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Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. References

Objective To describe and assess the selection criteria currently being used when booking women for different places of birth.

Design A cross-sectional survey.

Setting The South and West region of England.

Sample The 27 NHS Trusts who provide maternity care in the South and West region of England.

Main measures Selection criteria used when booking pregnant women for different places of birth; length of time criteria in use; whether criteria applied individually or as part of a risk score; and method by which criteria developed.

Results The response rate was 81%; 128 different, individual criteria, used as the basis to select women for different places of birth, were identified. No single criterion appeared on all the sets of criteria. None of the trusts who responded used the criteria in order to calculate a risk score. In all but one case the criteria were being used to select women who might be suitable for birth outside a consultant-led maternity unit. Only two trusts used sets of criteria which identified, to any extent, 1. outcomes for which women could be at risk and 2. strategies that should be implemented to reduce that risk. Over half the trusts were able to identify a rationale for the particular set of criteria which they used but in only two cases was any reference made to an evidence base.

Conclusions A large variety of criteria are being used as a basis on which to book women for different places of birth but they appear to be poorly focused on particular adverse outcomes. To be effective, selection criteria must identify quantifiable differences in the risk of particular preventable adverse outcomes for births booked at different locations. Furthermore, there must be evidence that the risk could be reduced by a selecting a particular location. A systematic review is required to determine which selection criteria, if any, should be employed at booking.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. References

Before 1992 successive government committees advocated phasing out birth outside hospital on the grounds of safety1–3. That year, however, witnessed a considerable change in policy with the publication of the House of Commons Health Committee Second Report on Muternity Services4 which declared that ‘the policy of encouraging all women to give birth in hospital cannot be justified on the grounds of safety’ and that it was ‘no longer acceptable that the pattern of maternity care provision should be driven by presumptions about the applicability of a medical model of care based on unproven assertions’. The government of the day set up the Expert Maternity Group to investigate matters further. The Expert Maternity Group, under the chairmanship of Baroness Cumberlege, came to similar conclusions to the House of Commons Committee and in its report Changing Childbirth, recommended that ‘women should receive clear, unbiased advice and be able to choose where they would like their baby to be born’5

This change in policy developed out of a growing consensus among those providing maternity care that there was a gh-Eighty-one percenroup of women at low risk of an adverse perinatal outcome who could give birth safely outside hospital6. In addition, there was increasing demand from users for a more pluralistic maternity service. A detailed review of the evidence on safety and place of birth had also concluded that there was no evidence to support the policy that hospitals were the safest places to give birth for all women7. What ‘low risk’ Actaally meant and thus who could give birth safely outside hospital was never closely defined.

As a consequence of having to offer women a choice of where to have their baby, and in order to fulfil the requirement specified in Changing Childbirth that 30% of women have a midwife leading their care, many NHS trusts providing maternity care have felt it necessary to draw up criteria in order to select women who would be suitable for care outside a consultant-led obstetric unit.

This use of selection criteria in determining place of birth is not new. Published lists of criteria used today8–12 have at their core criteria developed during the 1950s for selection for hospital care at a time when demand exceeded supply. Selection criteria published in a summary report13 on maternal mortality in 1964 included the following:

  • 1
    All women who suffer from any illness that in any way impairs the general state of health, such as diabetes and valvular disease of the heart.
  • 2
    Grand multiparae: parity >4 is accompanied by a diminishing margin of safety and > 9 the risk of death is very greatly increased.
  • 3
    All primigravidae older than 30 years of age, and multiparae > 35 years of age.
  • 4
    Any woman who has had abnormal previous pregnancies, labours or puerperia such as toxaemia or postpartum haemorrhage.
  • 5
    All women who have a multiple pregnancy.
  • 6
    Those with adverse social conditions.

Analyses of maternal mortality by maternal age and parity had appeared in the second and third reports of the confidential enquires in to maternal and it was these analyses which were used as the basis for making recommendations about who should receive hospital care. It was tacitly assumed that women who fell into the categories with the highest death rates, and their babies would have a better chance of survival if the birth took place in hospital. Neither the confidential enquiry into maternal mortality nor a largescale detailed study16 of the social and biological factors in infant mortality which analysed births and deaths in 1949 and 1950 regarded it necessary to test this assumption7.

