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Written on 24th June 2020 by Susan Brown

In the UK, healthy women with low-risk pregnancies can choose the setting in which they want to have their baby. Increasing numbers of women are choosing to give birth in midwifery-led maternity settings, such as in an ‘alongside unit’ on the same site as an obstetric (doctor-led) unit, a freestanding (totally separate) midwifery unit or at home.

For healthy, low-risk, pregnant women wanting to avoid medical intervention in labour and delivery, a midwifery-led setting may be an attractive option. Mothers and babies are entitled to safe maternity and neonatal care in any setting that has been agreed with their maternity team. Where midwifery-led maternity care is being considered, safe care begins with thorough assessment and advice about the woman’s individual risk, with regular reviews and agreed, workable plans to maintain safe care if complications arise or her risk status changes. Where labour takes place in a unit without obstetric help or emergency facilities on site,  changes in risk or complications must be recognised and acted upon quickly. Regular risk assessment, careful monitoring, and clear processes for escalation and transfer are vital if serious maternal or neonatal injury is to be avoided. 

What was the ESMiE enquiry?

In May 2020, the ESMiE (Enhancing the Safety of Midwifery-led Births) confidential enquiry examined the care given to 64 mothers who, at the start of labour, planned to give birth in midwifery-led settings and went on to have a stillbirth or neonatal death. Panels of midwives, consultant obstetricians, neonatologists and perinatal pathologists reviewed the medical records of the mothers and babies, taken from data gathered by MBRRACE-UK between 2013 and 2016. The panels assessed the standard of care in each case against accepted standards and national guidance and identified themes where care often needed improvement.

Results of ESMiE enquiry into maternity care standards in midwifery-led settings

At the start of labour, 23 of the reviewed mothers planned to give birth in ‘alongside’ midwifery units, 26 in freestanding units and 15 at home. Only 18 (28%) went on to give birth in their planned setting. Two of the planned home births took place in an ambulance. 30 had stillbirths and 34 resulted in neonatal deaths.

In 75% of the cases reviewed, the panels believed that improvements in care could have led to a better outcome for the baby and the physical and psychological wellbeing of the mother. The high percentage of these injuries which were caused by substandard maternity care echoed the findings of Each Baby Counts and MBRRACE-UK’s maternity safety reports, as did many of the recommended areas for improvement. These reports were based largely on births in obstetric units. The ESMiE report focussed on the safety themes which most commonly arise in midwifery-led care.

Planning place of birth and risk assessment during pregnancy:

The ESMiE panels found that in over half the deaths reviewed, there was little evidence of any discussions having taken place with women about the risks and benefits of different birth settings. 28 (44%) of the women had or developed risk factors in pregnancy which were relevant to their decisions about their planned place of birth. Only five high risk women had a care plan in place to manage their risks in a midwifery-led setting. In 12 cases these risk factors were not even recognised by their maternity carers.  The panel found that in 24 (39%) cases, there was incorrect assessment, planning, management, documentation or discussion of their risk factors and this ‘probably or almost certainly’ affected the outcome for the baby.

Planning place of birth and risk assessment at the start of labour care:

At the start of labour, 25 women (39%) had existing risk factors or new complications which should have prompted consideration and discussion with the mother about transferring her to an obstetric-led maternity unit. 15 of these women received incorrect care. These complications included:

Common errors included incorrect risk assessment at the start of labour care and poor risk assessment or birth-place planning during pregnancy. These errors affected the outcome for 12 of the babies.

Planning home birth against advice:

Ten of the 15 women planning home births had risk factors for labour or birth complications. Five women opted for home birth against medical advice and in four cases the panel believed this contributed to the outcome for the baby.

Common issues included:

  • women failing to cooperate with antenatal care or disclose their health concerns;
  • their healthcare professionals failing to escalate their concerns about the woman’s risk factors or wellbeing;
  • woman declining care and interventions, such as scans, induction of labour, fetal heart rate monitoring, vaginal examinations and transfer to obstetric-led care.

