Local guidelines for admission to UK midwifery units compared with national guidance: A national survey using the UK Midwifery Study System (UKMidSS).

OBJECTIVES: To describe the extent to which local guidelines for admission to UK midwifery units align with national guidance; to describe variation in individual admission criteria; and to describe the extent to which alongside midwifery units (AMUs) are the default option for eligible women.
DESIGN: National cross-sectional survey.
SETTING: All 122 UK maternity services with midwifery units, between October 2018 and February 2019. OUTCOME MEASURES: Alignment of local admission guidelines with national guidance (NICE CG190); frequency and nature of variation in individual admission criteria; percentage of services with AMU as default birth setting for eligible women.
RESULTS: Admission guidelines were received from 87 maternity services (71%), representing 153 units, and we analysed 85 individual guideline documents. Overall, 92% of local admission guidelines varied from national guidance; 76% contained both some admission criteria that were 'more inclusive' and some that were 'more restrictive' than national guidance. The most common 'more inclusive' admission criteria, occurring in 40-80% of guidelines, were: explicit admission of women with parity ≥4; aged 35-40yrs; with a BMI 30-35kg/m2; selective admission of women with a BMI 35-40kg/m2; Group B Streptococcus carriers; and those undergoing induction of labour. The most common 'more restrictive' admission criteria, occurring in around 30% of guidelines, excluded women who: declined blood products; had experienced female genital cutting; were aged <16yrs; or had not attended for regular antenatal care. Over half of services (59%) reported the AMU as the default option for healthy women with straightforward pregnancies.
CONCLUSIONS: The variation in local midwifery unit admission criteria found in this study represents a potentially confusing and inequitable basis for women making choices about planned place of birth. A review of national guidance may be indicated and where a lack of relevant evidence underlies variation in admission criteria, further research by planned place of birth is required.

Introduction

Since the early 1990s United Kingdom (UK) maternity care policy has supported women’s choice of planned place of birth and increased access to midwifery-led models of intrapartum care for healthy women with straightforward pregnancies, and this is now supported by maternity care strategy and guidance documents in all four countries of the UK [1-8]. There is robust evidence about the safety of midwifery-led settings for these women in terms of lower chances of intrapartum interventions and comparable maternal and neonatal outcomes to obstetric settings [9-14], and about benefits in terms of women’s satisfaction with their birth experience [10-13]. Psychological safety through access to choice and retaining a sense of control in childbirth is important to women [15], as is the chance of having a straightforward birth [16], and a positive childbirth experience [17]. In the UK, where midwifery-led settings are an integrated part of NHS maternity care (Health and Social Care in Northern Ireland), this evidence is recognised in national guidance and strategy documents which recommends that four birth place options: obstetric unit (OU), home and two types of midwifery unit (MU), are offered by providers of maternity services [3,5,6,8].

Planned birth in an MU is considered “particularly suitable” for healthy women with straightforward pregnancies [3]. An MU is “a location offering maternity care to healthy women with straightforward pregnancies in which midwives take primary professional responsibility for care” [18,19] and can be either ‘alongside’ (AMU), located on the same site as a consultant-led OU, or ‘freestanding’ (FMU), located on a separate site, away from an OU. The number of MUs has increased across all four countries of the UK, most notably in the case of AMUs in England which increased from 26 to 132 between 2007 and 2019 [20-22]. In England, the number of FMUs has remained fairly static over the same period and remains fewer than AMUs [22,23], but the picture in the rest of the UK is varied. In Scotland in 2017 there were six AMUs and 19 FMUs [5]; in Northern Ireland the first AMU opened in 2001 and by 2014 there were six AMUs and three FMUs [24]; in Wales in 2018 there were eight AMUs and 14 FMUs [25]. In 2015, in England, around 14% of women gave birth in an MU and it is estimated that over a third of women may be potentially eligible to do so [21].

In order to exercise choice over where to give birth, women and their midwives need accurate, unbiased information about the relative benefits and risks of the options available [4,26]. Discussion or assessment of risk with women is complex, and how best to identify whether a women is at ‘higher’ or ‘lower’ risk of complications has been the subject of debate and discussion [27-32], but the aim of risk assessment is to screen for where an intervention could improve outcomes [29,33]. One of the complications of assessment criteria for place of birth is that the ‘intervention’ has changed from being admission to hospital, to ‘permission’ to plan birth outside of an OU [34], which may have led to MUs developing their own admission criteria independently of national guidance [33]. In the UK there is clear national guidance to support decision making about planned place of birth [3], but there is some evidence that admission criteria used by MUs may vary between units and depart from national recommendations [33,35,36], and it is unclear whether MUs or OUs are the default option for women with straightforward pregnancies. This variation may result in inequality of access to MUs for women, inconsistent application of evidence about the relative benefits and risks, and potential confusion about which women may be most suitable for MU care.

We aimed to document and describe variation in local maternity service guidelines for planned admission for intrapartum care (‘admission guidelines’) to AMUs and FMUs across the UK. Our main objectives were to describe the extent to which admission guidelines aligned with or varied from national guidance; explore whether this variation was associated with selected characteristics of maternity services; explore and describe variation in individual MU admission criteria; and describe admission policies in AMUs, i.e. whether the AMU was the default for women considered suitable (opt-out) or whether women needed to actively request birth in the AMU (opt-in).

Methods

Study design

We carried out a national cross-sectional survey to collect and describe MU admission guidelines. National guidance in the form of the NICE guideline CG190: Intrapartum care for healthy women and babies [3] was chosen as a reference against which to measure variation. While this guideline applies formally in England and Wales, guidance in Scotland and Northern Ireland is also broadly in line with NICE CG190.

