Born before arrival in NSW, Australia (2000-2011): a linked population data study of incidence, location, associated factors and maternal and neonatal outcomes

Early antenatal risk factors for births before arrival: An unmatched case-control study

INTRODUCTION

Birth before arrival is associated with maternal morbidity and neonatal morbidity and mortality. Yet, timely risk stratification remains challenging. Our objective was to identify risk factors for birth before arrival which may be determined at the first antenatal appointment.

MATERIAL AND METHODS

This was an unmatched case-control study involving 37 348 persons who gave birth at a minimum of 22+0 weeks' gestation over a 5-year period from January 2014 to October 2019 (IRAS project ID 222260; REC reference: 17/SC/0374). The setting was a large UK university hospital. Data obtained on maternal characteristics at booking was examined for association with birth before arrival using a stepwise multivariable logistic regression analysis. Data are presented as adjusted odds ratios with 95% confidence intervals. Area under the receiver-operator characteristic curves (C-statistic) were employed to enable discriminant analysis assessing the risk prediction of the booking data on the outcome.

RESULTS

Multivariable analysis identified significant independent predictors of birth before arrival that were detectable at booking: parity, ethnicity, multiple deprivation, employment status, timing of booking, distance from home to the nearest maternity unit, and safeguarding concerns raised at booking by clinical staff. Our model demonstrated good discrimination for birth before arrival; together, the predictors accounted for 77% of the data variance (95% confidence interval 0.74-0.80).

CONCLUSIONS

Information gathered routinely at booking may discriminate individuals at risk for birth before arrival. Better recognition of early factors may enable maternity staff to direct higher-risk women towards specialized care services at an early point in their pregnancy, enabling time for clinical and social interventions.

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.

Cohort profile: Born in Wales-a birth cohort with maternity, parental and child data linkage for life course research in Wales, UK

PURPOSE

Using Wales's national dataset for maternity and births as a core dataset, we have linked related datasets to create a more complete and comprehensive entire country birth cohort. Data of anonymised identified persons are linked on the individual level to data from health, social care and education data within the Secure Anonymised Information Linkage (SAIL) Databank. Each individual is assigned an encrypted Anonymised Linking Field; this field is used to link anonymised individuals across datasets. We present the descriptive data available in the core dataset, and the future expansion plans for the database beyond its initial development stage.

PARTICIPANTS

Descriptive information from 2011 to 2023 has been gathered from the National Community Child Health Database (NCCHD) in SAIL. This comprehensive dataset comprises over 400 000 child electronic records. Additionally, survey responses about health and well-being from a cross-section of the population including 2500 parents and 30 000 primary school children have been collected for enriched personal responses and linkage to the data spine.

FINDINGS TO DATE

The electronic cohort comprises all children born in Wales since 2011, with follow-up conducted until they finish primary school at age 11. The child cohort is 51%: 49% female: male, and 7.8% are from ethnic minority backgrounds. When considering age distribution, 26.8% of children are under the age of 5, while 63.2% fall within the age range of 5-11.

FUTURE PLANS

Born in Wales will expand by 30 000 new births annually in Wales (in NCCHD), while including follow-up data of children and parents already in the database. Supplementary datasets complement the existing linkage, including primary care, hospital data, educational attainment and social care. Future research includes exploring the long-term implications of COVID-19 on child health and development, and examining the impact of parental work environment on child health and development.

In France, the organization of perinatal care has a direct influence on the outcome of the mother and the newborn: Contribution from a French nationwide study

OBJECTIVE

To investigate maternal and neonatal outcomes after a delivery in France in 2019, according to hospital characteristics and the impact of distance and time of travel on mother and newborn.

METHODS

All parturients above 18 years of age who delivered in 2019 and were identified in the French health insurance database were included, with their newborns, in this retrospective cohort study. Main outcome measures were Severe Maternal Morbidity score and the Neonatal Adverse Outcome Indicator (NAOI).

RESULTS

Among the 733 052 pregnancies included, 10 829 presented a severe maternal morbidity (1.48%) and 77 237 had a neonatal adverse outcome (10.4%). Factors associated with an unfavorable maternal or neonatal outcome were Obstetric Comorbidity Index, primiparity, and cesarean or instrumental delivery. Prematurity was associated with less severe maternal morbidity but more neonatal adverse outcomes. Time of travel above 30 min was associated with a higher NAOI rate.