Whether such criteria are valid for use today can be questioned on various grounds. Firstly, they were developed in response to confidential enquiries into maternal deaths, and were meant to ensure that those in greatest need obtained a hospital delivery. Now they are being used, in the main for the opposite purpose, to select women to give birth outside hospital or in a non-medicalised environment. Secondly, not only is maternal death very rare in England and Wales, but stillbirths and neonatal deaths have become uncommon. In 1996 the stillbirth rate was 5.4 and the early neonatal mortality rate 3.1 per lo00 births17. Thus, while it is important to strive to eliminate all preventable maternal or infant deaths the issue now is whether such criteria are capable of making a favourable impact on these deaths. Furthermore, by 1995 the average age at childbirth was 28–518 years and in the last decade fertility among women in their late thirties19 and early forties20 has risen substantially and continues to do so. Thus, many more women now fall outside the age limits set in the 1950s. Evidence from the General Household Survey shows that women with higher educational qualifications delay their childbearing and have on average more children in their thirties than do women whose educational attainment is low. Thus, the socioeconomic and health profile of women who fell outside the age limits in the 1950s is almost certainly very different from the profile for this group of women today21.

A final reason for questioning the usefulness of selection criteria developed in the 1950s is that since these were first devised, little work has been undertaken to assess their effectiveness. This may, in part, have been because in pursuing a policy of hospital delivery for all, such criteria were regarded as redundant. By contrast, in the last three decades, a good deal of effort has been spent devising systems of risk scoring as a method of hying to predict which women are most likely to experience serious complications during pregnancy and delivery. A number of reviews of these scores have highlighted problems with this approach22–24. The most comprehensive concluded that ‘risk scoring appears to be a very mixed blessing for the individual woman and her baby’24.

The main objective of this study was to document which criteria were being used to select women for different places of birth and to determine how they were being applied. A secondary objective was to find out how the criteria had been compiled and what role evidence had played in their development.

METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. References

To meet the objectives of this study a survey of all relevant trusts in the South and West region of England was undertaken between August and October 1996. A list of heads of midwifery was supplied by the National Perinatal Epidemiology Unit, Oxford. Before commencing the survey a telephone call was made to each trust confirming the correct name and address were used. Heads of midwifery services were asked to forward copies of the selection criteria used in their trust when booking women for different places of birth. They were also asked to complete a brief questionnaire about the origins of the criteria. Nonresponders were followed up once by letter and then by telephone.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. References

Eighty-one percent (22/27) of the trusts responded. Three trusts were not using any criteria when booking women for different places of birth, and one trust was using more than one set. Consequently 21 different sets of criteria were available for analysis. Of the three trusts who were not using any criteria one trust indicated that they were about to develop selection criteria, and a second submitted a very short set of guidelines for midwifery-only bookings which simply drew attention to and quoted specific parts of The Midwife's Code of Practice25 and Midwifes Rules26.

The majority of the sets of booking criteria had been in use for a short time. Sixty-two percent (13/21) had been in use for one or two years only. In 86% (1 8/21) the criteria were reported to have been devised locally. Only one trust indicated that the criteria it used were based on those employed in a published study of midwife-led care, while another trust indicated that it had considered criteria published in the literature when finalising its own criteria. In some cases it was clear that developing criteria locally meant copying those used by a neighbouring trust. For example, two geographically adjacent trusts were using identical booking criteria, and another three trusts in the region were using almost identical sets of criteria. In the case of the two geographically adjacent trusts it is possible that the criteria were developed before the establishment of self governing trusts at a time when the two maternity units were within the same health authority. This would not have been the case with the other three trusts as all reported that the criteria had been in use for less than a year before the survey.

The sets of criteria varied considerably in length. The number of individual criteria specified in any one set ranged from 12 to 61. In total, 128 different individual criteria were being used in the region. Of the 128 criteria found, 82 appeared on more than one set. For example, 10 protocols included a height limit. Table 1 shows details of these, together with the frequency with which they appeared. A further 11 social, 16 medical, 9 obstetric/gynaecological, and 5 family history criteria only appeared on one protocol.

