Researchers at City are leading the way in influencing governments with the benefits of Midwifery-led Units, which can improve choice and birth outcomes.

Midwifery-led Units (MLUs) offer maternity care to women and provide a social model of care where women and families are cared for and supported to experience birth as a normal physiological, psychological and social process. They can be ‘free-standing’ Midwifery-led Units or Alongside Midwifery-led Units (AMUs), located close to hospital obstetric units for use by women who are likely to have a healthy birth.

Indeed, research has shown that women at low risk of complications, giving birth in MLUs) have better outcomes, at lower cost, with better experiences compared to those women who give birth in Obstetric Units in hospitals.

Led by Professor Christine McCourt and Dr Lucia Rocca-Ihenacho, the Centre for Maternal and Child Health Research (CMCHR) at City, produces and implements ground-breaking research into Midwifery-led Units which has led to both national and global impact advocating their use.

To understand the need for this research and its context, it is important to understand the historical trends in where women have typically given birth in the UK over the last century, and how government policy has influenced these trends.

Prior to the First World War, most UK births happened in the home. When they were in labour, women would call for a midwife or their general practitioner, with midwives attending over three quarters of births and usually working alone.

During the 1920s and 1930s, with advancing medical technology and concerns about rates of maternal death during childbirth, maternity (antenatal) care developed significantly and led to the medical field of obstetrics, able to manage complex emergency situations.

In the years leading up to World War Two, the number of women giving birth in hospitals in the UK increased steadily. Whilst maternal deaths reduced dramatically during the same period, this reduction has been associated with the development of new technologies including antibiotics, rather than hospital birth having a significant impact. Indeed, in 1965, the UK’s maternal death rate fell to 27 out of 100,000 births, from 415 in 1935, while the number of home births dropped to one fifth of all deliveries.

Throughout the 1960s the focus of maternity care was on safety, and in 1970 the UK Government’s Peel Report recommended the allowance of all deliveries to take place in the hospital, despite a lack of evidence supporting this, and in a move which nevertheless proved popular.

However, the status-quo of place of birth began to be seriously questioned again in the 1990s.

Professor McCourt comments:

“In 1992, the government published the Winterton Report in response to concerns from groups including women’s organisations that whilst hospital birth was considered safe, the experience was felt to be lacking some of the benefits of more traditional approaches of maternity care, including midwife-led care. The report led to policies that advocated more midwife-led care, and for women to be given better choice, and to be much more partners in their own care.

“In 1996, my senior colleague at City, Professor Alison McFarlane, revisited the statistics used in the Peel Report. She found that when comparing hospital births to home births the report had not taken into consideration that many of the home births registered were not delivered with the appropriate clinical support from a midwife for example, and could essentially be considered births taking place outside the healthcare system. Her re-analysis of these statistics suggested that the evidence for hospitals being a safer setting for low-risk births was weak.”

Funded by the UK government, The Birthplace in England Programme took place between 2007-2015 and was a collaboration between many UK institutions including City, which looked into many aspects of the effect of birthplace on mother, child and other outcomes. In terms of safety of mother and child, the programme found that there was little difference between hospital births, appropriately supported home births, or indeed appropriately supported births in a midwifery-led Unit. Professor McCourt has commented:

“The study found that births in midwifery units were particularly safe and were optimal in many ways. It was a more positive experience and it was the safest form of care, equally safe for babies, safer for mothers and that home births, certainly for women who had a baby before and who were low risk health pregnancies, homebirth was clearly an optimal place for them to have their baby.”

Professor Christine McCourt.

The programme also found that informed choice of service users was not working well. Professor McCourt continues:

“There is a combination of factors influencing that, from the service end, time pressures for professionals, professionals’ own lack of confidence with the evidence and to some extent the sheer challenge for them of adapting having had two generations of being firmly instructed that it was safest to have your baby in hospital. It was a big change for professionals to process as well.”

The programme’s findings led to the National Institute for Health and Care Excellence (NICE) guidelines in England being updated and provided Professor McCourt and Dr Rocca-Iheanacho with a clear mandate for finding ways to drive the implementation of the findings the Birthplace in England Programme into practice.

Funded by the National Institute for Healthcare Research (NIHR), they have since led several projects at City, which have formed part of the follow up work to the programme and have been outlined as a research impact in the case study forming part of the Research Excellence Framework 2021.

These projects have explored the barriers and facilitators to implementation – and the organisational culture issues – affecting the effectiveness of midwifery units nationally. They also explored strategies for scaling up the offer and use of midwifery units.

Between 2010-2012, ‘The Organisational Study of Alongside Midwifery Units’ authored by Professor McCourt explored the implications of organisational and contextual characteristics which affected the functioning of AMUs. This was the first study to investigate emerging issues relating to provision of care in AMUs, including professional deployment, training and experiences of working in midwifery or obstetric units, user experiences of the service, and organisational challenges to their development and sustainability.

Furthermore, Professor McCourt and Dr Rocca-Ihenacho’s study ‘The Barkantine Birth Centre (BaBC): an ethnographic study of the philosophy, culture and practice in a freestanding urban midwife-led unit (2010-2014)’ identified key elements which make a midwifery unit effective and developed conceptual models to guide midwives and managers in developing and improving these services and support service users’ choice.

The ‘Factors influencing the utilisation of free-standing and alongside midwifery units in England: A Mixed Methods Research Study (2015-2018)’ led by Dr Denis Walsh, Associate Professor in Midwifery at University of Nottingham, mapped the pattern of provision in alongside or freestanding midwifery units since the publication of the Birthplace in England Programme (and update of the NICE clinical guidelines) and identified and explored barriers and facilitators to their development and use.

The evidence from these studies fed into the Birthplace Action Study (2016-2019), a NIHR Knowledge Mobilisation Fellowship awarded to Dr Rocca-Ihenacho. This was the first study which actively explored implementation strategies for scaling up the implementation and use of midwifery units.

City’s research team were invited to feed into NHS England’s Maternity Transformation Plan and has contributed to the increase in midwifery unit births in England from 5 per cent to14 per cent (2010-2016), representing NHS savings of £10 million.

Global impact of the work includes the introduction of midwifery units in Spain, Bulgaria, the Czech Republic, and France for the first time in history and influencing the International Confederation of Midwives (ICM) and the International Federation of Gynecology and Obstetrics (FIGO) to release a position statement in support of midwifery-units globally.

The Birthplace Action Study developed a set of evidence-based European Midwifery Unit Standards which are globally recognised. It also developed the Embedding Midwifery Units Pathway which provides practical frameworks to guide service managers and practitioners on how to assess their midwifery unit, how to produce an improvement plan or how to open a new midwifery unit. Most recently this had led to the first ever Birth Standards published for Saudi Arabia.

Commenting, Professor McCourt said:

“The impact in Saudi Arabia I think has been particularly interesting, because this is a country where they did not have midwifery units before. They have really had a dramatic change in one generation from almost all women having their babies at home with traditional midwives to all women having their babies in hospital, so now they are really skilling up and scaling up their midwifery services, which is fantastic to see.”

The Midwifery Unit Network (MUNet) has also created as an implementation arm of the CMCHR to extend the reach and impact of the underpinning academic work into practice. Led by Dr Rocca-Ihenacho, it has provided training for over 500 NHS staff and a further 500 maternity staff globally to date.