CONCLUSIONS

Results suggest the efficiency of regionalization of perinatal care in France, although a difference in both outcomes persists according to unit volume, suggesting the need for a further step in concentrating perinatal care. Perinatal care organization should focus on mapping the territory with high-level, high-volume maternity throughout the territory; this suggests closing down high-volume units and improving low-volume ones to maintain coherent mapping.

[Involvement and Handling of Paramedics in Unplanned Out-of-Hospital Births: An Online Survey]

INTRODUCTION

Unplanned out-of-hospital births are very rare in the ambulance service and there is evidence that emergency paramedics do not feel comfortable with this operational picture. At the same time, there is an increased of morbidity and mortality for both the mother and the newborn. The aims of the present cross-sectional study were to identify insecurities of emergency paramedics in connection with unplanned out-of-hospital births, to analyse the reasons for this and to derive possible support measures to be implemented.

MATERIAL AND METHODS

This study is a quantitative cross-sectional study examining management of unplanned out-of-hospital births by paramedics using a self-designed questionnaire. 65 participants took part in the online survey during the period from April 6, 2022 to April 30, 2022. SPSS was used for statistical data analysis. The central tendency of various influencing variables was examined with the help of the Mann-Whitney U test, the significance level was α<0.05.

RESULTS

On average, preparation Median (IQR): 2.0 (1.0) and safety with the measures to be performed 3.0 (01.0), as well as knowledge about unplanned out-of-hospital births 2.0 (1.0) were rated moderately well. The participating paramedics had particular difficulties with the documentation of the birth process 3.0 (1.0). There was a great deal of respect for out-of-hospital birth attendance among participants 1.0 (1.0). Participation in an interdisciplinary simulation session appeared to have had a positive influence on the handling and preparation for safety in the measures to be taken (p=0.016).

CONCLUSION

Insecurites as well as possible reasons for them could be identified. Possible suggestions for improvement for emergency paramedics in unplanned out-of-hospital births were developed. For example, specific birth protocols and participation in a simulation are good ways to help.

Epidemiology of Emergency Medical Services-Attended out-of-Hospital Deliveries and Complications in the United States

BACKGROUND

Prehospital obstetric events, including out-of-hospital deliveries and their complications, are a rare but high-risk event encountered by emergency medical services (EMS). Understanding the epidemiology of these encounters would help identify strategies to improve prehospital obstetric care. Our objective was to determine the characteristics of out-of-hospital deliveries and high-risk complications treated by EMS clinicians in the U.S.

METHODS

We conducted a cross-sectional analysis of EMS patient care records in the 2018 and 2019 National EMS Information System Public Release Version 3.4 datasets. We included EMS activations after a 9-1-1 scene response for patients aged 12-50 years with evidence of an out-of-hospital delivery or delivery complication, or where the patient was a newborn aged 0-<6 h. We examined patient, community, emergency response, and clinical characteristics using descriptive statistics.

RESULTS

Of the 56,735,977 EMS activations included in the 2018 and 2019 datasets, there were 8,614 out-of-hospital deliveries, 1,712 delivery complications, and 5,749 records for newborns. Most maternal (76%) out-of-hospital deliveries involved patients between the ages of 20-34 years, occurred on a weekday (73%), were treated by an advanced life support crew (85%), and occurred in a home or residence (73%). EMS-assisted field delivery was documented in 3,515 (34%) of all maternal activations but only 2% of activations with a delivery complication. Few patients received an EMS-administered medication (e.g., 0.4% received oxytocin). Supplemental oxygen was administered in 870 (15%) of newborn activations. Activations from counties with the most racial/ethnic diversity were more often treated by a BLS-level unit (16% vs. 12%, p < 0.001), and activations from rural areas had significantly longer transport times (19.7 min [IQR 8.7, 32.8] vs. urban, 13.1 min [IQR 8.7, 19.7], p < 0.001).

CONCLUSION

In this large, national repository of EMS patient care records from across the U.S., most activations for out-of-hospital delivery, delivery complication, or a newborn included only routine EMS care. There were potential disparities in level of care, clinical care provided, and measures of access to definitive care based on maternal and community factors. We also identified gaps in current practice, such as for postpartum hemorrhage, that could be addressed with changes in EMS clinical protocols and regulations.

