Is the operative delivery rate in low-risk women dependent on the level of birth care? A randomised controlled trial

Midwife continuity of care models versus other models of care for childbearing women

BACKGROUND

Midwives are primary providers of care for childbearing women globally and there is a need to establish whether there are differences in effectiveness between midwife continuity of care models and other models of care. This is an update of a review published in 2016.

OBJECTIVES

To compare the effects of midwife continuity of care models with other models of care for childbearing women and their infants.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Trials Register, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) (17 August 2022), as well as the reference lists of retrieved studies.

SELECTION CRITERIA

All published and unpublished trials in which pregnant women are randomly allocated to midwife continuity of care models or other models of care during pregnancy and birth.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion criteria, scientific integrity, and risk of bias, and carried out data extraction and entry. Primary outcomes were spontaneous vaginal birth, caesarean section, regional anaesthesia, intact perineum, fetal loss after 24 weeks gestation, preterm birth, and neonatal death. We used GRADE to rate the certainty of evidence.

MAIN RESULTS

We included 17 studies involving 18,533 randomised women. We assessed all studies as being at low risk of scientific integrity/trustworthiness concerns. Studies were conducted in Australia, Canada, China, Ireland, and the United Kingdom. The majority of the included studies did not include women at high risk of complications. There are three ongoing studies targeting disadvantaged women. Primary outcomes Based on control group risks observed in the studies, midwife continuity of care models, as compared to other models of care, likely increase spontaneous vaginal birth from 66% to 70% (risk ratio (RR) 1.05, 95% confidence interval (CI) 1.03 to 1.07; 15 studies, 17,864 participants; moderate-certainty evidence), likelyreduce caesarean sections from 16% to 15% (RR 0.91, 95% CI 0.84 to 0.99; 16 studies, 18,037 participants; moderate-certainty evidence), and likely result in little to no difference in intact perineum (29% in other care models and 31% in midwife continuity of care models, average RR 1.05, 95% CI 0.98 to 1.12; 12 studies, 14,268 participants; moderate-certainty evidence). There may belittle or no difference in preterm birth (< 37 weeks) (6% under both care models, average RR 0.95, 95% CI 0.78 to 1.16; 10 studies, 13,850 participants; low-certainty evidence). We arevery uncertain about the effect of midwife continuity of care models on regional analgesia (average RR 0.85, 95% CI 0.79 to 0.92; 15 studies, 17,754 participants, very low-certainty evidence), fetal loss at or after 24 weeks gestation (average RR 1.24, 95% CI 0.73 to 2.13; 12 studies, 16,122 participants; very low-certainty evidence), and neonatal death (average RR 0.85, 95% CI 0.43 to 1.71; 10 studies, 14,718 participants; very low-certainty evidence). Secondary outcomes When compared to other models of care, midwife continuity of care models likely reduce instrumental vaginal birth (forceps/vacuum) from 14% to 13% (average RR 0.89, 95% CI 0.83 to 0.96; 14 studies, 17,769 participants; moderate-certainty evidence), and may reduceepisiotomy 23% to 19% (average RR 0.83, 95% CI 0.77 to 0.91; 15 studies, 17,839 participants; low-certainty evidence). When compared to other models of care, midwife continuity of care models likelyresult in little to no difference inpostpartum haemorrhage (average RR 0.92, 95% CI 0.82 to 1.03; 11 studies, 14,407 participants; moderate-certainty evidence) and admission to special care nursery/neonatal intensive care unit (average RR 0.89, 95% CI 0.77 to 1.03; 13 studies, 16,260 participants; moderate-certainty evidence). There may be little or no difference in induction of labour (average RR 0.92, 95% CI 0.85 to 1.00; 14 studies, 17,666 participants; low-certainty evidence), breastfeeding initiation (average RR 1.06, 95% CI 1.00 to 1.12; 8 studies, 8575 participants; low-certainty evidence), and birth weight less than 2500 g (average RR 0.92, 95% CI 0.79 to 1.08; 9 studies, 12,420 participants; low-certainty evidence). We are very uncertain about the effect of midwife continuity of care models compared to other models of care onthird or fourth-degree tear (average RR 1.10, 95% CI 0.81 to 1.49; 7 studies, 9437 participants; very low-certainty evidence), maternal readmission within 28 days (average RR 1.52, 95% CI 0.78 to 2.96; 1 study, 1195 participants; very low-certainty evidence), attendance at birth by a known midwife (average RR 9.13, 95% CI 5.87 to 14.21; 11 studies, 9273 participants; very low-certainty evidence), Apgar score less than or equal to seven at five minutes (average RR 0.95, 95% CI 0.72 to 1.24; 13 studies, 12,806 participants; very low-certainty evidence) andfetal loss before 24 weeks gestation (average RR 0.82, 95% CI 0.67 to 1.01; 12 studies, 15,913 participants; very low-certainty evidence). No maternal deaths were reported across three studies. Although the observed risk of adverse events was similar between midwifery continuity of care models and other models, our confidence in the findings was limited. Our confidence in the findings was lowered by possible risks of bias, inconsistency, and imprecision of some estimates. There were no available data for the outcomes: maternal health status, neonatal readmission within 28 days, infant health status, and birth weight of 4000 g or more. Maternal experiences and cost implications are described narratively. Women receiving care from midwife continuity of care models, as opposed to other care models, generally reported more positive experiences during pregnancy, labour, and postpartum. Cost savings were noted in the antenatal and intrapartum periods in midwife continuity of care models.

AUTHORS' CONCLUSIONS

Women receiving midwife continuity of care models were less likely to experience a caesarean section and instrumental birth, and may be less likely to experience episiotomy. They were more likely to experience spontaneous vaginal birth and report a positive experience. The certainty of some findings varies due to possible risks of bias, inconsistencies, and imprecision of some estimates. Future research should focus on the impact on women with social risk factors, and those at higher risk of complications, and implementation and scaling up of midwife continuity of care models, with emphasis on low- and middle-income countries.

Model of care and chance of spontaneous vaginal birth: a prospective, multicenter matched-pair analysis from North Rhine-Westphalia

Background

Advantages of midwife-led models of care have been reported; these include a higher vaginal birth rate and less interventions. In Germany, 98.4% of women are giving birth in obstetrician-led units. We compared the outcome of birth planned in alongside midwifery units (AMU) with a matched group of low-risk women who gave birth in obstetrician-led units.

Methods

A prospective, controlled, multicenter study was conducted. Six of seven AMUs in North Rhine-Westphalia participated. Healthy women with a singleton term cephalic pregnancy booking for birth in AMU were eligible. For each woman in the study group a control was chosen who would have been eligible for birth in AMU but was booking for obstetrician-led care; matching for parity was performed.

Mode of birth was chosen as primary outcome parameter. Secondary endpoints included a composite outcome of adverse outcome in the third stage and / or postpartum hemorrhage; higher-order obstetric lacerations; and for the neonate, a composite outcome (5-min Apgar < 7 and / or umbilical cord arterial pH < 7.10 and / or transfer to specialist neonatal care). Statistical analysis was by intention to treat. A non-inferiority analysis was performed.

Results

Five hundred eighty-nine case-control pairs were recruited, final analysis was performed with 391 case-control pairs. Nulliparous women constituted 56.0% of cases. For the primary endpoint vaginal birth superiority was established for the study group (5.66%, 95%-CI 0.42% – 10.88%). For the composite newborn outcome (1.28%, 95%-CI -1.86% - -4.47%) and for higher-order obstetric lacerations (2.33%, 95%-CI -0.45% - 5.37%) non-inferiority was established. Non-inferiority was not present for the composite maternal outcome (-1.56%, 95%-CI -6.69% - 3.57%). The epidural anesthesia rate was lower (22.9% vs. 41.1%), and the length of hospital stay was shorter in the study group (p < 0.001 for both).

