Article

Planned Place of Birth in New Zealand: Does it Affect Mode of Birth and Intervention Rates Among Low-Risk Women?

Authors:
  • International Confederation of Midwives
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Abstract

Midwives providing care as lead maternity caregivers in New Zealand provide continuity of care to women who may give birth in a variety of settings, including home, primary units, and secondary and tertiary level hospitals. The purpose of this study was to compare mode of birth and intrapartum intervention rates for low-risk women planning to give birth in these settings under the care of midwives. Data for a cohort of low-risk women giving birth in 2006 and 2007 were extracted from the Midwifery Maternity Provider Organisation database. Mode of birth, intrapartum interventions, and neonatal outcomes were compared with results adjusted for age, parity, ethnicity, and smoking. Women planning to give birth in secondary and tertiary hospitals had a higher risk of cesarean section, assisted modes of birth, and intrapartum interventions than similar women planning to give birth at home and in primary units. The risk of emergency cesarean section for women planning to give birth in a tertiary unit was 4.62 (95% CI: 3.66-5.84) times that of a woman planning to give birth in a primary unit. Newborns of women planning to give birth in secondary and tertiary hospitals also had a higher risk of admission to a neonatal intensive care unit (RR: 1.40, 95% CI: 1.05-1.87; RR: 1.78, 95% CI: 1.31-2.42) than women planning to give birth in a primary unit. Planned place of birth has a significant influence on mode of birth and rates of intrapartum intervention in childbirth.

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... Em países desenvolvidos, a prevalência de partos domiciliares atendidos por profissional qualificado, de forma planejada, varia: 11,3% na Nova Zelândia (1) , 2,8% na Inglaterra (2) e menos de 1% na Austrália (3) . Entretanto, na Holanda, 62,7% das mulheres planejam o parto no domicílio (4) . ...
... No Brasil, nem sempre a assistência obstétrica realizada nas instituições de saúde é baseada em práticas com evidências científicas, como mostra a pesquisa Nascer no Brasil (7) . Diferentemente do contexto hospitalar brasileiro, diversos estudos internacionais apontam que a assistência no PDP é pouco intervencionista (1,(3)(4) . ...
... As mulheres que optaram pelo PDP têm escolaridade elevada, resultado semelhante a outras pesquisas brasileiras (8)(9)(10)(11)(12) . Contudo, elas são mais jovens quando comparadas às dos estudos internacionais (1)(2)(3)(13)(14) . A alta escolaridade das mulheres mostra que se trata de um público com características singulares, que tem acesso à informação, questiona o modelo hegemônico atual e busca um local para o parto que atenda às suas expectativas, da mesma forma que as mulheres atendidas em CPN, uma vez que a assistência é menos intervencionista do que no hospital (7) . ...
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Objective: To describe obstetric practices in planned home births, assisted by qualified professionals in Brazil. Method: This is a descriptive study, with data collected in an online bank maintained by 49 professionals from December 2014 to November 2015, in which the target population was women and newborns assisted in home births. Data were analyzed through descriptive statistics. Results: A total of 667 women and 665 newborns were included. Most of the women gave birth at home (84.4%), in a nonlithotomic position (99.1%); none underwent episiotomy; 32.3% had intact perineum; and 37.8% had first-degree lacerations, some underwent amniotomy (5.4%), oxytocin administration (0.4%), and Kristeller's maneuver (0.2%); 80.8% of the women with a previous cesarean section had home birth. The rate of transfer of parturients was 15.6%, of puerperal women was 1.9%, and of neonates 1.6%. The rate of cesarean section in the parturients that started labor at home was 9.0%. Conclusion: The obstetric practices taken are consistent with the scientific evidence; however, unnecessary interventions are still performed. The rates of cesarean sections and maternal and neonatal transfers are low. Home can be a place of birth option for women seeking a physiological delivery.
... The place of birth impacts on birth outcomes for low risk women with those birthing in higher technology facilities having an increased risk of unnecessary intervention than those who birth in the low technology settings of home or primary maternity units (Davis et al, 2011). The reasons why women choose particular settings for birth are complex and there is limited research on this topic. ...