Displaced risk. Keeping mothers and babies safe: a UK ambulance service lens

Aim

The aim of this professional practice paper is to provide a critical commentary on displaced risk among perinatal and neonatal patients attended to by the ambulance service.

Background

NHS services across the United Kingdom are currently facing unprecedented demand and increased scrutiny in their ability to provide safe and personalised care to patients. While current focus in the system centres around addressing social care demand, hospital bed capacity, planned care waiting times, staffing and ambulance handover delays, a less explored cohort of patients impacted by the current healthcare crisis is perinatal and neonatal populations attended to by the ambulance service. Little focus has been paid within national agendas to the care provided to women and babies outside of planned maternity and obstetric care. A case is presented to highlight the importance of considering urgent and emergency maternity care provision provided by the ambulance service, and the impact of 'displaced risk' due to the current pressures within healthcare systems.

Conclusion

Placed in a national context, drawing upon current independent reviews into maternity services, national transformation agendas and the most recent MBRRACE-UK confidential enquiry into maternal deaths and morbidity, a case is made to commissioners and Integrated Care Systems to focus on and invest in the unplanned pre-hospital care of maternity and neonatal patients. Recognition of the ambulance service as a key provider of care to this cohort of patients is paramount, calling on services and systems to work together on realising and addressing displaced risk for perinatal populations across the United Kingdom. A system approach that acknowledges the need for high-quality care at every point of contact and equitability in access to services for pregnant, postpartum and neonatal patients is vital.

Relationship between out-of-facility deliveries and distance and travel time to delivery facilities in Hokkaido, Japan: An ecological study

AIM

This study aimed to investigate the relationship between the distance and travel time from each municipality to the nearest delivery facilities in the other municipalities and the frequency of out-of-facility deliveries in Hokkaido.

METHODS

Vital statistics from 2016 to 2020 were used. For municipalities without delivery facilities, the distance and travel time from the town office of each municipality to the nearest delivery facility was measured using Google maps. Negative binomial regression with an offset term was used to calculate the relative risks (RRs) and 95% confidence intervals (CIs) of out-of-facility delivery for distance (<30, 30-59, ≥60 km), and travel time by car (<30, 30-59, and ≥60 min) from the town office to the nearest delivery facility compared with the presence of delivery facilities.

RESULTS

The overall rate of out-of-facility deliveries in Hokkaido was 2.1‰; in municipalities with delivery facilities, 1.8‰, and in municipalities without delivery facilities, 3.1‰. The adjusted RRs (95% CIs) for out-of-facility deliveries were significantly higher in municipalities with less than 30 km and travel time of less than 30 min to delivery facilities, 2.63 (1.34-5.17) and 2.76 (1.36-5.58), respectively, compared to municipalities with delivery facilities. However, the adjusted RR of out-of-facility delivery for municipalities ≥30 km was higher, although the difference was not significant.

CONCLUSIONS

Even in municipalities with a distance to delivery facilities of less than 30 km or travel time of less than 30 min, we should keep in mind the occurrence of out-of-facility deliveries.

Midwives' experiences with accompaniment service work in Norway: A qualitative study

INTRODUCTION

The centralization of health services appears to be prevalent both in and outside Europe. As the distance to the nearest birth institution increases, so does the risk of unplanned births outside of an institution. A primary factor to prevent this is having a skilled birth attendant present. This study examines midwives' experiences of working in the accompaniment services in Norway.

METHODS

This was a qualitative interview study of 12 midwives working in the accompaniment services in Norway. Semi-structured interviews were conducted in January 2020. Systematic text condensation was used to analyze the data.

RESULTS

The analysis identified four main themes. The midwives felt that accompaniment service work was a heavy responsibility, but it was professionally fulfilling. They felt that being on call was a lifestyle, and they were motivated by their relationships with the pregnant women. Presenting themselves as confident midwives helped the women to feel reassured. The midwives considered the cooperation within the health service to be key to good transport midwifery.

CONCLUSIONS

The midwives who worked in the accompaniment services felt that their responsibility for caring for women in labor was challenging, but meaningful. Their professional knowledge was important for identifying the risk of complications and handling difficult situations. Despite carrying a heavy workload, they continued to work in the accompaniment services to ensure that women who had to travel long distances to birth institutions received appropriate help.