Transfer to obstetrician-led care occurred in 51.2% of cases, with a strong association to parity (p < 0.001). Request for regional anesthesia was the most common cause for transfer (47.1%).

Conclusion

Our comparison between care in AMU and obstetrician-led care with respect to mode of birth and other outcomes confirmed the superiority of this model of care for low-risk women. This pertains to AMU where admission and transfer criteria are in place and adhered to.

Centralisation of acute obstetric care in the Netherlands: a qualitative study to explore the experiences of stakeholders with adaptations in organisation of care

Background

In the past decade, acute obstetric care (AOC) has become centralised in many high-income countries. In this qualitative study, we explored how stakeholders in maternity care perceived and experienced adaptations in the organisation of maternity care in areas in the Netherlands where AOC was centralised.

Methods

A heterogenic group of fifteen maternity care stakeholders, including patients, were purposively selected for semi-structured interviews. An inductive thematic analysis was used.

Results

Three main themes were identified: (1) lack of involvement. (2) the process of making adaptations in the organisation of maternity care. (3) maintaining quality of care. Stakeholders in this study were highly motivated to maintain a high quality of maternity care and therefore made adaptations at several organisational levels. However, they felt a lack of involvement during the planning of centralisation of AOC and highlighted the importance of a collaborative process when making adaptations after centralisation of AOC.

Conclusions

Regions with AOC centralisation plans should invest time and money in change management, encourage early involvement of all maternity care stakeholders and acknowledge centralisation of AOC as a professional life event with associated emotions, including a feeling of unsafety.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07269-4.

Midwives' experiences of using the Obstetric Norwegian Early Warning System (ONEWS): A national cross-sectional study

INTRODUCTION

Increasing numbers of maternity units are implementing routine and standardized monitoring of all women using a form of Early Warning Score System with the aim to early detect women at risk of developing critical illness or a deterioration of their condition. The implementation in Norway is relatively new. This study aimed to describe Norwegian midwives' experiences with the Obstetric Norwegian Early Warning System (ONEWS).

METHODS

We performed a cross-sectional study based on an electronic questionnaire, sent to heads of midwifery at all maternity units in Norway for distribution to their clinically active midwives. Thirty-one of 48 units had implemented ONEWS for over a month. About 1020 midwives received the questionnaire, 232 (23%) responded.

RESULTS

Of the participants, 217 (93.5%) reported receiving sufficient training and 230 (99.1%) reported using the same scoring system, including the same vital parameters measured. The criteria for use of ONEWS varied between units regarding inclusion criteria and frequency of scoring. A total of 214 (92.2%) midwives agreed that ONEWS has value in the surveillance of high-risk women, while 152 (65.5%) agreed that ONEWS contributes to medicalization of the care of low-risk women. Some 166 (71.6%) midwives reported that ONEWS was time consuming and 159 (68.5%) that the measures need to be better adapted to childbearing women.

CONCLUSIONS

Maternity units in Norway implementing ONEWS use an almost identical scoring system but varying criteria for whom to score and how often. Midwives considered ONEWS particularly suited for high-risk women and not for low-risk childbearing women.

The "Cocoon," first alongside midwifery-led unit within a Belgian hospital: Comparison of the maternal and neonatal outcomes with the standard obstetric unit over 2 years

OBJECTIVES

Our aim was to compare maternal and neonatal outcomes of women with a low-risk pregnancy attending the "Cocoon," an alongside midwifery-led birth center and care pathway, with women with a low-risk pregnancy attending the traditional care pathway in a tertiary care hospital in Belgium.

METHODS

We performed a retrospective cohort study of maternal and neonatal outcomes of women with a low-risk pregnancy who chose to adhere to the Cocoon pathway of care (n = 590) and women with a low-risk pregnancy who chose the traditional pathway of care (n = 394) from March 1, 2014, to February 29, 2016. We performed all analyses using an intention-to-treat approach.

RESULTS

In this setting, the cesarean birth rate was 10.3% compared with 16.0% in the traditional care pathway (adjusted odds ratios [aOR] 0.42 [95% CI 0.25-0.69]), the induction rate was 16.3% compared with 30.5% (0.46 [0.30-0.69]), the epidural analgesia rate was 24.9% compared with 59.1% (0.15 [0.09-0.22]), and the episiotomy rate was 6.8% compared with 14.5% (0.31 [0.17-0.56]). There was no increase in adverse neonatal outcomes. Intrapartum and postpartum transfer rates to the traditional pathway of care were 21.1% and 7.1%, respectively.

CONCLUSIONS

Women planning their births in the midwifery-led unit, the Cocoon, experienced fewer interventions with no increase in adverse neonatal outcomes. Our study gives initial support for the introduction of similar midwifery-led care pathways in other hospitals in Belgium.

Factors influencing utilisation of ‘free-standing’ and ‘alongside’ midwifery units for low-risk births in England: a mixed-methods study

Background

Midwifery-led units (MUs) are recommended for ‘low-risk’ births by the National Institute for Health and Care Excellence but according to the National Audit Office were not available in one-quarter of trusts in England in 2013 and, when available, were used by only a minority of the low-risk women for whom they should be suitable. This study explores why.

Objectives

To map the provision of MUs in England and explore barriers to and facilitators of their development and use; and to ascertain stakeholder views of interventions to address these barriers and facilitators.

Design

Mixed methods – first, MU access and utilisation across England was mapped; second, local media coverage of the closure of free-standing midwifery units (FMUs) were analysed; third, case studies were undertaken in six sites to explore the barriers and facilitators that have an impact on the development of MUs; and, fourth, by convening a stakeholder workshop, interventions to address the barriers and facilitators were discussed.

Setting

English NHS maternity services.

Participants

All trusts with maternity services.

Interventions

Establishing MUs.

Main outcome measures

Numbers and types of MUs and utilisation of MUs.

Results

Births in MUs across England have nearly tripled since 2011, to 15% of all births. However, this increase has occurred almost exclusively in alongside units, numbers of which have doubled. Births in FMUs have stayed the same and these units are more susceptible to closure. One-quarter of trusts in England have no MUs; in those that do, nearly all MUs are underutilised. The study findings indicate that most trust managers, senior midwifery managers and obstetricians do not regard their MU provision as being as important as their obstetric-led unit provision and therefore it does not get embedded as an equal and parallel component in the trust’s overall maternity package of care. The analysis illuminates how provision and utilisation are influenced by a complex range of factors, including the medicalisation of childbirth, financial constraints and institutional norms protecting the status quo.

Limitations

When undertaking the case studies, we were unable to achieve representativeness across social class in the women’s focus groups and struggled to recruit finance directors for individual interviews. This may affect the transferability of our findings.

Conclusions

Although there has been an increase in the numbers and utilisation of MUs since 2011, significant obstacles remain to MUs reaching their full potential, especially FMUs. This includes the capacity and willingness of providers to address women’s information needs. If these remain unaddressed at commissioner and provider level, childbearing women’s access to MUs will continue to be restricted.

Future work

Work is needed on optimum approaches to improve decision-makers’ understanding and use of clinical and economic evidence in service design. Increasing women’s access to information about MUs requires further studies of professionals’ understanding and communication of evidence. The role of FMUs in the context of rural populations needs further evaluation to take into account user and community impact.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 12. See the NIHR Journals Library website for further project information.