Data and sources

The sampling frame for this study was all 122 maternity services (NHS Trusts and Health Boards) in the UK with at least one MU. We used the UK Midwifery Study System (UKMidSS), a national infrastructure for carrying out research in MUs across the UK, for this survey [37]. We emailed UKMidSS reporters in all maternity services with AMUs, and midwives nominated by Heads of Midwifery in services with FMUs only, in October 2018, introducing the study and giving a link to a brief study-specific online survey. As part of this survey we requested their current guidelines for admission to MUs, with a request to send separate AMU and FMU guidelines if these were in use. Up to six reminder emails were sent to non-responders and the survey was closed in February 2019.

In the survey we collected data about the number of AMUs and FMUs in each maternity service; the number of years each unit had been open for; AMU admission policy (‘opt-out’, i.e. AMU default option for eligible women; or ‘opt-in’, i.e. women required to actively chose AMU); and whether AMUs and FMUs in the service used the same admission guideline.

Data about the number of births in each maternity service were obtained from the MBRRACE-UK Perinatal Mortality Surveillance Report for 2016 [38]. Data about the number of births in each AMU came from the UKMidSS Severe Obesity Study in 2016 [39].

Admission guideline handling and data extraction

On receipt, admission guidelines were assigned an identification number to enable matching to corresponding survey response and additional births data. Some admission guidelines received were used by more than one maternity service; these were counted only once in the guideline analyses, but all maternity services covered by that guideline were considered to have returned a guideline for the purposes of calculating response. Some maternity services with more than one AMU/FMU, in which different units used separate admission criteria, sent more than one guideline. These were reviewed as separate guidelines in the guideline analyses. Some maternity services sent a single guideline which contained separate criteria for admission to AMUs and FMUs. These were reviewed as separate AMU and FMU guidelines.

Each guideline was read in full by CG prior to data extraction. Data about guideline characteristics and content were systematically extracted by CG and entered into a custom designed data collection tool, created to be responsive to guideline variation. Duplicate data extraction was not carried out because of resource constraints, but CG discussed any uncertainties with RR during data extraction.

Guideline characteristics

The study drew on the AGREE instrument for systematically evaluating guideline quality [40], to capture some characteristics that might be indicative of guideline quality, e.g. date of guideline, guideline authorship and evidence base. Other guideline characteristics extracted were: guideline length (number of pages), number of admission criteria, and whether there was an explicit care pathway for women wishing to give birth outside of guideline recommendations.

Admission criteria

Four tables from NICE Guideline CG190 [3], listing specific criteria to be assessed for women planning place of birth, were used as a reference against which to compare the individual admission criteria listed in each guideline (Tables in S1 File). CG compared each criterion listed in each guideline to the information in these tables and categorised them in one of the following ways:

‘More restrictive’ than NICE CG190:

Criteria not listed in NICE CG190, for which the MU required women to have an individual assessment for admission

Criteria for which NICE CG190 recommends individual assessment, but the MU did not admit women with the specific criteria, irrespective of individual assessment

Criteria not listed in NICE CG190, for which the MU did not admit women with the specific criteria.

‘More inclusive’ than NICE CG190:

Criteria for which NICE CG190 recommends OU birth, but where the MU explicitly admitted women with the specific criteria

Criteria for which NICE CG190 recommends OU birth, but where the MU offered admission following individual assessment

Criteria for which NICE CG190 recommends individual assessment, but where the MU explicitly admitted women without requiring individual assessment.

Individual criteria that were ‘more inclusive’ were only considered as such if they were explicitly listed in admission guidelines; no inferences were made about MUs admitting women if criteria from Tables 6–9 of NICE CG190 were not listed.

For each guideline, the individual admission criteria that were ‘more restrictive’ or ‘more inclusive’ than those listed in NICE CG190 were extracted by CG. For a small number of specific commonly-occurring admission criteria that were rarely aligned with NICE CG190, where there was substantial variation between guidelines, CG extracted more detailed information about each admission criteria and how they varied.

Using these categorisations of admission criteria as ‘more restrictive’ or ‘more inclusive’ CG categorised each guideline in one of the following ways:

Aligned with NICE CG190: guidelines which explicitly stated that the admission criteria used were those listed in NICE CG190 or which reproduced the tables from CG190 in the guideline

‘More restrictive’ than NICE CG190: guidelines in which at least one admission criterion was ‘more restrictive’, and no criteria were ‘more inclusive’

‘More inclusive’ than NICE CG190: guidelines in which at least one criterion was ‘more inclusive’ and no criteria were ‘more restrictive’

‘Both more restrictive and more inclusive’ than NICE CG190: guidelines in which at least one criterion was ‘more restrictive’ and at least one criterion was ‘more inclusive’.

Analysis

All data extracted from the guidelines were imported into Stata 15 statistical analysis software [41] and merged with data from other sources (data about number of births from MBRRACE-UK and UKMidSS) to produce a single dataset. We summarised the data generating descriptive statistics as frequencies and percentages. We tested for the presence of response bias by using the Chi-square test to compare selected characteristics of maternity services (AMU/FMU configuration, number of births per year, percentage of AMU births) that did and did not send an admission guideline. We also used the Chi-square test to explore associations between selected guideline and maternity service characteristics and the extent to which guidelines were aligned with national guidance.

Patient and public involvement

Lay members of the Co-investigator Group for the NIHR Policy Research Unit in Maternal and Neonatal Health and Care, and the UKMidSS Steering Group, were involved in discussing the research questions for this study, interpretation, and will be involved in further dissemination of the results.

Ethics statement

Using the Health Research Authority classification tool for research for England [42], this study was classified as research not requiring NHS research ethics approval. Information about the aims of the study and how the results would be used was included in the invitation email, and return of a completed survey response and/or guideline was considered as consent to take part.

Results

Response rate and configuration of care

Overall, 122 maternity services across the UK were identified as having at least one MU, with 216 MUs in total (Fig 1, S1 Table). Complete survey responses were received from 102 services (84%), representing 164 MUs, and guidelines were received from 87 services (71%) representing 153 MUs. All maternity services in Northern Ireland reported using the GAIN guideline [24], which was reviewed once. Most MUs in Wales reported using the All Wales Midwife-led Care Guidelines [43], which was also reviewed once. In total, 85 separate guidelines were included in the analyses.