Suspected Labour as a Reason for Emergency Medical Services Team Interventions in Poland—A Retrospective Analysis

The purpose of this study was to present the characteristics of Emergency Medical Services (EMS) team responses to calls regarding suspected labour in out-of-hospital settings in Poland. We performed a retrospective analysis of EMS team interventions in cases of suspected onset of labour outside a hospital setting. The analysis included 12,816 EMS team responses to calls regarding women in suspected labour in the period between January 2018 and December 2019. The mean age of the patients studied was 28.24 years (SD = 6.47). The majority of patients were at term (76.36%) and in their second pregnancy (29.96%). EMS teams were most often dispatched in the summer (25.95%) and in urban areas (63.26%). Most EMS teams were basic (68.99%) and interventions most often took place between 19:00 and 06:59 (63.14%). Significant differences were observed between preterm and term pregnant women attended by EMS teams in terms of variables such as the age of the patient, number of previous labours, history of miscarriage, presence of vaginal bleeding, time of year, location of call, type and composition of EMS team dispatched, urgency code and time of call, duration of intervention, selected emergency medical procedures performed and test results.

A scoping review on data integration in the field of infectious diseases, 2009-2018

Background and Aim: Little is known about data integration in public health research and its impact. This study aimed to summarize known collaboration information, the characteristics of the datasets used, the methods of data integration, and knowledge gaps. Materials and Methods: We reviewed papers on infectious diseases from two or more datasets published during 2009- 2018, before the coronavirus disease pandemic. Two independent researchers searched the Medline and Global Health databases using predetermined criteria. Results: Of the 2375 items retrieved, 2272 titles and abstracts were reviewed. Of these, 164 were secondary reviews. Full-text reviews identified 153 relevant articles; we excluded 11 papers that did not meet our inclusion criteria. Of the 153 papers, 150 were single-country studies. Most papers were from North America (n=47). Viral diseases were the most commonly researched diseases (n=66), and many studies sought to define infection rates (n=62). Data integration usually employed unique national identifiers (n=37) or address-based identifiers (n=30). Two data sources were combined (n=121), and at least one data source typically included routine surveillance information. Conclusion: We found a growing usage of data integration in infectious diseases, emphasizing the advantages of data integration and linkage analysis, and reiterating its importance in public health emergency preparedness and response.

What influences rural women's choices in maternity care: A qualitative exploratory study

Rural women are likely to experience difficulties accessing maternity care that is readily available in metropolitan areas. This limited access can impede women's ability to make informed choices that enhance safety and minimize harm. This study explored the experiences of women who had given birth in a rural environment and the factors that influenced their choices regarding their maternity care. Semistructured interviews were conducted with 10 women for this qualitative, exploratory study. These women had birthed within rural areas of Victoria, Australia, between May 2016 and May 2017. Thematic analysis was undertaken. Three main themes emerged: (i) being influenced by previous childbirth experiences, (ii) feeling safe and supported with their maternity care provider, and (iii) being supported in their birthing choices. The availability of maternity care providers and travel time to facilities limited the choices of rural women. This study provided valuable insights into what was behind the decisions of rural women's choices regarding their maternity care. To assist with making informed decisions regarding their maternity care, all available models of maternity care should be presented to rural women.

Inclusion and exclusion criteria for publicly-funded homebirth in Australia: A scoping review

BACKGROUND

There are fifteen publicly-funded homebirth programs currently operating in Australia. Suitability for these programs is determined by a series of inclusion and exclusion criteria.

AIM

The aim of this scoping review is to identify common inclusion and exclusion criteria for publicly-funded homebirth programs and other related factors that affect access to these programs.

METHODS

A Google search was conducted for publicly-funded homebirth programs listed on the National Publicly-funded Homebirth Consortium website. Public websites, documents, and policies were analysed to identify inclusion and exclusion criteria for these programs.

FINDINGS

Eleven of the 15 publicly-funded homebirth programs mention the availability of homebirth on their health service website, with varying levels of information about the inclusion and exclusion criteria available. Two of the programs with no information on their health service website are covered by a state-wide guideline. Additional details were sought directly from programs and obtaining further information from some individual homebirth programs was challenging. Variation in inclusion and exclusion criteria exists between programs. Common areas of variation include restrictions relating to Body Mass Index, parity, age, English language ability, tests required during pregnancy, and gestation at booking to the homebirth program.

CONCLUSION

The inclusion and exclusion criteria for a publicly-funded homebirth program determines women's access to the program. Limited publicly available information regarding inclusion and exclusion criteria for many publicly-funded homebirth programs is likely to limit women's awareness of and access to these programs.

Differential access to continuity of midwifery care in Queensland, Australia

ObjectiveTo determine maternal access to continuity of midwifery care in public maternity hospitals across the state of Queensland, Australia. MethodsMaternal access to continuity of midwifery care in Queensland was modelled by considering the proportion of midwives publicly employed to provide continuity of midwifery care alongside 2017 birth data for Queensland Hospital and Health Services. The model assumed an average caseload per full-time equivalent midwife working in continuity of care with 35 women per annum, based on state Nursing and Midwifery Award conditions. Hospitals were grouped into five clusters using standard Australian hospital classifications. ResultsTwenty-seven facilities (out of 39, 69%) across all 15 hospital and health services in Queensland providing a maternity service offered continuity of midwifery care in 2017 (birthing onsite). Modelling applying the assumed caseload of 35 women per full-time equivalent midwife found wide variations in the percentage of women able to access continuity of midwifery care, with access available for an estimated 18% of childbearing women across the state. Hospital classifications with higher clinical services capability and birth volume did not equate with higher access to continuity of midwifery care in metropolitan areas. Regional health services with level 3 district hospitals assisting with &lt;500 births showed higher levels of access, potentially due to additional challenges to meet local population needs to those of a metropolitan service. Access to full continuity of midwifery care in level 3 remote hospitals (&lt;500 births) was artificially inflated due to planned pre-labour transfers for women requiring specialised intrapartum care and women who planned to birth at other hospitals. ConclusionsDespite strong evidence that continuity of midwifery care offers optimal care for women and their babies, there was significant variation in implementation and scale-up of these models across hospital jurisdictions. What is known about the topic?Access to continuity of midwifery care for pregnant women within the public health system varies widely; however, access variation among different hospital classification groups in Australian states and territories has not been systematically mapped. What does this paper add?This paper identified differential access to continuity of midwifery care among hospital classifications grouped for clinical services capability and birth volume in one state, Queensland. It shows that higher clinical services capability and birth volume did not equate with higher access to continuity of midwifery care in metropolitan areas. What are the implications for practitionersScaling up continuity of midwifery care among all hospital classification groups in Queensland remains an important public health strategy to address equitable service access.

Exploring the conceptualisation and study of freebirthing as a historical and social phenomenon: a meta-narrative review of diverse research traditions

Freebirthing is a clandestine practice whereby women intentionally give birth without healthcare professionals (HCPs) present in countries where there are medical facilities available to assist them. Women who make this decision are frequently subjected to stigma and condemnation, yet research on the phenomenon suggests that women's motivations are often complex. The aim of this review was to explore how freebirth has been conceptualised over time in the English-language academic and grey literature. The meta-narrative methodology employed enables a phenomenon to be understood within and between differing research traditions, as well as against its social and historical context. Our research uncovered nine research traditions (nursing, autobiographical text with birthing philosophy, midwifery, activism, medicine, sociology, law and ethics, pregnancy and birth advice, and anthropology) originating from eight countries and spanning the years 1957-2018. Most of the texts were written by women, with the majority being non-empirical. Empirical studies on freebirth were usually qualitative, although there were a small number of quantitative medical and midwifery studies; these texts often focused on women's motivations and highlighted a range of reasons as to why a woman would decide to give birth without HCPs present. Motivations frequently related to women's previous negative maternity experiences and the type of maternity care available, for example medicalised and hospital-based. The use of the meta-narrative methodology allowed the origins of freebirth in 1950s America to be traced to present-day empirical studies of the phenomenon. This highlighted how the subject and the publication of literature relating to freebirth are embedded within their social and historical contexts. From its very inception, freebirth aligns with the medicalisation of childbirth, the position of women in society, the provision of maternity care and the way in which women experience maternity services.

Cohort profile: the eLIXIR Partnership-a maternity-child data linkage for life course research in South London, UK

PURPOSE

Linked maternity, neonatal and maternal mental health records were created to support research into the early life origins of physical and mental health, in mothers and children. The Early Life Cross Linkage in Research (eLIXIR) Partnership was developed in 2018, generating a repository of real-time, pseudonymised, structured data derived from the electronic health record systems of two acute and one Mental Health Care National Health Service (NHS) Provider in South London. We present early descriptive data for the linkage database and the robust data security and governance structures, and describe the intended expansion of the database from its original development. Additionally, we report details of the accompanying eLIXIR Research Tissue Bank of maternal and neonatal blood samples.

PARTICIPANTS

Descriptive data were generated from the eLIXIR database from 1 October 2018 to 30 June 2019. Over 17 000 electronic patient records were included.

FINDINGS TO DATE

10 207 women accessed antenatal care from the 2 NHS maternity services, with 8405 deliveries (8772 infants). This diverse, inner-city maternity service population was born in over 170 countries with an ethnic profile of 46.1% white, 19.1% black, 7.0% Asian, 4.1% mixed and 4.1% other. Of the 10 207 women, 11.6% had a clinical record in mental health services with 3.0% being treated during their pregnancy. This first data extract included 947 infants treated in the neonatal intensive care unit, of whom 19.1% were postnatal transfers from external healthcare providers.

FUTURE PLANS

Electronic health records provide potentially transformative information for life course research, integrating physical and mental health disorders and outcomes in routine clinical care. The eLIXIR database will grow by ~14 000 new maternity cases annually, in addition to providing child follow-up data. Additional datasets will supplement the current linkage from other local and national resources, including primary care and hospital inpatient data for mothers and their children.

Epidemiology of Oxytocin Administration in Out-of-Hospital Births Attended by Paramedics

AIM

Primary postpartum hemorrhage (PPH) is a life-threatening obstetric emergency that can be mitigated through the administration of a uterotonic to actively manage the third stage of labor. This study describes the prehospital administration of oxytocin by paramedics following attendance of out-of-hospital (OOH) births.

METHODS

A retrospective analysis was undertaken of all OOH births between the 1^st January 2018 and 31^st December 2018 attended by the Queensland Ambulance Service. The demographic and epidemiological characteristics of patients that were administered oxytocin and the occurrence of adverse side effects were described.

RESULTS

In total, 350 OOH births were included in this study with the majority involving multigravidas women (94.3%) and all but two involving singleton pregnancies. Oxytocin was administered following 222 births (63.4%), while 67 patients (19.1%) declined administration preferring a physiological third stage of labor, and in 61 cases (17.4%) oxytocin was withheld by the attending paramedic. There were no documented adverse events or side effects following administration. Oxytocin administration occurred on average 14 minutes (interquartile range 9-25) following the time of birth. The median time from oxytocin administration to placenta delivery was 10 minutes (interquartile range 5-22).

CONCLUSION

Oxytocin is well accepted and safe treatment adjunct for the management of the third stage of labor in OOH births and should be considered for routine practice by other emergency medical services.

Why do women choose homebirth in Australia? A national survey

BACKGROUND

In Australia there have been regulatory and insurance changes negatively affecting homebirth.

AIM

The aim of this study is to explore the characteristics, needs and experiences of women choosing to have a homebirth in Australia.

METHODS

A national survey was conducted and promoted through social media networks to women who have planned a homebirth in Australia. Data were analysed to generate descriptive statistics.

FINDINGS

1681 surveys were analysed. The majority of women indicated a preference to give birth at home with a registered midwife. However, if a midwife was not available, half of the respondents indicated they would give birth without a registered midwife (freebirth) or find an unregistered birthworker. A further 30% said they would plan a hospital or birth centre birth. In choosing homebirth, women disclosed that they wanted to avoid specific medical interventions and the medicalised hospital environment. Nearly 60% of women reported at least one risk factor that would have excluded them from a publicly funded homebirth programme. Many women described their previous hospital experience as traumatic (32%) and in some cases, leading to a diagnosis of post-traumatic stress disorder (PTSD, 6%). Only 5% of women who reported on their homebirth experience considered it to be traumatic (PTSD, 1%). The majority of these were associated with how they were treated when transferred to hospital in labour.

CONCLUSION

There is an urgent need to expand homebirth options in Australia and humanise mainstream maternity care. A potential rise in freebirth may be the consequences of inaction.