Factors associated with low Apgar in newborns in birth center

OBJECTIVE

to analyze factors associated with Apgar of 5 minutes less than 7 of newborns of women selected for care at the Center for Normal Birth (ANC).

METHOD

a descriptive cross-sectional study with data from 9,135 newborns collected between July 2001 and December 2012. The analysis used absolute and relative frequency frequencies and bivariate analysis using Pearson's chi-square test or the exact Fisher.

RESULTS

fifty-three newborns (0.6%) had Apgar less than 7 in the 5th minute. The multivariate analysis found a positive association between low Apgar and gestational age less than 37 weeks, gestational pathologies and intercurrences in labor. The presence of the companion was a protective factor.

CONCLUSION

the Normal Birth Center is a viable option for newborns of low risk women as long as the protocol for screening low-risk women is followed.

Maternal and perinatal outcomes by planned place of birth in Australia 2000 - 2012: a linked population data study

OBJECTIVE

To compare perinatal and maternal outcomes for Australian women with uncomplicated pregnancies according to planned place of birth, that is, in hospital labour wards, birth centres or at home.

DESIGN

A population-based retrospective design, linking and analysing routinely collected electronic data. Analysis comprised χ² tests and binary logistic regression for categorical data, yielding adjusted ORs. Continuous data were analysed using analysis of variance.

SETTING

All eight Australian states and territories.

PARTICIPANTS

Women with uncomplicated pregnancies who gave birth between 2000 and 2012 to a singleton baby in cephalic presentation at between 37 and 41 completed weeks' gestation. Of the 1 251 420 births, 1 171 703 (93.6%) were planned in hospital labour wards, 71 505 (5.7%) in birth centres and 8212 (0.7%) at home.

MAIN OUTCOME MEASURES

Mode of birth, normal labour and birth, interventions and procedures during labour and birth, maternal complications, admission to special care/high dependency or intensive care units (mother or infant) and perinatal mortality (intrapartum stillbirth and neonatal death).

RESULTS

Compared with planned hospital births, the odds of normal labour and birth were over twice as high in planned birth centre births (adjusted OR (AOR) 2.72; 99% CI 2.63 to 2.81) and nearly six times as high in planned home births (AOR 5.91; 99% CI 5.15 to 6.78). There were no statistically significant differences in the proportion of intrapartum stillbirths, early or late neonatal deaths between the three planned places of birth.

CONCLUSIONS

This is the first Australia-wide study to examine outcomes by planned place of birth. For healthy women in Australia having an uncomplicated pregnancy, planned births in birth centres or at home are associated with positive maternal outcomes although the number of homebirths was small overall. There were no significant differences in the perinatal mortality rate, although the absolute numbers of deaths were very small and therefore firm conclusions cannot be drawn about perinatal mortality outcomes.

Through the resident lens: examining knowledge and attitudes about midwifery among physician trainees

Interprofessional collaboration optimizes maternal-newborn outcomes and satisfaction with care. Since 2002, midwives have provided an increasing proportion of maternity care in British Columbia (BC). Midwives often collaborate with and/or refer to physicians; but no study to date has explored Canadian medical trainees' exposure to, knowledge of, and attitudes towards midwifery practice. We designed an online cross-sectional questionnaire that included a scale to measure attitudes towards midwifery (13 items) and residents' knowledge of midwifery (94 items across 5 domains). A multi-disciplinary expert panel rated each item for importance, relevance, and clarity. The survey was distributed to family medicine (n = 338) and obstetric (n = 40) residents in BC. We analyzed responses from 114 residents. Residents with more favourable exposures to midwifery during their education had significantly more positive attitudes towards midwives (rs = 0.32, p = 0.007). We also found a significant positive correlation between residents' attitudes towards midwifery and four of five knowledge domains: scope of practice (rs = 0.41, p < 0.001); content of education (rs = 0.30, p = 0.002), equipment midwives carry to home births (rs = 0.30, p = 0.004) and tests that midwives can order (rs = 0.39, p < 0.001). The most unfavourable exposures were observing interprofessional conversations (66.2%), and providing inpatient consultations for midwives (61.4%). Findings suggest increased interprofessional education may foster improved midwife-physician collaboration. Abbreviations: BC - British Columbia; UBC - University of British Columbia.

Non-clinical interventions for reducing unnecessary caesarean section

BACKGROUND

Caesarean section rates are increasing globally. The factors contributing to this increase are complex, and identifying interventions to address them is challenging. Non-clinical interventions are applied independently of a clinical encounter between a health provider and a patient. Such interventions may target women, health professionals or organisations. They address the determinants of caesarean births and could have a role in reducing unnecessary caesarean sections. This review was first published in 2011. This review update will inform a new WHO guideline, and the scope of the update was informed by WHO's Guideline Development Group for this guideline.

OBJECTIVES

To evaluate the effectiveness and safety of non-clinical interventions intended to reduce unnecessary caesarean section.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers in March 2018. We also searched websites of relevant organisations and reference lists of related reviews.

SELECTION CRITERIA

Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series studies and repeated measures studies were eligible for inclusion. The primary outcome measures were: caesarean section, spontaneous vaginal birth and instrumental birth.

DATA COLLECTION AND ANALYSIS

We followed standard methodological procedures recommended by Cochrane. We narratively described results of individual studies (drawing summarised evidence from single studies assessing distinct interventions).

MAIN RESULTS

We included 29 studies in this review (19 randomised trials, 1 controlled before-after study and 9 interrupted time series studies). Most of the studies (20 studies) were conducted in high-income countries and none took place in low-income countries. The studies enrolled a mixed population of pregnant women, including nulliparous women, multiparous women, women with a fear of childbirth, women with high levels of anxiety and women having undergone a previous caesarean section.Overall, we found low-, moderate- or high-certainty evidence that the following interventions have a beneficial effect on at least one primary outcome measure and no moderate- or high-certainty evidence of adverse effects.Interventions targeted at women or familiesChildbirth training workshops for mothers alone may reduce caesarean section (risk ratio (RR) 0.55, 95% confidence interval (CI) 0.33 to 0.89) and may increase spontaneous vaginal birth (RR 2.25, 95% CI 1.16 to 4.36). Childbirth training workshops for couples may reduce caesarean section (RR 0.59, 95% CI 0.37 to 0.94) and may increase spontaneous vaginal birth (RR 2.13, 95% CI 1.09 to 4.16). We judged this one study with 60 participants to have low-certainty evidence for the outcomes above.Nurse-led applied relaxation training programmes (RR 0.22, 95% CI 0.11 to 0.43; 104 participants, low-certainty evidence) and psychosocial couple-based prevention programmes (RR 0.53, 95% CI 0.32 to 0.90; 147 participants, low-certainty evidence) may reduce caesarean section. Psychoeducation may increase spontaneous vaginal birth (RR 1.33, 95% CI 1.11 to 1.61; 371 participants, low-certainty evidence). The control group received routine maternity care in all studies.There were insufficient data on the effect of the four interventions on maternal and neonatal mortality or morbidity.Interventions targeted at healthcare professionalsImplementation of clinical practice guidelines combined with mandatory second opinion for caesarean section indication slightly reduces the risk of overall caesarean section (mean difference in rate change -1.9%, 95% CI -3.8 to -0.1; 149,223 participants). Implementation of clinical practice guidelines combined with audit and feedback also slightly reduces the risk of caesarean section (risk difference (RD) -1.8%, 95% CI -3.8 to -0.2; 105,351 participants). Physician education by local opinion leader (obstetrician-gynaecologist) reduced the risk of elective caesarean section to 53.7% from 66.8% (opinion leader education: 53.7%, 95% CI 46.5 to 61.0%; control: 66.8%, 95% CI 61.7 to 72.0%; 2496 participants). Healthcare professionals in the control groups received routine care in the studies. There was little or no difference in maternal and neonatal mortality or morbidity between study groups. We judged the certainty of evidence to be high.Interventions targeted at healthcare organisations or facilitiesCollaborative midwifery-labourist care (in which the obstetrician provides in-house labour and delivery coverage, 24 hours a day, without competing clinical duties), versus a private practice model of care, may reduce the primary caesarean section rate. In one interrupted time series study, the caesarean section rate decreased by 7% in the year after the intervention, and by 1.7% per year thereafter (1722 participants); the vaginal birth rate after caesarean section increased from 13.3% before to 22.4% after the intervention (684 participants). Maternal and neonatal mortality were not reported. We judged the certainty of evidence to be low.We studied the following interventions, and they either made little or no difference to caesarean section rates or had uncertain effects.Moderate-certainty evidence suggests little or no difference in caesarean section rates between usual care and: antenatal education programmes for physiologic childbirth; antenatal education on natural childbirth preparation with training in breathing and relaxation techniques; computer-based decision aids; individualised prenatal education and support programmes (versus written information in pamphlet).Low-certainty evidence suggests little or no difference in caesarean section rates between usual care and: psychoeducation; pelvic floor muscle training exercises with telephone follow-up (versus pelvic floor muscle training without telephone follow-up); intensive group therapy (cognitive behavioural therapy and childbirth psychotherapy); education of public health nurses on childbirth classes; role play (versus standard education using lectures); interactive decision aids (versus educational brochures); labourist model of obstetric care (versus traditional model of obstetric care).We are very uncertain as to the effect of other interventions identified on caesarean section rates as the certainty of the evidence is very low.

