Cost effectiveness of alternative planned places of birth in woman at low risk of complications: evidence from the Birthplace in England national prospective cohort study

Exploring Factors Influencing Pregnant Women's Perceptions and Attitudes Towards Midwifery Care in Romania: Implications for Maternal Health Education Strategies

BACKGROUND

Midwives are strong advocates for vaginal births. However, their visibility and accessibility are poorly perceived by women in Romania. Consequently, the women's options are limited to a single direction when pregnancy occurs, involving the family doctor, the obstetrician, and often an interventional technical approach at the time of birth. The aim of this research is to identify specific variables that affect the perceptions and attitudes of pregnant women towards the care provided by midwives. This knowledge could contribute to the development of more effective education and information strategies within maternal health services.

METHODS

A cross-sectional observational analytical survey was conducted in Romania among pregnant women from the general population. Data were collected through a self-administered questionnaire, with informed consent obtained from each participating pregnant woman. The questionnaire was administered online using the cloud-based Google Forms platform and was available on the internet for seven months, from January to July 2023. The questionnaire was distributed through various media channels, both individually and in communication groups, in the form of a link. All questions were mandatory, and the questionnaire could only be submitted after answering all questions.

RESULTS

A total of 1301 individual responses were collected. The analysis of the socio-demographic and obstetrical profile of the pregnant women revealed that approximately half, 689 (52.95%), of the participants were aged between 18-29 years, and 1060 (81.47%) of the participants were married. Among our group of 1301 pregnant women, 973 (74.78%) had higher education, and 987 (75.86%) had a regular job. A majority of the survey participants, 936 (71.94%), lived in an urban geographic area, while 476 (36.58%) had attended childbirth education courses, and 791 (60.79%) were in the third trimester of pregnancy. A total of 298 (22.9%) respondents did not want to give birth in a hospital, and one-third, 347 (26.67%), did not place significant importance on control over the childbirth process.

CONCLUSIONS

The main factors influencing women's decisions regarding perinatal care and the importance of midwives as a component of the maternal-infant care team are modifiable, and thorough educational and psychological preparation would reduce the increasing predominance of preference for cesarean section, thereby promoting healthier and more woman- and child-centered perinatal care.

Validation of the Greek version of Mother's Autonomy in Decision Making (MADM) scale

INTRODUCTION

Ensuring expectant mothers have the capacity to make well-informed decisions regarding their prenatal care, encompassing medical interventions, and birthing preferences are crucial for fostering favorable health outcomes for both mother and newborn. The Mother's Autonomy in Decision Making (MADM) scale serves as a commonly utilized tool for evaluating the autonomy of pregnant women in the decision-making processes related to prenatal care and childbirth. The aim of this study is to validate the MADM scale in women who had at least one home childbirth experience in Greece.

METHODS

A retrospective online survey collected data from Greek women with home childbirth experience (January 2010 - December 2023). We utilized a self-administered questionnaire and the Greek version of the MADM scale.

RESULTS

The study included 162 women, predominantly of Greek nationality (94.4%) and residing in Attica (54%). The MADM scale showed a median score of 38. The confirmatory factor analysis indicated acceptable fit and reliability (comparative fit index, CFI=0.92; Tucker-Lewis index, TLI=0.91; root mean square error of approximation, RMSEA=0.07; Cronbach's α=0.92). Age correlated weakly negatively with the MADM scale score (Spearman's rho= -0.166, p=0.035). Additionally, women attending antenatal preparation courses with a midwife before their first home birth had higher MADM scores (median 39 vs 35, p=0.037).

CONCLUSIONS

The study underscores the importance of the MADM scale, demonstrating its reliability and validity for women living in Greece. Younger age and attending antenatal preparation courses with a midwife were associated with higher MADM scores, highlighting education's role in maternal autonomy.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

The financial impact of offering publicly funded homebirths: A population-based microsimulation in Queensland, Australia

BACKGROUND

Despite strong evidence of benefits and increasing consumer demand for homebirth, Australia has failed to effectively upscale it. To promote the adoption and expansion of homebirth in the public health care system, policymakers require quantifiable results to evaluate its economic value. To date, there has been limited evaluation of the financial impact of birth settings for women at low risk of pregnancy complications.

OBJECTIVE

This study aimed to examine the difference in inpatient costs around birth between offering homebirth in the public maternity system versus not offering public homebirth to selected women who meet low-risk pregnancy criteria.

METHODS

We used a whole-of-population linked administrative dataset containing all women who gave birth in Queensland (one Australian State) between 01/07/2012 and 30/06/2018 where publicly funded homebirth is not currently offered. We created a static microsimulation model to compare the inpatient cost difference for mother and baby around birth based on the women who gave birth between 01/07/2017 and 30/06/2018 (n = 36,314). The model comprised of a base model - representing standard public hospital care, and a counterfactual model - representing a hypothetical scenario where 5 % of women who gave birth in public hospitals planned to give birth at home prior to the onset of labour (n = 1816). Costs were reported in 2021/22 AUD.

RESULTS

In our hypothetical scenario, after considering the effect of assumptive place and mode of birth for these planned homebirths, the estimated State-level inpatient cost saving around birth (summed for mother and babies) per pregnancy were: AU$303.13 (to Queensland public hospitals) and AU$186.94 (to Queensland public hospital funders). This calculates to a total cost saving per annum of AU$11 million (to Queensland public hospitals) and AU$6.8 million (to Queensland public hospital funders).

CONCLUSION

A considerable amount of inpatient health care costs around birth could be saved if 5 % of women booked at their local public hospitals, planned to give birth at home through a public-funded homebirth program. This finding supports the establishment and expansion of the homebirth option in the public health care system.

A systematic review of the cost-effectiveness of maternity models of care

OBJECTIVES

In this systematic review, we aimed to identify the full extent of cost-effectiveness evidence available for evaluating alternative Maternity Models of Care (MMC) and to summarize findings narratively.

METHODS

Articles that included a decision tree or state-based (Markov) model to explore the cost-effectiveness of an MMC, and at least one comparator MMC, were identified from a systematic literature review. The MEDLINE, Embase, Web of Science, CINAHL and Google Scholar databases were searched for papers published in English, Arabic, and French. A narrative synthesis was conducted to analyse results.

RESULTS

Three studies were included; all using cost-effectiveness decision tree models with data sourced from a combination of trials, databases, and the literature. Study quality was fair to poor. Each study compared midwife-led or doula-assisted care to obstetrician- or physician-led care. The findings from these studies indicate that midwife and doula led MMCs may provide value.

CONCLUSION

The findings of these studies indicate weak evidence that midwife and doula models of care may be a cost-effective or cost-saving alternative to standard care. However, the poor quality of evidence, lack of standardised MMC classifications, and the dearth of research conducted in this area are barriers to conclusive evaluation and highlight the need for more research incorporating appropriate models and population diversity.

The first alongside midwifery unit in Spain: A retrospective cohort study of maternal and neonatal outcomes

BACKGROUND

Midwife-led units have been shown to be safer and reduce interventions for women at low risk of complications at birth. In 2017, the first alongside birth center was opened in Spain. The aim of this study was to compare outcomes for women with uncomplicated pregnancies giving birth in the Midwife-led unit (MLU) and in the Obstetric unit (OU) of the same hospital.

METHODS

Retrospective cohort study comparing birth outcomes between low-risk women, depending on their planned place of birth. Data were analyzed with an intention-to-treat approach for women that gave birth between January 2018 and December 2020.

RESULTS

A total of 878 women were included in the study, 255 women chose to give birth in the MLU and 623 in the OU. Findings showed that women in the MLU were more likely to have a vaginal birth (91.4%) than in the OU (83.8%) (aOR 2.98 [95%CI 1.62-5.47]), less likely to have an instrumental delivery, 3.9% versus 11.2% (0.25 [0.11-0.55]), to use epidural analgesia, 19.6% versus 77.9% (0.15 [0.04-0.17]) and to have an episiotomy, 7.4% versus 15.4% (0.27 [0.14-0.53]). There were no differences in rates of postpartum hemorrhage, retained placenta, or adverse neonatal outcomes. Intrapartum and postpartum transfer rates from the MLU to the OU were 21.1% and 2.4%, respectively.

CONCLUSIONS

The high rate of obstetric interventions in Spain could be reduced by implementing midwife-led units across the whole system, without an increase in maternal or neonatal complications.

More than time: travel time to the delivery ward and maternal outcomes - onset of labour, postpartum haemorrhage and obstetric anal sphincter injury

BACKGROUND

Closing delivery units increases travel time for some women. Whether increased travel time is associated with maternal outcomes is important for understanding the consequences of such closures. Previous studies are limited in measuring travel time and restricted to the outcome of caesarean section.

METHODS

Our population-based cohort includes data from the Swedish Pregnancy Register for women giving birth between 2014 and 2017 (N = 364,630). We estimated travel time from home to the delivery ward using coordinate pairs of actual addresses. The association between travel time and onset of labour was modelled using multinomial logistic regression, and logistic regression was used for the outcomes postpartum haemorrhage (PPH) and obstetric anal sphincter injury (OASIS).

FINDINGS

Over three-quarters of women had ≤30 min travel time (median 13.9 min). Women who travelled ≥60 min arrived to care sooner and laboured there longer. Women with further to travel had increased adjusted odds ratio (aOR) of having an elective caesarean section (31-59 min aOR 1.11; 95% confidence interval [CI] 1.07-1.16; ≥60 min aOR 1.25; 95% CI 1.16-1.36) than spontaneous onset of labour. Women (at full term with spontaneous onset) living ≥60 min away had reduced odds of having a PPH (aOR 0.84; 95% CI 0.76-0.94) or OASIS (aOR 0.79; 95% CI 0.66-0.94).

INTERPRETATION

Longer travel time increased the odds of elective caesarean section. Women with furthest to travel arrived sooner and spent more time in care; although they had a lower risk of PPH or OASIS, they also tended to be younger, have a higher body mass index and were Nordic born.

Developing the midwifery Unit Self-Assessment (MUSA) Framework: A mixed methods study in six European midwifery units

OBJECTIVE

Evidence indicates that midwifery units are associated with improved health outcomes and experiences; however, there are barriers to their development and scale-up. Guidelines are crucial to their implementation, ensuring that they are developed and integrated sustainably and safely. This study aimed to evaluate and explore the use of a self-assessment tool and improvement process for midwifery units in Europe.

METHODS

A mixed methods study was conducted with six midwifery units located in Europe. Quantitative and qualitative data were collected and analysed concurrently, and each informed the other, making the approach both interactive and iterative. The six midwifery units were invited to complete the self-assessment tool, the responses of which were analysed descriptively, and implement an improvement process into practice. Interviews were conducted with midwives using the tool and analysed thematically.

RESULTS

Findings indicate benefits and potential feasibility of an improvement process for midwifery units, and suggest that the self-assessment tool is a generative and reflexive practice for midwives. However, issues were identified around limitations of the tool, structural barriers and professional autonomy. Midwifery units require a framework to guide and support their implementation, improvement and scale-up.

CONCLUSION

Results highlight the need for more consideration of how macro-level barriers, encompassing social, legal and political dimensions of maternity care, factor locally in the implementation and scale-up of midwifery units. More research is needed to evaluate the feasibility and outcomes of implementing a self-assessment and improvement framework in midwifery units across Europe.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Maternity service reconfigurations for intrapartum and postnatal midwifery staffing shortages: modelling of low-risk births in England

INTRODUCTION

Choice of birth setting is important and it is valuable to know how reconfiguring available settings may affect midwifery staffing needs. COVID-19-related health system pressures have meant restriction of community births. We aimed to model the potential of service reconfigurations to offset midwifery staffing shortages.

METHODS

We adapted the Birthrate Plus method to develop a tool that models the effects on intrapartum and postnatal midwifery staffing requirements of changing service configurations for low-risk births. We tested our tool on two hypothetical model trusts with different baseline configurations of hospital and community low-risk birth services, representing those most common in England, and applied it to scenarios with midwifery staffing shortages of 15%, 25% and 35%. In scenarios with midwifery staffing shortages above 15%, we modelled restricting community births in line with professional guidance on COVID-19 service reconfiguration. For shortages of 15%, we modelled expanding community births per the target of the Maternity Transformation programme.

RESULTS

Expanding community births with 15% shortages required 0.0 and 0.1 whole-time equivalent more midwives in our respective trusts compared with baseline, representing 0% and 0.1% of overall staffing requirements net of shortages. Restricting home births with 25% shortages reduced midwifery staffing need by 0.1 midwives (-0.1% of staffing) and 0.3 midwives (-0.3%). Suspending community births with 35% shortages meant changes of -0.3 midwives (-0.3%) and -0.5 midwives (-0.5%) in the two trusts. Sensitivity analysis showed that our results were robust even under extreme assumptions.

CONCLUSION

Our model found that reconfiguring maternity services in response to shortages has a negligible effect on intrapartum and postnatal midwifery staffing needs. Given this, with lower degrees of shortage, managers can consider increasing community birth options where there is demand. In situations of severe shortage, reconfiguration cannot recoup the shortage and managers must decide how to modify service arrangements.

What are the strategies for implementing primary care models in maternity? A systematic review on midwifery units

Background

Midwifery Units (MUs) are associated with optimal perinatal outcomes, improved service users’ and professionals’ satisfaction as well as being the most cost-effective option. However, they still do not represent the mainstream option of maternity care in many countries. Understanding effective strategies to integrate this model of care into maternity services could support and inform the MU implementation process that many countries and regions still need to approach.

Methods

A systematic search and screening of qualitative and quantitative research about implementation of new MUs was conducted (Prospero protocol reference: CRD42019141443) using PRISMA guidelines. Included articles were appraised using the CASP checklist. A meta-synthesis approach to analysis was used. No exclusion criteria for time or context were applied to ensure inclusion of different implementation attempts even under different historical and social circumstances. A sensitivity analysis was conducted to reflect the major contribution of higher quality studies.

Results

From 1037 initial citations, twelve studies were identified for inclusion in this review after a screening process. The synthesis highlighted two broad categories: implementation readiness and strategies used. The first included aspects related to cultural, organisational and professional levels of the local context whilst the latter synthesised the main actions and key points identified in the included studies when implementing MUs. A logic model was created to synthesise and visually present the findings.

Conclusions

The studies selected were from a range of settings and time periods and used varying strategies. Nonetheless, consistencies were found across different implementation processes. These findings can be used in the systematic scaling up of MUs and can help in addressing barriers at system, service and individual levels. All three levels need to be addressed when implementing this model of care.

