Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: a retrospective cohort study

Outcomes associated with planned place of birth among low-risk pregnancies in Ontario, Canada (2012-2021): A protocol for a population-based propensity score weighted cohort study

BACKGROUND

Evidence suggests that for low-risk pregnancies, planned home births attended by a skilled health professional in settings where such services are well integrated are associated with lower risk of intrapartum interventions and no increase in adverse health outcomes. Monitoring and updating evidence on the safety of planned home births is necessary to inform ongoing clinical and policy decisions.

METHODS

This protocol describes a population-based retrospective cohort study which aims to compare risk of (a) neonatal morbidity and mortality, and (b) maternal outcomes and birth interventions, between people at low obstetrical risk with a planned home birth with a midwife, a planned a hospital birth with a midwife, or a planned hospital birth with a physician. The study population will include Ontario residents who gave birth in Ontario, Canada between April 1, 2012, and March 31, 2021. We will use data collected prospectively in a provincial perinatal data registry. The primary outcome will be severe neonatal morbidity or mortality, a composite binary outcome that includes one or more of the following conditions: stillbirth during the intrapartum period, neonatal death (death of a liveborn infant in the first 28 completed days of life), five-minute Apgar score <4, or infant resuscitation requiring cardiac compressions. We will conduct a stratified analysis with three strata: nulliparous, parous-no previous caesarean birth, and parous-prior caesarean birth. To reduce the impact of selection bias in estimating the effect of planned place of birth on neonatal and maternal outcomes, we will use propensity score (PS) overlap weighting (OW) and modified Poisson regression to conduct multivariate analyses.

Perceptions and Attitudes Toward Genetic Counselors and Genetic Testing Among Certified Professional Midwives in Vermont: A Modified Grounded Theory Study

Increasingly, pregnant people in the United States are choosing to give at birth at home, and certified professional midwives (CPMs) often attend these births. Care by midwives, including home birth midwives, has the potential to decrease unnecessary medical interventions and their associated health care costs, as well as to improve maternal satisfaction with care. However, lack of integration into the health care system affects the ability of CPMs to access standard medications and testing for their clients, including prenatal screening. Genetics and genomics are now a routine part of prenatal screening, and genetic testing can contribute to identifying candidates for planned home birth. However, research on genetics and midwifery care has not, to date, included the subset of midwives who attend the majority of planned home births, CPMs. The purpose of this study was to examine CPMs' access to, and perspectives on, one aspect of prenatal care, genetic counselors and genetic counseling services. Using semi-structured interviews and a modified grounded theory approach to narrative analysis, we identified three key themes: (1) systems-level issues with accessing information about genetic counseling and genetic testing; (2) practice-level patterns in information delivery and self-awareness about knowledge limitations; and (3) client-level concerns about the value of genetic testing relative to difficulties with access and stress caused by the information. The results of this study can be used to develop decision aids that include information about genetic testing and genetic counseling access for pregnant people intending home births in the United States.

Intrapartum time intervals and transfer of nulliparae from community births to maternity care units in Germany

BACKGROUND

Over one-third of nulliparae planning births either at home or in freestanding midwife-led birthing centers (community births) in high-income countries are transferred during labor. Perinatal data are reported each year in Germany for women planning community birth. So far, data sets have not been linked to describe time-related factors associated with nulliparous transfer to hospital.

OBJECTIVES

To describe the prevalence of referral for nulliparae and assess maternal and labor characteristics associated with intrapartum transfer.

METHODS

Perinatal data from 2010 to 2015 were linked (n = 26,115). Women were reviewed with respect to international eligibility criteria for community birth; 1997 women were excluded (7.6%). Descriptive statistics were reported; unadjusted and adjusted odds ratios with 95% confidence intervals (CI) tested the predictive effect of demographic and labor factors on rates of intrapartum transfer.

RESULTS

One in three nulliparous women (30.6%) were transferred to hospital. Compared with community births, transferred women were significantly more likely to experience longer time intervals during labor: from rupture of membranes (ROM) until birth lasting 5 to 18 h (OR 6.05, CI 5.53-6.61) and 19 to 24 h (OR 10.83, CI 9.45-12.41) compared to one to 4 h; and from onset of labor until birth 11 to 24 h (OR 6.72, CI 6.24-7.23) and 25 to 29 h (OR 26.62, CI 22.77-31.11) compared to one to 10 h. When entering all factors into the model, we found the strongest predictors of transfer to be fetal distress, longer time intervals between ROM until birth and onset of labor until birth.

CONCLUSIONS

Nulliparous transfer rates were similar to rates in other high-income countries; 94% of referrals were non-urgent. Time was found to be an independent risk factor for the transfer of nulliparae planning community birth.

Examining respect, autonomy, and mistreatment in childbirth in the US: do provider type and place of birth matter?

BACKGROUND

Analyses of factors that determine quality of perinatal care consistently rely on clinical markers, while failing to assess experiential outcomes. Understanding how model of care and birth setting influence experiences of respect, autonomy, and decision making, is essential for comprehensive assessment of quality.

METHODS

We examined responses (n = 1771) to an online cross-sectional national survey capturing experiences of perinatal care in the United States. We used validated patient-oriented measures and scales to assess four domains of experience: (1) decision-making, (2) respect, (3) mistreatment, and (4) time spent during visits. We categorized the provider type and birth setting into three groups: midwife at community birth, midwife at hospital-birth, and physician at hospital-birth. For each group, we used multivariate logistic regression, adjusted for demographic and clinical characteristics, to estimate the odds of experiential outcomes in all the four domains.

RESULTS

Compared to those cared for by physicians in hospitals, individuals cared for by midwives in community settings had more than five times the odds of experiencing higher autonomy (aOR: 5.22, 95% CI: 3.65-7.45), higher respect (aOR: 5.39, 95% CI: 3.72-7.82) and lower odds of mistreatment (aOR: 0.16, 95% CI: 0.10-0.26). We found significant differences across birth settings: participants cared for by midwives in the community settings had significantly better experiential outcomes than those in the hospital settings: high- autonomy (aOR: 2.97, 95% CI: 2.66-4.27), respect (aOR: 4.15, 95% CI: 2.81-6.14), mistreatment (aOR: 0.20, 95% CI: 0.11-0.34), time spent (aOR: 8.06, 95% CI: 4.26-15.28).

CONCLUSION

Participants reported better experiential outcomes when cared for by midwives than by physicians. And for those receiving midwifery care, the quality of experiential outcomes was significantly higher in community settings than in hospital settings. Care settings matter and structures of hospital-based care may impair implementation of the person-centered midwifery care model.

A Bibliometric Analysis of Research Articles on Midwifery Based on the Web of Science

Objective

This study aimed to bibliometrically analyse the main features of the 100 top-cited articles on the midwifery index on the Web of Science.

Methods

Academic articles on midwifery' research published from 1985 to 2020 were included. VOSviewer 1.6.15, SPSS 22.0 software and a homemade applet were used to identify, analyse and visualise the citation ranking, publication year, journal, country and organisation of origin, authorship, journal impact factor and keywords along with the total link strength of countries, organisations and keywords.