Table 1.  Selection criteria used when booking pregnant women for different places of birth in the South and West of England. GTT = glucose tolerance test; IUGR = intrauterine growth retardation; IUCD = intrauterine ontraceptive device.
CriterionNo. of trusts citing criterionCriterionNo. of trusts citing criterion
Demographic, social and anthropometric Obstetric history (continued) 
  Age: lower limit14Pre-eclampsideclampsia14
  Age: upper limit15Previous gestational diabetes/abnormal G'IT3
  Age and parity limits9Preterm delivery17
  Panty14Caesarean section19
  Non-Caucasian4Retained placenta7
  Height limit10Inverted uterus3
  Weight14Forceps/rotational forceps7
  Body mass index limits4Ventouse3
  Single parendlack of social support4Precipitate labour5
  In receipt of social security2Shoulder dystocia5
  Service family2Cephlo pelvic disproportion4
  Woman's choice of obstetric referral3Difficult vaginal delivery3
  11 other social criteria1Postpartum haemorrhage18
  Third degreelanal tear5
Medical history Previous baby with congenital abnormality10
  Diabetes18Previous baby weighing < 2.5 kg/IUGR16
  Cardiac disease16Previous macrosomiahaby weighing > 4.5 kg12
  Renal disease17Previous baby admitted to neonatal intensive care2
  Deep vein thrombosis105 other problems with previous baby1
  Pulmonary embolism11Rhesus antibodies18
  Cardiovascular disease177 other labour and delivery complications1
  Respiratory disease7  
  Haematological disorder14Gynaecological history 
  Epilepsy8Infertility13
  Psychiatric illness8Spontaneous abortion15
  Asthma4Termination of pregnancy2
  Thyrotoxicosis3Uterine abnormality9
  Myasthenia gravis2Hysterotomy13
  Chronic diseasehedical condition9Myomectomy6
  On prescription medication5Fibroids6
  Hepatitis B antigen positive10Pelvic floor repair4
  HIV positive12IUCD in situ7
  Autoimmune disease4Cervical disease4
  Genital herpes3Cervical stitch3
  Major surgery2Cone biopsy3
  Anaesthetic problems4Tubal surgery2
  Hypertension at booking3Vaginal surgery2
  Drug abuser15Ovarian tumour3
  Smoker7Significant gynaecological surgery6
  Alcohol abusedheavy drinker122 other gynaecological criteria1
  16 other medical criteria1  
  Family history 
Obstetric history Inherited disease7
  Previous stillbirthheonatal death19Congenital abnormality5
  Previous multiple birth5Diabetes3
  Previous ectopic pregnancy3Neural tube defects2
  Antepartum haemorrhage5Haemoglobinopathy2
  Previous abruption25 other family history criteria5

There was no single criterion which appeared on all of the sets. Previous stillbirth or neonatal death and previous caesarean section, both of which appeared on 19 out of the 21 sets, were the criteria most frequently recorded as indicators of women who should not be booked for delivery outside a consultant-led obstetric unit. The next most frequently occumng criteria were mother with a history of diabetes (18/21), previous postpartum haemorrhage (18/21) and presence of rhesus antibodies (18/21).

The way in which specific factors were defined, as indicators of an increased risk, also demonstrated considerable variation. For example, previous spontaneous abortion, which was listed on 15 different sets of criteria, was defined in 10 different ways (Table 2). Selection criteria based on age, parity or combinations of both were also common, and the limits set also varied a good deal (Table 3).

Table 2.  Definitions of previous spontaneous abortion(s).
DefinitionNo. using it
< 2 consecutively2
≥3 previous miscarriages2
≥3 mid-trimester abortiodfetal loss1
>2 miscarriages1
>2 first trimester or 1 second trimester1
Previous history of mid term loss1
Spontaneous abortions1
Repeat abortions/recurrent spontaneous abortion2
After 14 weeks3
1 more than 20 weeks or 2 less than 12 weeks1
Not included as a criterion on booking protocol/guidelines3
TOTAL18
Table 3.  Different age, parity and age and parity limits.
DefinitionNo. of different protocols using it
  1. *Two trusts had > 1 age and parity criterion.