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.

A comparison between midwifery and obstetric care at birth in Spain: Across-sectional study of perinatal outcomes

BACKGROUND

The organizational structure of maternity services determines the choice of which professionals provide care during pregnancy, birth, and the postnatal period, and it influences the kind of care they deliver and the level of continuity of care offered. There is considerable evidence that demonstrates a relationship between how care is provided and the maternal and neonatal health outcomes. Registered midwives and obstetricians provide maternity care across Spain. To date, no studies have assessed whether maternity outcomes differ between these two groups.

OBJECTIVE

The aim of this study was to examine the association between the care received (midwifery care versus obstetric care) and the maternal and neonatal outcomes in women with normal, low- and medium-risk pregnancies in Spain from 2016 to 2019.

DESIGN

A prospective, multicentre, cross-sectional study was carried out as part of COST Action IS1405 at 44 public hospitals in Spain in the years 2016-2019. The protocol can be accessed through the registry ISRCTN14062994. The sample size of this study was 11,537 women. The primary outcome was mode of birth. The secondary outcomes included augmentation with oxytocin, use of epidural analgesia, women's position at birth, perineal integrity, third stage of labour management, maternal and neonatal admission to intensive care, Apgar score, neonatal resuscitation, and early initiation of breastfeeding. Chi-square tests for categorical variables and independent sample t-test for continuous variables to assess differences between the midwifery and obstetric groups were calculated. Odds ratio with intervals of confidence at 95% were calculated for obstetric interventions and perinatal outcomes. A multivariate logistic regression model was applied in order to examine the effect of type of healthcare provider on perinatal outcomes. These models were adjusted for care provider, type of onset of labour, use of anaesthesia, pregnancy risk, maternal age, parity, and gestational age at birth.

RESULTS

Midwifery care was associated with lower rates of operative births and severe perineal damage and had no higher adverse outcomes. No statistically significant differences were observed in the use of other obstetric interventions between the two groups.

CONCLUSIONS

The findings of this study should encourage a shift in the current maternity care system towards a greater integration of midwifery-led services in order to achieve optimal birth outcomes for women and newborns.

REGISTRY NUMBER

ISRCTN14062994.

Modelling the cost of place of birth: a pathway analysis

BACKGROUND

In New South Wales (NSW), Australia there are three settings available for women at low risk of complications to give birth: home, birth centre and hospital. Between 2000 and 2012, 93.6% of babies were planned to be born in hospital, 6.0% in a birth centre and 0.4% at home. Availability of alternative birth settings is limited and the cost of providing birth at home or in a birth centre from the perspective of the health system is unknown.

OBJECTIVES

The objective of this study was to model the cost of the trajectories of women who planned to give birth at home, in a birth centre or in a hospital from the public sector perspective.

METHODS

This was a population-based study using linked datasets from NSW, Australia. Women included met the following selection criteria: 37-41 completed weeks of pregnancy, spontaneous onset of labour, and singleton pregnancy at low risk of complications. We used a decision tree framework to depict the trajectories of these women and Australian Refined-Diagnosis Related Groups (AR-DRGs) were applied to each trajectory to estimate the cost of birth. A scenario analysis was undertaken to model the cost for 30 000 women in one year.

FINDINGS

496 387 women were included in the dataset. Twelve potential outcome pathways were identified and each pathway was costed using AR-DRGs. An overall cost was also calculated by place of birth: $AUD4802 for homebirth, $AUD4979 for a birth centre birth and $AUD5463 for a hospital birth.

CONCLUSION

The findings from this study provides some clarity into the financial saving of offering more options to women seeking an alternative to giving birth in hospital. Given the relatively lower rates of complex intervention and neonatal outcomes associated with women at low risk of complications, we can assume the cost of providing them with homebirth and birth centre options could be cost-effective.

The opportunity costs of birth in Australia: Hospital resource savings for a post-COVID-19 era

BACKGROUND

COVID-19 caused significant disruptions to health systems globally; however, restricting the family presence during birth saw an increase in women considering community birth options. This study aimed to quantify the hospital resource savings that could occur if all low-risk women in Australia gave birth at home or in birth centers.

METHODS

A whole-of-population linked administrative data set containing all women (n = 44 498) who gave birth in Queensland, Australia, between 01/07/2012 and 30/06/2015 was reweighted to represent all Australian women giving birth in 2017. A static microsimulation model of woman and infant health service resource use was created based on 2017 data. The model was comprised of a base model, representing "current" care, and a counterfactual model, representing hypothetical scenarios where all low-risk Australian women gave birth at home or in birth centers.

RESULTS

If all low-risk women gave birth at home in 2017, cesarean rates would have reduced from 13.4% to 2.7%. Similarly, there would have been 860 fewer inpatient bed days and 10.1 fewer hours of women's intensive care unit time per 1000 births. If all women gave birth in birth centers, cesarean rates would have reduced to 6.7%. In addition, over 760 inpatient bed days would have been saved along with 5.6 hours of women's intensive care unit time per 1000 births.

CONCLUSIONS

Significant health resource savings could occur by shifting low-risk births from hospitals to home birth and birth center services. Greater examination of Australian women's preferences for home birth and birth center birth models of care is needed.

Association between travel time to delivery unit and unplanned out-of-hospital birth, infant morbidity and mortality: A population-based cohort study

INTRODUCTION

Over the last decade, a number of delivery units have been closed in Sweden, justified by both economic incentives and patient safety issues. However, concentrating births to larger delivery units naturally increases travel time for some parturient women, which may lead to unintended negative consequences. We aimed to investigate the association between travel time to delivery unit and unplanned out-of-hospital birth, and subsequent infant morbidity and mortality.

MATERIAL AND METHODS

We performed a population-based cohort study including 365 604 women in the Swedish Pregnancy Register, giving birth between 2014 and 2017. Modified Poisson regression was used to investigate the association between travel time from home address to actual delivery unit, based on geographic information system analysis, and risk of an unplanned out-of-hospital birth. Analyses were stratified by parity and urban/rural residence. Lastly, the associations between an unplanned out-of-hospital birth and severe infant morbidity, stillbirth, peripartum, perinatal and neonatal mortality were investigated.

RESULTS

Of those with an unplanned out-of-hospital birth (n = 2159), 65% had a travel time up to 30 minutes. A travel time between 31 and 60 minutes was associated with a doubled risk of unplanned out-of-hospital birth (adjusted risk ratio [RR] 1.96, 95% confidence interval [CI] 1.74-2.22) and women with a travel time of more than 1 hour had an adjusted RR of 3.19 (95% CI 2.64-3.86), compared with those with a travel time of <30 minutes. No difference in results was seen when stratified for parity and urban/rural residence. No association was found between unplanned out-of-hospital birth and severe infant morbidity. Significant associations were found in crude analyses for stillbirth (RR 1.85, 95% CI 1.09-3.13), peripartum (RR 1.93, 95% CI 1.18-3.16), perinatal (RR 2.03, 95% CI 1.28-3.23) and neonatal mortality (RR 3.08, 95% CI 1.27-7.46), although neonatal mortality was very rare (2.3/1000 out-of-hospital births). Similar effect estimates were found in the adjusted analyses, though no longer significant.