Results

Among the 100 top-cited articles, the highest number of citations of the retrieved articles was 484. The median number of citations per year was 5.16 (interquartile range: 3.74-8.38). Almost two-thirds of the included articles (n = 61) centred on nursing and obstetrics/gynaecology. The top-cited articles were published in 38 different journals, the highest number of which was published by Midwifery (15%). Australia was the most productive country (24%). According to the total link strength, the sequence ran from the United States (28) to England (28) to Australia (19). The University of Technology Sydney and La Trobe University in Australia topped the list with four papers each. Hunter B was the most productive author (n = 4), and the average citations were positively related to the number of authors (r = 0.336, p < 0.05).

Conclusion

This study identified the most influential articles on midwifery and documented the core journals and the most productive countries, organisations and authors along with future research hotspots for this field; the findings may be beneficial to researchers in their publication and scientific cooperation endeavours.

Vaginal Birth at Term - Part 1. Guideline of the DGGG, OEGGG and SGGG (S3-Level, AWMF Registry No. 015/083, December 2020)

Purpose This guideline aims to summarize the current state of knowledge about vaginal birth at term. The guideline focuses on definitions of the physiological stages of labor as well as differentiating between various pathological developments and conditions. It also assesses the need for intervention and the options to avoid interventions. This first part presents recommendations and statements about patient information and counselling, general patient care, monitoring of patients, pain management and quality control measures for vaginal birth. Methods The German recommendations largely reproduce the recommendations of the National Institute for Health and Care Excellence (NICE) CG 190 guideline "Intrapartum care for healthy women and babies". Other international guidelines were also consulted in specific cases when compiling this guideline. In addition, a systematic search and analysis of the literature was carried out using PICO questions, if this was considered necessary, and other systematic reviews and individual studies were taken into account. For easier comprehension, the assessment tools of the Scottish Intercollegiate Guidelines Network (SIGN) were used to evaluate the quality of the additionally consulted studies. Otherwise, the GRADE system was used for the NICE guideline and the evidence reports of the IQWiG were used to evaluate the quality of the evidence. Recommendations Recommendations and statements were formulated based on identified evidence and/or a structured consensus.

Why are women deciding against birth in alongside midwifery units? A prospective single-center study from Germany

OBJECTIVES

For healthy women entering labor after an uneventful pregnancy, advantages of birth in midwife-led models of care have been demonstrated. We aimed to study the level of awareness regarding care in alongside midwifery units (AMU), factors involved in the decision for birth in obstetrician-led units (OLU), and wishes for care and concerns about birth in women registering for birth in OLU who would have been eligible for care in AMU.

METHODS

Healthy women with a term singleton cephalic fetus after an uneventful pregnancy course booking for birth in OLU were prospectively recruited. Data were collected by questionnaire.

RESULTS

In total, 324 questionnaires were analyzed. One quarter (23.1%) of participants never had heard of care in AMU. Two thirds (64.2%) of women had made their choice regarding model of care before entering late pregnancy; only 16.4% indicated that health professionals had the biggest impact on their decision. One-to-one care and the availability of a pediatrician were most commonly quoted wishes (30.8 and 34.0%, respectively), and the occurrence of an adverse maternal or perinatal event the greatest concern (69.5%).

CONCLUSIONS

Although the majority of respondents had some knowledge about care in AMU, expressed wishes for birth matching core features of AMU and concerns matching those of OLU, a decision for birth in OLU was taken. This finding may be a result of lack of knowledge about details of care in AMU; additionally, wishes and concerns may be put aside in favor of other criteria.

Determinants of Place of Delivery during the COVID-19 Pandemic-Internet Survey in Polish Pregnant Women

Background and Objectives: COVID-19 is a pandemic disease, and its unpredictable outcome makes it particularly dangerous, especially for pregnant women. One of the decisions they have to make is where they will give birth. This study aimed to determine the factors influencing the choice of place of delivery and the impact of the COVID 19 pandemic on these factors. Materials and Methods: The study was conducted on 517 respondents from Poland. The research methods comprised the authors' own survey questionnaire distributed via the Internet from 8 to 23 June 2021. The survey was fully anonymous, voluntary, and addressed to women who gave birth during the pandemic or will give birth shortly. Results: A total of 440 (85.1%) respondents were afraid of SARS-CoV-2 infection. The most frequently indicated factors were fear of complications in the newborn, fear of intrauterine fetal death, and congenital disabilities in a newborn. A total of 74 (14.3%) women considered home delivery. The main factors that discouraged the choice of home birth were the lack of professional medical care 73.1% (N = 378), the lack of anesthesia 23.6% (N = 122), and the presence of indications for caesarean section 23.4% (N = 121). The possibility of mother-child isolation caused the greatest fear about hospital delivery. During the COVID-19 pandemic, pregnant women concerned about SARS-CoV-2 infection were more likely to consider home delivery than those without such fears. The most important factors affecting the choice of the place of delivery included the possibility of a partner's presence, excellent sanitary conditions and optimal distance from the hospital, and the availability of epidural analgesia for delivery. Conclusions: Our study identifies the determinants of place of delivery during the COVID-19 pandemic. The data we obtained can result in the healthcare system considering patients' needs in case of similar crisis in the future.

Expanding certified professional midwife services during the COVID-19 pandemic

Given concerns of coronavirus disease 2019 (COVID-19) acquisition in health care settings and hospital policies reducing visitors for laboring patients, many pregnant women are increasingly considering planned home births. Several state legislatures are considering increasing access to home births by granting licensure and Medicaid coverage of certified professional midwife (CPM) services. In this commentary, issues surrounding the expansion of CPM services including safety, standardization of care, patient satisfaction, racial and income equity, and an overburdened health care system are discussed. Lawmakers must account for these factors when considering proposals to expand CPM practice and payment during a pandemic.

“I got to catch my own baby”: a qualitative study of out of hospital birth

Background

About 1.6% of planned births in the United States occur out of hospitals. Studies indicate that planned out-of-hospital birth (OOHB) is safe and satisfying for women; however, there is great variation among ethnic groups, and Black women are underrepresented. A recent phenomenon is the choice to have an unassisted birth (UAB) with no midwife or other professional maternity care attendant. The purpose of this study is to fill a gap in understanding reasons for choosing OOHB or UAB for two clinically important sub-groups of women: Black women, and women who have experienced childhood physical or sexual abuse.

Methods

This study recruited 18 women who had an OOHB or UAB and who identified as either Black or survivors of trauma to participate in in-depth qualitative interviews concerning their choice to give birth out of hospital. A grounded theory approach was utilized that involved a discursive process of data collection, coding textual passages to identify focused themes, memo writing to document analytic decision-making, and eventual conceptual modeling.

Results

All 18 participants endorsed a history of trauma. Focused coding to identify inherent concepts led to the emergence of a theoretical model of the arc of decision-making around choice of place of birth and birth attendant, or lack thereof. Women may choose OOHB or UAB because of a previous trauma, or because they feel discriminated against by healthcare professionals, either because of skin color, age, pregnancy, weight, or some other health condition. Women may choose OOHB or UAB because it affords more control during the process of giving birth.

