunity to plan for a home birth.

What shall we do?

  • Be proactive in suggesting home birth as an option to women whose pregnancy is straightforward. Offer it first or second as a birth option, not as the afterthought or final option.
  • Aim for a home birth rate of at least 5% in your local authority area. We (NCT BirthchoiceUK) have hypothesised that unless there is a critical mass of 1 in 20 pregnant women having a home birth there probably isn’t sufficient infrastructure in place to offer the service universally, there may be too few community-based midwives to offer home birth pro-actively and – crucially – women and men will not know others in their neighbourhood or friendship groups who have planned for a home birth, so it won’t seem like a ‘normal’, achievable, mainstream option. (see Location, Location, Location, NCT https://www.nct.org.uk/get-involved/campaigns/pregnancy-birth-campaigning/location-location-location)
  • Provide women with positive information about home birth. Share the other practical issues including letting first-time women know about transfer rates and the small additional risk to their baby. Discuss this openly and in context. Let the woman decide and support her decision-making. Use the information summary published as part of the NICE Intrapartum Care guideline. https://www.nice.org.uk/guidance/cg190/chapter/1-recommendations Use infographics to show what the numbers mean visually (e.g. Kirstie Coxon decision support: http://www.midwiferyunitnetwork.com/generic/
  • Encourage women to attend local home birth groups, online home birth communities and networks. Midwives need to know about good links to suggest.
  • As midwives, run regular groups for women and couples interested in home birth and invite women and their partners to attend. As women/couples to help run the groups.
  • Provide continuity models of midwifery care. Give women a mobile phone number for contact at any stage. Experience suggests that women respect this and don’t abuse it.
  • Discuss with women and men planning for or considering a home birth ways of preparing for labour and birth. Know of good books to recommend, such as The Homebirth Handbook (Vermilion) by Annie Francis, published June 2016.
  • Talk to women about the joy, comfort, intimacy, convenience and cleanliness of a home birth. Discuss positively how birth is a special social occasion filled with emotional significance and a rewarding physical challenge, rather than a clinical episode.
  • Discuss the benefits for babies of straightforward birth, not being separated from the mother after birth, skin-to-skin, easier start to breastfeeding, all of which can be enhanced in the setting of home.
  • Acknowledge that women and men are on their own territory at home. The midwives are guests in their home. The power dynamic shifts.
  • Talk in a matter of fact way about how birth doesn’t always go according to plan and if a women needs an epidural or she or her baby need assistance, that’s what the hospital is for. It’s all about having the best experience in the particular circumstances.
  • Collect and share (with permission) women’s and men’s accounts of their labour and birth and the hours /days afterwards.


NB: There is debate later in the afternoon about how much information women want about possible ‘risks’ and risk assessment. Four women attending the conference who had had a home birth felt the discourse around risk was unwelcome and dispiriting. Often a constant source of negativity throughout pregnancy. This prompted discussion on how much information is needed for informed decision making.

NICE Intrapartum Care guideline. https://www.nice.org.uk/guidance/cg190/chapter/1-recommendations Use infographics to show what the numbers mean visually

Birth Place Decisions, Coxon K. decision support: http://www.midwiferyunitnetwork.com/generic/

Location, Location, Location, NCT  Available at: https://www.nct.org.uk/get-involved/campaigns/pregnancy-birth-campaigning/location-location-location 

Singh D and Newburn M (July 2006) Feathering the nest, Midwives 9;7,266-269. Available at: https://www.rcm.org.uk/news-views-and-analysis/analysis/feathering-the-nest-what-women-want-from-the-birth-environment

Life lesson 1 How to prepare a conference talk – living and learning

I’m on the train heading home after the wonderful Bradford home birth conference organised by University of Bradford Midwifery Society.   It’s been a great day with a combination of established speakers and fresh new voices. This was an occasion when I feel I didn’t get my talk quite right. So, I’m reflecting now on what I’ve learned over 25 years of public speaking but didn’t fully put into practice today. And I’ll share a few tips with you, based on these thoughts. I’ll finish up with a few notes on my preparation for today and I’ll write a separate blog summary of intended (or useful?) messages for today’s delegates.

Preparing a conference talk

Study the programme and be clear what contribution you and others are being asked to make – You may well need to check with the organisers what they are looking for and want to avoid. It may make good sense to check with other speakers what they will be covering. It doesn’t matter if there is some overlap as it can help to familiarise people with key material, but it may help you prioritise.

Make a plan and identify two or three key messages – Ask yourself as you develop the talk, Are the points clear? Are they well made? It’s entirely up to you how much you flag up in a formal introduction what your talk will cover, but it’s probably helpful to summarise the key messages before you finish.

Less is more – know how many minutes to you have been allocated to speak. Work out, and check with the organisers, how long you will speak for and how long you will allocate for questions and discussion with the delegates.

