Survey of women's experiences of care in a new freestanding midwifery unit in an inner city area of London, England: 2. Specific aspects of care

What is 'physiological birth'? A scoping review of the perspectives of women and care providers

PROBLEM

Physiological birth was defined by the World Health Organization in 1997, however, clinical practices in childbirth have changed considerably since this time.

BACKGROUND

Ambiguous terms in healthcare such as 'physiological birth' may cause confusion amongst care providers and consumers.

AIM

To identify what is known about physiological birth, and how perceptions of physiological birth manifest in current literature.

METHODS

This review followed the Joanna Briggs Institute methodology for scoping reviews and the PRISMA-ScR checklist. Four databases were searched using keywords relating to physiological birth. Relevant studies were identified using agreed criteria, and data were extracted and synthesised.

RESULTS

A total of 24 studies met the inclusion criteria for this review. Three connected factors were identified: (1) Physiological birth in a risk-averse system, (2) Dominant voices in birth, and (3) Lack of exposure to physiological birth. No unified universal definition of physiological birth was identified in the literature.

DISCUSSION

'Physiological birth' as a term lacks consistency. A risk-averse healthcare system could be a barrier to physiological birth. Dominant voices in the birthing space can dictate the way birth occurs. Lack of exposure to physiological birth may diminish the acquisition and maintenance of important skills and knowledge among care providers. Recognising the factors important to women could lead to a positive birth experience.

CONCLUSION

Excluding a woman's subjective experience from health professionals' understanding of physiological birth increases the likelihood of risk management being the paramount objective in clinical decision-making. We propose it is timely to align clinical understanding of physiological birth with midwifery's woman-centred professional philosophy.

Midwife-led birthing centres in Bangladesh, Pakistan and Uganda: an economic evaluation of case study sites

INTRODUCTION

Achieving the Sustainable Development Goals to reduce maternal and neonatal mortality rates will require the expansion and strengthening of quality maternal health services. Midwife-led birth centres (MLBCs) are an alternative to hospital-based care for low-risk pregnancies where the lead professional at the time of birth is a trained midwife. These have been used in many countries to improve birth outcomes.

METHODS

The cost analysis used primary data collection from four MLBCs in Bangladesh, Pakistan and Uganda (n=12 MLBC sites). Modelled cost-effectiveness analysis was conducted to compare the incremental cost-effectiveness ratio (ICER), measured as incremental cost per disability-adjusted life-year (DALY) averted, of MLBCs to standard care in each country. Results were presented in 2022 US dollars.

RESULTS

Cost per birth in MLBCs varied greatly within and between countries, from US$21 per birth at site 3, Bangladesh to US$2374 at site 2, Uganda. Midwife salary and facility operation costs were the primary drivers of costs in most MLBCs. Six of the 12 MLBCs produced better health outcomes at a lower cost (dominated) compared with standard care; and three produced better health outcomes at a higher cost compared with standard care, with ICERs ranging from US$571/DALY averted to US$55 942/DALY averted.

CONCLUSION

MLBCs appear to be able to produce better health outcomes at lower cost or be highly cost-effective compared with standard care. Costs do vary across sites and settings, and so further exploration of costs and cost-effectiveness as a part of implementation and establishment activities should be a priority.

[Impact of hospital architecture on the birthing experience: a phenomenological study with mothers-to-be who are design experts]

BACKGROUND

The birthplace has a crucial role in shaping the childbirth experience and mothers' satisfaction levels. This study aimed to identify the experiences and perceptions that may have an impact in the long-term on mothers' birthing experience, considering hospital design features in the birthing environment until discharge.

METHODS

Inductive thematic analysis of twenty-five hospital labor testimonies employing a phenomenological research approach and utilizing a biographical method. Participants were women with a professional background in architecture, landscape architecture, engineering, or interior design.

