Date	2^nd November 2012
Responsible Director	Executive Director of Nursing
Directorate of Obstetrics, Gynaecology and Sexual Health Draft Report of Evaluation of Tair Afon Birth Centre (PCH) May – October 2012

Situation

This draft report presents an evaluation of Tair Afon Birth Centre since its relocation to Prince Charles Hospital, following the closure of Aberdare General Hospital in April 2012.

Aspects reviewed in the evaluation include:

· An analysis of the activity in Tair Afon

· The views of women who have used the service

· The views of midwives providing birth centre care

· Other observations regarding provision of care

Background

Birth Centre births have been shown to be a safe option for maternity care for women in a recent study carried out by the National Perinatal Epidemiology Unit and published in November 2011, however the research also acknowledges that a number of women will develop a complication during pregnancy or labour and birth which necessitates transfer to an obstetric facility.

There are strict rules governing which women are suitable to give birth in a birth centre.  In the Cynon Valley only 50% of pregnant women meet these criteria.  Despite efforts to increase the number of women who are able to use the birth centre, there were on average only 160 births in Tair Afon each year.  This represented only half the women who initially planned to give birth in Tair Afon, as the remaining women developed a complication during pregnancy or labour.

A number of women who were suitable to have care in the birth centre in Aberdare preferred instead to give birth in the maternity unit in Prince Charles Hospital as they felt more confident with having medical staff on site, should a complication arise.

With the closure of Aberdare Hospital in April 2012, it was decided to relocate Tair Afon Birth Centre on a temporary basis to Ward 20, Prince Charles Hospital , to allow an opportunity to review the service and how it is best provided.    The birth centre, (maintaining the name Tair Afon) is now in a designated area, adjacent but separate to the existing maternity unit in Prince Charles Hospital.  Care in labour continues to be provided by the birth centre midwives from Cynon Valley, in the same way that it was formerly provided.

Antenatal care facilities were transferred as planned to Ysbyty Cwm Cynon, when Aberdare Hospital closed.

Assessment

Activity in the birth centre

The number of intended and actual births and transfers in the antenatal period and during labour were compared between 2011 and 2012, in the six-month period May to October.  The same months were used to allow for the seasonal variation in the number of births.  The overall birth numbers for Prince Charles Hospital were very similar in both years, showing that the change in numbers was not attributable to a large increase or decrease in the overall  birth rate.

The number of women intending to use the birth centre rose following relocation to Prince Charles Hospital, as did the actual number of births.  There was also a rise in the number of antenatal transfers of women, with proportionally more women during 2012 (34% of women, compared to 28% of women in 2011), although the reasons for this were not explored further.  Labour transfers from Tair Afon Prince Charles increased, which is consistent with figures from other birth centres located alongside obstetric units. 

These results show that the total number of women who intended to give birth in the birth centre rose by 22% following relocation of the unit to Prince Charles Hospital – it is presumed that this represents the number of women suitable for birth centre care but who would previously have chosen to give birth in Prince Charles Hospital.  Proportionally, the number of women actually giving birth also rose in 2012, with 86% of women who began labour* in the birth centre doing so, compared to 71% during 2011.

*(i.e not including the number of women who were transferred antenatally).

Women’s Views

(Please note that as the evaluation finished on 31^st October, there are still a number of evaluation forms outstanding, which when received will give a more robust representation of women’s views).

Women who had used the birth centre in Prince Charles Hospital (PCH) were asked to complete a questionnaire giving their views of the service provided.  The questionnaire was approved for use by the Health Board’s Research and Development Group, and given out by the community midwife following birth.

Women were asked to rate satisfaction with aspects of their care, and about the birth pool.  The questionnaire also asked if women would choose birth centre care in a future pregnancy, and if so, where they would like this to be located – Ysbyty Cwm Cynon or Prince Charles Hospital.  Women who had had a previous birth in the birth centre in Aberdare were asked to compare their experiences, and again give their views on a permanent location for the birth centre.

There has been a disappointing response to this aspect of the evaluation so far with only 25% of responses received to date, although the total response rate is not yet established.  However some clear themes and opinions have already been expressed.