Conclusion

Previous trauma and experiences of discrimination were influential factors for women in the study sample in their choice of birthplace setting and choice of provider. These findings can inform clinical understanding for birth professionals, including doctors, midwives, doulas, nurses, social workers, and psychologists, and contributes more broadly to the national conversation about birth choices in the USA.

This study shares information from qualitative interviews with Black women and women who are survivors of abuse regarding their choice to have a planned out-of-hospital birth, or to choose an unassisted birth (UAB) with no midwife or other professional birth attendant. Black women are less well represented among those who choose OOHB, and little is known about the reasons that they may choose OOHB. Previous studies show that women who have experienced childhood physical or sexual abuse may prioritize having a sense of control and autonomy during their birthing experiences; however, little is known about their specific choice for OOHB. Our study recruited 18 women who had an OOHB or UAB and who identified as either Black and/or survivors of trauma to participate in in-depth interviews concerning their choice to give birth out of hospital. Through qualitative research methods, we analyzed transcripts of these interviews and developed a theoretical model about women’s decision making related to OOHB or UAB. We found that women may choose OOHB or UAB because of a previous trauma, or because they feel discriminated against by healthcare professionals, either because of skin color, age, pregnancy, weight, or some other health condition, and that choosing OOHB or UAB allowed them to have more control during the process of giving birth. Understanding the role that previous trauma and experiences of discrimination play in birthplace choice may help birth professionals to consider bodily autonomy, physical and emotional safety, anti-racism, and independence as important factors in their clinical interactions with birthing women.

Neonatal Hypoxic Ischemic Encephalopathy and Planned Home Birth

INTRODUCTION

As planned home births increase, emerging evidence on the perinatal outcomes of newborns who were planned hospital births versus planned home births has been inconsistent, and a growing number of states have attempted to legislate community births. We sought to determine whether an association exists between neonatal hypoxic ischemic encephalopathy (HIE), a complication of ischemic birth injury, and planned location of birth.

METHODS

A case-control study design was used to compare data from neonates with HIE obtained from electronic health records at Kapiolani Medical Center for Women and Children in Honolulu, Hawaii, with data from neonates without HIE obtained from Hawaii state birth certificate data. A penalized backward stepwise logistic regression was performed to control for confounders.

RESULTS

We included 164 neonates with HIE and 656 neonates in the control group. The odds of having been a planned home birth were 2.77 times higher in neonates with HIE compared with those without HIE (95% CI, 1.05-6.87). After adjusting for insurance, mode of birth, meconium fluid, maternal hypertension, and chorioamnionitis, neonates with HIE were still more likely to have been a planned home birth compared with those without HIE (odds ratio, 11.56; 95% CI, 1.37-118.77).

DISCUSSION

Neonates with HIE were more likely to have been a planned home birth compared with neonates without HIE.

Let complete numbers speak for themselves

The authors describe the challenges they encountered, having attempted to retrospectively complete a home birth outcome data set for New York State. In addition, they provide a compelling argument for a midwifery data collective that would bring together health record data for all midwife-attended births nationwide, regardless of setting.

What Mother, Midwives, and Traditional Birth Helper Said About Early Initiation of Breastfeeding in Buginese-Bajo Culture

Introduction

The aim of this study is to investigate how mothers, families, midwives, and traditional birth attendants in the Buginese-Bajo culture understanding breastfeeding and early initiation of breastfeeding (EIBF). Also to assess what support mothers receive from families, midwives, and traditional birth attendants during pregnancy, birth, and EIBF.

Methods

This qualitative study included 21 subjects (11 pregnant women, three midwives, and seven traditional birth attendants). Recorded interviews with the three groups of participants were transcribed verbatim and analyzed separately, using latent content analysis. The study started in December 2014 and ended in July 2015.

Results

Some mothers understood the meaning of EIBF, but engaged in it for different reasons. The midwives interpreted the principle of EIBF differently from a duration perspective. Traditional birth attendants explained it as a way to strengthen the relationship between mothers, and babies; they believed that prolonging breastfeeding until 2 years would change babies into caring children. According to them, this skin-to-skin contact has been practice for a century by traditional birth helpers. The philosophy of breastfeeding, according to the Buginese-Bajo, is creating “peru” relationships for mothers and babies each other for their whole lives.

Conclusion

These findings show a connection between established science and cultural beliefs. The concept of peru is the central philosophy to be achieved in EIBF. Breast-feeding's psychological value is known and passed from generation to generation; this essential fact needs to be preserved as local capital for changing breastfeeding behavior. The government should pay more attention to this opportunity to increase awareness and promote breastfeeding behavior changes.

The role of midwifery and other international insights for maternity care in the United States: An analysis of four countries

BACKGROUND

The United States (US) spends more on health care than any other high-resource country. Despite this, their maternal and newborn outcomes are worse than all other countries with similar levels of economic development. Our purpose was to describe maternal and newborn outcomes and organization of care in four high-resource countries (Australia, Canada, the Netherlands, and United Kingdom) with consistently better outcomes and lower health care costs, and to identify opportunities for emulation and improvement in the United States.

METHOD

We examined resources that described health care organization and financing, provider types, birth settings, national, clinical guidelines, health care policies, surveillance data, and information for consumers. We conducted interviews with country stakeholders representing the disciplines of obstetrics, midwifery, pediatrics, neonatology, epidemiology, sociology, political science, public health, and health services. The results of the analysis were compared and contrasted with the US maternity system.

RESULTS

The four countries had lower rates of maternal mortality, low birthweight, and newborn and infant death than the United States. Five commonalities were identified as follows: (1) affordable/ accessible health care, (2) a maternity workforce that emphasized midwifery care and interprofessional collaboration, (3) respectful care and maternal autonomy, (4) evidence-based guidelines on place of birth, and (5) national data collections systems.

CONCLUSIONS

The findings reveal marked differences in the other countries compared to the United States. It is critical to consider the evidence for improved maternal and newborn outcomes with different models of care and to examine US cultural and structural failures that are leading to unacceptable and substandard maternal and infant outcomes.

Maternal outcomes and birth interventions among women who begin labour intending to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analyses

BACKGROUND

We previously concluded that risk of stillbirth, neonatal mortality or morbidity is not different whether birth is intended at home or hospital. Here, we compare the occurrence of birth interventions and maternal outcomes among low-risk women who begin labour intending to birth at home compared to women intending to birth in hospital.

METHODS

We used our registered protocol (PROSPERO, http://www.crd.york.ac.uk, No.CRD42013004046) and searched five databases from 1990-2018. Using R, we obtained pooled estimates of effect (accounting for study design, study setting and parity).

FINDINGS

16 studies provided data from ~500,000 intended home births for the meta-analyses. There were no reported maternal deaths. When controlling for parity in well-integrated settings we found women intending to give birth at home compared to hospital were less likely to experience: caesarean section OR 0.58(0.44,0.77); operative vaginal birth OR 0.42(0.23,0.76); epidural analgesia OR 0.30(0.24,0.38); episiotomy OR 0.45(0.28,0.73); 3rd or 4th degree tear OR 0.57(0.43,0.75); oxytocin augmentation OR 0.37(0.26,0.51) and maternal infection OR 0.23(0.15,0.35). Pooled results for postpartum haemorrhage showed women intending home births were either less likely or did not differ from those intending hospital birth [OR 0.66(0.54,0.80) and RR 1.30(0.79,2.13) from 2 studies that could not be pooled with the others]. Similar results were found when data were stratified by parity and by degree of integration into health systems.