RESULTS

The results are organized into four themes and seven subthemes. The first theme is "First sight and long term impression" which is subdivided into the subthemes "Depersonalized itinerary in entrances and corridors" and "Instinctive search for connection with nature". The second theme deals with "Accompaniment and tucking in during the birthing process", subdivided into "Hotel-like: space for movement and personalized adaptation" and "Helplessness, cold and uncertainty: spaces to be against one's will". The third theme is "Damage in collateral rooms", which includes "The integration of toilets in the birthing process", "Operating rooms unchangeable in the face of cesarean delivery" and "Neonatal units that do not integrate families". Finally, the fourth theme includes "Improvement proposals for new designs".

CONCLUSIONS

This study contributes to the existing literature by deepening the understanding of the design features identified in hospitals in recent studies. Further research incorporating the experiences of women in the birthing process is needed to facilitate evidence-based design policies.

Cooperation between midwives and doulas in the context of perinatal care - a integrative review of qualitative and quantitative studies

BACKGROUND

A doula is a person who provides support to women in the perinatal period without providing medical services. During childbirth, the doula becomes a member of the interdisciplinary team. This integrative review aims to analyse the nature of the cooperation between doulas and midwives, its efficiency and challenges and ways of strengthening this cooperation.

METHODS

A structured integrative review of empirical and theoretical studies written in English was conducted. The literature search included MEDLINE, Cochrane, Scopus, ProQuest, Science Direct, Web of Science, and Embase Health Source: Nursing/Academic Edition databases. The analysis included papers published in 1995-2020. Dedicated documents were searched for different combinations of terms and standard logical operators. A manual search of the studies was included for additional references.

RESULTS

Twenty-three articles from 75 full-text records were analysed. Three main themes emerged. (1) doulas are needed to prop up the system (2) barriers in collaboration between midwives and doulas; and (3) how cooperation between midwives and doulas can be strengthened. None of the articles referred directly to the impact of collaboration between midwives and doulas on the quality of perinatal care.

CONCLUSION

This is the first review to analyse the impact of collaboration between midwives and doulas on the quality of perinatal care. Ensuring adequate collaboration between doulas and midwives requires effort from both of these professional groups and the health care system. However, such collaboration is supportive for birthing women and the perinatal care system. Further research in terms of the impact of this collaboration on the quality of perinatal care is needed.

Implementing midwifery units in a European country: Situational analysis of an Italian case study

INTRODUCTION

Strong evidence recommends midwifery-led care for women with uncomplicated pregnancies. International research is now focusing on how to implement midwifery models of care in countries where they are not well established. In Europe, many countries like Italy are promoting midwifery-led care in national guidelines but often struggle to apply this change in practice.

METHODS

This study collected data on professional, organisational and service users' levels to conduct a situational analysis of an Italian service which is approaching the implementation of a midwifery unit. Participatory Action Research was used together with the support of the Consolidated Framework for Implementation Research to conduct data collection and analysis.

RESULTS

Forty-eight participants amongst professionals (midwives, obstetricians and neonatologists) and at organisational level (midwifery leaders and medical directors) were recruited; secondary data on service users' views was analysed via regional online surveys. Barriers and facilitators to the implementation were identified to assess the readiness of the local context.

CONCLUSIONS

This study is the first to include professionals, managers and service users in a European context such as Italy. Facilitators to the implementation of the alongside midwifery unit were found in national guidelines, allocated funding, collaborative engagement and medical support. Hierarchical structures, a prevalent medical model and lack of trust and awareness of the evidence of safety of midwifery-led models were main barriers.

Relationships and trust: Two key pillars of a well-functioning freestanding midwifery unit

BACKGROUND

Despite strong evidence supporting the expansion of midwife-led unit provision, as a result of optimal maternal and perinatal outcomes, cost-effectiveness, and positive service user and staff experiences, scaling-up has been slow. Systemic barriers associated with gender, professional, economic, cultural, and social factors continue to constrain the expansion of midwifery as a public health intervention globally. This article aimed to explore relationships and trust as key components of a well-functioning freestanding midwifery unit (FMU).

