A Few More Notes On the Nice Guidance

When I wrote about the new NICE guidelines yesterday I hadn’t been able to find the actual document and was relying on the news stories about it (none of them seemed to link to the source, helpful!). Inevitably about 25 seconds after I hit the publish button I found the document. Cue hurried skim reading and even more hurried re-write.

I’ve now had chance to read at least a couple of the relevant sections and some of the many other blogs that have been written on the subject and I thought it was worth adding a few notes.

Firstly, for the most part I agree with the new guidance. It says:

Explain to the woman that she may choose any birth setting (home, freestanding midwifery unit, alongside midwifery unit or obstetric unit), and support her in her choice of setting wherever she chooses to give birth

But it goes on to say:

Advise low-risk multiparous women to plan to give birth at home or in a midwifery-led unit 

Advise low-risk nulliparous women to plan to give birth in a midwifery-led unit

(nulliparous women are those who haven’t given birth before, multiparous have)
And it was that word – “advise” that concerned me. 
Low risk women should be advised that a midwife led unit is just as safe as an obstetric ward. It should be explained that these units have lower rates of interventions, and of the potential risks of these interventions. If that’s done many more women will probably choose this option and I’d welcome that. 
But I don’t think they should be “advised” that this is what they should plan. You’re not giving someone a choice, if you then tell them what their choice should be.
For all their benefits there are a couple of down sides to the NICE approved options. Firstly, the transfer rate, especially for first timers is high. Women need to be aware of this and prepared for the very real possibility of a fraught ambulance trip if they aren’t in hospital. Would that be better or worse for them than having medical intervention hovering in the background all along? It won’t be the same answer for everyone.
The other snag is pain relief. If you really want the pain to go away an epidural is your best bet. It’s very safe and I for one see nothing morally wrong with choosing to avoid the pain of birth. The guidance says:
If a woman in labour asks for regional analgesia, comply with her request. 

It also adds that women must be cautioned about the risks and benefits and, importantly that you can’t have an epidural at home or in a midwife unit.

So effectively the new guidance is advising women to give birth in a setting where serious pain relief is not available to them. It’s saying you have a choice, you can have this nice place where you won’t have nasty things done to you but, if you want pain relief, you will have to give all that up and argue against your doctor or midwife’s advice.
It also sends a very strong message that epidurals are somehow a wrong choice or at least unnecessary if you do this birth thing properly. 
Then there is the risk that we create a two tier system for birth. 
Already women choosing a home birth are likely to have better continuity of care throughout pregnancy, birth and the postnatal period. Rather than sharing one stressed out midwife with other women on the labour ward, a home birth Mum will have two who she may know already, all to herself. At the hospital where Miss E was born the facilities and environment of the midwife unit were sufficiently enticing to encourage women to choose it over the obstetric ward, even without information on interventions. Women should be able to choose between epidural or no epidural, not between pain relief or decent care.

What also seems to have been forgotten in all these debates is that not all women are low risk. Actually an awful lot aren’t (and sometimes the judgement over who is and who isn’t can be wrong, which is another issue). All these other women seem to have been swept aside in this debate, are we only interested in those who through dumb luck are able to have a choice? If we demonise obstetric units how will that make women feel when they are told that, for them, the people most in need of care and support, the “wrong” choice is their only choice?
Let’s have midwife units available to everyone, ideally (in my opinion) on a hospital site so the transfers aren’t too traumatic. Let’s offer home births where it is appropriate and lets continue to make those environments as welcoming and stress free as possible. But let’s do the same for obstetric units too and let’s be careful not to place a moral judgement on pain relief.  Then we can advise women of the theoretical best option but not dictate a one size fits all “correct” choice.
Here are a few other good posts related to this, I’ll add more if I spot them:
US Obstetrician Dr Jen Gunter on the pros and cons of epidurals
MummySays blog – Home births are for the brave and other myths

UK Obstetrician Roger Marwood on the new guidelines

and here is the NICE document

For what it’s worth I thought it may be helpful to explain my own experiences. Inevitably they influence my opinions. I was low risk for my first pregnancy, I chose to give birth in a midwife unit in a hospital. I was hoping for a natural birth, maybe water, I wasn’t keen on epidurals and was confident in my ability to cope with pain and exhaustion but I also liked having the obstetric unit down the corridor just in case. I never expected to use it. At that point I thought that if all went well I might have a home birth for any subsequent babies. Basically my choices were exactly what the guidelines would recommend.

In the event things weren’t straight forward and I had to transfer. When it became clear I was in for a long haul I had an epidural for a while. I let it wear off to push the baby out but unfortunately that didn’t work out either and I had an emergency C-section. For my second child I wasn’t low risk and I opted to have a planned C-section.

If I were doing it again, I would still opt for the midwife unit, I’d still want to avoid an epidural but I would perhaps try to be a bit more prepared for things not going to plan!

One response to “A Few More Notes On the Nice Guidance”

  1. Great post – so right it needs to be about choices and practicalities of transfer need to be considered. Home birth when you're 5 minutes from Kings is one thing, v different in an hour from hospital


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