... The lack of primary units within some geographical areas of NZ and the lack of access to primary units for many women domiciled in urban areas limit the options available to women and to LMC midwives. This is important because there is increasing evidence that when low risk women birth in high technology maternity facilities their outcomes are not as good as those low risk women who birth at home or in primary maternity facilities (Davis et al., 2011). ...
... Cragin and Kennedy (2006) found that women cared for by midwives had less use of technology and intervention with NO difference in neonatal outcomes, even when pre-existing conditions were taken into account. Results from the planned place of birth in New Zealand (Davis et al., 2011) study from the MMPO database indicate that perinatal outcomes are favourable for babies of women who planned homebirth or birth in primary birthing units under the care of a midwife. ...
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JOURNAL Do low risk women actually birth in their planned places of birth, and does ethnicity influence women's choice of birthplace? Quantity or quality of postnatal length of stay? Literature review examining the issues and the evidence.
... 9,10 Clinical outcomes in midwife-led units compared with higher-level maternity units show no differences in perinatal mortality or morbidity 6,11 ; improved outcomes for maternal morbidity 12 ; reduced birth interventions, including less caesarean section 6,12-14 and improved neonatal outcomes. 6,14 This study describes the maternal characteristics, labour, birthing and neonatal outcomes of a maternity service at a small public district hospital in rural NSW ('the district hospital') following the adaptation of the service from an obstetrician and general practitionerobstetrician (GPO)-led service to an MGP model with a planned caesarean section service (PCS). The results demonstrate that the service maintained quality care outcomes for a group of low-risk women and provide an example of the successful adaptation of a rural maternity service to meet sustainability challenges. ...
... Previous caseload midwifery studies have demonstrated fewer obstetric interventions such as induction of labour, epidurals, instrumental deliveries, episiotomies and CS. 6,14,15 The results for the MGP in our study suggest a similar trend. Reduced casemix complexity and differing philosophies of practice may explain these trends. ...
... This is consistent with other MGP studies that have demonstrated comparable or improved neonatal outcomes. 6,14,23 Limitations This study was unable to make comparisons between the GPO and MGP/PCS service due to the differences in the casemix of the services. In addition, transfer data were not available to explore outcomes for women from the MGP program transferred to the regional referral hospital to give birth. ...
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Objective: To describe the outcomes of a public hospital maternity unit in rural New South Wales (NSW) following the adaptation of the service from an obstetrician and general practitioner-obstetrician (GPO)-led birthing service to a low-risk midwifery group practice (MGP) model of care with a planned caesarean section service (PCS). Design: A retrospective descriptive study using quantitative methodology. Setting: Maternity unit in a small public hospital in rural New South Wales, Australia. Participants: Data were extracted from the ward-based birth register for 1172 births at the service between July 2007 and June 2012. Main outcome measures: Birth numbers, maternal characteristics, labour, birthing and neonatal outcomes. Results: There were 750 births over 29 months in GPO and 277 and 145 births over 31 months in MGP and PCS, respectively, totalling 422 births following the change in model of care. The GPO had 553 (73.7%) vaginal births and 197 (26.3%) caesarean section (CS) births (139 planned and 58 unplanned). There were almost universal normal vaginal births in MGP (>99% or 276). For normal vaginal births, more women in MGP had no analgesia (45.3% versus 25.1%) or non-invasive analgesia (47.9% versus 38.6%) and episiotomy was less common in MGP than GPO (1.9% versus 3.4%). Neonatal outcomes were similar for both groups with no difference between Apgar scores at 5 min, neonatal resuscitations or transfer to high-level special care nurseries. Conclusion: This study demonstrates how a rural maternity service maintained quality care outcomes for low-risk women following the adaptation from a GPO to an MGP service.
... In high income countries, evidence is increasingly showing benefits for women at low risk of complications who choose to birth outside of hospital and are attended by skilled carers. These women experience lower rates of vacuum or forceps birth [9,10], caesarean section [10][11][12], and greater satisfaction [13][14][15] and breastfeeding rates [11], and their babies have fewer admissions to neonatal intensive care [9] than similar low risk women who plan hospital birth. Medical interventions such as induction of labour and caesarean section are beneficial or life-saving in some contexts, yet they can also be inappropriately or routinely used with potentially harmful outcomes [16]. ...