AUTHORS' CONCLUSIONS

We evaluated a wide range of non-clinical interventions to reduce unnecessary caesarean section, mostly in high-income settings. Few interventions with moderate- or high-certainty evidence, mainly targeting healthcare professionals (implementation of guidelines combined with mandatory second opinion, implementation of guidelines combined with audit and feedback, physician education by local opinion leader) have been shown to safely reduce caesarean section rates. There are uncertainties in existing evidence related to very-low or low-certainty evidence, applicability of interventions and lack of studies, particularly around interventions targeted at women or families and healthcare organisations or facilities.

Comparison of midwife-led care and obstetrician-led care on maternal and neonatal outcomes in Singapore: A retrospective cohort study

OBJECTIVES

to examine the maternal and neonatal outcomes of low-risk women receiving midwife-led care and obstetrician-led care. DESIGN, SETTING,&PARTICIPANTS: a retrospective cohort study design was used. Data were collected from a large tertiary maternity hospital in Singapore. This involved a medical record review of 368 women who had singleton, normal to low-risk, term pregnancy, and received midwife-led care and obstetrician-led care between 2013 to 2014.

MEASUREMENTS

a data extraction tool was used to solicit information on the outcome measures, including duration of labour, mode of delivery, episiotomy, and 5-minutes Apgar score (<7). Descriptive statistics were used to summarise the women's 'characteristics. χ² and independent sample t-test were used to assess the differences in demographics and birth outcomes. Multiple linear and logistic regressions were used to examine the difference between the two comparison groups after adjusted for potential confounders.

FINDINGS

statistically significant differences (p<0.05) between the midwife-led care group and the obstetrician-led care group in terms of the total duration of labour and total antenatal visits were found. No statistically significant differences were observed for mode of delivery, episiotomy, intrapartum pain management, labour augmentation, labour induction, postpartum haemorrhage, perineal trauma, birth status, 5-minutes Apgar score (<7), low birth weight (<2500g), and neonatal admission to intensive care units between the midwife-led care group and the obstetrician-led care group.

KEY CONCLUSIONS

while interventions such as episiotomies and labour augmentation were more common in the midwife-led care group, no significant differences were found for most of the outcome measures between the two maternity groups except for total antenatal visits and duration of labour. Findings suggest that midwife-led care is as safe and effective as obstetrician-led care in achieving optimal birth outcomes, with no higher risk of adversities for low-risk women. Additional studies are necessary to continuously evaluate midwife-led care and to promote normal birth and reduce excessive use of obstetric procedures.

IMPLICATIONS FOR PRACTICE

the provision of midwife-led care should continue to be extended as an additional choice in maternity care for women with low-risk pregnancies. Professional staff development with continuous education is needed to clear misconceptions about midwife-led care and to promote awareness in current practice guidelines. Prospective evaluation of midwife-led care will be beneficial in informing policies and practise guidelines.

Birth setting, labour experience, and postpartum psychological distress

OBJECTIVE

although psychosocial risk factors have been identified for postpartum depression (PPD) and perinatal posttraumatic stress disorder (PTSD), the role of labour- and birth-related factors remains unclear. The present investigation explored the impact of birth setting, subjective childbirth experience, and their interplay, on PPD and postpartum PTSD.

METHOD

in this prospective longitudinal cohort study, three groups of women who had vaginal births at a tertiary care hospital, a birthing center, and those transferred from the birthing centre to the tertiary care hospital were compared. Participants were followed twice during pregnancy (12-14 and 32-34 weeks gestation) and twice after childbirth (1-3 and 7-9 weeks postpartum).

RESULTS

symptoms of PPD and PTSD did not significantly differ between birth groups; however, measures of subjective childbirth experience and obstetric factors did. Moderation analyses indicated a significant interaction between pain and birth group, such that higher ratings of pain among women who were transferred was associated with greater symptoms of postpartum PTSD.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

women who are transferred appear to have a unique experience that may put them at greater risk for postpartum psychological distress. It may be beneficial for care providers to help prepare women for pain management and potential unexpected complications, particularly if it is their first childbirth.

Effect of planned place of birth on obstetric interventions and maternal outcomes among low-risk women: a cohort study in the Netherlands

BACKGROUND

The use of interventions in childbirth has increased the past decades. There is concern that some women might receive more interventions than they really need. For low-risk women, midwife-led birth settings may be of importance as a counterbalance towards the increasing rate of interventions. The effect of planned place of birth on interventions in the Netherlands is not yet clear. This study aims to give insight into differences in obstetric interventions and maternal outcomes for planned home versus planned hospital birth among women in midwife-led care.

METHODS

Women from twenty practices across the Netherlands were included in 2009 and 2010. Of these, 3495 were low-risk and in midwife-led care at the onset of labour. Information about planned place of birth and outcomes, including instrumental birth (caesarean section, vacuum or forceps birth), labour augmentation, episiotomy, oxytocin in third stage, postpartum haemorrhage >1000 ml and perineal damage, came from the national midwife-led care perinatal database, and a postpartum questionnaire.

RESULTS

Women who planned home birth more often had spontaneous birth (nulliparous women aOR 1.38, 95 % CI 1.08-1.76, parous women aOR 2.29, 95 % CI 1.21-4.36) and less often episiotomy (nulliparous women aOR 0.73, 0.58-0.91, parous women aOR 0.47, 0.33-0.68) and use of oxytocin in the third stage (nulliparous women aOR 0.58, 0.42-0.80, parous women aOR 0.47, 0.37-0.60) compared to women who planned hospital birth. Nulliparous women more often had anal sphincter damage (aOR 1.75, 1.01-3.03), but the difference was not statistically significant if women who had caesarean sections were excluded. Parous women less often had labour augmentation (aOR 0.55, 0.36-0.82) and more often an intact perineum (aOR 1.65, 1.34-2.03). There were no differences in rates of vacuum/forceps birth, unplanned caesarean section and postpartum haemorrhage >1000 ml.