Parity limits 
  ≥4th birth3
  ≥5th birth6
  1st birth or ≥ 6th birth1
  Grand multiparityhigh parity undefined2
  1 st baby or gravida 42
  No parity limits7
  Total no. of sets of booking criteria21
Age limits 
  Lower age limit 
   164
   171
   189
  No lower age limit7
  Total no. of sets of booking criteria21
  Upper age limit 
   357
   361
   381
   405
  No upper age limit3
  Age and parity limits 
  Upper age limit for nulliparous women 
   351
   362*
   381*
   401
  Upper age limit for 2nd or subsequent birth 
   401*
  Total no. of sets of booking criteria21

Some criteria found seemed to be tautological, such as ‘women who will refuse essential treatment’. Inconsistencies were also identified. For example, a woman aged 36 could be booked for delivery in one particular midwife-led unit if under the care of one consultant but not if under the care of the other consultant. Another trust reported that four different protocols and risk assessments were used because local clinicians could not agree on common selection criteria for booking. One of these four was exactly the same as that used in an adjacent trust; this protocol has only been entered once in the analysis.

Details recorded on the questionnaires revealed that none of the sets of criteria was being used as part of an antenatal risk scoring system to locate women on some continuum of risk. In 38% of cases, failure to meet any single criterion meant a woman was automatically booked for delivery in a consultant-led obstetric unit. In 62% the criteria were used as a risk assessment tool to guide decisions about the appropriate place of booking. Even then it seemed from written comments that the risk assessment based on whatever criteria were being applied could weigh quite heavily in decisions about what sort of care was booked. For example, one respondent wrote ‘Criteria are used to inform professionals of the safest course of action, but the women's wishes are taken into account and a compromise course of action will be agreed’.

Only four out of the 21 sets of criteria were structured in such a way that for each criterion some indication was given as to what the nature of the risk was and what action should be taken to minimise it.

In response to a direct question about whether there was a rationale underpinning the use of their particular set of criteria or evidence indicating its effectiveness, 57% (12/21) recorded that there was. Respondents were asked to give precise details which are shown in Table 4 together with any references recorded on the sets of criteria submitted. The documents cited fell into four categories: policy documents which provided the rationale for developing criteria; documents covering the professional practice of midwives (which were the documents most frequently referred to); reviews of evidence relating to many aspects of pregnancy and childbirth; and lists of criteria used elsewhere.

Table 4.  References cited as evidence of effectiveness of selection criteria and rationale for their use.
Reference no.DocumentsYear publishedNo. of times cited
 Policy documents  
4House of Commons Health Committee: Maternity Services19921
5Department of Health: Changing Childbirth19933
 Professional practice  
25UKCC: The Midwife's Code of Practice19947
26UKCC: Midwives Rules19937
21UKCC: Standards for Record Keeping1993 
28UKCC: Standards for the Administration of Medicines1992 
 Details of criteria used elsewhere  
12Tucker et al.: The Scottish Antenatal Care Study1994 
29Dutch Board of Medical Insurance Funds: The Obstetric Indications List1987 
30Midwifery Development Unit, Glasgow Royal Maternity Hospital: The Establishment of a Midwifery Development Unit Based at Glasgow Royal Maternity Hospital19951
 Reviews of evidence  
24Alexander & Keirse: Formal Risk Scoring during Pregnancy19892
31Enkin et al.: Effective Care in Pregnancy and Childbirth19951
32Cochrane Pregnancy and Childbirth Database: Pregnancy and Childbirth Module19951

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. References

That this survey should find such a wide variety of selection criteria being applied at booking, and so many different ways in which certain aspects of a women's reproductive or medical history could be defined as a risk factor, is disquieting. Such variation must inevitably lead to inequity. For example, a 37 year old school teacher expecting her second child after a previous normal birth, who wished to have a home birth would, as a result of her age, meet the criteria for care outside a consultant-led obstetric unit in 13 of the 21 protocols reviewed. It could be argued that much of the variation, in for example the different ways in which previous spontaneous abortion is defined as an indicator of increased risk of a poor pregnancy outcome, is Actaally very small and that the definitions are very similar. For individual women, however, even small differences may matter a good deal if it means they are not able to book for a delivery at their preferred location.