... Medical interventions such as induction of labour and caesarean section are beneficial or life-saving in some contexts, yet they can also be inappropriately or routinely used with potentially harmful outcomes [16]. Despite the lower rates of interventions, no difference in maternal or neonatal mortality rates have been observed between attended, low risk home and hospital birth in Australia [17,18], New Zealand [12], The United Kingdom [10], the Netherlands [19] or Canada [9,11]. Additionally, home births have been found to be more cost effective than hospital births [20,21]. ...
... However, the overall positive outcomes are supporting increased acceptability for home birth in many high income countries. Women in The Netherlands, New Zealand and Canada are publicly financially supported in their choice of birth setting and care provider including home birth [12,13,26], and almost all states and territories in Australia now have government funded home birth programs [17]. Recent policy shift in the UK encourages low risk women to birth out of hospital. ...
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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.
... Halfdandottir [27] Hutton [28] Hutton [3] Janssen [21] Janssen [22] van der Kooy [29] van der Kooy [19] Wiegers [24] Blix [30] Lindgren [31] Within standards (includes only women who meet criteria for birth at home at ibset ) Brocklehurst [23] Davis [20] de Jonge [25] Hermus [26] Pang [18] Hiraizumi [32] Homer [33] Fig. 1. Flow diagram of study selection. ...
... For a variety of reasons the multiple hospital comparison groups in Janssen's papers could not be combined [21,22] therefore we used the physician-attended hospital comparison group. For Davis et al., we used the primary unit comparison group [20]. For the paper by Homer et al. we included home and hospital groups and excluded the birth centre group because it may have included out of hospital birth centres. ...
... [30À33] as described elsewhere [9]. A pragmatic study design was used by ten studies [3,19,21,22,24,27À30,31], whereas seven studies included only those women who met local standards for home birth in their intended home birth cohorts [18,20,23,25,26,32,33]. ...
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Background: More women are choosing to birth at home in well-resourced countries. Concerns persist that out-of-hospital birth contributes to higher perinatal and neonatal mortality. This systematic review and meta-analyses determines if risk of fetal or neonatal loss differs among low-risk women who begin labour intending to give birth at home compared to low-risk women intending to give birth in hospital. Methods: In April 2018 we searched five databases from 1990 onward and used R to obtain pooled estimates of effect. We stratified by study design, study settings and parity. The primary outcome is any perinatal or neonatal death after the onset of labour. The study protocol is peer-reviewed, published and registered (PROSPERO No.CRD42013004046). Findings: We identified 14 studies eligible for meta-analysis including ~ 500,000 intended home births. Among nulliparous women intending a home birth in settings where midwives attending home birth are well-integrated in health services, the odds ratio (OR) of perinatal or neonatal mortality compared to those intending hospital birth was 1.07 (95% Confidence Interval [CI], 0.70 to 1.65); and in less integrated settings 3.17 (95% CI, 0.73 to 13.76). Among multiparous women intending a home birth in well-integrated settings, the estimated OR compared to those intending a hospital birth was 1.08 (95% CI, 0.84 to 1.38); and in less integrated settings was 1.58 (95% CI, 0.50 to 5.03). Interpretation: The risk of perinatal or neonatal mortality was not different when birth was intended at home or in hospital. Funding: Partial funding: Association of Ontario Midwives open peer reviewed grant. Research in context: Evidence before this study Although there is increasing acceptance for intended home birth as a choice for birthing women, controversy about its safety persists. The varying responses of obstetrical societies to intended home birth provide evidence of contrasting views. A Cochrane review of randomised controlled trials addressing this topic included one small trial and noted that in the absence of adequately sized randomised controlled trials on the topic of intended home compared to intended hospital birth, a peer reviewed protocol be published to guide a systematic review and meta-analysis including observational studies. Reviews to date have been limited by design or methodological issues and none has used a protocol published a priori.Added value of this study Individual studies are underpowered to detect small but potentially important differences in rare outcomes. This study uses a published peer-reviewed protocol and is the largest and most comprehensive meta-analysis comparing outcomes of intended home and hospital birth. We take study design, parity and jurisdictional support for home birth into account. Our study provides much needed information to policy makers, care providers and women and families when planning for birth.Implications of all the available evidence Women who are low risk and who intend to give birth at home do not appear to have a different risk of fetal or neonatal loss compared to a population of similarly low risk women intending to give birth in hospital.