CONCLUSIONS

Women who planned home birth were more likely to give birth spontaneously and had fewer medical interventions.

Onsite midwife-led birth units (OMBUs) for care around the time of childbirth: a systematic review

Introduction

To ensure timely access to comprehensive emergency obstetric care in low- and middle-income countries, a number of interventions have been employed. This systematic review assesses the effects of onsite midwife-led birth units (OMBUs) embedded within hospitals which provide comprehensive emergency obstetric and newborn care.

Methods

Both interventional and observational studies that compared OMBUs with standard medical-led obstetric care were eligible for inclusion. Cochrane Central Register of Controlled Trials, PubMed/Medline, EMBASE, CINAHL, Science Citation and Social Sciences Citation Index, Global Health Library and one Chinese database were searched. Meta-analysis was conducted to synthesise data from randomised controlled trials (RCTs). Findings of observational studies were summarised by forest plots with brief narratives.

Results

Three RCTs, one controlled before-and-after study and six cohort studies were included. There were no or very few maternal and perinatal deaths in either OMBUs or standard obstetric units, with no significant differences between the two. Women giving birth in OMBUs were less likely to use epidural analgesia (risk ratio (RR) 0.67, 95% CI 0.55 to 0.82; three trials, n=2431). The UK national cohort study and two other cohorts in China and Nepal found less oxytocin augmentation, more spontaneous vaginal deliveries, fewer caesarean sections and fewer episiotomies performed in OMBUs than in standard obstetric units. These differences were not statistically significant in RCTs and the remaining cohorts. One study investigated satisfaction with midwife-led birth care among women and midwives, with positive findings in both groups favouring OMBUs. In addition, two studies found that the total cost of birth was lower in OMBUs than in standard obstetric units.

Conclusions

OMBUs could be an alternative model for providing safe and cost-effective childbirth care, which may be particularly important in low- and middle-income countries to meet the growing demand for facility-based birth for low-risk women and improve efficiency of health systems.

Different settings of place of midwife-led birth: evaluation of a midwife-led birth centre

Objectives

The claimed advantages of home deliveries, including fewer medical interventions, are potentially counter balanced by the small additional risk on perinatal adverse outcome compared to hospital deliveries in low risk women. Homelike birth centres have been proposed a new setting for low risk women combining the advantages of home and hospital, resulting in lower intervention rates with equal safety. This paper addresses whether the introduction of a midwife-led birth centre adjacent to the hospital combines the advantages of home and hospital deliveries. Additionally, we investigate whether the introduction of a midwife-led birth centre leads to a different risk selection of women planning their delivery either at home, at the hospital or at the birth centre.

Methods

Anonymized data, between January 2007 and June 2012, was collected from the four participating midwife practices. Women (n = 5558) were categorized according to intended place of birth. Women’s characteristics and pregnancy outcomes were compared between the period before and after its introduction using Chi square and Fisher’s Exact tests. Direct and indirect standardized rates were calculated for different outcomes [(1) intrapartum and neonatal mortality (<24 h), (2) composite outcome of neonatal morbidities, (3) composite outcome of maternal morbidities, and (4) medical intervention], taking the period before introduction as reference.

Results

After the introduction of the birth centre a different risk selection was observed. Women’s characteristics were most unfavourable for intended birth centre births. Additionally, an higher neonatal risk load was seen within these women. After its introduction neonatal morbidities decreased (5.0 vs. 3.8 %) and maternal morbidities decreased (8.3 vs. 7.3 %). Interventions were about equal. Direct and indirect standardization provided similar results.

Conclusion

Neonatal morbidity and maternal morbidity tended to decrease, while overall intervention rates were unaffected. The introduction of the midwife-led birth centre seems to benefit the outcome of midwife-led deliveries. We interpret this change by the redistribution of the higher risk women among the low risk population intending birth at the birth centre instead of home.

Evaluation of satisfaction with care in a midwifery unit and an obstetric unit: a randomized controlled trial of low-risk women

Background

Satisfaction with birth care is part of quality assessment of care. The aim of this study was to investigate possible differences in satisfaction with intrapartum care among low-risk women, randomized to a midwifery unit or to an obstetric unit within the same hospital.

Methods

Randomized controlled trial conducted at the Department of Obstetrics and Gynecology, Østfold Hospital Trust, Norway. A total of 485 women with no expressed preference for level of birth care, assessed to be at low-risk at onset of spontaneous labor were included. To assess the overall satisfaction with intrapartum care, the Labour and Delivery Satisfaction Index (LADSI) questionnaire, was sent to the participants 6 months after birth. To assess women’s experience with intrapartum transfer, four additional items were added. In addition, we tested the effects of the following aspects on satisfaction; obstetrician involved, intrapartum transfer from the midwifery unit to the obstetric unit during labor, mode of delivery and epidural analgesia.

Results

Women randomized to the midwifery unit were significantly more satisfied with intrapartum care than those randomized to the obstetric unit (183 versus 176 of maximum 204 scoring points, mean difference 7.2, p = 0.002). No difference was found between the units for women who had an obstetrician involved during labor or delivery and who answered four additional questions on this aspect (mean item score 4.0 at the midwifery unit vs 4.3 at the obstetric unit, p = 0.3). Intrapartum transfer from the midwifery unit to an obstetric unit, operative delivery and epidurals influenced the level of overall satisfaction in a negative direction regardless of allocated unit (p < 0.001).

Conclusion

Low-risk women with no expressed preference for level of birth care were more satisfied if allocated to the midwifery unit compared to the obstetric unit.

Trial registration

The trial is registered at www.clinicaltrials.govNCT00857129. Initially released 03/05/2009.

Maternity Outcomes in Manitoba Women: A Comparison between Midwifery-led Care and Physician-led Care at Birth

BACKGROUND

Registered midwives, obstetricians/gynecologists, and general or family practice physicians (GPs) provide maternity care across Canada. Few North American studies have assessed whether maternity outcomes differ across these three groups. This study compared maternal and neonatal outcomes of low-risk pregnant women whose birth was attended by registered midwives, obstetricians/gynecologists, and family practice physicians in Winnipeg, Manitoba from 2001/02 to 2012/13.

METHODS

Descriptive statistics and logistic regression were used to examine differences in types of intervention, mode of delivery, and outcomes by provider type among low-risk women. Logistic regression models controlled for socio-demographic and birth-related covariates.

RESULTS

Low-risk births comprised 83,774 (48.7%) of total births (n = 171,910). The adjusted odds ratio (aOR), (95% confidence interval) for midwife vs OB/GYN showed women who had a midwife attend the birth had reduced odds of having an episiotomy 0.47 (0.40-0.54), epidural 0.25 (0.23-0.27), and cesarean delivery 0.13 (0.10-0.16) and their infants had less Neonatal Intensive Care Unit admissions 0.28 (0.18-0.43). The aOR for GP versus OB/GYN showed women who had a GP had reduced odds of having an epidural/spinal 0.83 (0.79-0.88) and cesarean delivery 0.44 (0.40-0.48).

CONCLUSIONS

The effectiveness of Manitoba maternity services can be improved with increased use of integrated midwifery services. Future research should examine how midwifery and physician-led models of care differ, and the influence of these differences on birth outcomes and cost-effectiveness to the health care system. Improvement of data tracking systems is also needed.