Fig 1

Number of maternity services completing survey and sending a guideline, and number of guidelines analysed, by configuration of care.

There was no statistically significant difference between the characteristics of maternity services that did and did not send a guideline (Table 1 in S2 File). Services with FMUs only were less likely to complete the survey (p = 0.004, Table 2 in S2 File). This difference was also reflected in the finding that services with <10% of AMU births per year were less likely to respond to the survey.

AMU admission policy (opt-in vs opt-out)

Over half (59%) of maternity services with AMUs reported operating an opt-out policy whereby the AMU was the default planned place of birth for eligible women (S2 Table). AMU admission policy was not statistically associated with configuration of care, the length of time the longest standing AMU in the service had been open, the number of births per year in the service, or the percentage of AMU births in the service, but services where the AMU had an opt-out policy had higher proportions of births in the AMU, compared with those where the AMU had an opt-in policy.

Guideline characteristics

The characteristics of the guidelines are presented in Table 1. Most guidelines (71%) gave a publication date and 57 of these (95%) had been written or updated in the previous three years (January 2015 to December 2018). Almost a third of guidelines (31%) did not list the author(s) or a guideline development group. Of those that did, there were three guidelines in which there was evidence of service user involvement in the development of the guideline (5% of those for whom authors were listed and 3.5% of guidelines analysed). Guidelines ranged from 1–100 pages in length, with around a quarter of guidelines (26%) comprising four pages or less. This was partly attributable to the fact that some MUs sent only the guideline pages listing admission criteria and some sent entire guidelines. A quarter of guidelines (25%) listed more individual admission criteria than the 88 listed in Tables 6–9 in NICE CG190. Just over half of the guidelines (57%) cited at least one reference as an evidence base for their recommendations. These ranged from a single reference to NICE CG190, to a page of references to recent research articles. Three guidelines explicitly discussed the evidence base behind the recommendations. Just over half of guidelines (53%) specified a referral pathway for women who wished to birth outside of an OU, but fell outside of the MU eligibility criteria.

Table 1

Characteristics of guidelines.

Characteristic	Number of guidelines
	n	%
Authorship
None listed	26	30.6
Author listed	50	58.8
Guideline development group	9	10.6
Service user involvement
No	82	96.5
Yes	3	3.5
Length (number of pages)
1–4	22	25.9
5–14	23	27.1
15–24	22	25.9
25–103	18	21.2
Evidence base
None listed	34	40.0
Reference list	48	56.5
Evidence reviewed	3	3.5
Number of admission criteria
8–31	22	25.9
32–64	21	24.7
65–88	21	24.7
89–153	21	24.7
Outside guideline referral pathway
No	40	47.1
Yes	45	52.9

Admission guidelines compared with national guidance

The extent to which admission guidelines were aligned with NICE CG190 is presented in Table 2. Overall, over three quarters of guidelines (77%) listed both some criteria that were ‘more restrictive’ than those listed in NICE CG190 and other criteria that were ‘more inclusive’. Less than one in ten of the guidelines (7%) were aligned explicitly with the criteria listed in NICE CG190, although a further 18 guidelines (21%) had a small number of variant criteria (1–5) and some of these were otherwise similar in layout and content to NICE CG190. The number of individual criteria in each guideline that varied from NICE CG190 ranged from 1–19.

Table 2

Guideline alignment with NICE CG190 and selected characteristics of guidelines and maternity services.

	Aligned with NICE (n = 6)			Either more restrictive or more inclusive (n = 14)		Both more restrictive and more inclusive (n = 65)		All guidelines (n = 85)		p-value
	n		%	n	%	n	%	n	%
Scope of guideline
AMU only	4		66.7	9	64.3	46	70.8	59	69.4
FMU only	1		16.7	2	14.3	10	15.4	13	15.3
AMU & FMU	1		16.7	3	21.4	9	13.9	13	15.3	0.97
Number of criteria
8–31	0		0.0	4	28.6	15	24.6	22	25.9
32–64	0		0.0	2	14.3	19	31.2	21	24.7
65–88	6		100	3	21.4	11	18.0	21	24.7
89–153	0		0.0	5	35.7	16	26.2	21	24.7	0.645a
Number of births per yearb
<3,500	2		33.3	5	35.7	13	20.0	20	23.5
3,500–4,999	1		16.7	3	21.4	15	23.1	19	22.3
5,000–5,999	0		0.0	4	28.6	16	24.6	20	23.5
6,000–17,000	3		50.0	2	14.3	21	32.3	26	30.6	0.519
% of births in AMU
<10	1		20.0	2	14.3	7	11.3	10	12.4
10.1–15	2		40.0	5	35.7	17	27.4	24	29.6
15.1–20	1		20.0	4	28.6	24	38.7	29	35.8
20.1–39	1		20.0	3	21.4	14	22.6	18	22.2	0.959

a Chi-squared test excluding the 6 guidelines that aligned with NICE CG190 as they all listed 88 admission criteria.

b Overall annual number of births in the maternity service (NHS Trust or Health Board).

None of the guideline or maternity service characteristics studied were statistically significantly associated with the extent to which guidelines aligned with national guidance, but numbers of guidelines in some groups were very small.

As in NICE CG190, all guidelines specified that current pregnancies should be singleton, cephalic and >37 weeks’ gestation, with most guidelines specifying an upper gestational limit of either 41+6 or 42+0 weeks. All guidelines listed some specific admission criteria, with no guideline giving only non-specific criteria such as ‘straightforward pregnancy’ or ‘suitable for midwifery-led care’.

Individual admission criteria compared with national guidance

Overall, 73 guidelines (86%) listed at least one admission criterion which was ‘more inclusive’ than NICE CG190 and 71 guidelines (84%) listed at least one admission criterion which was more restrictive than NICE CG190. In total, 53 individual admission criteria were identified that varied from national guidance, 26 that were ‘more inclusive’ (Tables in S3 File) and 27 that were ‘more restrictive’ (Tables in S4 File). The most frequently occurring individual ‘more inclusive’ and ‘more restrictive’ criteria across all guidelines are shown in Table 3.