CONCLUSIONS

Although the majority of unplanned out-of-hospital births occurred in the group of women with a travel time of 0-30 minutes, increasing travel time to a delivery unit is associated with unplanned out-of-hospital birth, which may increase the risk of mortality.

Economic evaluation of computerised interpretation of fetal heart rate during labour: a cost-consequence analysis alongside the INFANT study

OBJECTIVE

Economic evaluation of computerised decision-support software intended to assist in the interpretation of a cardiotocography (CTG) during birth.

DESIGN

Individual patient level data from the INFANT study (an unmasked randomised controlled trial).

SETTING

Maternity units in the UK and Ireland.

POPULATION

Singleton or twin pregnancy women of 35 weeks' gestation or more and receiving continuous electronic fetal monitoring during labour.

INTERVENTION

Computerised decision-support software.

METHODS

Cost-consequence analysis presenting costs and outcomes with a time horizon of 2 years from a government healthcare perspective. Unit cost data collected from a combination of primary and secondary sources.

MAIN OUTCOME MEASURES

Primary clinical outcomes were (i) composite 'poor neonatal outcome' and (ii) developmental assessment at age 2 years in a subset of surviving children. Mean cost per mother and infant dyad from birth to hospital discharge, and from hospital discharge to 24 months follow-up. Maternal health-related quality of life was assessed at 12 and 24 months follow-up using the EuroQol three-level health-related quality of life instrument (EQ-5D-3L).

RESULTS

Data were analysed for 46 042 women and 46 614 infants. No statistically significant differences were detected between trial arms in any of the primary clinical outcomes or maternal quality of life. No statistically significant differences in costs were detected in maternal or infant costs from trial entry to hospital discharge or overall from hospital discharge to 2-year follow-up.

CONCLUSIONS

Decision-support software during labour is not associated with additional maternal or infant benefits and over a 2-year period the software did not lead to additional costs or savings to the National Health Service.

TRIAL REGISTRATION NUMBER

ISRCTN98680152.

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.

Costing the impact of interventions during pregnancy in the UK: a systematic review of economic evaluations

OBJECTIVE

The aim of this review was to summarise the current evidence on the costing of resource use within UK maternity care, in order to facilitate the estimation of incremental resource and cost impacts potentially attributable to maternity care interventions.

METHODS

A systematic review of economic evaluations was conducted by searching Medline, the Health Management Information Consortium, the National Health Service (NHS) Economic Evaluations Database, CINAHL and National Institute for Health and Care Excellence (NICE) guidelines for economic evaluations within UK maternity care, published between January 2010 and August 2019 in the English language. Unit costs for healthcare activities provided to women within the antenatal, intrapartum and postnatal period were inflated to 2018-2019 prices. Assessment of study quality was performed using the Quality of Health Economic Analyses checklist.

RESULTS

Of 5084 titles or full texts screened, 37 papers were included in the final review (27 primary research articles, 7 review articles and 3 economic evaluations from NICE guidelines). Of the 27 primary research articles, 21 were scored as high quality, 3 as medium quality and 3 were low quality. Variation was noted in cost estimates for healthcare activities throughout the maternity care pathway: for midwife-led outpatient appointment, the range was £27.34-£146.25 (mean £81.78), emergency caesarean section, range was £1056.44-£4982.21 (mean £3508.93) and postnatal admission, range was £103.00-£870.10 per day (mean £469.55).

CONCLUSIONS

Wide variation exists in costs applied to maternity healthcare activities, resulting in challenges in attributing cost to maternity activities. The level of variation in cost calculations is likely to reflect the uncertainty within the system and must be dealt with by conducting sensitivity analyses. Nationally agreed prices for granular unit costs are needed to standardise cost-effectiveness evaluations of new interventions within maternity care, to be used either for research purposes or decisions regarding national intervention uptake.

PROSPERO REGISTRATION NUMBER

CRD42019145309.

A critical interpretive synthesis of the roles of midwives in health systems

BACKGROUND

Midwives' roles in sexual and reproductive health and rights continues to evolve. Understanding the profession's role and how midwives can be integrated into health systems is essential in creating evidence-informed policies. Our objective was to develop a theoretical framework of how political system factors and health systems arrangements influence the roles of midwives within the health system.

METHODS

A critical interpretive synthesis was used to develop the theoretical framework. A range of electronic bibliographic databases (CINAHL, EMBASE, Global Health database, HealthSTAR, Health Systems Evidence, MEDLINE and Web of Science) was searched through to 14 May 2020 as were policy and health systems-related and midwifery organisation websites. A coding structure was created to guide the data extraction.

RESULTS

A total of 4533 unique documents were retrieved through electronic searches, of which 4132 were excluded using explicit criteria, leaving 401 potentially relevant records, in addition to the 29 records that were purposively sampled through grey literature. A total of 100 documents were included in the critical interpretive synthesis. The resulting theoretical framework identified the range of political and health system components that can work together to facilitate the integration of midwifery into health systems or act as barriers that restrict the roles of the profession.

CONCLUSIONS

Any changes to the roles of midwives in health systems need to take into account the political system where decisions about their integration will be made as well as the nature of the health system in which they are being integrated. The theoretical framework, which can be thought of as a heuristic, identifies the core contextual factors that governments can use to best leverage their position when working to improve sexual and reproductive health and rights.

Freestanding Midwife-Led Units: A Narrative Review

Background

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

Materials and Methods

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

Results

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

Conclusions

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

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.

Factors influencing the utilisation of free-standing and alongside midwifery units in England: a qualitative research study

OBJECTIVE

To identify factors influencing the provision, utilisation and sustainability of midwifery units (MUs) in England.

DESIGN

Case studies, using individual interviews and focus groups, in six National Health Service (NHS) Trust maternity services in England.

SETTING AND PARTICIPANTS

NHS maternity services in different geographical areas of England Maternity care staff and service users from six NHS Trusts: two Trusts where more than 20% of all women gave birth in MUs, two Trusts where less than 10% of all women gave birth in MUs and two Trusts without MUs. Obstetric, midwifery and neonatal clinical leaders, managers, service user representatives and commissioners were individually interviewed (n=57). Twenty-six focus groups were undertaken with midwives (n=60) and service users (n=52).

MAIN OUTCOME MEASURES

Factors influencing MU use.

FINDINGS

The study findings identify several barriers to the uptake of MUs. Within a context of a history of obstetric-led provision and lack of decision-maker awareness of the clinical and economic evidence, most Trust managers and clinicians do not regard their MU provision as being as important as their obstetric unit (OU) provision. 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 implementation of complex interventions in health services is influenced by a range of factors including the medicalisation of childbirth, perceived financial constraints, adequate leadership and institutional norms protecting the status quo.

CONCLUSIONS

There are significant obstacles to MUs reaching their full potential, especially free-standing midwifery units. These include the lack of commitment by providers to embed MUs as an essential service provision alongside their OUs, an absence of leadership to drive through these changes and the capacity and willingness of providers to address women's information needs. If these remain unaddressed, childbearing women's access to MUs will continue to be restricted.

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.

Developing routinely recorded clinical data from electronic patient records as a national resource to improve neonatal health care: the Medicines for Neonates research programme

Background

Clinical data offer the potential to advance patient care. Neonatal specialised care is a high-cost NHS service received by approximately 80,000 newborn infants each year.

