The COVID-19 outbreak has had an impact on all areas of health and social care. While understandably the focus of the healthcare system currently rests on the pandemic, it is important that we also consider the impact on non COVID-19 treatment and care. This has been recently highlighted by the UK Chief Medical Officer Professor Chris Whitty, who has warned about the impact that the pandemic will have on other areas as the health system is “reorientated towards COVID”.[1] Patient Safety Learning believe that in this context the need to pay attention to patient safety is now more important than ever.
Pregnant women represent a unique patient group, facing very specific challenges. Although early evidence indicates that babies and children are less severely affected by the virus, many are concerned for the safety of their baby within the unfamiliar backdrop of COVID-19. It is understandable that fears persist when there are reports of pregnant women, children and midwives who have tragically lost their lives.
This is the first blog where we will look at the impact of the pandemic on maternity services. Here we will focus on the safety implications of both low and high-risk women choosing to birth at home due to fears of contracting the virus in hospital. We also raise questions as to whether a blanket suspension of home birth services is putting some women and babies at greater risk.
Home births: a woman’s choice?
Maternity services are rapidly adapting the way they work in light of the pandemic. Pregnant women are being asked to attend antenatal appointments alone or remotely in order to reduce risk of infection. In some areas, the option to have a midwife-led home birth has been suspended.[2] A recent report from the BBC suggests that as many as one third of Trusts could have removed home birth as an option.[3]
For those who are not considered high-risk and have given birth before, home birth is often a very positive experience and clinical outcomes are good, with transfer rates to hospital and medical intervention very low among this group.[4]
There is some evidence to suggest that more women are requesting to birth at home to reduce the risk of catching COVID-19 while in hospital.[5] This will, of course, require the appropriate level of support midwives being available to enable this. Commenting on the role of midwife-led care during the pandemic, joint guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) states:
“The positive impact of midwife-led birth settings is well documented, including reductions in the need for a range of medical interventions. These positive impacts remain of significant importance to prevent avoidable harm, and availability of midwife-led care settings for birth should therefore be continued as far as is possible during the pandemic.”[6]
For some women though this option is now being taken off the table. Due to the pressures on services caused by the pandemic, the RCOG/RCM guidance also includes a framework to help maternity teams understand when and how they may need to suspend midwife-led services such as home births. We are hearing that, in some areas of the UK, this is already happening and low-risk pregnant women are no longer being offered the full spectrum of birthing choices, as recommended by the National Institute of Health and Care Excellence (NICE).[7] There doesn’t seem to be publicly available information on the extent of this service suspension.
The guidance recommends a staged approach in responding to emerging issues with staff shortages and other service pressures during the pandemic. It states that decisions about when to implement each stage will need to be made at a local level based on current local data including:
- bed occupancy in the maternity unit(s)
- community workload
- sickness rate among midwifery staff (midwives, maternity support workers and senior student midwives)
- available midwifery staffing (including additional midwives from the NMC emergency register, those previously in non-clinical roles or year-3 student midwives)
- skill mix of available midwifery staffing – including level of seniority and experience in provision of community-based care
- availability of ambulances and trained paramedic staff, to provide emergency transfer.
COVID-19 is therefore having the direct impact of reducing birthing options available to some pregnant women.
Patient Safety Learning is concerned with the safety of mums and babies with this erosion of a woman’s right to choose the birth they want. We are hearing that:
- Some women have serious concerns and anxiety about attending hospital during the pandemic and how they and their babies are being protected from COVID-19.
- Suspension of services could have a major impact on women who are frightened to birth in a hospital setting due to past trauma.
- Low-risk women are not being offered a home birth service in some areas.
- Women are unclear as to why they cannot home birth; is it because there are safety concerns where midwife-led services were critically understaffed when responding to home births?
We think there are risks to patient safety and that there are significant questions that need to be answered:
- Are Trusts able to evidence that their decision-making around the suspension of home births is appropriate and proportionate, particularly for low-risk women where evidence indicates good clinical outcomes?
- Are Trusts’ decisions to suspend home births (and the basis behind these decisions) being shared publicly with the women under their care?
- RCOG/RCM guidance gives advice on reinstating services and recommends suspensions be regularly reviewed. How regularly are these suspensions being reviewed? Is this information publicly available?
- What steps are being put in place to preserve midwife-led services for women and their babies, whose health outcomes may be adversely affected by these changes? Are the health outcomes of these women and babies being monitored and reported on?
- How are women being reassured and informed of their safety from COVID-19 in hospital maternity care?
High-risk pregnancies
Some pregnancies are deemed as ‘high-risk’ and these women often fall under the care of a consultant. High-risk women and their babies are more likely to need extra medical support that is unavailable in a midwife-led birth setting. They would usually be advised by to go to a hospital labour ward to have their baby where that clinical support is available if needed.