Midwife-led continuity models versus other models of care for childbearing women

BACKGROUND

Midwives are primary providers of care for childbearing women around the world. However, there is a lack of synthesised information to establish whether there are differences in morbidity and mortality, effectiveness and psychosocial outcomes between midwife-led continuity models and other models of care.

OBJECTIVES

To compare midwife-led continuity models of care with other models of care for childbearing women and their infants.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (25 January 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

All published and unpublished trials in which pregnant women are randomly allocated to midwife-led continuity models of care or other models of care during pregnancy and birth.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

We included 15 trials involving 17,674 women. We assessed the quality of the trial evidence for all primary outcomes (i.e. regional analgesia (epidural/spinal), caesarean birth, instrumental vaginal birth (forceps/vacuum), spontaneous vaginal birth, intact perineum, preterm birth (less than 37 weeks) and all fetal loss before and after 24 weeks plus neonatal death using the GRADE methodology: all primary outcomes were graded as of high quality.For the primary outcomes, women who had midwife-led continuity models of care were less likely to experience regional analgesia (average risk ratio (RR) 0.85, 95% confidence interval (CI) 0.78 to 0.92; participants = 17,674; studies = 14; high quality), instrumental vaginal birth (average RR 0.90, 95% CI 0.83 to 0.97; participants = 17,501; studies = 13; high quality), preterm birth less than 37 weeks (average RR 0.76, 95% CI 0.64 to 0.91; participants = 13,238; studies = eight; high quality) and less all fetal loss before and after 24 weeks plus neonatal death (average RR 0.84, 95% CI 0.71 to 0.99; participants = 17,561; studies = 13; high quality evidence). Women who had midwife-led continuity models of care were more likely to experience spontaneous vaginal birth (average RR 1.05, 95% CI 1.03 to 1.07; participants = 16,687; studies = 12; high quality). There were no differences between groups for caesarean births or intact perineum.For the secondary outcomes, women who had midwife-led continuity models of care were less likely to experience amniotomy (average RR 0.80, 95% CI 0.66 to 0.98; participants = 3253; studies = four), episiotomy (average RR 0.84, 95% CI 0.77 to 0.92; participants = 17,674; studies = 14) and fetal loss less than 24 weeks and neonatal death (average RR 0.81, 95% CI 0.67 to 0.98; participants = 15,645; studies = 11). Women who had midwife-led continuity models of care were more likely to experience no intrapartum analgesia/anaesthesia (average RR 1.21, 95% CI 1.06 to 1.37; participants = 10,499; studies = seven), have a longer mean length of labour (hours) (mean difference (MD) 0.50, 95% CI 0.27 to 0.74; participants = 3328; studies = three) and more likely to be attended at birth by a known midwife (average RR 7.04, 95% CI 4.48 to 11.08; participants = 6917; studies = seven). There were no differences between groups for fetal loss equal to/after 24 weeks and neonatal death, induction of labour, antenatal hospitalisation, antepartum haemorrhage, augmentation/artificial oxytocin during labour, opiate analgesia, perineal laceration requiring suturing, postpartum haemorrhage, breastfeeding initiation, low birthweight infant, five-minute Apgar score less than or equal to seven, neonatal convulsions, admission of infant to special care or neonatal intensive care unit(s) or in mean length of neonatal hospital stay (days).Due to a lack of consistency in measuring women's satisfaction and assessing the cost of various maternity models, these outcomes were reported narratively. The majority of included studies reported a higher rate of maternal satisfaction in midwife-led continuity models of care. Similarly, there was a trend towards a cost-saving effect for midwife-led continuity care compared to other care models.

AUTHORS' CONCLUSIONS

This review suggests that women who received midwife-led continuity models of care were less likely to experience intervention and more likely to be satisfied with their care with at least comparable adverse outcomes for women or their infants than women who received other models of care.Further research is needed to explore findings of fewer preterm births and fewer fetal deaths less than 24 weeks, and all fetal loss/neonatal death associated with midwife-led continuity models of care.

Midwife-led continuity models versus other models of care for childbearing women

BACKGROUND

Midwives are primary providers of care for childbearing women around the world. However, there is a lack of synthesised information to establish whether there are differences in morbidity and mortality, effectiveness and psychosocial outcomes between midwife-led continuity models and other models of care.

OBJECTIVES

To compare midwife-led continuity models of care with other models of care for childbearing women and their infants.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

All published and unpublished trials in which pregnant women are randomly allocated to midwife-led continuity models of care or other models of care during pregnancy and birth.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

We included 15 trials involving 17,674 women. We assessed the quality of the trial evidence for all primary outcomes (i.e., regional analgesia (epidural/spinal), caesarean birth, instrumental vaginal birth (forceps/vacuum), spontaneous vaginal birth, intact perineum, preterm birth (less than 37 weeks) and overall fetal loss and neonatal death (fetal loss was assessed by gestation using 24 weeks as the cut-off for viability in many countries) using the GRADE methodology: All primary outcomes were graded as of high quality.For the primary outcomes, women who had midwife-led continuity models of care were less likely to experience regional analgesia (average risk ratio (RR) 0.85, 95% confidence interval (CI) 0.78 to 0.92; participants = 17,674; studies = 14; high quality), instrumental vaginal birth (average RR 0.90, 95% CI 0.83 to 0.97; participants = 17,501; studies = 13; high quality), preterm birth less than 37 weeks (average RR 0.76, 95% CI 0.64 to 0.91; participants = 13,238; studies = 8; high quality) and less overall fetal/neonatal death (average RR 0.84, 95% CI 0.71 to 0.99; participants = 17,561; studies = 13; high quality evidence). Women who had midwife-led continuity models of care were more likely to experience spontaneous vaginal birth (average RR 1.05, 95% CI 1.03 to 1.07; participants = 16,687; studies = 12; high quality). There were no differences between groups for caesarean births or intact perineum.For the secondary outcomes, women who had midwife-led continuity models of care were less likely to experience amniotomy (average RR 0.80, 95% CI 0.66 to 0.98; participants = 3253; studies = 4), episiotomy (average RR 0.84, 95% CI 0.77 to 0.92; participants = 17,674; studies = 14) and fetal loss/neonatal death before 24 weeks (average RR 0.81, 95% CI 0.67 to 0.98; participants = 15,645; studies = 11). Women who had midwife-led continuity models of care were more likely to experience no intrapartum analgesia/anaesthesia (average RR 1.21, 95% CI 1.06 to 1.37; participants = 10,499; studies = 7), have a longer mean length of labour (hours) (mean difference (MD) 0.50, 95% CI 0.27 to 0.74; participants = 3328; studies = 3) and more likely to be attended at birth by a known midwife (average RR 7.04, 95% CI 4.48 to 11.08; participants = 6917; studies = 7). There were no differences between groups for fetal loss or neonatal death more than or equal to 24 weeks, induction of labour, antenatal hospitalisation, antepartum haemorrhage, augmentation/artificial oxytocin during labour, opiate analgesia, perineal laceration requiring suturing, postpartum haemorrhage, breastfeeding initiation, low birthweight infant, five-minute Apgar score less than or equal to seven, neonatal convulsions, admission of infant to special care or neonatal intensive care unit(s) or in mean length of neonatal hospital stay (days).Due to a lack of consistency in measuring women's satisfaction and assessing the cost of various maternity models, these outcomes were reported narratively. The majority of included studies reported a higher rate of maternal satisfaction in midwife-led continuity models of care. Similarly, there was a trend towards a cost-saving effect for midwife-led continuity care compared to other care models.