METHOD(S)

A critical realist ethnographic study of an FMU located in East London, England, was conducted over a period of 15 months. Recruitment of the 82 participants was purposive. Data collection included participant observation and semi-structured interviews, and data were analyzed thematically along with relevant local guidelines and documents.

RESULTS

Twelve themes emerged. Relationships and Trust were identified as a core theme. The other 11 themes were grouped into six families, three of which: Ownership, Autonomy, and Continuous Learning; Team Spirit, Interdependency, and Power Relations; and Salutogenesis will be covered in this paper. The remaining three families: Friendly Environment; Having Time and Mindfulness; and Social Capital, will be covered in a separate paper.

CONCLUSIONS

A relationship-based model of care was crucial for both the functioning of the FMU and service users' satisfaction and may offer a compelling response to high levels of stress and burnout among midwives.

Is directed open-glottis pushing more effective than directed closed-glottis pushing during the second stage of labor? A pragmatic randomized trial - the EOLE study

OBJECTIVE

To compare the effectiveness of directed open-glottis and directed closed-glottis pushing.

DESIGN

Pragmatic, randomised, controlled, non-blinded superiority study.

SETTINGS

Four French hospitals between July 2015 and June 2017 (2 academic hospitals and 2 general hospitals).

PARTICIPANTS

250 women in labour who had undergone standardised training in the two types of pushing with a singleton fetus in cephalic presentation at term (≥37 weeks) were included by midwives and randomised; 125 were allocated to each group. The exclusion criteria were previous caesarean birth or fetal heart rate anomaly. Participants were randomised during labour, after a cervical dilation ≥ 7 cm.

INTERVENTIONS

In the intervention group, open-glottis pushing was defined as a prolonged exhalation contracting the abdominal muscles (pulling the stomach in) to help move the fetus down the birth canal. Closed-glottis pushing was defined as Valsalva pushing.

MEASUREMENTS

The principal outcome was "effectiveness of pushing" defined as a spontaneous birth without any episiotomy, second-, third-, or fourth-degree perineal lesion. The results in our intention-to-treat analysis are reported as crude relative risks (RR) with their 95% confidence intervals. A multivariable analysis was used to take the relevant prognostic and confounding factors into account and obtain an adjusted relative risk (aRR).

FINDINGS

In our intention-to-treat analysis, most characteristics were similar across groups including epidural analgesia (>95% in each group). The mean duration of the expulsion phase was longer among the open-glottis group (24.4 min ± 17.4 vs. 18.0 min ± 15.0, p=0.002). The two groups did not appear to differ in the effectiveness of their pushing (48.0% in the open-glottis group versus 55.2% in the closed-glottis group, for an adjusted relative risk (aRR) of 0.92, 95% confidence interval (CI) 0.74-1.14) or in their risk of instrumental birth (aRR 0.97, 95%CI 0.85-1.10).

KEY CONCLUSIONS

In maternity units with a high rate of epidural analgesia, the effectiveness of the type of directed pushing does not appear to differ between the open- and closed-glottis groups.

IMPLICATIONS FOR PRACTICE

If directed pushing is necessary, women should be able to choose the type of directed pushing they prefer to use during birth. Professionals must therefore be trained in both types so that they can adequately support women as they give birth.

Cross-cultural validation and psychometrics' evaluation of women's experience of maternity care scale in French: the ESEM

BACKGROUND

Evaluating women's satisfaction should reflect the entire maternity care experience (antenatal, intrapartum and postnatal). The Women's Experience Maternity Care Scale (WEMCS) questionnaire enables this assessment. The purpose of this study was to translate in French, adapt and explore the psychometric properties of the WEMCS and to determine the best cut-off on the optimal satisfaction for the three scales.

