[Modified midwife managed unit--an alternative for small birthing departments?]

BACKGROUND

The Norwegian Board of Health has proposed to divide the delivery units into three categories. For several of today's smaller consultant managed units this could lead to a reclassification into midwife managed units.

MATERIAL AND METHODS

During 1997 and 1998 the community hospital in Lofoten has tried out a modified type of midwife managed unit. By a continuous selection process a high risk and a low risk group of gravidas were identified. The high risk group was referred to the central hospital in Bodø, while the low risk group was offered to deliver locally.

RESULTS

Previously more than 90% delivered at the community hospital in Lofoten, while approximately 70% still delivered locally during the trial period. There were no deliveries during transport and no serious complications for mother or child caused by the new system. The community hospital had facilities for performing emergency caesarean sections. In 1997 nine caesarean sections out of 211 deliveries and in 1998 four out of 224 were performed. The caesarean section rate for the total population was lower during the trial period than over the previous five years.

INTERPRETATION

A modified midwife managed unit could be a good alternative for small consultant managed units if the Norwegian Board of Health's proposal is carried through.

Child births in a modified midwife managed unit: selection and transfer according to intended place of delivery

BACKGROUND

As small obstetrical departments may not be able to give second-level perinatal care, the delivery unit at Lofoten hospital was for the years 1997-98 reorganized to a modified midwife managed unit. Women at low obstetrical risk were delivered at this unit and women at high risk were referred to the central hospital. We assessed the effectiveness of the risk selection.

MATERIAL AND METHODS

The study was a prospective, pragmatic, population-based trial. Desired outcome was defined as a non-operative delivery at 35-42 weeks gestational age giving an infant not needing resuscitation. Intermediate outcomes: Operative deliveries, infants transferred to neonatal intensive care unit and infants diverging from normal. The intended place of delivery was ultimately decided at admittance to the midwife managed unit.

RESULTS

Of the 628 women in study 435 (69.3%) gave birth at the midwife managed unit, 152 (24.2%) were selected to be delivered at the central hospital and 41 (6.5%) were transferred to the central hospital after admittance to the midwife managed unit. Desired outcome was recorded in 94% of the deliveries at the midwife managed unit as compared to 50.3% at the central hospital. Women who intended to be delivered at the midwife managed unit, needed fewer operative deliveries and relatively few infants were transferred to the neonatal intensive care unit or diverged from normal.

CONCLUSIONS

As nearly 70% of the births occurred at the midwife managed unit and 94% of these deliveries had a desired outcome, this indicates an effective selection process. This model might be an alternative to centralization of births in sparsely population areas.

Perinatal deaths in a Norwegian county 1986-96 classified by the Nordic-Baltic perinatal classification: geographical contrasts as a basis for quality assessment

BACKGROUND

Quality assessment of perinatal care can be carried out by classifying perinatal deaths. In the following we have analyzed the geographical contrasts in perinatal deaths according to the Nordic-Baltic perinatal death classification in a sparsely populated Norwegian county.

MATERIAL AND METHODS

All stillbirths (> or =28 weeks of gestation) and neonatal deaths (gestational age > or =22 weeks; death < or =28 days) in 1986-96 from Nordland county (240,000 inhabitants) were classified. For comparison the county was geographically divided into six general local hospital areas and one central hospital area.

RESULTS

The classification showed a well acceptable inter and intra observer variation. One hundred and seventy-one stillbirths and 155 neonatal deaths were analyzed. The death rate (pr 1,000 births) for single, non-malformed, antenatal stillbirths was higher in the central hospital area than in the local hospital areas (3.22 vs. 2.02). The death rate for extreme preterm infants (22-27 weeks of gestation) was on the other hand higher in the local hospital areas (2.45 vs. 1.05). One of the general local hospital areas was singled out with an especially high neonatal death rate among extreme preterm infants. This was to some extent explained by the death of extreme preterm twins and triplets.

CONCLUSION

The Nordic-Baltic perinatal death classification system is a consistent and reproducible tool also for studying perinatal death in restricted geographical areas. The observed contrasts in perinatal deaths were used as basis for programs aimed at improving perinatal care. The observation of an unexplained increased number of antenatal stillbirths in the central hospital area resulted in a program for prospective recording and better characterization of the placenta and umbilical cord. Proposals for a better antenatal program preventing extreme preterm birth of twins for the whole county has been launched. In utero transfer to a hospital with a neonatal intensive care unit seems crucial in improving the prognosis for these infants.

[Can deliveries at risk be selected at smaller delivery units?]

In order to explore the possibility of converting a delivery unit at a small hospital to a maternity home, we examined the medical records of those women who delivered by Caesarean section, forceps or vacuum extraction at Lofoten hospital during 1995. How many of these women might it have been necessary to transfer to an obstetrical department if Lofoten hospital had been a maternity home caring for low risk deliveries (primipara and multipara)? Out of a total of 271 deliveries (primiparas 98), 49 women delivered by Caesarean section (n = 35), forceps (n = 5) or vacuum extraction (n = 9). Using risk assessment, 22 women (45%) would have been selected for antenatal transfer, and 20 (41%) for intrapartum transport. For seven women no transfer would have been possible. These women would have delivered locally by vacuum extraction. Primipara versus multipara had a relative risk of 2.8 for Caesarean section or assisted vaginal delivery. It is estimated that 8-9% of the women would be selected prenatally for planned delivery at a hospital unit and that 7-8% would be transferred in labour if primiparas delivered at the maternity home. If primiparas were excluded, the proportions would be 41% and 1-2% respectively. In 1997 the delivery unit at Lofoten hospital was temporarily converted to a maternity home for a period of two years.