Objectives

(1) To develop the use of routinely recorded operational clinical data from electronic patient records (EPRs), secure national coverage, evaluate and improve the quality of clinical data, and develop their use as a national resource to improve neonatal health care and outcomes. To test the hypotheses that (2) clinical and research data are of comparable quality, (3) routine NHS clinical assessment at the age of 2 years reliably identifies children with neurodevelopmental impairment and (4) trial-based economic evaluations of neonatal interventions can be reliably conducted using clinical data. (5) To test methods to link NHS data sets and (6) to evaluate parent views of personal data in research.

Design

Six inter-related workstreams; quarterly extractions of predefined data from neonatal EPRs; and approvals from the National Research Ethics Service, Health Research Authority Confidentiality Advisory Group, Caldicott Guardians and lead neonatal clinicians of participating NHS trusts.

Setting

NHS neonatal units.

Participants

Neonatal clinical teams; parents of babies admitted to NHS neonatal units.

Interventions

In workstream 3, we employed the Bayley-III scales to evaluate neurodevelopmental status and the Quantitative Checklist of Autism in Toddlers (Q-CHAT) to evaluate social communication skills. In workstream 6, we recruited parents with previous experience of a child in neonatal care to assist in the design of a questionnaire directed at the parents of infants admitted to neonatal units.

Data sources

Data were extracted from the EPR of admissions to NHS neonatal units.

Main outcome measures

We created a National Neonatal Research Database (NNRD) containing a defined extract from real-time, point-of-care, clinician-entered EPRs from all NHS neonatal units in England, Wales and Scotland (n = 200), established a UK Neonatal Collaborative of all NHS trusts providing neonatal specialised care, and created a new NHS information standard: the Neonatal Data Set (ISB 1595) (see http://webarchive.nationalarchives.gov.uk/±/http://www.isb.nhs.uk/documents/isb-1595/amd-32–2012/index_html; accessed 25 June 2018).

Results

We found low discordance between clinical (NNRD) and research data for most important infant and maternal characteristics, and higher prevalence of clinical outcomes. Compared with research assessments, NHS clinical assessment at the age of 2 years has lower sensitivity but higher specificity for identifying children with neurodevelopmental impairment. Completeness and quality are higher for clinical than for administrative NHS data; linkage is feasible and substantially enhances data quality and scope. The majority of hospital resource inputs for economic evaluations of neonatal interventions can be extracted reliably from the NNRD. In general, there is strong parent support for sharing routine clinical data for research purposes.

Limitations

We were only able to include data from all English neonatal units from 2012 onwards and conduct only limited cross validation of NNRD data directly against data in paper case notes. We were unable to conduct qualitative analyses of parent perspectives. We were also only able to assess the utility of trial-based economic evaluations of neonatal interventions using a single trial. We suggest that results should be validated against other trials.

Conclusions

We show that it is possible to obtain research-standard data from neonatal EPRs, and achieve complete population coverage, but we highlight the importance of implementing systematic examination of NHS data quality and completeness and testing methods to improve these measures. Currently available EPR data do not enable ascertainment of neurodevelopmental outcomes reliably in very preterm infants. Measures to maintain high quality and completeness of clinical and administrative data are important health service goals. As parent support for sharing clinical data for research is underpinned by strong altruistic motivation, improving wider public understanding of benefits may enhance informed decision-making.

Future work

We aim to implement a new paradigm for newborn health care in which continuous incremental improvement is achieved efficiently and cost-effectively by close integration of evidence generation with clinical care through the use of high-quality EPR data. In future work, we aim to automate completeness and quality checks and make recording processes more ‘user friendly’ and constructed in ways that minimise the likelihood of missing or erroneous entries. The development of criteria that provide assurance that data conform to prespecified completeness and quality criteria would be an important development. The benefits of EPR data might be extended by testing their use in large pragmatic clinical trials. It would also be of value to develop methods to quality assure EPR data including involving parents, and link the NNRD to other health, social care and educational data sets to facilitate the acquisition of lifelong outcomes across multiple domains.

Study registration

This study is registered as PROSPERO CRD42015017439 (workstream 1) and PROSPERO CRD42012002168 (workstream 3).

Funding

The National Institute for Health Research Programme Grants for Applied Research programme (£1,641,471). Unrestricted donations were supplied by Abbott Laboratories (Maidenhead, UK: £35,000), Nutricia Research Foundation (Schiphol, the Netherlands: £15,000), GE Healthcare (Amersham, UK: £1000). A grant to support the use of routinely collected, standardised, electronic clinical data for audit, management and multidisciplinary feedback in neonatal medicine was received from the Department of Health and Social Care (£135,494).

The cost of vaginal birth at home, in a birth centre or in a hospital setting in New South Wales: A micro-costing study

BACKGROUND

Women want greater choice of place of birth in New South Wales, Australia. It is perceived to be more costly to health services for women with a healthy pregnancy to give birth at home or in a birth centre. It is not known how much it costs the health service to provide care for women planning to give birth in these settings.

AIM

The aim of this study was to determine the direct cost of giving birth vaginally at home, in a birth centre or in a hospital for women at low risk of complications, in New South Wales.

METHODS

A micro-costing design was used. Observational (time and motion) and resource use data collection was undertaken to identify the staff time and resources required to provide care in a public hospital, birth centre or at home for women with a healthy pregnancy.

FINDINGS

The median cost of providing care for women who plan to give birth at home, in a birth centre and in a hospital were similar (AUD $2150.07, $2100.59 and $2097.30 respectively). Midwifery time was the largest contributor to the cost of birth at home, and overhead costs accounted for over half of the total cost of BC and hospital birth. The cost of consumables was low in all three settings.

CONCLUSION

In this study, we have found there is little difference in the cost to the health service when a woman has an uncomplicated vaginal birth at home, in a birth centre or in a hospital setting.

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.

Computerised interpretation of the fetal heart rate during labour: a randomised controlled trial (INFANT)

BACKGROUND

Continuous electronic fetal monitoring (EFM) in labour is widely used and computerised interpretation has the potential to increase its utility.

OBJECTIVES

This trial aimed to find out whether or not the addition of decision support software to assist in the interpretation of the cardiotocograph (CTG) reduced the number of poor neonatal outcomes, and whether or not it was cost-effective.

DESIGN

Two-arm individually randomised controlled trial. The allocations were computer generated using stratified block randomisation employing variable block sizes. The trial was not masked.

SETTING

Labour wards in England, Scotland and the Republic of Ireland.

PARTICIPANTS

Women in labour having EFM, with a singleton or twin pregnancy, at ≥ 35 weeks' gestation.

INTERVENTIONS

Decision support or no decision support.

MAIN OUTCOME MEASURES

The primary outcomes were (1) a composite of poor neonatal outcome {intrapartum stillbirth or early neonatal death (excluding lethal congenital anomalies), or neonatal morbidity [defined as neonatal encephalopathy (NNE)], or admission to a neonatal unit within 48 hours for ≥ 48 hours (with evidence of feeding difficulties, respiratory illness or NNE when there was evidence of compromise at birth)}; and (2) developmental assessment at the age of 2 years in a subset of surviving children.