INTERPRETATION

Among low-risk women, those intending to birth at home experienced fewer birth interventions and untoward maternal outcomes. These findings along with earlier work reporting neonatal outcomes inform families, health care providers and policy makers around the safety of intended home births.

FUNDING

Partial funding: Association of Ontario Midwives open peer reviewed grant.

Trends in very early discharge from hospital for newborns under midwifery care in Ontario from 2003 to 2017: a retrospective cohort study

BACKGROUND

Very early discharge from hospital is an element of Ontario midwifery care. Our aim in the present study was to describe the frequency of very early hospital discharge for newborns in Ontario midwifery care over time.

METHODS

We conducted a retrospective population-based cohort study, including all midwife-attended singleton term cephalic newborns delivered by spontaneous vaginal birth at Ontario hospitals between April 2003 and February 2017. Our primary outcome was very early hospital discharge (< 6 h after birth) for newborns. Secondary outcomes were pediatric consultation before hospital discharge, phototherapy before hospital discharge and readmission for treatment of jaundice. We used generalized linear mixed models to estimate the relation between maternal, neonatal and hospital factors and very early discharge, while accounting for clustering by hospital.

RESULTS

The study cohort included 101 852 newborns born at 89 hospitals. Between 2003/04 and 2016/17, the unadjusted rate of very early discharge decreased from 34.3% to 30.7%. This trend was not significant after adjustment for covariates (odds ratio 1.0, 95% confidence interval 0.99-1.0). Unadjusted rates of pediatric consultation, phototherapy and readmission for jaundice all rose slightly over the study period. Hospital-specific risk-adjusted frequencies of very early discharge ranged from 5% (n = 1479) to 83% (n = 3459) across the 75 Ontario hospitals with at least 100 newborns included in the study cohort.

INTERPRETATION

Hospital-level factors contributed to the observed decrease in crude rates of very early discharge for midwifery clients. Wide variation in these rates across Ontario hospitals points to room for improvement to make more efficient use of health care resources by promoting optimal levels of very early discharge.

Understanding the conditions that influence the roles of midwives in Ontario, Canada's health system: an embedded single-case study

BACKGROUND

Despite the significant variability in the role and integration of midwifery across provincial and territorial health systems, there has been limited scholarly inquiry into whether, how and under what conditions midwifery has been assigned roles and integrated into Canada's health systems.

METHODS

We use Yin's (2014) embedded single-case study design, which allows for an in-depth exploration to qualitatively assess how, since the regulation of midwives in 1994, the Ontario health system has assigned roles to and integrated midwives as a service delivery option. Kingdon's agenda setting and 3i + E theoretical frameworks are used to analyze two recent key policy directions (decision to fund freestanding midwifery-led birth centres and the Patients First primary care reform) that presented opportunities for the integration of midwives into the health system. Data were collected from key informant interviews and documents.

RESULTS

Nineteen key informant interviews were conducted, and 50 documents were reviewed in addition to field notes taken during the interviews. Our findings suggest that while midwifery was created as a self-regulated profession in 1994, health-system transformation initiatives have restricted the profession's integration into Ontario's health system. The policy legacies of how past decisions influence the decisions possible today have the most explanatory power to understand why midwives have had limited integration into interprofessional maternity care. The most important policy legacies to emerge from the analyses were related to payment mechanisms. In the medical model, payment mechanisms privilege physician-provided and hospital-based services, while payment mechanisms in the midwifery model have imposed unintended restrictions on the profession's ability to practice in interprofessional environments.

CONCLUSIONS

This is the first study to explain why midwives have not been fully integrated into the Ontario health system, as well as the limitations placed on their roles and scope of practice. The study also builds a theoretical understanding of the integration process of healthcare professions within health systems and how policy legacies shape service delivery options.

Home and Birth Center Birth in the United States: Time for Greater Collaboration Across Models of Care

There has been a small, but significant, increase in community births (home and birth-center births) in the United States in recent years. The rate increased by 20% from 2004 to 2008, and another 59% from 2008 to 2012, though the overall rate is still low at less than 2%. Although the United States is not the only country with a large majority of births occurring in the hospital, there are other high-resource countries where home and birth-center birth are far more common and where community midwives (those attending births at home and in birth centers) are far more central to the provision of care. In many such countries, the differences in perinatal outcomes between hospital and community births are small, and there are lower rates of maternal morbidity in the community setting. In the United States, perinatal mortality appears to be higher for community births, though there has yet to be a national study comparing outcomes across settings that controls for planned place of birth. Rates of intervention, including cesarean delivery, are significantly higher in hospital births in the United States. Compared with the United States, countries that have higher rates of community births have better integrated systems with clearer national guidelines governing risk criteria and planned birth location, as well as transfer to higher levels of care. Differences in outcomes, systems, approaches, and client motivations are important to understand, because they are critical to the processes of person-centered care and to risk reduction across all birth settings.

Unplanned Out-of-Hospital Birth-Short and Long-Term Consequences for the Offspring

The unpredictable nature of childbirth infrequently results in unplanned out-of-hospital birth, in a pre-hospital setting. We evaluated the perinatal and long-term outcome of children accidentally born out-of-hospital. This was a population-based analysis of singleton deliveries occurring at a single tertiary hospital. The maternal characteristics and pregnancy outcome of unplanned out-of-hospital births were compared with in-hospital attended deliveries. Long-term cumulative incidence of hospitalizations (up to 18 years) involving respiratory, neurological, endocrine or infectious morbidity were evaluated using Kaplan-Meier survival curves and Cox regression models were used to control for confounders. In total, 243,682 deliveries were included, and 1.5% (n = 3580) were unplanned out-of-hospital births. Most occurred in multiparous women, and about a quarter of these women had inadequate prenatal care. Perinatal mortality rate was significantly higher for out-of-hospital births as compared with in-hospital births (OR = 2.9; 95% CI 2.2-3.8, p < 0.001). Kaplan-Meier survival curves demonstrated a significantly lower cumulative incidence of hospitalizations of children born out-of-hospital and the Cox models showed that hospitalization rates involving any of the above morbidities were significantly lower in children born out-of-hospital. While perinatal mortality was higher in unplanned out-of-hospital births, offspring born out-of-hospital showed a lower incidence of hospitalizations involving a variety of morbidities, possibly owing to under-utilization of healthcare services in this population.

Water Birth and Perinatal Outcomes in British Columbia: A Retrospective Cohort Study

OBJECTIVE

This study aimed to quantify adverse neonatal outcomes in a cohort of registered midwife (RM)-attended conventional and water births in British Columbia.

METHODS

The study included all term singleton births in British Columbia between January 1, 2005 and March 31, 2016 attended by RMs. Births were allocated to a conventional birth cohort or a water birth cohort according to where the actual birth of the neonate took place. The primary outcome was a composite adverse neonatal outcome (Apgar <7 at 5 minutes, resuscitation need, neonatal intensive care unit admission). Secondary outcomes included individual components of the primary outcome, maternal length of labour, and degree of perineal laceration (Canadian Task Force Classification Level II-2).