... Mothers who deliver at home as planned are more often older [2-4, 9, 12, 14, 15, 19-21], non-smokers [6,12,21], married [15,17,21], and have had more earlier pregnancies [14,19] and deliveries [3,4,9,10,15,17,19,20], and the length of pregnancy is more often almost or more than 42 weeks [2, 3, 7, 9-12, 14, 15, 20]. Socioeconomic status and/or education are usually better among these women [4,7,12,15,21]. ...
... Mothers who deliver at home as planned are more often older [2-4, 9, 12, 14, 15, 19-21], non-smokers [6,12,21], married [15,17,21], and have had more earlier pregnancies [14,19] and deliveries [3,4,9,10,15,17,19,20], and the length of pregnancy is more often almost or more than 42 weeks [2, 3, 7, 9-12, 14, 15, 20]. Socioeconomic status and/or education are usually better among these women [4,7,12,15,21]. ...
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Objective: To evaluate trends and perinatal outcomes of planned home deliveries in Finland. Study design: All infants born in 1996-2013, excluding those born preterm, by operative delivery, and without information on birth mode or gestational age, were studied. The study group included 170 infants born at home as planned, 720,047 infants born at hospital were controls. Result: The rate of planned home deliveries increased from 8.3 to 39.4 per 100,000. In the study group 63%, containing two perinatal deaths, were not low-risk pregnancies according to national guidelines. The rate of hypothermia, asphyxia, and need of invasive ventilation was increased in low-risk home deliveries. One infant had a major congenital malformation. Maternal outcomes were favorable. Conclusion: The rate of planned home deliveries increased. Guidelines for low-risk deliveries were not followed in a majority of cases, including two perinatal deaths. Even in low-risk home deliveries, the neonatal morbidity appeared to be increased.
... Changing provider-client interactions are often more challenging than modifying clinical practices. According to Davis et al. (2011) (25), provider behaviors are often rooted in deeply held attitudes, assumptions, and prejudices about the communities they serve. For example, some study participants expressed that healthcare providers' treatments of birthing women were not always good because they knew that they were mainly serving underprivileged communities. ...
... Changing provider-client interactions are often more challenging than modifying clinical practices. According to Davis et al. (2011) (25), provider behaviors are often rooted in deeply held attitudes, assumptions, and prejudices about the communities they serve. For example, some study participants expressed that healthcare providers' treatments of birthing women were not always good because they knew that they were mainly serving underprivileged communities. ...
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Background & aim: Women experience childbirth in a variety of contexts with different aspirations. However, the experience has far-reaching implications for women’s health and that of their neonates. To explore the childbirth experiences of women giving birth in Zambia in order to better understand how they give meaning to the experience this study was conducted. Methods: This study was carried out using an interpretive phenomenological approach. Purposive sampling was utilized to recruit 50 participants from all the 10 provinces of Zambia. The ages of the subjects ranged from 16 to 38 years. The deliveries, both home and institutional, occurred between 2005 and 2011. The data were collected through tape-recorded in-depth unstructured interviews. Data analysis was performed using van Manen’s six steps of analysis. Results: The major theme of “being there” constituted two subthemes, namely “feeling safe” and “sense of achievement” emerged from the obtained data. The major theme elucidated the physical presence of the provider, as well as feelings of safety, comfort, trust, being recognized, and respected. The subtheme of “feeling safe” explicated women’s feelings of being at ease and at peace with their care providers, while the subtheme of “sense of achievement” clarified the participants’ expressions of pride that came through experiencing childbirth perceived by the woman giving birth to be satisfactory. Conclusion: By being physically and psychologically present for the woman who is giving birth, birth attendants, particularly midwives assisted in raising their confidence levels. Caring behaviours, such as showing kindness and respect, giving privacy, as well as making the cases feel comfortable made a qualitative difference of the childbirth experience. Keywords Childbirth; Women; Interpretive phenomenology; Zambia
... Only 1 in 200 women have a homebirth in Victoria, Australia. This is despite international evidence that for healthy normal pregnant women, home birth is not associated with an increased rate of adverse perinatal outcomes [1][2][3][4][5][6][7], or maternal morbidity [1,[3][4][5][6][7][8] compared to similar women having a planned hospital birth, particularly if they are multiparous [9]. Whether homebirth is safe for women at high risk of adverse pregnancy outcomes is less clear. ...