RESULTS

Between 6 January 2010 and 31 August 2013, 47,062 women were randomised and 46,042 were included in the primary analysis (22,987 in the decision support group and 23,055 in the no decision support group). The short-term primary outcome event rate was higher than anticipated. There was no evidence of a difference in the incidence of poor neonatal outcome between the groups: 0.7% (n = 172) of babies in the decision support group compared with 0.7% (n = 171) of babies in the no decision support group [adjusted risk ratio 1.01, 95% confidence interval (CI) 0.82 to 1.25]. There was no evidence of a difference in the long-term primary outcome of the Parent Report of Children's Abilities-Revised with a mean score of 98.0 points [standard deviation (SD) 33.8 points] in the decision support group and 97.2 points (SD 33.4 points) in the no decision support group (mean difference 0.63 points, 95% CI -0.98 to 2.25 points). No evidence of a difference was found for health resource use and total costs. There was evidence that decision support did change practice (with increased fetal blood sampling and a lower rate of repeated alerts).

LIMITATIONS

Staff in the control group may learn from exposure to the decision support arm of the trial, resulting in improved outcomes in the control arm. This was identified in the planning stage and felt to be unlikely to have a significant effect on the results. As this was a pragmatic trial, the response to CTG alerts was left to the attending clinicians.

CONCLUSIONS

This trial does not support the hypothesis that the use of computerised interpretation of the CTG in women who have EFM in labour improves the clinical outcomes for mothers or babies.

FUTURE WORK

There continues to be an urgent need to improve knowledge and training about the appropriate response to CTG abnormalities, including timely intervention.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN98680152.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) HTA programme and will be published in full in Health Technology Assessment; Vol. 22, No. 9. See the NIHR Journals Library website for further project information. Sara Kenyon was part funded by the NIHR Collaboration for Leadership in Applied Health Research and Care West Midlands.

An analysis of media reporting on the closure of freestanding midwifery units in England

PROBLEM

Despite clinical guidelines and policy promoting choice of place of birth, 14 Freestanding Midwifery Units were closed between 2008 and 2015, closures reported in the media as justified by low use and financial constraints.

BACKGROUND

The Birthplace in England Programme found that freestanding midwifery units provided the most cost-effective birthplace for women at low risk of complications. Women planning birth in a freestanding unit were less likely to experience interventions and serious morbidity than those planning obstetric unit birth, with no difference in outcomes for babies.

METHODS

This paper uses an interpretative technique developed for policy analysis to explore the representation of these closures in 191 news articles, to explore the public climate in which they occurred.

FINDINGS AND DISCUSSION

The articles focussed on underuse by women and financial constraints on services. Despite the inclusion of service user voices, the power of framing was held by service managers and commissioners. The analysis exposed how neoliberalist and austerity policies have privileged representation of individual consumer choice and market-driven provision as drivers of changes in health services. This normative framing presents the reasons given for closure as hard to refute and cultural norms persist that birth is safest in an obstetric setting, despite evidence to the contrary.

CONCLUSION

The rise of neoliberalism and austerity in contemporary Britain has influenced the reform of maternity services, in particular the closure of midwifery units. Justifications given for closure silence other narratives, predominantly from service users, that attempt to present women's choice in terms of rights and a social model of care.

Cost-effectiveness of continuity of midwifery care for women with complex pregnancy: a structured review of the literature

BACKGROUND

Critical evaluation of the cost-effectiveness and clinical effectiveness of continuity of midwifery care models for women experiencing complex pregnancy is an important consideration in the review and reform of maternity services. Most studies either focus on women who experience healthy pregnancy or mixed risk samples. These results may not be generalised across the childbearing continuum to women with risk factors. This review critically evaluates studies that measure the cost of care for women with complex pregnancies, with a focus on method and quality.

AIMS / OBJECTIVES

To critically appraise and summarise the evidence relating to the combined cost-effectiveness, resource use and clinical effectiveness of midwifery continuity models for women who experience complex pregnancies and their babies in developed countries.

DESIGN

Structured review of the literature utilising a matrix method to critique the methods and quality of studies.

METHOD

A search of Medline, CINAHL, MIDIRS, DARE, EMBASE, OVID, PubMed, ProQuest, Informit, Science Direct, Cochrane Library, NHS Economic Evaluation Database (NHSEED) for the years 1994 - 2018 was conducted.

RESULTS

Nine articles met the inclusion criteria. The review identified four areas of economic evaluation that related to women who experienced complex pregnancy and continuity of midwifery care. (1) cost and clinical effectiveness comparisons between continuity of midwifery care versus obstetric-led units; (2) cost of continuity of midwifery care and/or team midwifery compared to Standard Care; (3) cost-effectiveness of continuity of midwifery care for Australian Aboriginal women versus standard care; (4) patterns of antenatal care for women of high obstetric risk and comparative provider cost. Cost savings specific to women from high risk samples who received continuity of midwifery care compared with obstetric-led standard care was stated for only one study in the review. Kenny et al. 1994 identified cost savings of AUS $29 in the antenatal period for women who received the midwifery team model from a stratified sub-set of high-risk pregnant woman within a mixed risk sample of 446 women. One systematic review relevant to the UK context, Ryan et al. (2013), applied sensitivity analysis to include women of all risk categories. Where risk ratio for overall fetal/neonatal death was systematically varied based on the 95% confidence interval of 0.79 to 1.09 from pooled studies, the aggregate annual net monetary benefit for continuity of midwifery care ranged extremely widely from an estimated gain of £472 million to a loss of £202 million. Net health benefit ranged from an annual gain of 15 723 QALYs to a loss of 6 738 QALYs. All other studies in this review reported cost savings narratively or within mixed risk samples where risk stratification was not clearly stated or related to the midwifery team model only.

CONCLUSIONS

Studies that measure the cost of continuity of midwifery care for women with complex pregnancy across the childbearing continuum are limited and apply inconsistent methods of economic evaluation. The cost and outcomes of implementing continuity of midwifery care for women with complex pregnancy is an important issue that requires further investigation. Robust cost-effectiveness evidence is essential to inform decision makers, to implement sustainable systems change in comparative maternity models for pregnant women at risk and to address health inequity.

Outcomes for women with BMI>35kg/m2 admitted for labour care to alongside midwifery units in the UK: A national prospective cohort study using the UK Midwifery Study System (UKMidSS)

OBJECTIVE

To describe and compare outcomes in severely obese (body mass index (BMI)>35kg/m2) women and other women admitted to alongside (co-located) midwifery units (AMU) in the United Kingdom.

METHODS

We carried out a national prospective cohort study using the UK Midwifery Study System (UKMidSS) in all 122 AMUs in the UK. We identified and collected data about 1122 severely obese women admitted to an AMU, 1st January-31st December 2016, and 1949 comparison women (BMI≤35kg/m2), matched on time of admission, and used Poisson regression to calculate relative risks adjusted for maternal characteristics.

RESULTS

92% of the severely obese cohort had BMI 35.1-40kg/m2. Severely obese multiparous women were no more likely than comparison women to experience the composite primary outcome (one or more of: augmentation, instrumental birth, Caesarean, maternal blood transfusion, 3rd/4th degree tear, maternal admission to higher level care) (5.6% vs. 8.1%, aRR = 0.68, 95% CI 0.44-1.07). For severely obese nulliparous women we found a non-significant 14% increased risk of the primary outcome (37.6% vs 34.8%, aRR = 1.14, 95% CI 0.97-1.33). High proportions of severely obese women had a 'straightforward vaginal birth' (nulliparous 67.9%; multiparous 96.3%). Severely obese women were more likely than comparison women to have an intrapartum Casearean section, but Caesarean section rates were low and the absolute difference small (4.7% vs 4.1%; aRR = 1.62; 95% CI 1.02-2.57). In nulliparous women, severely obese women were more likely to have an urgent Caesarean section (12.2% vs. 6.5%, aRR = 1.80, 95% CI 1.05-3.08), or a PPH≥1500ml (5.1% vs. 1.7%, aRR = 3.01, 95% CI 1.24-7.31).