RESULTS

The population included 25 798 births. Of these, 23 201 were conventional, and 2567 were water births. The rate of the composite adverse neonatal outcome was not higher in water births compared with conventional births (hospital conventional, 5.0%; hospital water, 4.2%; home conventional, 3.4%; and home water, 2.9%). Rates of individual components of the composite adverse neonatal score were not greater in the water birth cohort. Maternal outcomes included statistically shorter labours in the water birth cohort and no difference between the cohorts in incidence of third- and fourth-degree lacerations.

CONCLUSION

Water births attended by RMs in British Columbia are not associated with higher rates of adverse neonatal outcomes than conventional births attended by midwives.

Perinatal or neonatal mortality among women who intend at the onset of labour to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analyses

BACKGROUND

More women are choosing to birth at home in well-resourced countries. Concerns persist that out-of-hospital birth contributes to higher perinatal and neonatal mortality. This systematic review and meta-analyses determines if risk of fetal or neonatal loss differs among low-risk women who begin labour intending to give birth at home compared to low-risk women intending to give birth in hospital.

METHODS

In April 2018 we searched five databases from 1990 onward and used R to obtain pooled estimates of effect. We stratified by study design, study settings and parity. The primary outcome is any perinatal or neonatal death after the onset of labour. The study protocol is peer-reviewed, published and registered (PROSPERO No.CRD42013004046).

FINDINGS

We identified 14 studies eligible for meta-analysis including ~ 500,000 intended home births. Among nulliparous women intending a home birth in settings where midwives attending home birth are well-integrated in health services, the odds ratio (OR) of perinatal or neonatal mortality compared to those intending hospital birth was 1.07 (95% Confidence Interval [CI], 0.70 to 1.65); and in less integrated settings 3.17 (95% CI, 0.73 to 13.76). Among multiparous women intending a home birth in well-integrated settings, the estimated OR compared to those intending a hospital birth was 1.08 (95% CI, 0.84 to 1.38); and in less integrated settings was 1.58 (95% CI, 0.50 to 5.03).

INTERPRETATION

The risk of perinatal or neonatal mortality was not different when birth was intended at home or in hospital.

FUNDING

Partial funding: Association of Ontario Midwives open peer reviewed grant.

RESEARCH IN CONTEXT

Evidence before this study Although there is increasing acceptance for intended home birth as a choice for birthing women, controversy about its safety persists. The varying responses of obstetrical societies to intended home birth provide evidence of contrasting views. A Cochrane review of randomised controlled trials addressing this topic included one small trial and noted that in the absence of adequately sized randomised controlled trials on the topic of intended home compared to intended hospital birth, a peer reviewed protocol be published to guide a systematic review and meta-analysis including observational studies. Reviews to date have been limited by design or methodological issues and none has used a protocol published a priori.Added value of this study Individual studies are underpowered to detect small but potentially important differences in rare outcomes. This study uses a published peer-reviewed protocol and is the largest and most comprehensive meta-analysis comparing outcomes of intended home and hospital birth. We take study design, parity and jurisdictional support for home birth into account. Our study provides much needed information to policy makers, care providers and women and families when planning for birth.Implications of all the available evidence Women who are low risk and who intend to give birth at home do not appear to have a different risk of fetal or neonatal loss compared to a population of similarly low risk women intending to give birth in hospital.

Planned home birth in Slovenia-Are we ready?

Nowadays, women want a more intimate and familiar atmosphere during labour, which results in increased planned home birth rates. Every woman has the autonomy to decide where she will give birth; however, it is important that she is informed of risks and advantages beforehand. Home births can be distinguished between planned and unplanned home births. Planned home births can be conducted by professional birth attendants (licensed midwives) or birth assistants (doulas, etc). The rates of Slovenian women who decided to deliver at home are increasing year by year. Researches on home births still present discordant data about home birth safety. Their findings have shown that the main advantage of home birth is a spontaneous birth without medical interventions, especially in multiparous low-risk women. The main disadvantage, however, is a higher risk for neonatal death, in particular on occurrence of complications requiring a transfer to hospital and surgical intervention. Global guidelines emphasize careful selection of candidates suitable for home birth, well-informed pregnant women, education of birth attendants, and strict formation of transfer indications.

Outcomes by birth setting and caregiver for low risk women in Indonesia: a systematic literature review

BACKGROUND

Care for women during pregnancy, labour, birth and the postpartum period is essential to reducing maternal and neonatal mortality and morbidity, however the ideal place and organisation of care provision has not been established. The World Health Organization recommends a two-tier maternity care system involving first-level care in community facilities, with backup obstetric hospital care. However, evidence from high-income countries is increasingly showing benefits for low risk women birthing outside of hospital with skilled birth assistance and access to backup care, including lower rates of intervention. Indonesia is a lower middle-income country with a network of village based midwives who attend births at homes, clinics and hospitals, and has reduced mortality rates in recent decades while maintaining largely low rates of intervention. However, the country has not met its neonatal or maternal mortality reduction goals, and it is unclear whether greater improvements could be made if all women birthed in hospital. BODY: This paper reviewed the literature on birth outcomes by place of birth and/or caregiver for women considering their risk of complications in Indonesia. A systematic literature search of Pubmed, CINAHL, CENTRAL, Web of Science, Popline, WHOLIS and clinical trials registers in 2016 and updated in 2018 resulted in screening 2211 studies after removing duplicates. Twenty four studies were found to present outcomes by place of birth or caregiver and were included. The studies were varied in their findings with respect of the outcomes for women birthing at home and in hospital, with and without skilled care. The quality of most studies was rated as poor or moderate using the Effective Public Health Practice Project Quality Assessment Tool. Only one study gave an overall assessment of the risk status of the women included, making it impossible to draw conclusions about outcomes for low risk women specifically; other studies adjusted for various individual risk factors.

CONCLUSION

From the studies in this review, it is impossible to assess the outcomes for low risk women birthing with health professionals within and outside of Indonesian hospitals. This finding is supported by reviews from other countries with developing maternity systems. Better evidence and information is needed before determinations can be made about whether attended birth outside of hospitals is a safe option for low risk women outside of high income countries.

Creating the first national linked dataset on perinatal and maternal outcomes in Australia: Methods and challenges

BACKGROUND

Data linkage offers a powerful mechanism for examining healthcare outcomes across populations and can generate substantial robust datasets using routinely collected electronic data. However, it presents methodological challenges, especially in Australia where eight separate states and territories maintain health datasets. This study used linked data to investigate perinatal and maternal outcomes in relation to place of birth. It examined data from all eight jurisdictions regarding births planned in hospitals, birth centres and at home. Data linkage enabled the first Australia-wide dataset on birth outcomes. However, jurisdictional differences in data collection created challenges in obtaining comparable cohorts of women with similar low-risk pregnancies in all birth settings. The objective of this paper is to describe the techniques for managing previously linked data, and specifically for ensuring the resulting dataset contained only low-risk pregnancies.

METHODS

This paper indicates the procedures for preparing and merging linked perinatal, inpatient and mortality data from different sources, providing technical guidance to address challenges arising in linked data study designs.

RESULTS

We combined data from eight jurisdictions linking four collections of administrative healthcare and civil registration data. The merging process ensured that variables were consistent, compatible and relevant to study aims. To generate comparable cohorts for all three birth settings, we developed increasingly complex strategies to ensure that the dataset eliminated women with pregnancies at risk of complications during labour and birth. It was then possible to compare birth outcomes for comparable samples, enabling specific examination of the impact of birth setting on maternal and infant safety across Australia.

CONCLUSIONS

Data linkage is a valuable resource to enhance knowledge about birth outcomes from different settings, notwithstanding methodological challenges. Researchers can develop and share practical techniques to address these challenges. Study findings suggest that jurisdictions develop more consistent data collections to facilitate future data linkage.

Understanding the Allocation of Caesarean Outcome to Provider Type: A Chart Review

Introduction:

The concept, “most responsible provider” has a specific definition in the Canadian National Discharge Abstract Database (DAD). Variation exists in how care providers are defined in administrative data.

Methods:

We compared chart data with administrative data to understand how “most responsible provider” was identified in these two data sources.

Results:

We found a 3% discrepancy between data sources. Differences between data sources were attributable to transfers in care that occurred at birth.

Discussion:

“Most responsible provider” should consider the full trajectory of care when assigning outcomes in order to understand how to best support optimal health among low-risk births.

Planned home deliveries in Finland, 1996-2013

OBJECTIVE

To evaluate trends and perinatal outcomes of planned home deliveries in Finland.

STUDY DESIGN

All infants born in 1996-2013, excluding those born preterm, by operative delivery, and without information on birth mode or gestational age, were studied. The study group included 170 infants born at home as planned, 720,047 infants born at hospital were controls.

RESULT

The rate of planned home deliveries increased from 8.3 to 39.4 per 100,000. In the study group 63%, containing two perinatal deaths, were not low-risk pregnancies according to national guidelines. The rate of hypothermia, asphyxia, and need of invasive ventilation was increased in low-risk home deliveries. One infant had a major congenital malformation. Maternal outcomes were favorable.

CONCLUSION

The rate of planned home deliveries increased. Guidelines for low-risk deliveries were not followed in a majority of cases, including two perinatal deaths. Even in low-risk home deliveries, the neonatal morbidity appeared to be increased.

Distance from Home Birth to Emergency Obstetric Services and Neonatal Outcomes: A Cohort Study

INTRODUCTION

Little is known about the relationship between distance from hospital services and the outcomes of planned home births. We examined whether greater driving distance from a hospital with continuous cesarean capability was associated with a higher risk of adverse neonatal outcome among individuals who were planning to give birth at home.

METHODS

Using an intention-to-treat analysis, we conducted a population-based cohort study of 11,869 individuals who planned to give birth at home in Ontario, Canada, between April 1, 2012, and March 31, 2015. We used postal codes to determine the driving time from maternal residence to the closest hospital offering level 2 or higher maternity care services (ie, hospital with continuous cesarean birth capability). We used log binomial regression analysis to compare the outcomes of individuals who planned a birth more than a 30-minute drive from a level 2 hospital with those of individuals whose births were planned to occur within 30 minutes. We adjusted for maternal age, parity, gestational age, season, and maternal material deprivation quintile.

RESULTS

We found no statistically significant difference in the rates of 5-minute Apgar scores less than 7 (adjusted relative risk [aRR], 1.02; 95% CI, 0.95-1.10; P = .58), perinatal mortality, meconium aspiration syndrome, and emergency medical service usage. Neonates born to individuals who planned to give birth at a greater distance from a hospital had a lower rate of neonatal intensive care unit admission (aRR, 0.6; 95% CI, 0.44-0.81; P = .001).

DISCUSSION

We found no increased risk of adverse neonatal outcomes for births that were planned to occur more than 30 minutes from a hospital. Our findings can be considered, along with individual risk factors and contextual factors, in decision making about the choice of home birth for individuals who live more than half an hour from a hospital with cesarean capacity.

Outcomes for the First Year of Ontario's Birth Center Demonstration Project

INTRODUCTION

In 2014, Ontario opened 2 stand-alone midwifery-led birth centers. Using mixed methods, we evaluated the first year of operations for quality and safety, client experience, and integration into the maternity care community. This article reports on our study of safety and quality of care.

METHODS

This descriptive evaluation focused on women admitted to a birth center at the beginning of labor. For context, we matched this cohort (on a 1:4 basis) with similar low-risk midwifery clients giving birth in a hospital. Data sources included Ontario's Better Outcomes Registry and Network (BORN) Information System, the Canadian Institute for Health Information, Ontario census data, and birth center records.

RESULTS

Of 495 women admitted to a birth center, 87.9% experienced a spontaneous vaginal birth, regardless of the eventual location of birth, and 7.7% had a cesarean birth. The transport rate to a hospital was 26.3%. When compared with midwifery clients with a planned hospital birth, rates of intervention (epidural analgesia, labor augmentation, assisted vaginal birth, and cesarean birth) were significantly lower in the planned birth center group, even when controlled for previous cesarean birth and body mass index. Markers of potential morbidity were identified in about 10% of birth center births; however, there were no short-term health impacts up to discharge from midwifery care at 6 weeks postpartum. Care was low in intervention and safe (minimal negative outcomes and transport rates comparable to the literature).

DISCUSSION

In the first year of operation, care was consistent with national guidelines, and morbidity and mortality rates and intervention rates were low for women with low-risk pregnancies seeking a low-intervention approach for labor and birth. Further evaluation to confirm these findings is required as the number of births grows.

Planned private homebirth in Victoria 2000-2015: a retrospective cohort study of Victorian perinatal data

BACKGROUND

The outcomes for planned homebirth in Victoria are unknown. We aimed to compare the rates of outcomes for high risk and low risk women who planned to birth at home compared to those who planned to birth in hospital.

METHODS

We undertook a population based cohort study of all births in Victoria, Australia 2000-2015. Women were defined as being of low or high risk of adverse pregnancy outcomes according to the eligibility criteria for homebirth and either planning to birth at home or in a hospital setting at the at the onset of labour. Rates of perinatal and maternal mortality and morbidity as well as obstetric interventions were compared.

RESULTS

Three thousand nine hundred forty-five women planned to give birth at home with a privately practising midwife and 829,286 women planned to give birth in a hospital setting. Regardless of risk status, planned homebirth was associated with significantly lower rates of all obstetric interventions and higher rates of spontaneous vaginal birth (p ≤ 0.0001 for all). For low risk women the rates of perinatal mortality were similar (1.6 per 1000 v's 1.7 per 1000; p = 0.90) and overall composite perinatal (3.6% v's 13.4%; p ≤ 0.001) and maternal morbidities (10.7% v's 17.3%; p ≤ 0.001) were significantly lower for those planning a homebirth. Planned homebirth among high risk women was associated with significantly higher rates of perinatal mortality (9.3 per 1000 v's 3.5 per 1000; p = 0.009) but an overall significant decrease in composite perinatal (7.8% v's 16.9%; p ≤ 0.001) and maternal morbidities (16.7% v's 24.6%; p ≤ 0.001).

CONCLUSION

Regardless of risk status, planned homebirth was associated with significantly lower rates of obstetric interventions and combined overall maternal and perinatal morbidities. For low risk women, planned homebirth was also associated with similar risks of perinatal mortality, however for women with recognized risk factors, planned homebirth was associated with significantly higher rates of perinatal mortality.

Home birth integration into the health care systems of eleven international jurisdictions

BACKGROUND

The purpose of this study was to develop assessment criteria that could be used to examine the level of integration of home birth within larger health care systems in developed countries across 11 international jurisdictions.

METHODS

An expert panel developed criteria and a definition to assess home birth integration within health care systems. We selected jurisdictions based on the publications that were eligible for inclusion in our systematic review and meta-analysis on planned place of birth. We sent the authors of the included publications a questionnaire about home birth practitioners and practices in their respective health care system at the time of their studies. We searched published peer-reviewed, non-peer-reviewed, and gray literature, and the websites of professional bodies to document information about home birth integration in each jurisdiction based on our criteria. Where information was lacking, we contacted experts in the field from the relevant jurisdiction.

RESULTS

Home birth is well integrated into the health care system in British Columbia (Canada), England, Iceland, the Netherlands, New Zealand, Ontario (Canada), and Washington State (USA). Home birth is less well integrated into the health care system in Australia, Japan, Norway, and Sweden.

CONCLUSIONS

This paper is the first to propose criteria for the evaluation of home birth integration within larger maternity care systems. Application of these criteria across 11 international jurisdictions indicates differences in the recognition and training of home birth practitioners, in access to hospital facilities, and in the supplies and equipment available at home births, which give rise to variation in the level of integration across different settings. Standardized criteria for the evaluation of systems integration are essential for interpreting planned home birth outcomes that emerge from contextual differences.

The Integration of Ontario Birth Centers into Existing Maternal-Newborn Services: Health Care Provider Experiences

INTRODUCTION

In 2014, 2 freestanding, midwifery-led birth centers opened in Ontario, Canada. The purpose of this study was to qualitatively investigate the integration of the birth centers into the local, preexisting intrapartum systems from the perspective of health care providers and managerial staff.

METHODS

Focus groups or interviews were conducted with health care providers (paramedics, midwives, nurses, physicians) and managerial staff who had experienced urgent and/or nonurgent maternal or newborn transports from a birth center to one of 4 hospitals in Ottawa or Toronto. A descriptive qualitative approach to data analysis was undertaken.

RESULTS

Twenty-four health care providers and managerial staff participated in a focus group or interview. Participants described positive experiences transporting women and/or newborns from the birth centers to hospitals; these positive experiences were attributed to the collaborative planning, training, and communication that occurred prior to opening the birth centers. The degree of integration was dependent on hospital-specific characteristics such as history, culture, and the presence or absence of midwifery privileging. Participants described the need for only minor improvements to administrative processes as well as the challenge of keeping large numbers of staff updated with respect to urgent transport policies. Planning and opening of the birth centers was seen as a driving force in further integrating midwifery care and improving interprofessional practice.

DISCUSSION

The collaborative approach for the planning and implementation of the birth centers was a key factor in the successful integration into the existing maternal-newborn system and contributed to improving integrated professional practice among midwives, paramedics, nurses, and physicians. This approach may be used as a template for the integration of other new independent health care facilities and programs into the existing health care system.

Social Network Analysis Applied to a Historical Ethnographic Study Surrounding Home Birth

Safety during birth has improved since hospital delivery became standard practice, but the process has also become increasingly medicalised. Hence, recent years have witnessed a growing interest in home births due to the advantages it offers to mothers and their newborn infants. The aims of the present study were to confirm the transition from a home birth model of care to a scenario in which deliveries began to occur almost exclusively in a hospital setting; to define the social networks surrounding home births; and to determine whether geography exerted any influence on the social networks surrounding home births. Adopting a qualitative approach, we recruited 19 women who had given birth at home in the mid 20th century in a rural area in Spain. We employed a social network analysis method. Our results revealed three essential aspects that remain relevant today: the importance of health professionals in home delivery care, the importance of the mother’s primary network, and the influence of the geographical location of the actors involved in childbirth. All of these factors must be taken into consideration when developing strategies for maternal health.

'I didn't think you were allowed that, they didn't mention that.' A qualitative study exploring women's perceptions of home birth

Background

Evidence suggests that home birth is as safe as hospital birth for low risk multiparous women, and is associated with reduced intervention rates and increased rates of normal birth. However the home birth rate in the UK is low, and few women choose this option. The aims of this study were to identify what influences multiparous women’s choice of birth place, and to explore their views of home birth.

Methods

Five focus groups were conducted with multiparous women (n = 28) attending mother and baby groups in a city in the UK with a diverse multi-ethnic population. Data were analysed thematically using the Framework Method, combining deductive and inductive approaches to the data.

Results

Several themes were developed from the data, these were: the expectation that birth would take place in an Obstetric Unit; perceptions of birth as a ‘natural’ event; lack of knowledge of what home birth looked like; and a lack of confidence in the reliability of the maternity service. Two themes emerged regarding the influences on women’s choices: clear information provision, particularly for those from ethnic minority groups, and the role of health care professionals. A final theme concerned women’s responses to the offer of choice.

Conclusions

There are gaps in women’s knowledge about the reality and practicalities of giving birth at home that have not been previously identified. Other findings are consistent with existing evidence, suggesting that many women still do not receive consistent, comprehensive information about home birth. The findings from this research can be used to develop approaches to meet women’s information and support needs, and facilitate genuine choice of place of birth.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1733-1) contains supplementary material, which is available to authorized users.

“Lost births,” service delivery, and human resources to health

Purpose

The purpose of this paper is to advocate for improved service delivery of maternal-newborn care in northern Indigenous communities. This is done through critical examination of the loss of pregnancy and birthing knowledge and practice in these communities, from both a historical and contemporary lens. Supporting the return of traditional midwifery practices to the communities is the recommended solution.

Design/methodology/approach

The paper is a general review of the available literature regarding Indigenous birthing practices, historical and contemporary Canadian maternal health service provision, and midwifery.

Findings

Current maternal health care practice in these northern communities is not resolving service delivery and human resource inadequacies, highlighting the need for a community-based and midwifery-driven primary health care approach. Potential recommendations include implementing a comprehensive birthing initiative, innovative midwifery training, and promotion and support of the role of the community midwife.

Originality/value

“Lost births” is a largely unrecognized issue in Canadian public health literature. The value of this paper lies in its potential to stimulate discourse and advocacy.

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.

Length of Stay, Health Care Cost, Postpartum Discomfort, and Satisfaction with Medical Service in Puerperas Giving Birth in Midwifery Clinic and Hospitals

PURPOSE

To determine traits related to pregnancy and delivery, length of stay, health care cost, postpartum discomfort, and satisfaction with medical service of puerperas giving birth in midwifery clinic and hospitals.