Birthing outside the system: the motivation behind the choice to freebirth or have a homebirth with risk factors in Australia

BACKGROUND

Childbirth in Australia occurs predominantly in a biomedical context, with 97% of births occurring in hospital. A small percentage of women choose to birth outside the system - that is, to have a midwife attended homebirth with risk factors, or a freebirth, where the birth at home is intentionally unattended by any health professional.

METHOD

This study used a Grounded Theory methodology. Data from 13 women choosing homebirth and 15 choosing freebirth were collected between 2010 and 2014 and analysed over this time.

RESULTS

The core category was 'wanting the best and safest,' which describes what motivated the women to birth outside the system. The basic social process, which explains the journey women took as they pursued the best and safest, was 'finding a better way'. Women who gave birth outside the system in Australia had the countercultural belief that their knowledge about what was best and safest had greater authority than the socially accepted experts in maternity care. The women did not believe the rhetoric about the safety of hospitals and considered a biomedical approach towards birth to be the riskier birth option compared to giving birth outside the system. Previous birth experiences taught the women that hospital care was emotionally unsafe and that there was a possibility of further trauma if they returned to hospital. Giving birth outside the system presented the women with what they believed to be the opportunity to experience the best and safest circumstances for themselves and their babies.

CONCLUSION

Shortfalls in the Australian maternity care system is the major contributing factor to women's choice to give birth outside the system. Systematic improvements should prioritise humanising maternity care and the expansion of birth options which prioritise midwifery-led care for women of all risk.

Out-of-maternity deliveries in France: A nationwide population-based study

Introduction

In France, many maternity hospitals have been closed as a result of hospital restructuring in an effort to reduce costs through economies of scale. These closures have naturally increased the distance between home and the closest maternity ward for women throughout the country. However, studies have shown a positive correlation between this increase in distance and the incidence of unplanned out-of-maternity deliveries (OMD). This study was conducted to estimate the frequency of OMD in France, to identify the main risk factors and to assess their impact on maternal mortality and neonatal morbidity and mortality.

Materials and methods

We conducted a population-based observational retrospective study using data from 2012 to 2014 obtained from the French hospital discharge database. We included 2,256,797 deliveries and 1,999,453 singleton newborns in mainland France, among which, 6,733 (3.0‰) were OMD. The adverse outcomes were maternal mortality in hospital or during transport, stillbirth, neonatal mortality, neonatal hospitalizations, and newborn hypothermia and polycythemia. The socio-residential environment was also included in the regression analysis. Maternal and newborn adverse outcomes associated with OMD were analyzed with Generalized Estimating Equations regressions.

Results

The distance to the nearest maternity unit was the main factor for OMD. OMD were associated with maternal death (aRR 6.5 [1.6–26.3]) and all of the neonatal adverse outcomes: stillbirth (3.3 [2.8–3.8]), neonatal death (1.9 [1.2–3.1]), neonatal hospitalization (1.2 [1.1–1.3]), newborn hypothermia (5.9 [5.2–6.6]) and newborn polycythemia (4.8 [3.5–6.4]).

Discussion

In France, OMD increased over the study period. OMD were associated with all the adverse outcomes studied for mothers and newborns. Caregivers, including emergency teams, need to be better prepared for the management these at-risk cases. Furthermore, the increase in adverse outcomes, and the additional generated costs, should be considered carefully by the relevant authorities before any decisions are made to close or merge existing maternity units.

Listening to women's voices: the experience of giving birth with paramedic care in Queensland, Australia

Background

Unplanned out-of-hospital birth is generally assumed to occur for women who are multiparous, have a history of a short pushing phase of labour or are experiencing a precipitate birth. However, there is little research that examines the woman’s perspective regarding factors that influenced their decision on when to access care. This research aimed to explore women’s experience of unplanned out-of-hospital birth in paramedic care. Due to the size of the data in the larger study of ‘Women’s experience of unplanned out-of-hospital birth in paramedic care’ [1], this paper will deal directly with the women’s narrative concerning her decision to access care and how previous birth experience and interactions with other healthcare professionals influenced her experience.

Method

Narrative inquiry, underpinned from a feminist perspective, was used to guide the research. Twenty-two women who had experienced an unplanned out-of-hospital birth within the last 5 years in Queensland, Australia engaged in this research.