Connect with the delegates – interactive communication is better than a monologue. Share something of yourself. It might be something personal about your life or career, or a story about a particular insight or favourite quotation and why it means a lot to you. Today, Mary Nolan, shared a quote from a 17th century midwife and read the quote showing us how the rhythm reflected the rhythm of labour and contractions that come and then pass. If you give a little of yourself, the delegates will give back. Ask some questions as you go, and make sure to allow time at the end for discussion. Unless you know the perspectives, interests and concerns of those you’re talking to, you may not give them what they really want to know or to explore.

Find your own voice – what are you and your contribution all about? Are you an educator or teacher? Are you a practitioner sharing your practice? Are you a lobbyist? Are you there to tell your own story, perhaps as a service user?  Are you a representative of women, there to communicate a range of experiences or concerns? Maybe you’ve been invited to provide an objective set of information impartially? How much do you want to influence, how much to inform? How much to entertain? How much do you want people to question their own thinking and behaviour? Do you want to stir up an emotional reaction?

Make the case – One of the things we do as part of NCT Voices training for service user representatives on maternity services liaison committees (MSLCs) is encourage them to identify a change they want to see realised and make the case for change. Why is it important? Who would benefit and how? What do local women and families say? What formal evidence is there? What could we do differently? Would it be cost-effective? These kinds of questions might enable you to plan your talk, depending on its purpose.

Avoid the pitfalls presenting evidence – I’ll stick to a few points here, as a whole text book could be written on this alone.

  • If presenting quantitative findings, make sure you know what all the numbers relate to and what they mean. If you don’t know, ask someone who does. Many colleagues and contacts will help a friend willingly or support a new contact who asks for help.
  • Don’t go into more detail than necessary just because you find the data fascinating. Think about your key points and what is mission-critical. Think about what the audience needs to know. Let them know if there a place they can look up the detail afterwards.
  • Don’t feel that you have to do all the work. Introduce a few ideas and maybe encourage people to check-out a key review, or audit report.
  • It’s not acceptable to make claims, e.g. about cause and effect, and not cite a reference.
  • Avoid jargon. Make sure to use language most of the audience will understand.
  • Don’t assume much prior knowledge. It is important to be inclusive, so explain concepts briefly to carry as many people with you as possible.
  • Make sure you state the more important points. If you are very familiar with something, you may overlook to mention key points of methodology that sets a study apart.
  • Don’t read out every number shown on a slide. Often the trends can be seen at a glance and the detail can be followed up by those who need it. Add a source for everything, and a date of publication. That shows you know your stuff and others can fact-check if they want to.

Experiment with humour – Any speaker who can make an audience laugh will feel good and get a great reception. Some people and some subjects lend themselves better to laughs than others, which is why I say experiment. What it takes is being relaxed and appearing spontaneous. Practise spontaneity at home. If it’s not your thing, or you can’t pull it off, forget it. Don’t be smug. People who laugh at their own jokes more than the audience do, don’t make a good impression. The idea is to be sincere and likeable; the witty person others want to know. The more you relax and manage to be yourself, the more likely you are to succeed with the humour thing.

Practice giving your talk out loud – This will demonstrate how long it’s going to take. If you spend a few seconds longer on each slide than anticipated, the talk will over-run. Practice will enable you to hone the vital points to make and ditch the rest. You don’t need to repeat yourself. Work out how to be succinct and to segue fluently on to the next point or following slide. In my experience, practice makes perfect. Each run through tends to show where some minor adjustment can be made. Your aim is to be fluent and have oomph. Have you make our key points clearly? Do you need to shift the focus or emphasis?

Ask a friend for feedback – It can be galling to take tips after you have worked hard to come up with something profound and original, but better to bomb with one friend than with a roomful of blank faces at the event. Joking aside, it’s more about polishing so that the whole shines brightly and leaves the audience wanting more.

My performance today

Well, I broke a fair few of my rules. I should have done more research on the other speakers and the needs of the delegates. The title I had been given was Putting evidence into practice and promoting choice.  I changed my talk at the last minute, shifting the emphasis too far towards sharing the evidence and doing too little on ‘into practice’. I didn’t do a full run through because of the late changes. I didn’t interact enough or leave time for discussion. Thankfully, two lovely midwives did talk with me at the tea break abut questions they had, which gives me useful ideas. Not my best day at the office, though it could have been worse. See my linked blog on Home birth: putting evidence into practice and promoting choice.

The NHS Constitution & The Berwick Report: service user involvement & co-design

What a fabulous introduction to The NHS Constitution AND how it can be applied in maternity services user engagement and involvement #MSLC – a must read!

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Review of the “Celebrating Continuity, Rhetoric into Reality, Policy into Practice” Conference

I was delighted to be asked to chair this conference. I was so impressed by so many of the women who spoke about their experiences and why continuity of midwifery care matters to them, and by midwives talking about the practical details of delivering continuity models of care.

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The 13th April brought us “Celebrating Continuity, Rhetoric into Reality, Policy into Practice” a conference created through a collaboration between AIMS, RCM, The Positive Birth Movement, Neighbourhood Midwives and a Birmingham NHS Trust.

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