Intermittent auscultation (listening to the fetal heart at intervals):

46 women (72%) had intermittent auscultation (IA) at some stage during their labour. Despite clear national guidance about the timing and frequency of IA during labour, more than half of these women were incorrectly monitored, ‘probably or almost certainly’ affecting the outcome for 19 of the babies. Common failings included incorrect timing and poor recording of the auscultation or the fetal heart rate and failing to recognise or act on abnormalities in the fetal heart rate. Two women planning home births had inadequate or no auscultation, at their own request.

Transfer during labour:

The ability to transfer a woman in labour quickly to an obstetric unit when complications occur or intervention is needed is an essential requirement for safe midwifery-led care.

46 women (72%) who had planned to give birth in midwifery-led settings were transferred to obstetric care during labour. Two gave birth during transfer. 35 women received incorrect care in relation to transfer, ‘probably or almost certainly’ affecting the baby’s outcome in 16 cases. Errors included leaving the decision to transfer too late so that labour was too advanced to transfer safely, and failing to consider transfer at all when it was needed. Delays in recognising the need for transfer, arranging urgent transfer, ambulance arrival and care after transfer were very common. Two women, both wanting home births, delayed or denied their own transfer to an obstetric unit.

Resuscitation and transfer of the baby:

11 babies were resuscitated after birth at midwifery units or the mother’s home with no neonatal care facilities. Six of these compromised babies received incorrect resuscitation, management and transfer, which almost certainly affected the outcome for four of them. Failings in the neonatal care of these babies included uncertainty over leadership of resuscitation between midwives and other health professionals such as paramedics, confusion over the transfer process and poor communication about the urgency of transfer of the baby.  In all six cases, lack of local guidance or protocols for managing neonatal emergencies in freestanding midwifery units led to delayed or inadequate resuscitation.

Follow up and review:

Following the stillbirth or neonatal tragedies in the 64 reviewed cases, 58 were followed up with local reviews (investigations) of the care, but only nine reviews were of good quality. Parents had a follow up appointment with health professionals in 49 cases. Midwives were not involved in many of the local reviews and follow up appointments. 

ESMiE enquiry recommends improvements for safe midwifery-led maternity care

ESMiE recommended that all maternity services providing midwifery-led care should review their practice based on the following recommendations:

  • All low-risk pregnant women and those considering birth in a midwifery-led setting, should have an evidence-based discussion with a midwife and/or a doctor about the risks and benefits of different birth settings. The discussion should take into account the woman’s risk factors and preferences. The discussion, the relevant safety evidence and a specific care plan for management of any risk factors should be fully documented in the woman’s medical notes.  
  • Decisions about the planned place of birth and any care plan should be reviewed during pregnancy and at the start of the woman’s labour care.
  • Maternity services should consider developing a standardised risk assessment tool for use at the start of labour care and as labour progresses.
  • There should be a routine audit of the frequency and timing of monitoring in labour to ensure it complies with guidance.
  • Maternity services in freestanding midwifery units or supporting home birth should:
    • work with local ambulance services to develop protocols for prompt ambulance attendance and transfer in emergencies;
    • standardise communication in relation to urgency of transfer with ambulance services and the receiving hospital;
    • develop and maintain clear guidance for management of neonatal emergencies in midwifery-led settings, including mandatory annual training in multidisciplinary skills or in situ simulation training.
  • There should be a process to ensure prompt obstetric and neonatal assessment of women who are transferred urgently for obstetric-led care.
  • When a baby dies after planned birth in a midwifery-led setting, local review and follow up should involve a senior midwife with experience of providing care in a midwifery-led setting and, if transfer took place, information from paramedics and the ambulance service.

At Boyes Turner, we are always saddened by studies which reveal the amount of avoidable harm that is caused by maternity mistakes. However, we recognise the importance of the vital work that ESMiE has done in shining a spotlight on the improvements needed to provide women with safe midwifery-led care. Women have a right to be involved in decisions about the setting for labour and delivery. They also have a right to make their childbirth decisions on the basis of full and current information, and against a background of reliable standards of safe maternity care.

If you have been affected by maternal death, or are caring for a child with cerebral palsy or birth-related disability, and would like to find out more about how Boyes Turner’s birth injury specialists can help you make a claim, contact us via email at