It is time for Action!

Robust evidence suggests that midwifery-led birth settings, such as midwifery units in
hospital or community can reduce intervention such as instrumental and cesarean births while offering care that is as safe for the baby and safer for the mother.
Midwifery-led birth settings are also more cost effective than obstetric units (OU).
For this reason the NICE Intrapartum Guidelines published in 2014 recommended clinicians to advise healthy women with uncomplicated pregnancies to consider planning their births in midwifery-led settings.

You would think, that’s all great; this evidence will have a massive impact on practice now…
But the reality is that most NHS services here in inner London are still offering obstetric units as the mainstream option and midwifery-led birth settings as an alternative!

To give you a small idea about the numbers: in 2013, planned out-of-hospital birth only accounted for 3% of all births and in London the number of births in midwifery-led birth settings varies from 3% to 25%.

So it is time for ACTION! 

With this research project we aim to address the challenge of implementation of research knowledge into NHS settings. The evidence is there, guidelines have clearly been written and now we, The ‘NICE Birthplace Action Research team’ are investigating what helps or hinders the implementation of the evidence more effectively in practice. Very practically we aim to have an impact on the number of births outside obstetric units and assess the impact of this project on front-line staff and service users (mums, dads and birth partners). We also aim to help developing a culture of active participation of service users and front-line staff in research and planning service delivery.


Exciting right?!

I can almost imagine you thinking now….so how are you planning to do this?!

Let’s clarify in a few simple steps:

Step 1: Researchers, Time and Money

After writing a quite lengthy and very detailed research proposal with her mentors (Chris and Jane), Lucia was awarded a NIHR Knowledge Mobilisation fellowship at City University. For 3 years she will be dedicating 70% of her time to this project.
A few months later I (Ellen) came into the picture, since I was awarded with an Imperial College NHS Charity Fellowship for 15 months so I could work for 50% of my time on the project.
As this is a massive task, 6 months after that Laura was employed as a research midwife to support the evaluation. She also will dedicate 50% of her time to the project.

With our team we are working very closely together with other fantastic people who are working on different projects around the same theme!


Step 2: Ethics approval, Methodology and Case Study

Ethics approval was obtained in October 2016.

We are conducting a ‘Participatory Action Research’ (PAR), which consists of a family of research methodologies that aim to implement change with the engagement of the co-participants. Change will be implemented and evaluated at the same time, so we will not be following a linear process.

We will extract data from interviews, focus groups, observational notes, pictures, official engagement events, only when informed consent has been given by participants in the study and off course in an anonymous and sensitive way.

Off course we also had to find a service to be our ‘gynea pig’. The trust where our case study takes place has got all four places of birth available (Home, alongside midwifery units, freestanding midwifery units and obstetric units).  Each location has got a different history and operational management, a nice variety of impeding and facilitating factors for the implementation of the NICE guidelines. It makes our study so much more challenging, but the information that we could extract will be so much juicier and adaptable to other places.



Step 3: Engagement and Training

We are engaging with people at so many different levels, from a more external advisory group with experts – to management of the trust – to front line staff – to mums, dads and birth partners. Everyone involved plays a vital role and we value so much the time and effort they spent taking ownership of this project and moving their services forward.

Engagement includes:
– Meetings
– Advisory groups
– Walkabouts (where we adapt a fresh eye approach on the midwifery unit environment and try to learn lessons to improve the birth environment)
– Attending team meetings
– Engagement events with groups of multidisciplinary front-line staff and service users all connected to the midwifery units and communities (midwives, healthcare assistants, cleaners, GP’s, paediatricians, obstetricians, mums, dads, ward clerks, …) to find out what their perceived local impeding and facilitating factors are for the implementation of the NICE guidelines and we make an individualised action plan at that point.
– We try to involve service users at every step of the way as they play a vital role in moving services forward. Their voices are massively valuable as we believe in family centred care and maternity services need to be shaped to fit their needs.

Training is of massive importance as we want to achieve a safe uptake in births at midwifery led units. Staff needs to feel ready to work in a midwifery unit, they need to know how to inform woman and their partners about the choices they have in regards to place of birth, they need to know about the evidence based knowledge that is available and should be updated on a regular basis. This is why we will adapt a learning needs approach and create a learning program that is adapted to the existing knowledge gap.

MUStandards engagement event


Step 4: Outputs and impact

Like I said before, we are conduction a PAR, so while planning our next steps we are also acting on other things, observing outcomes and reflecting on what has been done already (#Multitaskers)! This process will enable us to create a ‘pathway’ which is flexible and adaptable so it can be implemented in many different services in the near future!

In the meantime we are very proud to announce that we are also working on an update of the Midwifery Unit Standards which is a collaboration between City University, Midwifery Unit Network and the Royal College Of Midwives (see our website for more information) which will form an important part of the outputs of this study (#busybees)!


We are a very enthusiastic team and I really hope I have been able to make you excited about the work we are doing too! I promise we will keep you up to date with the evolution and important new facts of the ‘NICE Birthplace Action Study’!

Have a lovely day,








Hollowell, H., Rowe, R., Townend, J., Knight, M., Li, Y., Linsell, L., Redshaw, M., Brocklehurst, P., Macfarlane, A., Marlow, N., McCourt, C., Newburn, M., Sandall, J., Silverton, L. (2015) The Birthplace in England national prospective cohort study: further analyses to enhance policy and service delivery decision-making for planned place of birth. Health Services And Delivery Research. Vol 3 Issue 36 Aug 2015 ISSN 2050-4349
Information Centre for Health and Social Care (2014). NHS Maternity Statistics, 2012-2013 England. Leeds: NHSIC
National Institute for Health and Care Excellence (2014) Intrapartum Care: Care of Healthy Women and their Babies During Childbirth. NICE guideline CG190. London: NICE.
National Institute for Health and Care Excellence (2014) Putting NICE guidance into practice. Costing statement: Intrapartum care: care of healthy women and their babies during childbirth Implementing the NICE guideline on intrapartum care (CG190).
The Royal College of Midwives (2009) Standards for Birth Centres in England. London:The Royal College of Midwives Trust.