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No place like home
Maternity services at Brighton and Sussex University Hospitals NHS Trust (BSUH) provide an
outstanding homebirth service which has seen an increase in homebirth rates from a previous 2% to
6.4 % July 2015 (BSUH statistics). This service is unique as all community midwives are committed
and all cover clinical homebirth shifts. The benefits to collective team working have been immense,
with both the obstetric and community departments seeing enhanced team cohesion and
communication, ultimately improving safety and quality of care for women and their families.
Before 2013 the Trust experienced a falling homebirth rate as a result of being unable to maintain
around the clock care for this service. In addition the caesarean section birth rate was well above the
national average (BSUH statistics). Pregnant women had limited birth options apart from the two
Obstetric Units (OUs) within the Trust. BSUH Trust covers a large geographical area of approximately
500 square miles comprising an inner city tertiary Obstetric Unit and a second Obstetric Unit serving
a predominantly rural population. Both Units have very different cliental with different demands.
Strong evidence exists about the benefits of midwife- led care for low risk women away from an OU
such as Midwife led Units (MUs) and homebirths. Women choosing these options experience more
spontaneous vaginal births, fewer medical interventions and greater satisfaction with the care
provided (Hollowell et al, 2011; NICE, 2014). The latter option is also significantly more cost
effective (Hollowell et al, 2011). However, there was no MU operating within the Trust and no
immediate plans for change, thus hugely limiting the choice for women opting to give birth in a
midwife- led setting.
With this in mind, a set of interventions was put in place to improve homebirth provision. This
included an extensive consultation period to ensure that all stakeholders’ views and ideas were
considered. This initiative has tripled homebirth rates by giving low risk women a robust, reliable and
sustainable homebirth service with outcomes that are known to have both short and long term
health benefits (Hollowell et al, 2011).The service is run by confident and motivated community
midwives. This in turn is building trust and assurance for parents, consequently increasing the
uptake in homebirth bookings as midwives are promoting a service they are confident in achieving
(Common, 2015).
Reconfiguration of the service was preceded by a significant period of planning and development.
Agreements were reached through an in-depth consultation period. Success was influenced by
encouraging ownership of the new model of service delivery, by the whole community midwifery
team. Shift patterns were adapted to include dedicated homebirth shifts thus moving away from an
‘on call’ system and instead providing 24 hour cover in line with EU Working Directives (2003).
During the day the homebirth midwives provide routine postnatal care and conduct home risk
assessments whilst ensuring availability in the event of a call out. At night they support the OU until
called to attend a homebirth. A specially designed homebirth flow chart was made available to avoid
misunderstandings regarding day/night time responsibilities of the homebirth midwife whilst
working in the community or the OU.
Marion Wilyman and Kate Stringer –Better Births 2016 – No Place Like Home
Four of the existing pool cars were transformed to fully equipped homebirth cars (including in-built
navigation system & blue tooth) and parked strategically at both OUs for rapid access at all times.
This reduced the overall equipment needs and costs in the community whilst improving safety and
quality for women. In addition, a number of measures were put in place to further support the
community midwives. These included emergency simulation workshops specifically targeted to
homebirth, updates on mandatory skill drill study days as well as an opportunity to work with the
practice development midwives in the OUs.
Multidisciplinary and collaborative working has been vastly improved following the
recommendations of the newly introduced homebirth protocol. The protocol highlights the
importance of an antenatal risk assessment at home and a guaranteed second midwife when birth is
imminent. It also contains a robust transfer procedure as a midwife’s ability to manage a transfer
safely and competently is crucial for the safety and wellbeing of mother and baby (Hollowell et al,
2011). In addition, making time to debrief after a transfer is prioritised for both parents and
midwives. This is recognised as extremely beneficial in the process of acceptance (Wilyman &
Lackey, 2013).
As a result of these combined interventions, the Trust has seen a significant rise in homebirth (up to
9.1 % in the City of Brighton) positively affecting normal birth rates (BSUH statistics). A snapshot
comparing low risk care in the OU to homebirth showed that the group of women giving birth at
home were more mobile in the 2nd stage of labour, had significantly shorter 2nd stages and made
more use of birthing pools.
Adverse outcomes are reviewed immediately by the multi-disciplinary team and any lessons learnt
are shared through processes such as ‘after action reviews’ and presented to the shared paediatric &
obstetric quality and safety meetings. Ambulance crews are invited to the emergency simulation
workshops to increase optimal team working and safe transfer.
National satisfaction scores such as the Family and friends test are extremely positive. A close
working relationship with the maternity liaisons committee (MSLC) has ensured that service users’
views are incorporated within the developing service. Women are encouraged to book an antenatal
‘myhomebirthmatters’ session and read the comprehensive Trust homebirth leaflet. Homebirth
stories blog was also launched in collaboration with the MSLC following a drive to share homebirth
experiences with a wider audience.
This service is a sustainable model with a simple and effective design which should be transferable
to any maternity departments. Existing models of care are used, rather than the development of a
specialist team which would require additional financial and human resources. Women are offered a
real choice as well as a reliable service which is not influenced by peaks and troughs of workflow.
Due to the homebirth commitments of all community midwives the service is safely and reliably
maintained at all times and not compromised by sickness, burnout or recruitment and retention
issues. This service has never been suspended since the reconfiguration over two years ago and all
booked homebirths to date have been provided with a midwife on request. Its cost effectiveness is
proven by increased homebirth rates and subsequent reduction in the number of births in the two
OUs.
Marion Wilyman and Kate Stringer –Better Births 2016 – No Place Like Home
This transformative solution has not only increased the homebirth rate but also facilitated the
integration of community midwives across service boundaries and enhanced job satisfaction,
ultimately increasing quality of care and choice in place of birth for women and their families.
References
Brighton and Sussex University Hospital Trust (BSUH) statistics: Maternity Dashboard BSUH.
Common L. (2015) Homebirth in England: Factors that impact on job satisfaction for community
midwives. British journal of Midwifery 23 (10): 716-22.
European Union Working Regulations (2003). The EU's Working Time Directive (2003/88/EC)
www.rcm.org.uk/stewards-european-working-time-directive (accessed 30 November 2015).
Hollowell J, Puddicombe D, Rowe R, Linsell L, Hardy P, Stewart M, 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 (7840): d7400.
National Institute for Health and Care Excellence (2014) Intrapartum care: care of healthy women
and their babies during childbirth. Clinical guideline 190. www.nice.org.uk/guidance/cg190
(accessed 23 November 2015).
Wilyman-Bugter M, Lackey T. (2013) Midwives ‘experience of homebirth transfer. Evidence Based
Midwifery 11 (1): 28-34.
Marion Wilyman and Kate Stringer –Better Births 2016 – No Place Like Home