METHODS

Backward, forward translation and cross-cultural adaptation were processed to validate the French version of WEMCS: Échelle de Satisfaction de l'Experience des soins en Maternité (ESEM). Psychometric tests assessed the questionnaire, which includes three scales, such as construct validity, internal consistency, Cronbach's alpha coefficients and ceiling and floor effects. A receiver operating characteristic (ROC) curve was used to determine the best cut-off values for optimal satisfaction. Reproducibility was verified by test-retest reliability.

RESULTS

Primiparas with uncomplicated pregnancies were recruited antenatally at the University Hospital of Geneva. Of the 229 patients who agreed to participate, 202 women (88.2%) returned the test and retest questionnaires. Principal component analysis for the antenatal, intrapartum and postnatal scales suggested the unidimensional character of the three scales; Cronbach's alpha coefficients were high for the three scales with values of > 0.85. Construct validity based on the five-point Likert scale values showed a Spearman's rho correlation of r = 0.56 for the antenatal scale (p < 0.001) and r = 0.62 for the intrapartum scale (p < 0.001), as well as a strong correlation with the postnatal scale, with r = 0.78 (p < 0.001). Optimum cut-off scores for the ROC curve of the antenatal, intrapartum and postnatal scores were equal to or higher than 48, 50 and 70, respectively. The three scales showed good sensitivity and good specificity. The stability of the ESEM questionnaire was confirmed by intra-class correlation coefficients of > 0.80. However, the three scales revealed ceiling effects.

CONCLUSION

The psychometric proprieties of the ESEM demonstrate it's ability to evaluate the quality of perinatal health care. The ESEM should be tested in the context of different models of women's care and with women with different degrees of pregnancy complications to explore the validity of this scale.

Freestanding Midwife-Led Units: A Narrative Review

Background

Strengthening of midwives' position and support for freestanding birth centers, frequently referred to as Freestanding Midwife-led Units (FMUs), raise hopes for a return to humanized labor. Our study aimed to review published evidence regarding FMUs to systematize the knowledge of their functioning and to identify potential gaps in this matter.

Materials and Methods

A structured integrative review of theoretical papers and empirical studies was conducted. The literature search included MEDLINE, Cochrane, Scopus, and Embase databases. The analysis included papers published in 1977-2017. Relevant documents were identified using various combinations of search terms and standard Boolean operators. The search included titles, abstracts, and keywords. Additional records were found through a manual search of reference lists from extracted papers.

Results

Overall, 56 out of 107 originally found articles were identified as eligible for the review. Based on the critical analysis of published data, six groups of research problems were identified and discussed, namely, 1) specifics of FMUs, 2) costs of perinatal care at FMUs, 3) FMUs as a place for midwife education, 4) FMUs from midwives' perspective, 5) perinatal, maternal, and neonatal outcomes, and 6) FMUs from the perspective of a pregnant woman.

Conclusions

FMUs offers a home-like environment and complex midwifery support for women with uncomplicated pregnancies. Although emergency equipment is available as needed, FMU birth is considered a natural spontaneous process. Midwives' supervision over low-risk labors may provide many benefits, primarily related to lower medicalization and fewer medical interventions than in a hospital setting.

Worldwide prevalence of mother-infant skin-to-skin contact after vaginal birth: A systematic review

BACKGROUND

Despite the World Health Organization's (WHO) recommendation for immediate skin-to-skin contact (SSC) after birth, separation of mothers and infants seems to be common practice in many hospitals. It is unknown how common the practice of SSC is worldwide. Therefore, we aimed to determine the reported prevalence of SSC for healthy mothers and infants immediately after normal birth.

METHODS

We systematically searched CINAHL, Medline, ProQuest Central, PubMed and the Cochrane Library for articles published between January 2007 and October 2017 using the keywords "kangaroo care" or "skin to skin contact" or "breastfeeding initiation" or "breast crawl" or "maternal infant contact" or "maternal newborn contact" or "baby friendly hospital initiative" or "ten steps for successful breastfeeding".