We are hearing that there is the potential for the number of high-risk women requesting to have their baby at home to rise, due to fears around coronavirus. This has serious safety implications and raises further questions around the number of experienced staff (and home birth equipment) available to support these labours. Where home births have been suspended there is also the frightening potential for high-risk women who choose not to go to hospital, to labour without clinical support. The RCM has highlighted there is anecdotal evidence that more women are choosing to birth at home unassisted due to reduced birth options and midwives are becoming increasingly concerned at the safety implications of this.[8]
Maria Booker, Programmes Director from Birthrights, a charity that protects human rights in childbirth, explained their concerns around restricted services:
"We are concerned that more women will have an unassisted birth that they have not actively chosen to have, due to the withdrawal of home births and midwifery led birth centres in some areas, which may put themselves and their babies at risk. Trusts need to be very clear that they can justify these restrictions on services as a proportionate response to their current situation and to review these decisions frequently as circumstances change."[9]
We think there are risks to patient safety and that there are significant questions need to be answered:
- Has there been an increase in high-risk women deciding to birth at home against clinical advice?
- Where home birth has been suspended, and a high-risk woman decides to birth at home against clinical advice, will she give birth without clinical assistance?
- Where there is an increase in women requesting to have their baby at home, are midwives (including those returning to the profession) receiving the right support? Do they have an adequate supply of homebirth kit and PPE?
- Are there enough staff experienced and confident in supporting both low and high-risk women to labour at home?
Safe births during the pandemic
Maternity services are faced with the challenge of adapting within unfamiliar and unpredictable territory. However, it is important that pregnant women and their babies continue to access the safest care options. There may not be a one-size-fits-all solution and the safety implications of blanket suspensions of home births, combined with a rising fear of hospitals, need due attention in order to protect mums and babies from suffering avoidable harm. Where Trusts take the decision to reduce birth options, these must be evidenced, proportionate and justifications must be made publicly available.
[1] BBC News, Coronavirus: Social restrictions ‘to remain for rest of year’, 22 April 2020. https://www.bbc.co.uk/news/uk-politics-52389285
[2] The Guardian, NHS trusts begin suspending home births due to coronavirus, 27 March 2020. https://www.theguardian.com/world/2020/mar/27/nhs-trusts-suspending-home-births-coronavirus; NHS Lanarkshire, NHS Lanarkshire restricts neonatal visiting and suspends home births, Friday 27 March 2020. https://www.nhslanarkshire.scot.nhs.uk/restricted-neonatal-visiting-suspended-home-births/; The Hillingdon Hospitals NHS Foundation Trust, Covid-19 virus infection and pregnancy, Last Accessed 24 April 2020. http://thh.nhs.uk/services/women_babies/COVID-19_infection_pregnancy.php
[3] BBC News, Coronavirus: Uncertainty over maternity care causing distress, 24 April 2020. https://www.bbc.co.uk/news/health-52356067
[4] Birthplace in England Collaborative Group, 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. https://www.bmj.com/content/343/bmj.d7400; National Institute for Health and Care Excellence, Intrapartum care for healthy women and babies: Clinical guideline [CG190], Last Updated 21 February 2017. https://www.nice.org.uk/guidance/cg190/chapter/Recommendations#place-of-birth
[5] Anonymous, Midwifery during COVID-19: A personal account, Patient Safety Learning the hub, 21 April 2020. https://www.pslhub.org/learn/coronavirus-covid19/273_blogs/midwifery-during-covid-19-a-personal-account-r2095/
[6] The Royal College of Midwifes and Royal College of Obstetricians & Gynaecologists, Guidance for provision of midwife-led settings and home birth in the evolving coronavirus (COVID-19) pandemic, 9 April 2020. https://www.rcm.org.uk/media/3875/midiwfe-led-settings-and-guidance.pdf
[7] National Institute for Health and Care Excellence, Intrapartum care: Quality Standard [QS105], Last Updated 28 February 2017. https://www.nice.org.uk/guidance/qs105/chapter/quality-statement-1-choosing-birth-setting
[8] The Royal College of Midwives, RCM Clinical Briefing Sheet: ‘freebirth’ or ‘unassisted childbirth’ during the COVID-19 pandemic, Last Accessed 27 April 2020. https://www.rcm.org.uk/media/3904/freebirth_draft_23-april-v5-002-mrd-1.pdf
[9] Birthrights are a UK registered charity who ‘provide advice and information to women, train doctors and midwives, and campaign for respectful and safe maternity care that protects women’s fundamental rights’. https://www.birthrights.org.uk/about-us/