CONCLUSIONS

We found no evidence of significantly increased risk associated with planning birth in an AMU for carefully selected multiparous severely obese women, with BMI 35.1-40kg/m2. Severely obese nulliparous women have a potential increased risk of having a more urgent Caesarean section or severe PPH compared with other women admitted to AMUs.

A multicentre, randomised controlled trial of position during the late stages of labour in nulliparous women with an epidural: clinical effectiveness and an economic evaluation (BUMPES)

BACKGROUND

Epidural analgesia leads to increased risk of instrumental vaginal delivery (IVD). There is debate about whether or not posture in second-stage labour influences the incidence of spontaneous vaginal birth (SVB).

OBJECTIVES

In nulliparous women with epidural analgesia, does a policy of adopting an 'upright position' throughout second-stage labour increase the incidence of SVB compared with a policy of adopting a 'lying-down' position?

DESIGN

Two-arm randomised controlled trial.

SETTING

Maternity units in England and Wales.

PARTICIPANTS

Nulliparous women aged ≥ 16 years, at ≥ 37 weeks' gestation with singleton cephalic presentation and intended SVB, in second-stage labour with an epidural providing effective pain relief.

INTERVENTIONS

(1) Upright position to maintain the pelvis in as vertical a plane as possible; and (2) lying-down position to maintain the pelvis in as horizontal a plane as possible.

MAIN OUTCOME MEASURES

The primary outcome measure was incidence of SVB. Secondary outcomes included augmentation, interventions to maintain blood pressure, duration of labour, episiotomy, genital tract trauma, post-partum haemorrhage, maternal satisfaction, neonatal metabolic acidosis, 5-minute Apgar score of < 4, resuscitation at birth and admission to neonatal unit. At 1 year for (1) women: urinary or faecal incontinence, dyspareunia and health-related quality of life; (2) for infants: major morbidity. A cost-consequences analysis with a time horizon of 1 year after the birth from a NHS perspective.

RESULTS

Between October 2010 and January 2014, 3236 women were randomised from 41 centres in England and Wales. There was a statistically significant difference in the incidence of SVB between groups, with 35.2% of women achieving a SVB in the upright group, compared with 41.1% in the lying-down group (adjusted risk ratio 0.86, 95% confidence interval 0.78 to 0.94). There was no evidence of differences in most of the secondary maternal or neonatal outcomes, or in long-term outcomes at the 12-month follow-up. No significant overall cost differences were observed between upright and lying-down positions for mothers or their babies.

LIMITATIONS

Measurement of adherence was challenging in this unmasked trial, and adherence could be influenced by midwives' beliefs about the allocated positions. If adherence was poor, this would have diluted the difference between the two groups.

CONCLUSIONS

There is clear evidence of the benefit of adopting a lying-down position in second-stage labour in nulliparous women with epidural analgesia, with no apparent disadvantages in either short- or long-term outcomes for mother or baby, and this is cost neutral for the NHS.

FUTURE WORK

Questions remain about whether or not other positions could increase the incidence of SVB further in this group of women. The results also raise questions about the role of maternal position in second-stage labour in women without an epidural.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN35706297.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in Health Technology Assessment, Vol 21, No. 65. See the NIHR Journals Library website for further project information.

Quality improvement opportunities for handover practices in birth centres: A case study from a process perspective

RATIONALE, AIMS AND OBJECTIVES

Handovers within and between health care settings are known to affect quality of care. Health care organizations, struggle how to guarantee best care during handovers. The aim of this paper is to evaluate handover practices in Dutch birth centres from a process perspective, to identify obstacles and opportunities for quality improvements.

METHODS

This case study in 7 Dutch birth centres was undertaken from a process perspective by conducting observations and using process mapping. This study is part of the Dutch Birth Centre Study.

RESULTS

Solutions to obstacles during handovers from a birth centre to a hospital were identified in at least 1 of the 7 birth centres. Four of the centres had agreements with a hospital for client support when a caregiver in a birth centre was absent. Face-to-face communication during handover was observed in 6 of the 7 centres. An electronic health record was noted in 1 centre; joint training of acute situations was available in 2 centres with 3 centres indicating that this was not compulsory. Continuity of caregiver was present in 4 birth centres with postpartum care available in 3 centres.

CONCLUSIONS

Ensuring quality during handovers requires a case-specific process approach. This study reveals distinctive aspects during handovers, concrete obstacles, and potential solutions for quality improvements in inter-organizational networks, transferrable to birth centres in other countries as well.

'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.

Comparing the Efficacy of a Mobile Phone-Based Blood Glucose Management System With Standard Clinic Care in Women With Gestational Diabetes: Randomized Controlled Trial

Background

Treatment of hyperglycemia in women with gestational diabetes mellitus (GDM) is associated with improved maternal and neonatal outcomes and requires intensive clinical input. This is currently achieved by hospital clinic attendance every 2 to 4 weeks with limited opportunity for intervention between these visits.

Objective

We conducted a randomized controlled trial to determine whether the use of a mobile phone-based real-time blood glucose management system to manage women with GDM remotely was as effective in controlling blood glucose as standard care through clinic attendance.

Methods

Women with an abnormal oral glucose tolerance test before 34 completed weeks of gestation were individually randomized to a mobile phone-based blood glucose management solution (GDm-health, the intervention) or routine clinic care. The primary outcome was change in mean blood glucose in each group from recruitment to delivery, calculated with adjustments made for number of blood glucose measurements, proportion of preprandial and postprandial readings, baseline characteristics, and length of time in the study.

Results

A total of 203 women were randomized. Blood glucose data were available for 98 intervention and 85 control women. There was no significant difference in rate of change of blood glucose (–0.16 mmol/L in the intervention and –0.14 mmol/L in the control group per 28 days, P=.78). Women using the intervention had higher satisfaction with care (P=.049). Preterm birth was less common in the intervention group (5/101, 5.0% vs 13/102, 12.7%; OR 0.36, 95% CI 0.12-1.01). There were fewer cesarean deliveries compared with vaginal deliveries in the intervention group (27/101, 26.7% vs 47/102, 46.1%, P=.005). Other glycemic, maternal, and neonatal outcomes were similar in both groups. The median time from recruitment to delivery was similar (intervention: 54 days; control: 49 days; P=.23). However, there were significantly more blood glucose readings in the intervention group (mean 3.80 [SD 1.80] and mean 2.63 [SD 1.71] readings per day in the intervention and control groups, respectively; P<.001). There was no significant difference in direct health care costs between the two groups, with a mean cost difference of the intervention group compared to control of –£1044 (95% CI –£2186 to £99). There were no unexpected adverse outcomes.