RESULTS

After an initial screening of 5266 records, 84 full text articles were assessed for eligibility, and 35 of these met the inclusion criteria. The studies were from 28 countries representing all six WHO world regions. There was a wide range in the practice of SSC for mother-infant dyads around the world: from 1% to 98%. Only 15 studies clearly defined SSC. Most of the studies were from high-income countries, and these reported higher rates of SSC than studies from low and middle-income countries.

CONCLUSION

There was a great heterogeneity in the definition of SSC as well as study designs, which makes cross-county comparison difficult. National studies reporting SSC rates are lacking. Future studies and guidelines to enhance SSC practice should include a standardised set of indicators and measurement tools that document SSC starting time and duration of SSC.

A systematic review of person-centered care interventions to improve quality of facility-based delivery

INTRODUCTION

We conducted a systematic review to summarize the global evidence on person-centered care (PCC) interventions in delivery facilities in order to: (1) map the PCC objectives of past interventions (2) to explore the impact of PCC objectives on PCC and clinical outcomes.

METHODS

We developed a search strategy based on a current definition of PCC. We searched for English-language, peer-reviewed and original research articles in multiple databases from 1990 to 2016 and conducted hand searches of the Cochrane library and gray literature. We used systematic review methodology that enabled us to extract and synthesize quantitative and qualitative data. We categorized interventions according to their primary and secondary PCC objectives. We categorized outcomes into person-centered and clinical (labor and delivery, perinatal, maternal mental health).

RESULTS

Our initial search strategy yielded 9378 abstracts; we conducted full-text reviews of 32 quantitative, 6 qualitative, 2 mixed-methods studies, and 7 systematic reviews (N = 47). Past interventions pursued these primary PCC objectives: autonomy, supportive care, social support, the health facility environment, and dignity. An intervention's primary and secondary PCC objectives frequently did not align with the measured person-centered outcomes. Generally, PCC interventions either improved or made no difference to person-centered outcomes. There was no clear relationship between PCC objectives and clinical outcomes.

CONCLUSIONS

This systematic review presents a comprehensive analysis of facility-based delivery interventions using a current definition of person-centered care. Current definitions of PCC propose new domains of inquiry but may leave out previous domains.

Care associated with stillbirth for the most disadvantaged women: A multi-method study of care in England

BACKGROUND

Most research on women experiencing stillbirth relies on online user group surveys or qualitative interviews. The objective of this study was to investigate the experience of women who are at a higher risk of stillbirth, living in areas of greatest deprivation, and are commonly not well represented.

METHODS

This study used birth and death registrations in 2012-2013 to identify a sample of mothers whose babies had died as a result of stillbirth. These women were sent a survey 6-9 months after the stillbirth. We undertook descriptive analysis of quantitative data and used binary logistic regression with the Index of Multiple Deprivation as a measure of disadvantage. We used thematic analysis to describe free text responses.

RESULTS

The survey response rate was 30% (N = 473). Ethnic minority, younger age, and single parenthood were associated with disadvantage. Women residents in the most deprived areas perceived care more negatively: during labor they were significantly less likely to be spoken to by medical staff so they could understand (73% compared with 90%, adjusted odds ratio [aOR] 0.33 [95% confidence interval {CI} 0.18-0.65]), or treated with respect by midwives (79% compared with 90%, aOR 0.41 [95% CI 0.22-0.77]). The qualitative themes identified were: "Difficulty in accessing care," "More could have been done," "Ineffective communication," and "Cared for and not cared for" which support the quantitative findings.

CONCLUSION

Women living in the most deprived areas reported poorer experiences of care compared with more advantaged women. All women need compassionate and sensitive care around the time of a stillbirth.

Exploring the Experiences and Perceptions of Women About Childbirth at Birthing Centers in Karachi, Pakistan

Objective:

The purpose of this study was to explore the perceptions of women about childbirth experiences at the birthing centers (BCs) in Karachi, Pakistan.