... Only 1 in 200 women have a homebirth in Victoria, Australia. This is despite international evidence that for healthy normal pregnant women, home birth is not associated with an increased rate of adverse perinatal outcomes [1][2][3][4][5][6][7], or maternal morbidity [1,[3][4][5][6][7][8] compared to similar women having a planned hospital birth, particularly if they are multiparous [9]. Whether homebirth is safe for women at high risk of adverse pregnancy outcomes is less clear. ...
Article
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Background The outcomes for planned homebirth in Victoria are unknown. We aimed to compare the rates of outcomes for high risk and low risk women who planned to birth at home compared to those who planned to birth in hospital. Methods We undertook a population based cohort study of all births in Victoria, Australia 2000–2015. Women were defined as being of low or high risk of adverse pregnancy outcomes according to the eligibility criteria for homebirth and either planning to birth at home or in a hospital setting at the at the onset of labour. Rates of perinatal and maternal mortality and morbidity as well as obstetric interventions were compared. ResultsThree thousand nine hundred forty-five women planned to give birth at home with a privately practising midwife and 829,286 women planned to give birth in a hospital setting. Regardless of risk status, planned homebirth was associated with significantly lower rates of all obstetric interventions and higher rates of spontaneous vaginal birth (p ≤ 0.0001 for all). For low risk women the rates of perinatal mortality were similar (1.6 per 1000 v’s 1.7 per 1000; p = 0.90) and overall composite perinatal (3.6% v’s 13.4%; p ≤ 0.001) and maternal morbidities (10.7% v’s 17.3%; p ≤ 0.001) were significantly lower for those planning a homebirth. Planned homebirth among high risk women was associated with significantly higher rates of perinatal mortality (9.3 per 1000 v’s 3.5 per 1000; p = 0.009) but an overall significant decrease in composite perinatal (7.8% v’s 16.9%; p ≤ 0.001) and maternal morbidities (16.7% v’s 24.6%; p ≤ 0.001). Conclusion Regardless of risk status, planned homebirth was associated with significantly lower rates of obstetric interventions and combined overall maternal and perinatal morbidities. For low risk women, planned homebirth was also associated with similar risks of perinatal mortality, however for women with recognized risk factors, planned homebirth was associated with significantly higher rates of perinatal mortality.
... The importance of making the choice of where to birth has been revealed in the overwhelming evidence concluding that, for women who do not have defined risk factors, birth outside of large, obstetric hospitals is safer (Birthplace in England Collaborative Group, 2011;Davis et al., 2011;Farry, 2015;Overgaard, Møller, Fenger-Grøn, Knudsen, & Sandall, 2011). Low risk women birthing in any one of CMDHB's three primary units had significantly lower odds of experiencing an emergency caesarean section, a postpartum haemorrhage, or an acute postpartum admission than those women giving birth in the tertiary unit (Farry, 2015). ...
... The prejudices of our research team were born of a commitment to supporting normal birth wherever that is a safe option, a belief that women are more likely to labour without intervention in a primary maternity unit, and an appreciation of the more relaxed atmosphere of the primary units. Underpinning these beliefs is substantive research evidence (Birthplace in England Collaborative Group, 2011;Davis et al., 2011;Farry, 2015;Overgaard et al., 2011). ...