Table 3

Most frequently occurring individual ‘more inclusive’ and ‘more restrictive’ criteria across all guidelines.

	Guidelines in which criteria were listed
	n	%a
‘More inclusive’ criteriab
Parity ≥4	57	67.1
Maternal age 35–40 years	54	63.5
BMI 30-35kg/m2	47	55.3
BMI 35-40kg/m2 multiparous or any parity	37	43.5
Group B Streptococcus colonisation	37	43.5
Induction of labour, one intervention	34	40.0
‘More restrictive’ criteriac
Declining blood products	26	30.6
Female genital cutting	24	28.2
Maternal age <16years	23	27.1
Late booking/no antenatal care	23	27.1

a Percentage of all guidelines (n = 85).

b Women explicitly eligible for MU intrapartum care or considered for admission following individual assessment.

c Women not mentioned in NICE CG190 explicitly excluded from or individually assessed for MU care.

Parity was the most frequently occurring ‘more inclusive’ criterion, but also had varying limits which are listed in more detail in Table 4. Maternal age 35–40 years and women with a BMI 30-35kg/m2, are criteria for which NICE CG190 recommends women are individually assessed, but in 54 (64%) and 47 (55%) admission guidelines respectively, these women were eligible for admission without an individual assessment. Women with a BMI 35-40kg/m2 (for whom NICE CG190 recommends birth in an OU) were listed either for admission or for individual assessment in 37 guidelines (44%), with multiparous women in this group specified in 21 guidelines. Group B Streptococcus colonisation and induction of labour requiring one intervention, for both of which NICE CG190 recommends OU birth, were listed as a reason to individually assess or to admit women in 37 (44%) and 34 guidelines (40%) respectively.

Table 4

Detailed midwifery unit admission criteria for parity, previous PPH and maternal anaemia.

Admission criteria	Number of guidelines
	n	%a
Parity
≤4	19	22.4
≤5	28	32.9
≤6	9	10.6
No limit	1	1.2
Same as NICE CG190b	13	15.3
Not mentioned	15	17.7
Previous PPH
<0.5 litre	5	5.9
<1 litre	23	27.1
<1.5 litre	3	3.5
<2 litre	1	1.2
Subsequent normal blood loss	1	1.2
No previous PPH	8	9.4
Same as NICE CG190c	28	32.9
Not mentioned	16	18.8
Maternal anaemia
Hb≥85g/l	18	21.2
Hb≥90g/l	20	23.5
Hb≥95g/l	6	7.1
Hb≥100g/l	11	12.9
Hb≥105g/l	2	2.4
Same as NICE CG190d	21	24.7
Not mentioned	7	8.2

a Percentage of all guidelines (n = 85).

b NICE CG190 recommends individual assessment for women of parity ≥4.

c NICE CG190 recommends planned OU birth for women with previous ‘primary postpartum haemorrhage requiring additional treatment or blood transfusion’.

d NICE CG190 recommends individual assessment for women with Hb 85-105g/l at onset of labour.

None of the most frequently occurring ‘more restrictive’ criteria (Table 3) were listed in NICE CG190. Declining blood products and having experienced female genital cutting were listed as a reason to individually assess or not to admit women in almost a third of all guidelines (31% and 28% respectively). Both maternal age less than 16 years and inadequate antenatal care were listed in over a quarter of guidelines overall (27%).

For admission criteria in relation to parity, previous PPH, maternal anaemia and prolonged rupture of membranes there was widespread variation from NICE CG190, the extent of which is shown in Table 4. Parity was specified as an admission criterion in 70 guidelines (82%), and less than a fifth of these (19%) were aligned with NICE CG190. A limit on previous postpartum blood loss was listed in 69 guidelines (81%), with 41% of these aligned with NICE CG190. A specific limit on maternal anaemia (Hb level in g/L) was mentioned in 78 guidelines (92%), a quarter of which (25%) were aligned with NICE CG190.

Discussion

Key findings

Over half (59%) of maternity services reported that their AMU was the default option for healthy women with straightforward pregnancies.

Admission guidelines varied considerably in their layout and characteristics, most notably in the number of admission criteria listed, and very few included an evidence base for the recommendations.

Few guidelines (<8%) were fully aligned with national guidance and 53 separate admission criteria were identified that departed from national recommendations. Over three-quarters of guidelines contained both criteria that were more inclusive and criteria that were more restrictive than national guidance.

Admission criteria that were more inclusive than national guidance tended to occur more frequently across guidelines than those that were more restrictive. The most frequently occurring more inclusive criteria included admission of women with parity of ≥4, maternal age 35-40yrs, BMI 30-35kg/m2, selective admission of women with a BMI 35-40kg/m2, Group B streptococcus colonisation and selective induction of labour. The most frequently occurring more restrictive criteria excluded women declining blood products, having experienced female genital cutting, with maternal age <16yrs and inadequate antenatal care.

Parity, previous PPH and maternal anaemia were listed as admission criteria very frequently across guidelines, and varied widely, with most not in alignment with national guidance.

Strengths and limitations

This is the first UK-wide study to document AMU admission policy (i.e. whether the AMU is the ‘default’ option for eligible women), to systematically document alignment with and variation from national guidance in local MU admission guidelines and in individual admission criteria. Data were collected using UKMidSS [37], a well-established, effective national research infrastructure for MUs across the UK, and derived from other reliable sources. High response rates and a low probability of response bias increase the generalisability of our findings. Resource and time constraints meant that data extraction and analysis was carried out by one author only (CG), but any uncertainties were discussed with RR, and this is unlikely to have introduced systematic bias into our study. There was some evidence that maternity services with FMUs only were under-represented in our study, almost certainly because at the time the data were collected, UKMidSS had established midwife reporters in AMUs, but contact with FMUs was new. The number of maternity services with no AMUs and only FMUs is relatively small (13%), but nevertheless the findings of this study may be less generalisable to FMU admission guidelines. It should be noted, however, that current national (NICE) guidance does not recommend different admission criteria for AMUs and FMUs, although guidance used for the whole of Northern Ireland does do so [24]. No formal assessment was made of guideline quality and numbers for some comparisons were small. Finally, because of time constraints we surveyed maternity service providers at only one point in time so were unable to follow up to ask, for example, why their guidelines were not aligned with national guidance.