Design:

A qualitative descriptive exploratory approach was employed using semistructured interviews.

Participants:

A purposive sample of eight women who had used BCs was enrolled from each site.

Findings:

Five themes emerged from content analysis including: (a) satisfaction with BC, (b) provision of homely environment, (c) promotion of normalcy, (d) facilitation of family support, and (e) protection of privacy.

Key Conclusions:

Overall, the findings of the study revealed that women who used BCs were satisfied with the services and the environment provided to them by the midwives during the antenatal, intranatal, and postnatal periods. Most of the women appreciated the privacy offered at the BCs. They considered BCs as a safe, accessible, and affordable option for childbirth and encouraged others in the community to opt for it.

Implications for Practice:

The findings of this study may help to advocate for births at BCs and provide women-friendly maternity care, by giving choice and control to women during childbirth, providing comfort to women by using fewer medical interventions, and promoting normalcy by attending spontaneous vaginal delivery.

'Keeping birth normal': Exploratory evaluation of a training package for midwives in an inner-city, alongside midwifery unit

OBJECTIVES

to gain understanding about how participants perceived the value and effectiveness of 'Keeping Birth Normal' training, barriers to implementing it in an along-side midwifery unit, and how the training might be enhanced in future iterations.

DESIGN

exploratory interpretive.

SETTING

inner-city maternity service.

PARTICIPANTS

31 midwives attending a one-day training package on one of three occasions.

METHODS

data were collected using semi-structured observation of the training, a short feedback form (23/31 participants), and focus groups (28/31 participants). Feedback form data were analysed using summative content analysis, following which all data sets were pooled and thematically analysed using a template agreed by the researchers.

FINDINGS

We identified six themes contributing to the workshop's effectiveness as perceived by participants. Three related to the workshop design: (1) balanced content, (2) sharing stories and strategies and (3) 'less is more.' And three related to the workshop leaders: (4) inspiration and influence, (5) cultural safety and (6) managing expectations. Cultural focus on risk and low prioritisation of normal birth were identified as barriers to implementing evidence-based practice supporting normal birth. Building a community of practice and the role of consultant midwives were identified as potential opportunities.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

a review of evidence, local statistics and practical skills using active educational approaches was important to this training. Two factors not directly related to content appeared equally important: catalysing a community of practice and the perceived power of workshop leaders to influence organisational systems limiting the agency of individual midwives. Cyclic, interactive training involving consultant midwives, senior midwives and the multidisciplinary team may be recommended to be most effective.

Quality of care provided in two Scottish rural community maternity units: a retrospective case review

BACKGROUND

Women in Scotland with uncomplicated pregnancies are encouraged by professional bodies and national guidelines to access community based models of midwife-led care for their labour and birth. The evidence base for these guidelines relates to comparisons of predominantly urban birth settings in England. There appears to be little evidence available about the quality of the care during the antenatal, birth and post birth periods available for women within the Scottish Community Maternity Unit (CMU) model. The research aim was to explore the safety and effectiveness of the maternity services provided at two rural Community Maternity Units in Scotland, both 40 miles by main road access from a tertiary obstetric unit.

METHODS

Following appropriate NHS and University ethical approval, an anonymous retrospective review of consecutive maternity records for all women who accessed care at the CMUs over a 12 month period (June 2011 to May 2012) was undertaken in 2013 -14. Data was extracted using variables chosen to provide a description of the socio-demographics of the cohort and the process and outcomes of the care provided. Data were analysed using descriptive statistics.

RESULTS

Regarding effectiveness, the correct care pathway was allocated to 97.5% of women, early access to antenatal care achieved by 95.7% of women, 94.8% of women at one CMU received continuity of carer and 78.6% of those clinically eligible accessed care in labour. 11.9% were appropriately transferred to obstetrician-led care antenatally and 16.9% were transferred in labour. All women received one-to one care in labour and 67.1% of babies born at the CMUs were breastfed at birth. Regarding safety, severe morbidity for women was rare, perineal trauma of 3rd degree tear occurred for 0.3% of women and 1.0% experienced an episiotomy. Severe post partum haemorrhage occurred for 0.3% of women. Babies admitted to the Neonatal unit were discharged within 48 hrs.