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ABSTRACT A Corresponding Author: jmcaraco@aut.ac.nz B Auckland University of Technology, Auckland C Midwife, Auckland Background: Birth is a socially constructed experience for Pasifika living in New Zealand that is shaped by their community and maternity provider’s influences. Pasifika women in the Counties Manukau region predominantly choose to birth in a tertiary facility despite there being primary facilities available. Aim: This study asked Pasifika women about their choices for place of birth within the Counties Manukau District Health Board region. Method: Six healthy, low risk Pasifika women, who had given birth in the Counties Manukau District Health Board region, participated in this study. All women were interviewed individually and conversations were analysed using thematic analysis, followed by a hermeneutic interpretation. Findings: The women shared a culture of “we birth at Middlemore [Hospital] and that is where you have babies”. Their data surprised us as researchers. Those who had been transferred postnatally to primary units tended to still prefer Middlemore. We use the word “prejudice” in recognising that we thought (backed by research evidence) that they would be more likely to have a normal birth in a primary unit, and would prefer that experience. They told us that Middlemore Hospital was close to home; it was a place they knew; and it was where they preferred to give birth. The Pasifika women’s understanding of choice of birthplace was influenced by their community and, perhaps, by their midwife. While they seemed to have minimal understanding of why they would choose to birth at a primary birthing unit, there was a sense that even if they had this knowledge, they would not have changed their minds. They had a trust of, and familiarity with, Middlemore Hospital that held firm. They had their prejudice; we had ours. Recognising these different views offers a different space for conversation. Conclusion: It is important that any new or re-designed birthing unit be planned in collaboration with Pasifika women if it is intended for their use. Further, it is important that midwives take the time to listen to Pasifika women, and those from other cultures, to understand their point of view. Keywords: Pasifika women, maternity care system, New Zealand, Pasifika culture, place of birth
... Observational studies found no differences in the risk of a low Apgar score in infants planned to be born at home compared with infants born in hospital [5,[7][8][9]]. An American cohort study reported an increased risk of a low Apgar score in planned home births compared with planned hospital births [10,11], and The American College of Obstetricians and Gynecologists emphasizes the importance of careful evaluation of risk factors before recommending home birth [12]. ...
... However, the generalizability of these studies may be questioned as the qualifications of the birth attendants and the background of the women who chose home birth may differ from one population to the next. Cohort studies from New Zealand and the Netherlands showed no differences in the risk of admission to a neonatal intensive care unit (NICU) in infants born in planned home and hospital births, respectively [4,7]. Additionally, a large descriptive study from the United States reported low prevalences of neonatal death, low birth weight and low Apgar score in planned home births [13]; and a review found no differences in neonatal morbidity (Apgar score and NICU admission), but suggested that more documentation of planned birth place would strengthen future studies [14]. ...
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INTRODUCTION: The safety of home births has been widely debated. Observational studies examining maternal and neonatal outcomes of home births have become more frequent, and the quality of these studies has improved. The aim of the present study was to describe neonatal outcomes of home births compared with hospital births and to discuss which data are needed to evaluate the safety of home births. METHODS: This was a register-based cohort study. Data on all births in Denmark (2003-2013) were collected from the Danish Medical Birth Registry (DMBR). The cohort included healthy women with uncomplicated pregnancies and no medical interventions during delivery. A total of 6,395 home births and 266,604 hospital births were eligible for analysis. Comparative analyses were performed separately in nulliparous and multiparous women. The outcome measures were neonatal mortality and morbidity. RESULTS: Frequencies of admission to a neonatal intensive care unit and treatment with continuous positive airway pressure were significantly lower in infants born at home than in infants born at a hospital. A slightly, but significantly increased rate of early neonatal death was found among infants delivered by nulliparous at home. CONCLUSIONS: This study indicates that home births in Denmark are characterized by a high level of safety owing to low rates of perinatal mortality and morbidity. Missing registration on intrapartum transfers and planned versus unplanned home births in the DMBR are, however, major limitations to the validity and utility of the reported results. Registration of these items of information is necessary to make reasonable assessments of home births in the future. FUNDING: none. TRIAL REGISTRATION: not relevant.
... Reconhecendo que características de modalidades extra-hospitalares e do hospital podem influenciar os resultados neonatais, alguns estudos comparam os resultados de acordo com a especificidade da modalidade extra-hospitalar e hospitalar (20)(21) . Prevalências de Apgar < 7 em partos de mulheres de baixo risco, referentes aos anos entre 2006 e 2010 na Nova Zelândia foram maiores do que as encontrados em nosso estudo: 1,5% para o parto domiciliar, 1,7% para o CPN extra-hospitalar, 2,3% para a assistência em hospital secundário e 2.8% em hospital terciário. ...