AUTHORS' CONCLUSIONS

This review suggests that women who received midwife-led continuity models of care were less likely to experience intervention and more likely to be satisfied with their care with at least comparable adverse outcomes for women or their infants than women who received other models of care.Further research is needed to explore findings of fewer preterm births and fewer fetal deaths less than 24 weeks, and overall fetal loss/neonatal death associated with midwife-led continuity models of care.

Physician-led, hospital-linked, birth care centers can decrease cesarean section rates without increasing rates of adverse events

BACKGROUND

This study compares outcomes at a hospital-linked, physician-led, birthing center to a traditional hospital labor and delivery service.

METHODS

Using de-identified electronic medical records, a retrospective cohort design was employed to evaluate 32,174 singleton births during 1998-2005.

RESULTS

Compared with hospital service, birth care center delivery was associated with a lower rate of cesarean sections (adjusted Relative Risk = 0.73, 95% confidence interval 0.59-0.91; p < 0.001) without an increased rate of operative vaginal delivery (adjusted Relative Risk = 1.04, 95% confidence interval 0.97-1.13; p = 0.25) and a higher initiation of breastfeeding (adjusted Relative Risk = 1.28, 95% confidence interval 1.25-1.30; p ≤ 0.001). A maternal length of stay greater than 72 hours occurred less frequently in the birth care center (adjusted Relative Risk = 0.60, 95% confidence interval 0.55-0.66; p < 0.001). Comparing only women without major obstetrical risk factors, the differences in outcomes were reduced but not eliminated. Adverse maternal and infant outcomes were not increased at the birth care center.

CONCLUSION

A hospital-linked, physician-led, birth care center has the potential to lower rates of cesarean sections without increasing rates of operative vaginal delivery or other adverse maternal and infant outcomes.

Midwife-led continuity models versus other models of care for childbearing women

BACKGROUND

Midwives are primary providers of care for childbearing women around the world. However, there is a lack of synthesised information to establish whether there are differences in morbidity and mortality, effectiveness and psychosocial outcomes between midwife-led continuity models and other models of care.

OBJECTIVES

To compare midwife-led continuity models of care with other models of care for childbearing women and their infants.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2013) and reference lists of retrieved studies.

SELECTION CRITERIA

All published and unpublished trials in which pregnant women are randomly allocated to midwife-led continuity models of care or other models of care during pregnancy and birth.

DATA COLLECTION AND ANALYSIS

All review authors evaluated methodological quality. Two review authors checked data extraction.

MAIN RESULTS

We included 13 trials involving 16,242 women. Women who had midwife-led continuity models of care were less likely to experience regional analgesia (average risk ratio (RR) 0.83, 95% confidence interval (CI) 0.76 to 0.90), episiotomy (average RR 0.84, 95% CI 0.76 to 0.92), and instrumental birth (average RR 0.88, 95% CI 0.81 to 0.96), and were more likely to experience no intrapartum analgesia/anaesthesia (average RR 1.16, 95% CI 1.04 to 1.31), spontaneous vaginal birth (average RR 1.05, 95% CI 1.03 to 1.08), attendance at birth by a known midwife (average RR 7.83, 95% CI 4.15 to 14.80), and a longer mean length of labour (hours) (mean difference (hours) 0.50, 95% CI 0.27 to 0.74). There were no differences between groups for caesarean births (average RR 0.93, 95% CI 0.84 to 1.02).Women who were randomised to receive midwife-led continuity models of care were less likely to experience preterm birth (average RR 0.77, 95% CI 0.62 to 0.94) and fetal loss before 24 weeks' gestation (average RR 0.81, 95% CI 0.66 to 0.99), although there were no differences in fetal loss/neonatal death of at least 24 weeks (average RR 1.00, 95% CI 0.67 to 1.51) or in overall fetal/neonatal death (average RR 0.84, 95% CI 0.71 to 1.00).Due to a lack of consistency in measuring women's satisfaction and assessing the cost of various maternity models, these outcomes were reported narratively. The majority of included studies reported a higher rate of maternal satisfaction in the midwifery-led continuity care model. Similarly there was a trend towards a cost-saving effect for midwife-led continuity care compared to other care models.

AUTHORS' CONCLUSIONS

Most women should be offered midwife-led continuity models of care and women should be encouraged to ask for this option although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.

Oxytocin and dystocia as risk factors for adverse birth outcomes: a cohort of low-risk nulliparous women

OBJECTIVES

augmented and not augmented women without dystocia were compared to investigate associations between oxytocin and adverse birth outcomes. Augmented women with and without dystocia were compared, to investigate associations between dystocia and adverse birth outcomes.

DESIGN

a cohort of low-risk nulliparous women originally included in a randomised controlled trial.

SETTING

the Department of Obstetrics and Gynaecology, Østfold Hospital Trust, Norway.

PARTICIPANTS

the study population consists of 747 well defined low-risk women.

MEASUREMENTS

incidence of oxytocin augmentation, and associations between dystocia and augmentation, and mode of delivery, transfer of newborns to the intensive care unit, episiotomy and postpartum haemorrhage.

FINDINGS

of all participants 327 (43.8%) were augmented with oxytocin of which 139 (42.5%) did not fulfil the criteria for dystocia. Analyses adjusted for possible confounders found that women without dystocia had an increased risk of instrumental vaginal birth (OR 3.73, CI 1.93-7.21) and episiotomy (OR 2.47, CI 1.38-4.39) if augmented with oxytocin. Augmented women had longer active phase if vaginally delivered and longer labours if delivered by caesarean section if having dystocia. Among women without dystocia, those augmented had higher body mass index, gave birth to heavier babies, had longer labours if vaginally delivered and had epidural analgesia more often compared to women not augmented.

KEY CONCLUSION

in low-risk nulliparous without dystocia, we found an association between the use of oxytocin and an increased risk of instrumental vaginal birth and episiotomy.

IMPLICATIONS FOR PRACTICE

careful attention should be paid to criteria for labour progression and guidelines for oxytocin augmentation to avoid unnecessary use.

Change in risk status during labor in a large Norwegian obstetric department: a prospective study

OBJECTIVE

This study aimed to observe risk status on admission to hospital and change in risk status during labor.

DESIGN

A prospective observational study allocating all women into low-risk and high-risk groups on admittance to hospital and during labor based on prespecified risk criteria.

SETTING

Department of Obstetrics and Gynecology in a district hospital.

POPULATION

All 6406 deliveries from 2 May 2004 to 30 September 2006.

METHODS

A special form was filled out for all women admitted to the department in labor classifying them as either low or high risk. A change in risk status during labor was also recorded.

MAIN OUTCOME MEASURES

Risk status (low and high risk) on admittance to hospital and change in risk status during first stage of labor.

RESULTS

On admittance, 67% of women with an intended vaginal delivery were low risk. During the first stage of labor, 41% of the low-risk women changed risk status. Use of epidural anesthesia gave rise to 73% of the risk changes during the first stage of labor and use of oxytocin caused 12%.

CONCLUSIONS

Two-thirds of the women were low risk before labor, and 39% of these remained low-risk at the end of the first stage of labor. The main reason for a change of risk status in the obstetric department was the use of epidural anesthesia.

Comparison of neonatal outcomes and intrapartum events in full term vaginal deliveries conducted by staff versus resident physicians

Objective

The objective of this study was to compare the neonatal outcomes and intrapartum events conducted by staff versus resident physicians in full term vaginal deliveries.