METHODS

This study used a comparative survey design. Data were collected from a total of 140 postpartum mothers composed of 70 mothers who gave births in two hospitals and another 70 mothers who delivered in one midwifery clinic.

RESULTS

Delivery in midwifery clinic had higher Apgar score at 1 minute and 5 minutes after birth than hospital. Those who delivered in midwifery clinic had shorter stay in the clinic, fewer health care cost, less postpartum discomfort in physical, environmental, social, and cultural areas, higher satisfaction with medical services than those who delivered in hospitals.

CONCLUSION

Results of this study can be used as a basis for studies on giving birth in midwifery clinic and hospitals. They might increase the autonomy of women in giving birth with positive effect on the delivery experience of the mother and her spouse.

Out-of-hospital births in California 1991-2011

OBJECTIVE

We investigated the frequencies and characteristics of out-of-hospital births in a 20-year period in California, where 1 of every 7 births in the United States occurs.

STUDY DESIGN

Birth certificate records of deliveries in California between 1991 and 2011 were analyzed. Out-of-hospital births were assessed by year, parity, gestational age and maternal race/ethnicity.

RESULTS

In the 20-year period there were 10 593,904 deliveries, of which 46 243 occurred out of hospital (0.44%). Out-of-hospital births decreased from 0.54 to 0.38% per year between 1991 and 2004, and increased from 0.41% in 2005 to 0.61% in 2011. In contrast, preterm out-of-hospital births declined from 7.2% in 2006 to 5.0% in 2011. The frequency of vaginal birth after cesarean in the out-of-hospital birth cohort increased from 1.2% (n=19) in 1996 to 4.2% (n=82) in 2011.

CONCLUSION

California birth records from a 20-year period show an increase in out-of-hospital births from years 2005 to 2011, following a period of decline from 1991 to 2004.

Contraindications in planned home birth in Iceland: A retrospective cohort study

OBJECTIVES

Icelandic national guidelines on place of birth list contraindications for home birth. Few studies have examined the effect of contraindication on home birth, and none have done so in Iceland. The aim of this study was to examine whether contraindications affect the outcome of planned home birth or have a different effect at home than in hospital.

METHODS

The study is a retrospective cohort study on the effect of contraindications for home birth on the outcome of planned home (n = 307) and hospital (n = 921) birth in 2005-2009. Outcomes were described for four different groups of women, by exposure to contraindications (unexposed vs. exposed) and planned place of birth (hospital vs. home). Linear and logistic regression analysis was used to evaluate the effect of the contraindications under study and to detect interactions between contraindications and planned place of birth.

RESULTS

The key findings of the study were that contraindications were related to higher rates of adverse maternal and neonatal outcomes, regardless of place of birth; women exposed to contraindications had higher rates of adverse outcomes in planned home birth; and healthy, unexposed women had higher rates of adverse outcomes in planned hospital birth. Contraindications significantly increased the risk of transfer in labour and postpartum haemorrhage in planned home births.

CONCLUSION

The defined contraindications for home birth had a negative effect on maternal and neonatal outcomes in Iceland, regardless of place of birth. The study results do not contradict the current national guidelines on place of birth.

Perspectives on risk: Assessment of risk profiles and outcomes among women planning community birth in the United States

BACKGROUND

There is little agreement on who is a good candidate for community (home or birth center) birth in the United States.

METHODS

Data on n=47 394 midwife-attended, planned community births come from the Midwives Alliance of North America Statistics Project. Logistic regression quantified the independent contribution of 10 risk factors to maternal and neonatal outcomes. Risk factors included: primiparity, advanced maternal age, obesity, gestational diabetes, preeclampsia, postterm pregnancy, twins, breech presentation, history of cesarean and vaginal birth, and history of cesarean without history of vaginal birth. Models controlled additionally for Medicaid, race/ethnicity, and education.

RESULTS

The independent contributions of maternal age and obesity were quite modest, with adjusted odds ratios (AOR) less than 2.0 for all outcomes: hospital transfer, cesarean, perineal trauma, postpartum hemorrhage, low/very-low Apgar, maternal or neonatal hospitalization, NICU admission, and fetal/neonatal death. Breech was strongly associated with morbidity and fetal/neonatal mortality (AOR 8.2, 95% CI, 3.7-18.4). Women with a history of both cesarean and vaginal birth fared better than primiparas across all outcomes; however, women with a history of cesarean but no prior vaginal births had poor outcomes, most notably fetal/neonatal demise (AOR 10.4, 95% CI, 4.8-22.6). Cesarean births were most common in the breech (44.7%), preeclampsia (30.6%), history of cesarean without vaginal birth (22.1%), and primipara (11.0%) groups.

DISCUSSION

The outcomes of labor after cesarean in women with previous vaginal deliveries indicates that guidelines uniformly prohibiting labor after cesarean should be reconsidered for this subgroup. Breech presentation has the highest rate of adverse outcomes supporting management of vaginal breech labor in a hospital setting.

Home delivery among antenatal care booked women in their last pregnancy and associated factors: community-based cross sectional study in Debremarkos town, North West Ethiopia, January 2016

BACKGROUND

In Ethiopia, nearly half of the mothers who were booked for antenatal care, who supposed to have institutional delivery, gave home delivery nationally. Home delivery accounts majority while few of childbirth were attended by the skilled provider in Amhara regional state. This study aimed to determine the proportion of home delivery and associated factors among antenatal care booked women who gave childbirth in the past 1 year in Debremarkos Town, Northwest Ethiopia.

METHODS

A community-based Cross sectional study was conducted from January 1st_- 25th 2016. Epi Info version 7 was used to determine a total sample size of 518 and simple random sampling procedure was employed. Data was collected through an interview by using pretested structured questionnaire. Data were entered into Epi Info version 7, cleaned and exported to SPSS version 21 for analysis. A p-value less than or equals to 0.05 at 95% Confidence Intervals of odds ratio were taken as significance level in the multivariable model.

RESULTS

A total of 127 (25.3%) women gave childbirth at home. Un-attending formal education (Adjusted Odds Ratio = 7.56, 95% CI: [3.28, 17.44]), absence of health facility within 30 min distance (AOR = 3.41, 95% CI: [1.42, 8.20]), not exposed to media (AOR = 4.46, 95% CI: [2.09, 9.49]), Unplanned pregnancy (AOR = 3.47, 95% CI [1.82, 6.61]), attending ANC at health post (AOR = 5.45, 95% CI: (1.21, 24.49) and health center (AOR = 2.74, 95% CI [1.29, 5.82]), perceived privacy during ANC (AOR = 3.69[1.25, 10.91]) and less than four times ANC visit (AOR = 5.04, 95% CI (2.30, 11.04]) were significantly associated with home delivery.

CONCLUSIONS

Home delivery in this study was found to be low. Educational level, media exposure, geographic access to a health facility, Unplanned pregnancy, an institution where ANC was booked, perceived privacy during ANC and number of ANC visit were found to be determinants of home delivery. Health institutions, health professionals, policy makers, community leaders and all concerned with the planning and implementation of maternity care in Ethiopia need to consider these associations in implementing services and providing care, for pregnant women.