Conclusions

Remote blood glucocse monitoring in women with GDM is safe. We demonstrated superior data capture using GDm-health. Although glycemic control and maternal and neonatal outcomes were similar, women preferred this model of care. Further studies are required to explore whether digital health solutions can promote desired self-management lifestyle behaviors and dietetic adherence, and influence maternal and neonatal outcomes. Digital blood glucose monitoring may provide a scalable, practical method to address the growing burden of GDM around the world.

Trial Registration

ClinicalTrials.gov NCT01916694; https://clinicaltrials.gov/ct2/show/NCT01916694 (Archived by WebCite at http://www.webcitation.org/6y3lh2BOQ)

Cost-effectiveness of healthy eating and/or physical activity promotion in pregnant women at increased risk of gestational diabetes mellitus: economic evaluation alongside the DALI study, a European multicenter randomized controlled trial

Background

Gestational diabetes mellitus (GDM) is associated with perinatal health risks to both mother and offspring, and represents a large economic burden. The DALI study is a multicenter randomized controlled trial, undertaken to add to the knowledge base on the effectiveness of interventions for pregnant women at increased risk for GDM. The purpose of this study was to evaluate the cost-effectiveness of the healthy eating and/or physical activity promotion intervention compared to usual care among pregnant women at increased risk of GDM from a societal perspective.

Methods

An economic evaluation was performed alongside a European multicenter-randomized controlled trial. A total of 435 pregnant women at increased risk of GDM in primary and secondary care settings in nine European countries, were recruited and randomly allocated to a healthy eating and physical activity promotion intervention (HE + PA intervention), a healthy eating promotion intervention (HE intervention), or a physical activity promotion intervention (PA intervention). Main outcome measures were gestational weight gain, fasting glucose, insulin resistance (HOMA-IR), quality adjusted life years (QALYs), and societal costs.

Results

Between-group total cost and effect differences were not significant, besides significantly less gestational weight gain in the HE + PA group compared with the usual care group at 35–37 weeks (−2.3;95%CI:-3.7;-0.9). Cost-effectiveness acceptability curves indicated that the HE + PA intervention was the preferred intervention strategy. At 35–37 weeks, it depends on the decision-makers’ willingness to pay per kilogram reduction in gestational weight gain whether the HE + PA intervention is cost-effective for gestational weight gain, whereas it was not cost-effective for fasting glucose and HOMA-IR. After delivery, the HE + PA intervention was cost-effective for QALYs, which was predominantly caused by a large reduction in delivery-related costs.

Conclusions

Healthy eating and physical activity promotion was found to be the preferred strategy for limiting gestational weight gain. As this intervention was cost-effective for QALYs after delivery, this study lends support for broad implementation.

Trial registration

ISRCTN ISRCTN70595832. Registered 2 December 2011.

Electronic supplementary material

The online version of this article (10.1186/s12966-018-0643-y) contains supplementary material, which is available to authorized users.

Mapping integration of midwives across the United States: Impact on access, equity, and outcomes

METHODS

Our multidisciplinary team examined published regulatory data to inform a 50-state database describing the environment for midwifery practice and interprofessional collaboration. Items (110) detailed differences across jurisdictions in scope of practice, autonomy, governance, and prescriptive authority; as well as restrictions that can affect patient safety, quality, and access to maternity providers across birth settings. A nationwide survey of state regulatory experts (n = 92) verified the 'on the ground' relevance, importance, and realities of local interpretation of these state laws. Using a modified Delphi process, we selected 50/110 key items to include in a weighted, composite Midwifery Integration Scoring (MISS) system. Higher scores indicate greater integration of midwives across all settings. We ranked states by MISS scores; and, using reliable indicators in the CDC-Vital Statistics Database, we calculated correlation coefficients between MISS scores and maternal-newborn outcomes by state, as well as state density of midwives and place of birth. We conducted hierarchical linear regression analysis to control for confounding effects of race.

RESULTS

MISS scores ranged from lowest at 17 (North Carolina) to highest at 61 (Washington), out of 100 points. Higher MISS scores were associated with significantly higher rates of spontaneous vaginal delivery, vaginal birth after cesarean, and breastfeeding, and significantly lower rates of cesarean, preterm birth, low birth weight infants, and neonatal death. MISS scores also correlated with density of midwives and access to care across birth settings. Significant differences in newborn outcomes accounted for by MISS scores persisted after controlling for proportion of African American births in each state.

CONCLUSION

The MISS scoring system assesses the level of integration of midwives and evaluates regional access to high quality maternity care. In the United States, higher MISS Scores were associated with significantly higher rates of physiologic birth, less obstetric interventions, and fewer adverse neonatal outcomes.

A methodological framework for assessing agreement between cost-effectiveness outcomes estimated using alternative sources of data on treatment costs and effects for trial-based economic evaluations

A new methodological framework for assessing agreement between cost-effectiveness endpoints generated using alternative sources of data on treatment costs and effects for trial-based economic evaluations is proposed. The framework can be used to validate cost-effectiveness endpoints generated from routine data sources when comparable data is available directly from trial case report forms or from another source. We illustrate application of the framework using data from a recent trial-based economic evaluation of the probiotic Bifidobacterium breve strain BBG administered to babies less than 31 weeks of gestation. Cost-effectiveness endpoints are compared using two sources of information; trial case report forms and data extracted from the National Neonatal Research Database (NNRD), a clinical database created through collaborative efforts of UK neonatal services. Focusing on mean incremental net benefits at £30,000 per episode of sepsis averted, the study revealed no evidence of discrepancy between the data sources (two-sided p values >0.4), low probability estimates of miscoverage (ranging from 0.039 to 0.060) and concordance correlation coefficients greater than 0.86. We conclude that the NNRD could potentially serve as a reliable source of data for future trial-based economic evaluations of neonatal interventions. We also discuss the potential implications of increasing opportunity to utilize routinely available data for the conduct of trial-based economic evaluations.

Cost-effectiveness of planned birth in a birth centre compared with alternative planned places of birth: results of the Dutch Birth Centre study

OBJECTIVES

To estimate the cost-effectiveness of a planned birth in a birth centre compared with alternative planned places of birth for low-risk women. In addition, a distinction has been made between different types of locations and integration profiles of birth centres.

DESIGN

Economic evaluation based on a prospective cohort study.

SETTING

21 Dutch birth centres, 46 hospital locations where midwife-led birth was possible and 110 midwifery practices where home birth was possible.

PARTICIPANTS

3455 low-risk women under the care of a community midwife at the start of labour in the Netherlands within the study period 1 July 2013 to 31 December 2013.

MAIN OUTCOME MEASURES

Costs and health outcomes of birth for different planned places of birth. Healthcare costs were measured from start of labour until 7 days after birth. The health outcomes were assessed by the Optimality Index-NL2015 (OI) and a composite adverse outcomes score.

RESULTS

The total adjusted mean costs for births planned in a birth centre, in a hospital and at home under the care of a community midwife were €3327, €3330 and €2998, respectively. There was no difference between the score on the OI for women who planned to give birth in a birth centre and that of women who planned to give birth in a hospital. Women who planned to give birth at home had better outcomes on the OI (higher score on the OI).

CONCLUSIONS

We found no differences in costs and health outcomes for low-risk women under the care of a community midwife with a planned birth in a birth centre and in a hospital. For nulliparous and multiparous low-risk women, planned birth at home was the most cost-effective option compared with planned birth in a birth centre.

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.