Methods

We divided study population (n = 5,007) into two groups: staff versus resident physicians. These two groups were sub-divided; faculty versus fellow and senior versus junior resident, respectively. The maternal characteristics, neonatal outcomes including Apgar score, admission to the neonatal intensive care unit and umbilical arterial pH and intrapartum event which was defined as the occurrence of shoulder dystocia and vacuum delivery were also investigated.

Results

There was no difference in neonatal outcomes between two groups. The group delivered by staff had a higher rate of nulliparity, large for gestational age and intrapartum events than the resident physician group. The subgroup analysis revealed a higher rate of vacuum delivery in the group delivered by faculty and senior members than the group delivered by fellows and junior members.

Conclusion

There was no significant difference in neonatal outcomes between the two groups; staff versus resident physicians in full term vaginal deliveries in low-risk pregnant women. Also, experienced obstetricians might tend to participate in difficult labors and would prefer applying vacuum compared to the obstetricians with fewer experiences.

Impact of non-clinical factors on primary cesarean deliveries

The patient characteristics that influence cesarean rates are well known. However, there are many non clinical factors that also influence cesarean rates. Understanding these non clinical factors and how they can be changed to improve care is an important part of obstetrics. Provider staffing patterns, the types of providers and how information can be used to effectively change practice patterns are explored in this article.

Obstetric interventions for low-risk pregnant women in France: do maternity unit characteristics make a difference?

BACKGROUND

In many countries the closure of small maternity units has raised concerns about how the concentration of low-risk pregnancies in large specialized units might affect the management of childbirth. We aimed to assess the role of maternity unit characteristics on obstetric intervention rates among low-risk women in France.

METHODS

Data on low-risk deliveries came from the 2010 French National Perinatal Survey of a representative sample of births (n = 9,530). The maternity unit characteristics studied were size, level of care, and private or public status; the interventions included induction of labor; cesarean section; operative vaginal delivery (forceps, spatulas or vacuum); and episiotomy. Multilevel logistic regression analyses were adjusted for maternal confounding factors, gestational age, and infant birthweight.

RESULTS

The rates of induction, cesarean section, operative delivery, and episiotomy in this low-risk population were 23.9 percent, 10.1 percent, 15.2 percent, and 19.6 percent, respectively, and 52.0 percent of deliveries included at least one of them. Unit size was unrelated to any intervention except operative delivery (adjusted odds ratio [aOR] = 1.47 (95% CI, 1.10-1.96) for units with >3,000 deliveries per year vs units with <1,000). The rate of every intervention was higher in private units, and the aOR for any intervention was 1.82 (95% CI, 1.59-2.08). After adjustment for maternal characteristics and facility size and status, significant variations in the use of interventions remained between units, especially for episiotomies. Results for level of care were similar to those for unit size.

CONCLUSIONS

The concentration of births in large maternity units in France is not associated with higher rates of interventions for low-risk births. The situation in private units could be explained by differences in the organization of care. Additional research should explore the differences in practices between maternity units with similar characteristics.

Alternative versus conventional institutional settings for birth

BACKGROUND

Alternative institutional settings have been established for the care of pregnant women who prefer little or no medical intervention. The settings may offer care throughout pregnancy and birth, or only during labour; they may be part of hospitals or freestanding entities. Specially designed labour rooms include bedroom-like rooms, ambient rooms, and Snoezelen rooms.

OBJECTIVES

Primary: to assess the effects of care in an alternative institutional birth environment compared to care in a conventional setting. Secondary: to determine if the effects of birth settings are influenced by staffing, architectural features, organizational models or geographical location.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 March 2012).

SELECTION CRITERIA

All randomized or quasi-randomized controlled trials which compared the effects of an alternative institutional birth setting to a conventional setting.

DATA COLLECTION AND ANALYSIS

We used the standard methods of the Cochrane Collaboration Pregnancy and Childbirth Group. Two review authors evaluated methodological quality. We performed double data extraction and presented results using risk ratios (RR) and 95% confidence intervals (CI).

MAIN RESULTS

Ten trials involving 11,795 women met the inclusion criteria. We found no trials of freestanding birth centres or Snoezelen rooms. Allocation to an alternative setting increased the likelihood of: no intrapartum analgesia/anesthesia (six trials, n = 8953; RR 1.18, 95% CI 1.05 to 1.33); spontaneous vaginal birth (eight trials; n = 11,202; RR 1.03, 95% CI 1.01 to 1.05); breastfeeding at six to eight weeks (one trial, n = 1147; RR 1.04, 95% CI 1.02 to 1.06); and very positive views of care (two trials, n = 1207; RR 1.96, 95% CI 1.78 to 2.15). Allocation to an alternative setting decreased the likelihood of epidural analgesia (eight trials, n = 10.931; RR 0.80, 95% CI 0.74 to 0.87); oxytocin augmentation of labour (eight trials, n = 11,131; RR 0.77, 95% CI 0.67 to 0.88); instrumental vaginal birth (eight trials, n = 11,202; RR 0.89, 95% CI 0.79 to 0.99), and episiotomy (eight trials, n = 11,055; RR 0.83, 95% CI 0.77 to 0.90). There was no apparent effect on other adverse maternal or neonatal outcomes. Care by the same or separate staff had no apparent effects. No conclusions could be drawn regarding the effects of continuity of caregiver or architectural characteristics. In several of the trials included in this review, the design features of the alternative setting were confounded by important differences in the organizational models for care (separate staff for the alternative setting, offering more continuity of caregiver), and thus it is difficult to draw inferences about the independent effects of the physical birth environment.

AUTHORS' CONCLUSIONS

Hospital birth centres are associated with lower rates of medical interventions during labour and birth and higher levels of satisfaction, without increasing risk to mothers or babies.

Economic evaluation of birth care in low-risk women. A comparison between a midwife-led birth unit and a standard obstetric unit within the same hospital in Norway. A randomised controlled trial

OBJECTIVE

to investigate the cost-effectiveness in birth care for low-risk women, in an alongside midwife-led unit (MU) compared to a standard obstetric unit (SCU) within the same hospital.

DESIGN

economic evaluation based on the findings of a randomised trial, randomising participants either into the MU or SCU. The hospital's activity-based costing system CPP was used to estimate costs, as no data on complete resource use exists.

SETTING

the Department of Obstetrics and Gynaecology, Østfold Hospital Trust, Norway.

PARTICIPANTS

the study population consists of 1,110 consenting healthy women, assessed to be at low-risk at spontaneous onset of labour.

MEASUREMENTS

effect measures; avoided caesarean sections, instrumental vaginal deliveries, complications requiring treatment in the operating room, epidural analgesia and oxytocin augmentation. Costs (€) were calculated by costs per day multiplied with length of stay, added costs for procedures performed outside the units. The results are expressed in incremental cost-effectiveness ratios (ICER) with SCU as comparator.

FINDINGS

total costs per stay were significantly lower for women at the MU (€1,672) compared to the SCU (€1,950, p<0.001). The ICER showed that MU was a dominant strategy (lower costs and reduction in clinical procedures) for all effect measures. Based on the sensitivity analysis, allocating low-risk women to MU significantly reduced costs, but was not a dominant strategy for all outcomes.

KEY CONCLUSIONS

the MU is more cost-effective than the SCU for low-risk women without prelabour preference for level of birth care provided equal capacity at the units.

IMPLICATIONS FOR PRACTICE

it is cost-effective to organise birth care for low-risk women in a separate midwife-led unit.