Interpretation in the light of other evidence

Some limited data about assessment criteria for admission to midwifery-led settings and MUs have been collected in previous studies, all of which found variation in admission criteria [33,35,36]. The move away from non-specific criteria such as ‘suitable for midwifery-led care’ as observed by Campbell [33], towards specific admission criteria is in keeping with the current national context for evidence-based care [44]. However, the extent of variation found by our study, reveals a lack of consensus about how best to identify women who are likely to have a straightforward birth and are therefore suitable for planning birth in a MU. This lack of consensus may be historical [33], may indicate inconsistency in the application of the available evidence, or a lack of relevant evidence on which to base clinical recommendations [45], leading to local bias [46].

Variation from national guidance in specific admission criteria may also be indicative of issues of concern in local populations for which there is little research evidence to guide practice. Some of the ‘more restrictive’ admission criteria identified in our study (declining blood products, having experienced female genital cutting, maternal age >16yrs and inadequate antenatal care), may reflect this, but may also disproportionately affect women from religious and ethnic minorities, and those of lower socio-economic status. There is some evidence that women in these groups may be at a higher risk of adverse outcome. For example, women who are Jehovah’s Witnesses have an increased risk of death and morbidity associated with obstetric haemorrhage [47,48]. There is some limited evidence that women who have experienced female genital cutting may have an increased risk an emergency Caesarean section and severe perineal trauma [49]. While young maternal age and fragmented or reduced antenatal care are both associated with adverse outcomes such as preterm birth and low birth weight, it is likely that the underlying causes of these adverse outcomes are socio-economic factors including social class, deprivation and smoking [50]. Although late presentation for antenatal care could lead to uncertain gestation and therefore place women outside of the criteria for MU care, none of the guidelines reviewed mentioned gestation in relation to late booking or fragmented antenatal care. None of the evidence about outcomes for women in these groups was considered sufficient justification to recommend OU birth during the development of NICE guidance [3].

AMU opt-out polices, whereby the AMU is the default option for eligible women, have the potential to increase equity of access to MU care. Our data suggest that maternity services with an opt-out AMU may have a higher proportion of births in the AMU. It is important that any default birth place option is not implemented at the expense of informed choice of all the available options [4,26], particularly in the light of evidence of frequent closures of FMUs [51], as these are associated with optimal outcomes for healthy women and their babies [52]. It is also important that MU admission criteria, irrespective of opt-out or opt-in policy, do not disproportionately deny access to midwifery-led care for women from minority and socio-economically deprived backgrounds, yet some of the deviations from NICE guidance evidenced by our study may have this effect.

Our study has provided evidence that, in some specific areas, relevant research published since the development of national guidance may be driving more inclusive admission criteria, particularly with regard to the explicit inclusion of women aged 35–40 years, with a BMI in the range 30-35kg/m2 and qualified inclusion of women with a BMI in the range 35-40kg/m2 [39,53,54]. Research into alternative settings for induction of labour [55] may reflect women’s desire for a different experience to that offered by conventional OU induction and the need for alternative management strategies in the context of rising induction rates [22,23], which may be driving the inclusion of these women in just under half of MU guidelines. The extent of widespread variation between admission guidelines for other specific criteria (multiparity, previous PPH and maternal anaemia) is evidence of further underlying uncertainty in relation to outcomes, perhaps particularly where there may be a continuum of increasing risk with no clear step-change. Ongoing studies into outcomes for women planning AMU birth after a previous PPH and the management and outcomes of women who experience a PPH in an MU, may help fill some evidence gaps [56].

Maternity services in England have a responsibility to enable NICE guidelines to be applied in their services, and providers in other UK countries should be guided by their own, similar, guidance or strategy documents. However, national clinical guidance is intended to guide, not prescribe, clinical practice and local guidance, in order to help practitioners and women make decisions about care [44]. Local variation from national guidance is perhaps inevitable, and may have benefits in terms of the ability to reflect local priorities and services, and promote increased local ownership and uptake [57]. It is also possible that in some services, in which MUs are less well established, local guidance may reasonably diverge from national guidance and evolve to converge with national guidance as the knowledge, skills and experience of MU midwives develops. We compared local guidance with national guidance in the form of NICE CG190 as an appropriate reference, not because all local guidance should ‘conform’ to this guidance. In some cases, variation from NICE may reflect the poor quality of underlying evidence, with some recommendations based on expert consensus. However, maternity services should be aware of the potential consequences of diverging from national guidance, and should as far as possible use robust methodology, refer to systematically identified evidence and consider equity. Small variations in recommendations can make a big difference to women who fall the ‘wrong’ side of the dividing line in admission guidelines [33]. Whilst half of the guidelines reviewed listed a referral pathway for women wishing to plan birth in the MU who fell outside of admission criteria, the specific limits proposed by local guidelines may affect women’s own perception of their risk status [32] and so deter otherwise suitable women from considering birth in an MU on the grounds of safety. Large numbers of admission criteria may affect the practicalities of guideline implementation [58], influence professionals’ perception of risk, and so impact on their birth place conversations with women [59]. Finally, the Birthplace study [9] provided much of the evidence about maternal and neonatal safety of planned birth in an MU for ‘low risk’ women, supporting the place of birth recommendations in NICE CG190. Birthplace used the guidance in the previous NICE intrapartum care guidelines [60] in order to classify women as ‘low’ or ‘higher’ risk. If local guidance about admission criteria diverges substantially from national guidance, some women may be making birth place decisions based on an assumption of risk status that is not evidence-based, potentially resulting in unnecessary OU admission for some and elevated risks in MUs for others. It also means that in practice, many local admission guidelines may not be meeting the needs of women, or the midwives caring for them, who are working to navigate risk assessment in the context of all available birth place options [59,61]. Potential increases in the numbers of women who require individual assessment also means that changes in local structures and staffing may be required to ensure that women who need this receive the support of a senior midwife. Given the significant changes to the maternity care landscape since the Birthplace study [20,21], and the shift in MU admission criteria evidenced by our study, further research to investigate the safety of planned birth in different settings for specific groups of women, and a review of national guidance, may soon be required.