CONCLUSION

These findings support the recommendations of professional bodies and national guidelines. Maternity service provision at rural CMUs achieved a consistently high standard of safety and effectiveness when measured against national standards and international evidence.

Are freestanding midwifery units a safe alternative to obstetric units for low-risk, primiparous childbirth? An analysis of effect differences by parity in a matched cohort study

Background

Intrapartum complications and the use of obstetric interventions are more common in primiparous childbirth than in multiparous childbirth, leading to concern about out of hospital birth for primiparous women. The purpose of this study was to determine whether the effect of birthplace on perinatal and maternal morbidity and the use of obstetric interventions differed by parity among low-risk women intending to give birth in a freestanding midwifery unit or in an obstetric unit in the North Denmark Region.

Methods

The study is a secondary analysis of data from a matched cohort study including 839 low-risk women intending birth in a freestanding midwifery unit (primary participants) and 839 low-risk women intending birth in an obstetric unit (individually matched control group). Analysis was by intention-to-treat. Conditional logistic regression analysis was applied to compute odds ratios and effect ratios with 95% confidence intervals for matched pairs stratified by parity.

Results

On no outcome did the effect of birthplace differ significantly between primiparous and multiparous women. Compared with their counterparts intending birth in an obstetric unit, both primiparous and multiparous women intending birth in a freestanding midwifery unit were significantly more likely to have an uncomplicated, spontaneous birth with good outcomes for mother and infant and less likely to require caesarean section, instrumental delivery, augmented labour or epidural analgesia (although for caesarean section this trend did not attain statistical significance for multiparous women). Perinatal outcomes were comparable between the two birth settings irrespective of parity. Compared to multiparas, transfer rates were substantially higher for primiparas, but fell over time while rates for multiparas remained stable.

Conclusions

Freestanding midwifery units appear to confer significant advantages over obstetric units to both primiparous and multiparous mothers, while their infants are equally safe in both settings. Our findings thus support the provision of care in freestanding midwifery units as an alternative to care in obstetric units for all low-risk women regardless of parity. In view of the global rise in caesarean section rates, we consider it an important finding that freestanding midwifery units show potential for reducing first-birth caesarean.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1208-1) contains supplementary material, which is available to authorized users.

The economic costs of intrapartum care in Tower Hamlets: A comparison between the cost of birth in a freestanding midwifery unit and hospital for women at low risk of obstetric complications

OBJECTIVE

to compare the economic costs of intrapartum maternity care in an inner city area for 'low risk' women opting to give birth in a freestanding midwifery unit compared with those who chose birth in hospital.

DESIGN

micro-costing of health service resources used in the intrapartum care of mothers and their babies during the period between admission and discharge, data extracted from clinical notes.

SETTING

the Barkantine Birth Centre, a freestanding midwifery unit and the Royal London Hospital's consultant-led obstetric unit, both run by the former Barts and the London NHS Trust in Tower Hamlets, a deprived inner city borough in east London, England, 2007-2010.

PARTICIPANTS

maternity records of 333 women who were resident in Tower Hamlets and who satisfied the Trust's eligibility criteria for using the Birth Centre. Of these, 167 women started their intrapartum care at the Birth Centre and 166 started care at the Royal London Hospital.