The majority of women were satisfied with their care, and found the birth centre environment on ward 20 to be welcoming.  Women were appreciative of their midwives, and all women said that they would choose birth centre care again. 

Four women preferred the birth centre to be located in Ysbyty Cwm Cynon (YCC), whilst 3 women felt it was important that the birth centre was near to the obstetric unit.  The remaining women did not have a particular preference – what was important  to all women was the option of having a birth centre, rather than its location. 

The reasons women gave for preferring the birth centre in YCC was the travel time to PCH, particularly when in labour, or if needing to attend the birth centre to see their midwife for reassurance (for example, if the woman thought she was in labour, but was not). 

One woman preferring PCH as the location explained that she had needed transfer during labour in a previous birth, so the location in PCH was much more reassuring, should the same thing have been required again. 

For the women who had previously given birth in Aberdare, although the further travelling distance to PCH was mentioned, overall, women found their experience to be enjoyable and comparable to that in Aberdare.

The birth pool was installed at the end of May, and after this date, all women who wished to use the pool were able to, if time allowed (78% of respondents).  This shows the importance that women place on having access to a birth pool in labour.

The conclusion so far from the women’s views is that birth centre care is an important option, and this is more important than the actual final location. 

Birth Centre Midwives’ Views

Midwives had a pragmatic approach to the relocation of Tair Afon – having the birth centre located adjacent to the obstetric unit had required some adjustment to their working schedules, but they all agreed that this was balanced out by transfer during labour being much easier to accommodate.  All midwives had at one time or another had to wait for a prolonged period of time for availability of an ambulance to transfer a woman in labour from Aberdare, and this was both stressful and associated with elements of risk to mother and / or baby. 

Midwives also mentioned that some women found travel to PCH difficult overnight, and if for example, the woman had no transport to get home again, then she would require admission to the birth centre, when this was unnecessary.

Following discussion with the birth centre midwives, it is apparent that they concur with the views of the women – that it is important to be able to provide birth centre care to women, irrespective of where this is located.

Other Observations

During the six-month evaluation period, 51 admission assessments were carried out on women in the birth centre, where there was a query regarding the onset of labour, or whether the membranes had ruptured.  These were mostly carried out during the night, as the midwife was likely to see the women at home or in YCC during the day.  All these women were later discharged home to await events.

Consideration of lone worker issues means that midwives do not usually see women at home out of hours, unless they feel that it is safe to do so.  On some occasions, the on-call midwife will already be in the birth centre thus needing the woman to attend PCH.  The provision of a suitable facility to use out of hours in YCC would reduce travel for both midwives and mothers in most instances, however, current out-patient areas are not suitable for out-of-hours lone-worker use.

The number of transfers during labour is slightly higher in PCH, although this is a recognised occurrence where birth centres are located alongside obstetric facilities, attributable to the birth taking place before transfer is expedited, in a stand-alone birth centre.  Conversely, two women whose baby needed a paediatric review following birth were able to remain in Tair Afon PCH, as the paediatrician attended the birth centre and reviewed the baby.  These women would have required transfer, had the birth centre remained in Cynon Valley.

Eight women from the Merthyr Valley used the birth centre to facilitate a planned pool birth during the six month period.

Conclusions

The relocation of the birth centre to PCH has meant that the number of Cynon Valley women choosing this option has increased, and all women who responded in the questionnaire confirmed that the option of having a birth centre was important to them.

The location of the birth centre was of lesser importance than a birth centre per-se to most women, although views for both PCH and YCC were expressed.  Women disliked the travel to PCH, but this was balanced by the ease of transfer to obstetric care, should this be necessary.

The birth pool was an important issue for women, and most women wanted to use the pool during labour, if not for birth.

An area in Cynon Valley to asses women who are not in obvious labour would be beneficial for use out of hours, although this option would depend on the availability of the on-call midwife.

If all suitable women from the Merthyr Valley also used the birth centre, the numbers would greatly increase.

Recommendations

It is recommended that the executive board consider the evaluation presented above, when considering the final location for Tair Afon Birth Centre.

Dr. Liz Edwards

Senior Midwife