Conclusions

This study found wide variation in local guideline layout and content, with frequent departure from national guidance and a lack of consensus regarding the parameters of straightforward pregnancy determining suitability for MU intrapartum care. This presents an inconsistent and potentially non-evidence based landscape for both women and the midwives responsible for facilitating women’s decision-making about place of birth that may be deterring some women from choosing MUs and inadvertently excluding others. Where a lack of relevant evidence underlies the variation found, further research into outcomes for specific groups of women by planned place of birth is needed. The extent of variation from national guidance indicates that a review of that guidance may also be required in order to enable women to make birth place decisions with confidence.

Criteria to be assessed for women planning place of birth, from NICE CG190.

(DOCX)

Click here for additional data file.

Characteristics of responding and non-responding maternity services.

(DOCX)

Click here for additional data file.

Individual admission criteria that were ‘more inclusive’ than NICE CG190.

(DOCX)

Click here for additional data file.

Individual admission criteria that were ‘more restrictive’ than NICE CG190.

(DOCX)

Click here for additional data file.

Number of midwifery units of each type in each country of the UK at the time of the survey.

(DOCX)

Click here for additional data file.

Organisational alongside midwifery unit (AMU) admission policy (opt-in or opt-out) by characteristics of maternity service.

(DOCX)

Click here for additional data file.

16 Apr 2020

PONE-D-20-02225

Local guidelines for admission to UK midwifery units compared with national guidance: a national survey using the UK Midwifery Study System (UKMidSS)

PLOS ONE

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #2: No

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Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear authors

I have read your manuscript with interest. The survey is important to enable equal services and evidence based care for labouring women, although it is important to allow for some local variations to reflect local settings and resources. The method used is adequate to investigate the matter. I find the text well written and easy to understand. The pragmatic approach and easy to understand descriptive statistics are adequate to present differences in admission guidelines and represent real life practice. The results showed guidelines both with more inclusive as well as more restrictive criteria and it is interesting to see that 55-67 percent allowed for higher parity, age and BMI. The results might be useful in revision of local and national guidelines.

Figure 1 could include reasons for numbers of guidelines analysed

Reviewer #2: This paper presents information that will be of interest to midwives; particularly those working in or interested in working in MUs.

The paper tends to focus on England specific policy and MU provision. However, it is reporting on a national survey using the UKMidSS and should therefore provide information on the four countries of the UK. Specific examples of where this has not happened are included below but are apparent throughout the paper. This is particularly important as MUs are generally growing in number outside of England.

For example: References to support the assertion in the first sentence should include those from all of the 4 countries in the UK, not just England, for example, Better Start (2017); NI Maternity Strategy (2012). Also at the end of paragraph one, references should include those from all of the 4 countries in the UK, not just England. NHS relates to NHS Scotland, NHS Wales and England - in Northern Ireland, the health service is referred to as Health and Social Care (HSC) which reflects the integrated service provision of health and social care.

Consideration should be given to using using the term maternity care provider, rather than NHS organisations.

P.3, the numbers of MUs in England is detailed but not the rest of the UK; the number of MUs in all countries of the UK should be provided.

P.6 Data was extracted by CG; was the data extraction validated i.e. was it checked by anyone else and if not, why not?

It is stated 'We compared each criterion listed in each guideline...'; it should indicate which authors did that.

P.7 Under ‘More inclusive’ than NICE CG190: it states 'Criteria for which NICE CG190 recommends OU birth, but where the MU offered individual assessment for women planning admission'- but NICE advocates multidisciplinary discussion and individualised assessment for women if necessary.

P. 8 Under Analysis, need to remind the reader what the 'other sources' were.

P.10 You state that 'Almost a third of guidelines (30%) did not list the author(s) or a guideline development

group'. However, of those that did include authorship, it would have been interesting to know how the MU guidelines had been developed, for example were they co-produced with women, were they multidisciplinary or developed by midwives only.

P.11 Table 2, should make it clear that number of births in NHS organisation.

You state 'had a small number of variant criteria (1-5) and a small number of these were otherwise similar in layout', I would suggest replacing the second 'a small number' with 'not many'.

P.14- You state- 'Few guidelines (<8%) were fully aligned with national guidance'- however as stated in CG190 P.81-'Putting recommendations into practice can take time. How long may vary from guideline to guideline, and depends on how much change in practice or services is needed. Implementing change is most effective when aligned with local priorities'.

It is important to remember that local guidelines may be developed for where individual services are or where they want to get to and may align more fully with regional guidelines as services develop and MU midwives develop their experience, knowledge and skills. Where more than one MU uses the same guideline, it may require a guideline to be less or more restrictive to meet the needs of the evolutionary stage of each of the MUs using the guideline.

P.15- you state- 'This is the first UK-wide study to document AMU admission policy'-what about FMUs?

P.16- You state- 'none of the guidelines reviewed mentioned gestation in relation to late booking or fragmented antenatal care'.; does social services input cover this?

P.17 You state the need to be careful that guidelines 'do not disproportionately deny access to midwifery-led care for women from minority and socioeconomically deprived backgrounds- is social services input criteria and the inclusion of <16 years by some guidelines an attempt to address this to some degree?

P.18. You state -Whilst half of guidelines listed a referral pathway' it should be- Whilst half of the guidelines reviewed listed a referral pathway- please amend.

P.18 It is interesting that you state that women and midwives.. 'who are working to navigate risk in their discussions about birth place choices'.[54, 56]. It is important to consider that risk is often only raised when MU and Home are considered as place of birth. There are many iatrogenic risks of giving birth in an OU, but these are rarely discussed with women.

It would have been interesting to ask MU's whose guidance did not align with NICE guidance, why this was the case?

The supporting information files, provide useful additional data, although not all of te titles reflect the content of the tables, e.g. table 1 (S3). However, a table detailing the number of FMU's/AMUs in each of the four countries of the UK would be helpful.

There are some minor typos, please proof read again following amendments.

I hope this feedback is helpful.

**********

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Reviewer #1: No

Reviewer #2: No

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4 Jun 2020

Editor

Well done on a nice paper. Please attend to the comments of the reviewer who would like a few changes made to the paper before it is accepted for publication.

Response

Thank you for your positive comment about our paper. We have responded to the reviewer’s comments below.

Reviewer #1

I have read your manuscript with interest. The survey is important to enable equal services and evidence based care for labouring women, although it is important to allow for some local variations to reflect local settings and resources. The method used is adequate to investigate the matter. I find the text well written and easy to understand. The pragmatic approach and easy to understand descriptive statistics are adequate to present differences in admission guidelines and represent real life practice. The results showed guidelines both with more inclusive as well as more restrictive criteria and it is interesting to see that 55-67 percent allowed for higher parity, age and BMI. The results might be useful in revision of local and national guidelines.

Figure 1 could include reasons for numbers of guidelines analysed.

Response

Thank you for your extremely positive comments about our paper.

With regard to Figure 1, we have revised this to make it clearer, including adding reasons for the numbers of guidelines analysed.

Reviewer #2

The paper tends to focus on England specific policy and MU provision. However, it is reporting on a national survey using the UKMidSS and should therefore provide information on the four countries of the UK. Specific examples of where this has not happened are included below but are apparent throughout the paper. This is particularly important as MUs are generally growing in number outside of England.

Response

Thank you for making this important point. Our intention was certainly to ensure that the focus of the paper was the whole of the UK, not just England, but we agree that we may not have given sufficient attention to this. This may be, in part, because much of the published evidence, about numbers of MUs etc, is based on English data, rather than data from the whole of the UK. We have made a number of changes to improve the paper in this regard, detailed below.

For example: References to support the assertion in the first sentence should include those from all of the 4 countries in the UK, not just England, for example, Better Start (2017); NI Maternity Strategy (2012). Also at the end of paragraph one, references should include those from all of the 4 countries in the UK, not just England. NHS relates to NHS Scotland, NHS Wales and England - in Northern Ireland, the health service is referred to as Health and Social Care (HSC) which reflects the integrated service provision of health and social care.

Response

We have added references to key documents from all four countries of the UK in this paragraph and reworded some sentences to make it clear that we are referring to the whole of the UK. We have also made it clear that in Northern Ireland the health service is referred to as Health and Social Care.

Consideration should be given to using using the term maternity care provider, rather than NHS organisations.

Response

Thank you for this suggestion. We can see the rationale for this change, but are concerned that ‘maternity care provider’ could be interpreted as referring to individual people rather than service organisations. We have therefore used the term ‘maternity service’ instead.

P.3, the numbers of MUs in England is detailed but not the rest of the UK; the number of MUs in all countries of the UK should be provided.

Response

This is largely because there is little published data relating to the rest of the UK. We have added some data about the number of MUs in other countries of the UK.

P.6 Data was extracted by CG; was the data extraction validated i.e. was it checked by anyone else and if not, why not?

Response

This was a student project carried out by CG for her Masters dissertation. Because of time and resource constraints it was not possible for duplicate data extraction to be carried out so CG did this alone with frequent discussion with RR, particularly when any uncertainties arose. We have added to our discussion of limitations to refer to this point.

It is stated 'We compared each criterion listed in each guideline...'; it should indicate which authors did that.

Response

We have now revised the paper so it is clear that this was carried out by CG.

P.7 Under ‘More inclusive’ than NICE CG190: it states 'Criteria for which NICE CG190 recommends OU birth, but where the MU offered individual assessment for women planning admission'- but NICE advocates multidisciplinary discussion and individualised assessment for women if necessary.

Response

We agree, NICE CG190 does advocate multidisciplinary discussion and individualised assessment for women if necessary. However, we set out to operationalise the guidance set out in the NICE CG190 chapter on planning place of birth and apply this to the guidelines analysed. For the criteria in Tables 6-7 in NICE CG190 it is advised that the woman plans birth in an obstetric unit. For the criteria listed in Tables 8-9 in NICE CG190, individualised assessment is recommended in considering planned place of birth. When it was clear, in a guideline we analysed, that women with a condition or factor listed in Tables 6-7 could be considered eligible for admission to the midwifery unit following individualised assessment, we considered this to be ‘more inclusive’ than NICE CG190.

P. 8 Under Analysis, need to remind the reader what the 'other sources' were.

Response

Thank you, this is helpful. We have added a reminder about what the ‘other sources’ were.

P.10 You state that 'Almost a third of guidelines (30%) did not list the author(s) or a guideline development

group'. However, of those that did include authorship, it would have been interesting to know how the MU guidelines had been developed, for example were they co-produced with women, were they multidisciplinary or developed by midwives only.

Response

Thank you for raising this, it is a really good point. Unfortunately we did not extract any data from the guidelines about the composition of the authorship or development group. However, we did extract data from the guidelines in relation to whether there was any evidence of the involvement of service users in the development of the guideline. We have added this information to Table 1 on page 12 and at lines 217-9 on page 11. In making these changes to Table 1 we noticed some errors, arising from copying by mistake from an earlier version. These have now been corrected. We have also checked other tables.

P.11 Table 2, should make it clear that number of births in NHS organisation.

Response

Thank you, we have added a footnote to clarify this.

You state 'had a small number of variant criteria (1-5) and a small number of these were otherwise similar in layout', I would suggest replacing the second 'a small number' with 'not many'.

