Big Birthas exists because of my frustrations with how data was presented to me in my pregnancies. It’s fair to say that I was even more frustrated when denied something despite a complete lack of data! So I’m delighted at this new UK data on diabetes in pregnancy and midwifery led care birthing outcomes. This will be hugely helpful for women and birthing people with gestational diabetes. Hopefully it will help to advocate for greater choice and access when planning their births. (For more information on the different options when planning birth, the NHS website has this helpful page).
Full disclosure, I was a member of the team for the UK Midwifery Study System who wrote the paper (UKMidSS). I am one of two lay representatives on the panel, and helped to review and edit the paper and summary.
UKMidSS meets 2-3 times per year and are actually recruiting for a new lay member, if you or someone you know might be interested! If so, please follow this link: https://forms.office.com/e/hjHUjSpff0
to find out more.
The Current Situation
Access to Midwifery Led Units (MLUs) has often denied to anyone but ‘low-risk’ pregnancies. But the trouble is that fewer and fewer pregnancies are conforming to a pretty narrow definition of ‘low-risk’ these days. Be it because of BMI, age, previous birth experience, medical history etc. not many people are actually ‘low’ risk!
Restricting access has various consequences. Personally, I would never have had my (wonderful!) home birth if I hadn’t been barred from using the MLU. It’s not something I regret, though! If I were pregnant again, knowing what my births were like, I’d plan a home birth at the outset. But at the time, it felt like I was stuck between a rock and a hard place… And frankly, when you’re pregnant, you want to be as comfy as possible!
(Luckily high BMI access is gradually improving, thanks in part to earlier research from the same team!).
Another consequence of the gatekeeping of Midwifery Unit access is that units are closing down due to lack of use… Yet, MLUs are associated with lower rates of intervention and greater maternal satisfaction. They’re very cost effective, with very similar outcomes for mum & baby compared with hospital births. I’m a firm believer that MLUs should be available for as many people as possible who want them, so hopefully this research will help to open the doors a little wider a little more often, and keep them open!
The Research
This study looked at what happens when women with diabetes – either gestational or preexisting – plan birth in MLUs in the UK.
Access to MLUs is usually restricted to pregnancies considered low-risk. That generally doesn’t include pregnancies with diabetes.
(I dislike the term ‘high risk’. The risk is very rarely ‘high’, it’s just marginally highER! I think it’s an unhelpful term, over-dramatises the situation, and clouds judgement)
A pre-study by the same team had already found that some MLUs were reporting births in pregnancies with diabetes… So the researchers decided to find out what happened. The big question was whether women with diabetes face more complications than women without diabetes when they have their babies in these units.
The study covered October 2021 to February 2023 and looked at over 56,000 women who planned birth in MLUs. Out of those, 420 women had diabetes, mostly gestational diabetes, detected during pregnancy and which usually goes away afterward. Most of the diabetes (84%) was recorded as being ‘diet controlled’, rather than requiring medication. This suggests that access was likely being granted to a subset of people with diabetes in pregnancy – those whose diabetes was not presenting major issues and were managing well.
The other major point to note was that almost all (411 out of 420) births were in Alongside Midwifery Units i.e. on the same site as a hospital with an Obstetric (doctor led) maternity unit. Only 9 were in Freestanding Maternity Units. This means there isn’t enough data to talk with confidence about outcomes of births planned in Freestanding Units.
Outcomes for Women/Birthing People
When the researchers compared the women with diabetes to those without, they found that those with diabetes weren’t more likely to experience serious problems, like needing a C-section, a blood transfusion, or a really bad tear. In fact, the numbers were pretty similar—about 18.7% of those with diabetes had some kind of complication compared to 20.7% of those without diabetes. (While the percentage is actually lower, the result is not ‘statistically significant’, meaning we can’t make any suggestions that it’s actually safer! It’s just broadly the same).
Outcomes for Babies
There were a few more babies born to women/birthing people with diabetes who needed extra care in the neonatal unit (3% vs 2%), but the difference was again ‘not statistically significant’ when you look at the numbers. And in terms of other things like whether the baby was healthy at birth (based on things like their Apgar score), there wasn’t much difference either.
Even more interesting was the association with breastfeeding. Almost 90% of the mums with diabetes in the study initiated breastfeeding, which is much higher than you would usually expect. This is especially significant when you consider many studies have shown breastfeeding rates are usually reduced in this group! Again, it makes you wonder (as I have mused before) about whether reported issues with breastfeeding would be better attributed to the circumstances and care offered, and less about ability or intention!
Whatever the reason, it’s great news because breastfeeding is well documented to be beneficial to mum and baby. It’s also associated with a reduced risk of type 2 diabetes longer term – which people who have had gestational diabetes are more likely to develop later in life.
The Conclusions
This is all pretty good news, and I really hope leads to greater access to MLUs for people with diabetes! There are a few caveats, however.
It’s important to remember that the women and birthing people who were granted access were clearly not representative of all cases of diabetes in pregnancy. They appear to have been a specially selected group for whom the midwives felt confident would be good candidates, because their diabetes was well-controlled, and most were not taking medication for it.
Secondly, almost all births took place in Alongside units – on the same site as a maternity suite with doctors. Presumably this helped the midwives to feel confident to grant access, knowing that they could transfer the mum and/or baby quickly for extra care if any complications arose. But the data shows their judgement was spot on!
What does this mean for me?
If you’re in similar circumstances – your diabetes is diet-controlled and well managed, and you’re looking to give birth in an Alongside Midwifery Unit – this is excellent evidence that your request should be considered, as your anticipated outcomes are likely to be pretty similar to anyone else’s! If you’re getting pushback from your care providers, it can often be helpful to discuss things in a bit more detail with a senior midwife.
Of course, plenty of people are very happy to give birth in a hospital setting! There is no right way or wrong way to give birth – it’s all about what works for you! Only you know what is likely to make you feel safe and secure and give you the best birth experience. And no one ever really knows what their birth experience will be until it’s over! Sometimes the best made plans are just that, plans, and plans can and do change. Previous birth experience is one of the best indicators of what will happen with the next, but nothing is guaranteed!
Good luck with whatever you decide to do, and remember – your body was made to do this!!
If you want to read the full study, it’s free to access on BMJ Open: