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Where should babies be born?
Midwifery (1987)3, I07 108 © Longman Group UK Ltd 1987
Midwifery
EDITORIAL
W h e r e should babies be born?
With the exception of Holland, most babies born in the West are born in institutions. Since the beginning of this century the medical profession in the U K have recommended an increasing institutional delivery rate. This was, first, to reduce infant mortality, then to improve maternal mortality and, currently, to bring the perinatal mortality rate in line with that of comparable countries. These recommendations culminated in a government report (DHSS, 1970) which stated that the ' . . . . greater safety of hospital confinement for mother and child' justified making provisions for facilities for 100% hospital delivery (DHSS, 1970 para 276). Not only were the babies to be born in hospital but the facilities made available were to be based at District General Hospitals. These recommendations were given further support by two subsequent government reports (DHSS, 1980; 1984). I recognise that I am in imminent danger of losing my readers from countries outside the UK. I can hear the comments about that person who thinks that what happens in her country automatically pertains to the rest of the world. But bear with me a little longer, please. I ask you to continue reading because I am aware that the British Maternity Service is often held up as a model to be recommended to other countries. A report has just been published which challenges the assumptions on which these Maternity Services are founded (Campbell & Mact~arlane, 1987). This report reviews and evaluates the available statistics and assesses the arguments on which medical recommendations and subsequent government policy have been based. The authors have domonstrated that there was a significantly higher mortality rate for women delivered in institutions prior to the Second World War.
However, as the introduction of sulphonamides appeared to bring down the death rates from puerperal sepsis, the obstetricians, who took over responsibility for the enquiries into maternal deaths from the Medical Officers of Health, stopped asking questions about the hospital as a dangerous place to have a baby (see M O H , 1957). (The more sceptical among us might ask if they dropped the idea of a hospital being a potentially dangerous place because of their vested interests in the hospital service.) Current concern with statistics related to childbirth centre round perinatal mortality. In spite of the higher mortality rates for deliveries in institutions, obstetricians and paediatricians stress the safety of hospital deliveries. They state that mortality rates are higher in institutions because of the large number of 'high risk' women delivering there and also quote the higher perinatal mortality rates of women transferred into hospital in labour in their (the medical profession's) defence. Campbell and Macfarlane (1987) acknowledge the work of Marjorie Tew who, by using standardisations of data, asserts that the higher mortality is a result of interventionist obstetric techniques. Campbell and Macfarlane (1987) do not wholly support Tew's line of argument, but do support her assertions that there isn't the statistical evidence to support current policy. Campbell and Macfarlane's (1987) report contains a wealth of information and the brevity of the above summary is an insult to the work they have produced. Although well argued, the information has to be read more than onc-e to aid digestion. This is partly because the report refutes a lot of what we have been taught and that isn't always easy to take. It is vital that all midwives in the U K read this report. But it is also 107
108
MIDWIFERY
vital reading for all midwives in the rest of the world, because although the statistics presented pertain to Britain, it points the reader to the questions which should be asked before n a t i o n a l policies are developed a n d adopted. T h e closing sentence of the report is a lesson for us all: 'Perhaps the most persistent and striking feature of the debate a b o u t where to be born, however, is the way policy has been formed with very little reference to the evidence.'
References Campbell R, Macfarlane A 1987 Where to be born? The debate and the evidence.NPEU, Oxford* DHSS 1970 Domicillary Midwifery and Maternity Bed Needs. HMSO, London DHSS 1980 Perinatal and Neonatal Mortality. HMSO, London DHSS 1984 Perinatal and Neonatal Mortality Report: Follow-up. HMSO, London MOH 1957 Report on confidential enquiries into maternal deaths in England and Vales 1952-54. HMSO, London * Available from: National Perinatal Epidemiology Unit, Radcliffe Infirmary, Oxford, OX2 6HE. Price £'2.00.
Midwifery
EDITORIAL
W h e r e should babies be born?
With the exception of Holland, most babies born in the West are born in institutions. Since the beginning of this century the medical profession in the U K have recommended an increasing institutional delivery rate. This was, first, to reduce infant mortality, then to improve maternal mortality and, currently, to bring the perinatal mortality rate in line with that of comparable countries. These recommendations culminated in a government report (DHSS, 1970) which stated that the ' . . . . greater safety of hospital confinement for mother and child' justified making provisions for facilities for 100% hospital delivery (DHSS, 1970 para 276). Not only were the babies to be born in hospital but the facilities made available were to be based at District General Hospitals. These recommendations were given further support by two subsequent government reports (DHSS, 1980; 1984). I recognise that I am in imminent danger of losing my readers from countries outside the UK. I can hear the comments about that person who thinks that what happens in her country automatically pertains to the rest of the world. But bear with me a little longer, please. I ask you to continue reading because I am aware that the British Maternity Service is often held up as a model to be recommended to other countries. A report has just been published which challenges the assumptions on which these Maternity Services are founded (Campbell & Mact~arlane, 1987). This report reviews and evaluates the available statistics and assesses the arguments on which medical recommendations and subsequent government policy have been based. The authors have domonstrated that there was a significantly higher mortality rate for women delivered in institutions prior to the Second World War.
However, as the introduction of sulphonamides appeared to bring down the death rates from puerperal sepsis, the obstetricians, who took over responsibility for the enquiries into maternal deaths from the Medical Officers of Health, stopped asking questions about the hospital as a dangerous place to have a baby (see M O H , 1957). (The more sceptical among us might ask if they dropped the idea of a hospital being a potentially dangerous place because of their vested interests in the hospital service.) Current concern with statistics related to childbirth centre round perinatal mortality. In spite of the higher mortality rates for deliveries in institutions, obstetricians and paediatricians stress the safety of hospital deliveries. They state that mortality rates are higher in institutions because of the large number of 'high risk' women delivering there and also quote the higher perinatal mortality rates of women transferred into hospital in labour in their (the medical profession's) defence. Campbell and Macfarlane (1987) acknowledge the work of Marjorie Tew who, by using standardisations of data, asserts that the higher mortality is a result of interventionist obstetric techniques. Campbell and Macfarlane (1987) do not wholly support Tew's line of argument, but do support her assertions that there isn't the statistical evidence to support current policy. Campbell and Macfarlane's (1987) report contains a wealth of information and the brevity of the above summary is an insult to the work they have produced. Although well argued, the information has to be read more than onc-e to aid digestion. This is partly because the report refutes a lot of what we have been taught and that isn't always easy to take. It is vital that all midwives in the U K read this report. But it is also 107
108
MIDWIFERY
vital reading for all midwives in the rest of the world, because although the statistics presented pertain to Britain, it points the reader to the questions which should be asked before n a t i o n a l policies are developed a n d adopted. T h e closing sentence of the report is a lesson for us all: 'Perhaps the most persistent and striking feature of the debate a b o u t where to be born, however, is the way policy has been formed with very little reference to the evidence.'
References Campbell R, Macfarlane A 1987 Where to be born? The debate and the evidence.NPEU, Oxford* DHSS 1970 Domicillary Midwifery and Maternity Bed Needs. HMSO, London DHSS 1980 Perinatal and Neonatal Mortality. HMSO, London DHSS 1984 Perinatal and Neonatal Mortality Report: Follow-up. HMSO, London MOH 1957 Report on confidential enquiries into maternal deaths in England and Vales 1952-54. HMSO, London * Available from: National Perinatal Epidemiology Unit, Radcliffe Infirmary, Oxford, OX2 6HE. Price £'2.00.