The existence of substantial differences in the criteria used to select women for different places of birth, highlighted by this study, is not unique to the South and West of England. One study33 has shown that a similarly diverse range of criteria are used in antenatal risk assessment. In a recently published study34 of DOMINO deliveries (a system in which the woman stays at home with her midwife during early labour, is transferred to hospital by her midwife for delivery and returns home a few hours later), the authors reported that when they sought information on eligibility criteria for different types of delivery from the five major providers of maternity care for their district, there was no consensus among the three who responded. A survey of heads of midwifery in Scotland has also highlighted considerable variation in local definitions of the term ‘low risk woman’35.

Labelling women as high or low risk is unhelpful if one cannot say what the nature and magnitude of the risk is and how a different booking will alter the risk. It is also strange that there should be no intermediate medium risk category. In this study only a small minority of the sets of criteria gave any indication of the nature of the risk associated with the individual criterion. This poor linkage between a risk factor and a particular adverse outcome may be because of the absence of clear epidemiological and statistical evidence about the effectiveness of these criteria, highlighted in the responses to this survey.

Even when there is clear evidence of a link between certain characteristics and adverse outcomes, these associations are usually established for groups of women. For example, it can be demonstrated statistically that the risk of stillbirth or neonatal death is greater for groups of women in some age and parity categories compared with others. This tells us nothing about the outcome for individual women and means that applying criteria, based on this information, to individual pregnant women is problematic. In addition, these demographic characteristics cannot be modified through care in the same way that good care can minimise the potentially adverse effects of a chronic condition, such as diabetes. Moreover, serious adverse outcomes, such as a stillbirth or neonatal death, are now rare. This makes it difficult to gather contemporary evidence of possible links between adverse outcomes and certain maternal characteristics.

The use of these selection criteria could be interpreted as a rational attempt to try to identify the optimal type and location of care for childbearing women, while trying to increase the choices available to women as far as place of birth is concerned. On the other hand, given the diversity of the criteria used and the absence of any clear evidence of their effectiveness, an alternative view might be that far from increasing choice for women, the application of these criteria amounts to a constraint on women's choice. The huge variation in criteria must inevitably lead to at least the perception of inequity in the choices of maternity care available between districts.

CONCLUSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. References

What is required ideally is a systematic review of the evidence of a relation between preventable adverse outcomes in either mother or baby, and the individual booking criteria in common use. Where the risk of an adverse outcome differs according to the presence or absence of a particular factor, the sensitivity, specificity and positive predictive value of that potential criterion would need to be examined. Evidence that a change in booking would reduce the risk of an adverse outcome would also need to be sought. Such a review would be difficult. Firstly, the volume of literature to be searched would be large. Secondly, patterns of maternity care differ widely from one country to another, and the absence in some systems of processes (such as booking for care and transfer between different levels of care) would increase the difficulty of undertaking such a review.

In the meantime, in the absence of better evidence, there seems no justification for making booking for a particular place of birth a one-off decision early in pregnancy. Rather it should be a choice that can be revised as the pregnancy progresses. Discussion and progress towards a greater consensus regarding which criteria, if any, should inform booking decisions would help to reduce current inequities in the system.

In summarising the evidence for choosing between the best alternative forms of care in pregnancy and childbirth, Enkin et al31 used two principles. The first was that ‘the only justification for practices that restrict a woman's autonomy, her freedom of choice and her access to her baby would be clear evidence that these restrictive practices do more good than harm’. They went on to suggest that ‘the onus of proof rests on those who advocate any intervention that interferes with the two principles proposed’. This challenge still has to be met as far as selection criteria used at booking are concerned.

Acknowledgements

The author would like to thank all the heads of midwifery services who participated in this study by completing questionnaires and supplying copies of the criteria used.

References

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. References
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