Results

The decision of a woman in labour to attend hospital to birth her baby is influenced by information received from healthcare providers, fear of unnecessary medical intervention in birth, and previous birth experience. All themes and subthemes that emerged in the women’s narratives relate to the notion of birth knowledge. These specifically include perceptions of what constitutes authoritative knowledge, who possesses the authoritative knowledge on which actions are based, and when and how women use their own embodied knowledge to assess the validity of healthcare workers’ advice and the necessity for clinical intervention.

Conclusions

The women interviewed communicated a tension between women’s knowledge, beliefs and experience of the birth process, and the professional models of care traditionally associated with the hospital environment. It is essential that information provided to women antenatally is comprehensive and comprehensible. The decisions women make concerning their birth plan represent the women’s expectations for their birth and this should be used as a means to openly communicate issues that may impact the birth experience.

Babies born in the pre-hospital setting attended by ambulance clinicians in the north east of England

Introduction:

The majority of births in the United Kingdom happen in hospital or at stand-alone midwife led centres, or with the support of midwives in a planned fashion outside of hospital. The unplanned birth of a baby in the pre-hospital setting is a rare event which may result in an ambulance being called, so attendance at a birth is a rare event for ambulance clinicians. A service evaluation was conducted to report which clinical observations were recorded on babies born in the pre-hospital setting who were attended by ambulance clinicians from the North East Ambulance Service (NEAS) over a one-year period.

Methods:

A retrospective service evaluation was conducted using routinely collected data. All electronic patient care records covering a one-year period between 1 October 2017 and 30 September 2018 with a primary impression of ‘childbirth’ were examined.

Results:

This evaluation identified 168 individual pre-hospital childbirth cases attended by NEAS clinicians during the evaluation timeframe. The majority (85%) of babies were born to multiparous mothers with a median gestation of 39 weeks. Very few clinical observations were recorded on the babies (respiratory rate 23%, heart rate 21%, temperature 10%, APGAR 8%, blood sugar 1%) and no babies had all five of these observations documented. Only 5% of babies had any complications documented.

Conclusion:

This study showed that NEAS ambulance clinicians rarely attend babies born in the pre-hospital setting and that complications were infrequently recorded. There was a lack of observations recorded on the babies, which is an issue due to the clear link between easily measurable characteristics such as temperature and mortality and morbidity.

Women's experience of unplanned out-of-hospital birth in paramedic care

BACKGROUND

Healthcare literature describes predisposing factors, clinical risk, maternal and neonatal clinical outcomes of unplanned out-of-hospital birth; however, there is little quality research available that explores the experiences of mothers who birth prior to arrival at hospital.

METHODS

This study utilised a narrative inquiry methodology to explore the experiences of women who birth in paramedic care.

RESULTS

The inquiry was underscored by 22 narrative interviews of women who birthed in paramedic care in Queensland, Australia between 2011 and 2016. This data identified factors that contributed to the planned hospital birth occurring in the out-of-hospital setting. Women in this study began their story by discussing previous birth experience and their knowledge, expectations and personal beliefs concerning the birth process. Specific to the actual birth event, women reported feeling empowered, confident and exhilarated. However, some participants also identified concerns with paramedic practice; lack of privacy, poor interpersonal skills, and a lack of consent for certain procedures.

CONCLUSIONS

This study identified several factors and a subset of factors that contributed to their experiences of the planned hospital birth occurring in the out-of-hospital setting. Women described opportunities for improvement in the care provided by paramedics, specifically some deficiencies in technical and interpersonal skills.

Emergency medical technicians' experiences with unplanned births outside institutions: A qualitative interview study

AIM

To explore emergency medical technicians' experiences with unplanned births outside institutions.

DESIGN

A qualitative interview study.

METHODS

Individual semi-structured interviews with 12 emergency medical technicians in Norway. Systematic text condensation was used to analyse the data material.

RESULTS

Analysis showed that there is a mismatch between society's expectations about emergency medical technicians and the reality they encounter in out-of-hospital maternity care, that emergency medical technicians experience a general lack of training in caring for labouring women and that poor communication with other health professions challenges patient safety. The participants expressed how they do their best in caring for both mother and child, in spite of a lack of education, training and competence in assisting labouring women.