MEASUREMENTS AND FINDINGS

women who planned their birth at the Birth Centre experienced continuous intrapartum midwifery care, higher rates of spontaneous vaginal delivery, greater use of a birth pool, lower rates of epidural use, higher rates of established breastfeeding and a longer post-natal stay, compared with those who planned for care in the hospital. The total average cost per mother-baby dyad for care where mothers started their intrapartum care at the Birth Centre was £1296.23, approximately £850 per patient less than the average cost per mother and baby who received all their care at the Royal London Hospital. These costs reflect intrapartum throughput using bottom up costing per patient, from admission to discharge, including transfer, but excluding occupancy rates and the related running costs of the units.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

the study showed that intrapartum throughput in the Birth Centre could be considered cost-minimising when compared to hospital. Modelling the financial viability of midwifery units at a local level is important because it can inform the appropriate provision of these services. This finding from this study contribute a local perspective and thus further weight to the evidence from the Birthplace Programme in support of freestanding midwifery unit care for women without obstetric complications.

Women's experience of intrapartum transfer from a Western Australian birth centre co-located to a tertiary maternity hospital

BACKGROUND

The aim of this Western Australian study was to describe the overall labour and birth experience of women who were transferred during the first and second stages of labour from a low risk woman-centred, midwifery-led birth centre to a co-located tertiary maternity referral hospital.

METHODS

Using a descriptive phenomenological design, fifteen women were interviewed up to 8 weeks post birth (July to October, 2013) to explore their experience of the intrapartum transfer. Giorgi's method of analysis was used.

RESULTS

The following themes and subthemes emerged: 1) The midwife's voice with subthemes, a) The calming effect and b) Speaking up on my behalf; 2) In the zone with subthemes, a) Hanging in there and b) Post birth rationalizing; 3) Best of both worlds with subthemes a) The feeling of relief on transfer to tertiary birth suite and b) Returning back to the comfort and familiarity of the birth centre; 4) Lost sense of self; and 5) Lost birth dream with subthemes a) Narrowing of options and b) Feeling of panic. Women found the midwife's voice guided them through the transfer experience and were appreciative of continuity of care. There was a sense of disruption to expectations and disappointment in not achieving the labour and birth they had anticipated. There was however appreciation that the referral facility was nearby and experts were close at hand. The focus of care altered from woman to fetus, making women feel diminished. Women were glad to return to the familiar birth centre after the birth with the opportunity to talk through and fully understand their labour journey which helped them contextualise the transfer as one part of the whole experience.

CONCLUSIONS

Findings can inform midwives of the value of a continuity of care model within a birth centre, allowing women both familiarity and peace of mind. Maternity care providers should ensure that the woman remains the focus of care after transfer and understand the significance of effective communication to ensure women are included in all care discussions.

Survey of women's experiences of care in a new freestanding midwifery unit in an inner city area of London, England. 1: Methods and women's overall ratings of care

OBJECTIVE

to describe and compare women's choices and experiences of maternity care before and after the opening of the Barkantine Birth Centre, a new freestanding midwifery unit in an inner city area.

DESIGN

telephone surveys undertaken in late pregnancy and about six weeks after birth in two separate time periods, Phase 1 before the birth centre opened and Phase 2 after it had opened.

SETTING

Tower Hamlets, a deprived inner city borough in east London, England, 2007-2010.

PARTICIPANTS

620 women who were resident in Tower Hamlets and who satisfied the Barts and the London NHS Trust's eligibility criteria for using the birth centre. Of these, 259 women were recruited to Phase 1 and 361 to Phase 2.

MEASUREMENTS AND FINDINGS

women who satisfied the criteria for birth centre care and who booked antenatally for care at the birth centre were significantly more likely to rate their care as good or very good overall than corresponding women who also satisfied these criteria but booked initially at the hospital. Women who started labour care in spontaneous labour at the birth centre were significantly more likely to be cared for by a midwife they had already met, have one to one care in labour and have the same midwife with them throughout their labour. They were also significantly more likely to report that the staff were kind and understanding, that they were treated with respect and dignity and that their privacy was respected.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

this survey in an inner city area showed that women who chose the freestanding midwifery unit care had positive experiences to report. Taken together with the findings of the Birthplace Programme, it adds further weight to the evidence in support of freestanding midwifery unit care for women without obstetric complications.