Response

Thank you for pointing this out, we have changed the wording for this sentence.

P.14- You state- 'Few guidelines (<8%) were fully aligned with national guidance'- however as stated in CG190 P.81-'Putting recommendations into practice can take time. How long may vary from guideline to guideline, and depends on how much change in practice or services is needed. Implementing change is most effective when aligned with local priorities'.

Response

We completely agree – this is an important point and we have discussed this issue in detail on page 18. The statement on page 14 is simply a factual summary of the key findings so we don’t think it would be appropriate to add to it.

It is important to remember that local guidelines may be developed for where individual services are or where they want to get to and may align more fully with regional guidelines as services develop and MU midwives develop their experience, knowledge and skills. Where more than one MU uses the same guideline, it may require a guideline to be less or more restrictive to meet the needs of the evolutionary stage of each of the MUs using the guideline.

Response

Thank you for making this point. We have discussed related issues on page 18, but have added a sentence reflecting the reviewer’s comment.

P.15- you state- 'This is the first UK-wide study to document AMU admission policy'-what about FMUs?

Response

We use the phrase “admission policy” to refer very specifically to AMUs and whether they are regarded as the ‘default option’ for eligible women (an ‘opt-out’ model) or whether women have to actively choose to plan birth there (an ‘opt-in’ model). This is not an approach taken for FMUs in the UK. We defined this at the end of the background section on page 5, under data and sources on the same page and in the results section on page 10. We have added to the sentence referred to on page 15 to clarify.

P.16- You state- 'none of the guidelines reviewed mentioned gestation in relation to late booking or fragmented antenatal care'.; does social services input cover this?

Response

We’re not sure that we completely understand the reviewer’s point here. The sentence referred to on page 16 relates specifically to admission criteria which exclude women who book late for care, or have fragmented antenatal care, from access to midwifery units. One possible interpretation of these apparently ‘more restrictive’ criteria is that they are a way to ensure that women for whom gestational age is uncertain or outside the usual criteria for admission to midwifery-led care, are not admitted to a midwifery unit. However, as this sentence explains, we found no mention of gestation in any of the guidelines reviewed in relation to late booking or fragmented antenatal care. As shown in the supplementary S4 file, some guidelines also included criteria which excluded women with social services input from admission to the midwifery unit, but we’re not sure how this relates to the reviewer’s comment. Social services input would not be a given for women who book late or choose not to access antenatal care in the UK.

P.17 You state the need to be careful that guidelines 'do not disproportionately deny access to midwifery-led care for women from minority and socioeconomically deprived backgrounds- is social services input criteria and the inclusion of <16 years by some guidelines an attempt to address this to some degree?

Response

NICE CG190 guidance does not consider age<16 years or social services input as reasons to advise women not to plan birth in a midwifery unit. The only way in which these criteria were used in guidelines were as ‘more restrictive’ criteria which could potentially exclude women from the midwifery unit. For example, this included guidelines where women with social services input or aged <16 years were admitted to the midwifery unit only after individual assessment or were explicitly excluded from admission. These are shown in the tables in supplementary file S4.

P.18. You state -Whilst half of guidelines listed a referral pathway' it should be- Whilst half of the guidelines reviewed listed a referral pathway- please amend.

Response

Thank you for pointing this out – we have amended this.

P.18 It is interesting that you state that women and midwives.. 'who are working to navigate risk in their discussions about birth place choices'.[54, 56]. It is important to consider that risk is often only raised when MU and Home are considered as place of birth. There are many iatrogenic risks of giving birth in an OU, but these are rarely discussed with women.

Response

We completely agree with your point, but feel that it would be beyond the scope of this paper to bring this into our discussion. We have reworded this sentence very slightly so that it now reads “who are working to navigate risk assessment in the context of all available birth place options”.

It would have been interesting to ask MU's whose guidance did not align with NICE guidance, why this was the case?

Response

We agree, this would have been really interesting. However, at the point when we carried out our survey and collected guidelines we did not know which service providers had guidance that did not align with NICE, and we did not have the time or resources to go back to participants afterwards. We have added a sentence to the strengths and limitations section acknowledging this as a potential limitation.

The supporting information files, provide useful additional data, although not all of te titles reflect the content of the tables, e.g. table 1 (S3). However, a table detailing the number of FMU's/AMUs in each of the four countries of the UK would be helpful.

Response

We have checked all supporting information files and revised where necessary. We don’t recognise that the title of Table 1 in S3 File does not reflect the content. We have added to the title, and to those of some other supplementary tables, to help clarify what is shown. We have added a new S1 Table detailing the number of midwifery units of each type in each of the four countries of the UK at the time the survey was carried out.

There are some minor typos, please proof read again following amendments.

I hope this feedback is helpful.

Response

Thank you, we have been over the whole manuscript and supplementary tables again and corrected any typos we found.

We are extremely grateful to you for reviewing our paper so carefully and thoughtfully. Your comments have resulted in changes which have improved the paper.

Submitted filename: Response to reviewers.docx

Click here for additional data file.

4 Sep 2020

Local guidelines for admission to UK midwifery units compared with national guidance: a national survey using the UK Midwifery Study System (UKMidSS)

PONE-D-20-02225R1

Dear Dr. Rachel Rowe,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Sharon Mary Brownie

Academic Editor

PLOS ONE

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Reviewer #1: Dear authors

I find this paper well written and interesting and had very few comments to the text in the first round. I do see that you now have taken my comments into consideration as well as the comments from reviewer #2.

Reviewer #2: My sincere apologies for ny delay in returning my review but this was unavoidable due to other workload and leave. I feel that the authors have responded positively and fully to my comments.

Please add HSC Trusts to the statements that refer to NHS Trusts and Health Boards

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

Reviewer #1: No

Reviewer #2: No

8 Sep 2020

PONE-D-20-02225R1

Local guidelines for admission to UK midwifery units compared with national guidance: a national survey using the UK Midwifery Study System (UKMidSS)

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