Choices beyond the hospital maternity ward • City, University of London

The researchers:

Professor Christine McCourt (Principal Investigator)
Dr Lucia Rocca-Ihenacho (Co-Investigator)
Professor Alison Macfarlane (Co-Investigator)

Research status:Ongoing

This is impact: Is a hospital the best place to give birth? 2 minutes

In summary

Since the 1970s, researchers at City, University of London have worked to improve the quality and safety of childbirth.

There is a long-standing assumption about the superiority of hospital births. But through a series of studies looking at midwifery units and home births, our academics have shown that’s simply not true for straightforward pregnancies.

Now the Centre for Maternal and Child Health Research is focusing on next steps: how can the healthcare system change its mindset and culture? How can the country scale up the number of midwifery units? What’s the best way to make sure these beneficial services get used?

What did we explore and how?

It’s easy for professionals to recommend a hospital birth – that way of thinking is embedded across healthcare services. But it’s not based on evidence. In fact, the evidence can point to the opposite: midwifery units can cut costs and improve outcomes for low-risk pregnancies.

Improving awareness and acceptance of different birth settings among professionals is a major challenge, but it will affect pregnant women everywhere. Benefits in these settings include reduced risk of caesarean and more positive care experiences.

City has decades of research to draw on. Back in 1994 Professor Alison Macfarlane published “Where to Be Born?” an important analysis of the statistics on birthplace and safety. In 2011, the Birthplace in England Programme (in collaboration with the University of Oxford and King’s College London) compared outcomes for 65,000 low-risk women. City also led a case study of one of the first midwifery units in the UK, showing that it gave women far more positive experiences of care and birth.

Recently, the AMU study and the Birth Place Action Study were the first to look at implementation challenges and strategies for scaling up midwifery units. Our researchers have been collaborating even further afield to develop good quality maternity facilities on a more global scale. There are ongoing projects with the University of São Paulo and the non-profit Casa Angela in Brazil and with partners in India and Africa.

For two generations, women were told it was safer to have a baby in hospital. We know that stopping things that aren

– Professor Christine McCourt

Benefits and influence of this research

By publishing in journals, releasing press statements, and circulating evidence to service managers, the public and practitioners, City researchers have helped change policy and reform maternity services across the world.

The National Institute for Health and Care Excellence’s latest clinical guidelines were directly influenced by the Birthplace in England programme. And, supported by the ongoing work at the Centre for Maternal and Child Health Research, the number of midwifery units in England has gone from 53 in 2010 to 173 in 2019. In that time, the percentage of births in these units has increased from 5% to 14%.

Many countries only offer birth in a hospital obstetric unit. But with support from Midwifery Unit Network, a community of practice created with the support of City in 2016, midwifery units are opening up for the first time in countries like Spain, the Czech Republic and Bulgaria. The Network’s Facebook group has over 4,000 members sharing resources and best practice. MUNet has also started the Global Confederation of Birth Centre Networks which will help lead to new maternity units in low- and middle-income countries.

Dr Rocca-Ihenacho has been working on an standards document to help all stakeholders implement or improve midwifery units in Europe. She has consulted widely and brought together best evidence and expertise. There has already been wide interest from around the world and the network. The MU Standards have been translated and published in Spanish and translations in Italian, Czech, French, Dutch, Portuguese and Brazilian are in progress.

These projects are working together to shift the focus away from childbirth in hospital as the routine. Women should have a choice – not just for ethical reasons, but because the evidence shows there are real cost and health benefits too.