... Houve um aumento gradativo na prevalência do baixo Apgar proporcional ao aumento da complexidade da modalidade assistencial (21) . Davis et al. (20) observaram risco de escore de Apgar < 7 no quinto minuto em hospital secundário e terciário 43% e 59% a mais, respectivamente, do que no parto na atenção primária. Estes resultados podem estar relacionados à subjetividade na atribuição do escore do Apgar ou à tendência dos profissionais, que lidam rotineiramente com situações de alto risco, em supervalorizar adaptações mais lentas, embora fisiológicas de alguns recém-nascidos. ...
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Objective: to analyze factors associated with Apgar of 5 minutes less than 7 of newborns of women selected for care at the Center for Normal Birth (ANC). Method: a descriptive cross-sectional study with data from 9,135 newborns collected between July 2001 and December 2012. The analysis used absolute and relative frequency frequencies and bivariate analysis using Pearson's chi-square test or the exact Fisher. Results: fifty-three newborns (0.6%) had Apgar less than 7 in the 5th minute. The multivariate analysis found a positive association between low Apgar and gestational age less than 37 weeks, gestational pathologies and intercurrences in labor. The presence of the companion was a protective factor. Conclusion: the Normal Birth Center is a viable option for newborns of low risk women as long as the protocol for screening low-risk women is followed.
... The psychosocial wellbeing of women is now viewed as equally important as her physical wellbeing [11]. Studies of place of birth have consistently shown lower rates of intervention in labor and birth for women with low-risk pregnancies who planned their birth at home [12][13][14]. Similarly, research confirms that when compared to other models of maternity care, midwife-led care reduces the rates of intervention in labor showed in their study that women using midwife care consistently reported attitudes supporting less frequent use of technology compared to women receiving care from obstetricians. ...
... it has been seen that the women who were given the choice of birthing suit and they deliver at home or midwifery led maternity centers have more smooth and swift course of labor when compared with the women who opted for hospital deliveries. [13] ©2019 Society of Education, India ...
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To compare the mode of delivery and Safety measures between planned home versus planned hospital delivery and to determine if differences in intervention rates and out come.At current, obstetric care in Saudi Arabia has a highly medicalized maternity care. Unfortunately, intervention rates are unacceptably high with a still rising rates for cesarean sections) and a completely normal physiologic birth a rarity. Data was collected by a questionnaire about Intervention and safety We enrolled only women expecting their first birth so that their previous birth experiences would not affect their preferences and outcomes. Recruitment in midwifery practices was carried out from March 2017 to feburary 2018 and in hospitals from March 2017 to December 2017.Besides adjustment for maternal and care factors, we included for additional casemix adjustment: presence of congenital anomaly , small for gestational age, preterm birth, or low Apgar score. The techniques used were nested multiple stepwise, and stratified analysis for separate risk groups. The women who previously have been delivered (inadvertently) at PHCs found it more comfortable and pleasant experience and wished (66.7%) to have next delivery in midwifery led centers. the women who gave birth to their babies in obstetrician led maternity hospitals were satisfied and opted (90%) the same for their next delivery. Women are felling safe and comfortable to have a hospital delivery and having good neonatal care how ever few less than ten percent women like to have home deliver or mid wife setting.
... For a variety of reasons the multiple hospital comparison groups in Janssen et al.'s studies could not be combined therefore we used the physician-attended hospital comparison group [20,21]. For Davis et al., we used the primary unit comparison group [22]. ...
... However, readers need to interpret the safety of home birth within their particular context because of the variation in how well home birth care providers are integrated into the health care system as well as variation in the ease of transfer to hospital, which may not be uniform across and even within settings. [15,22]. In order to reduce potential bias, this study included all relevant studies and addressed differences in study design by stratifying results. ...
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Background We previously concluded that risk of stillbirth, neonatal mortality or morbidity is not different whether birth is intended at home or hospital. Here, we compare the occurrence of birth interventions and maternal outcomes among low-risk women who begin labour intending to birth at home compared to women intending to birth in hospital. Methods We used our registered protocol (PROSPERO, http://www.crd.york.ac.uk, No.CRD42013004046) and searched five databases from 1990–2018. Using R, we obtained pooled estimates of effect (accounting for study design, study setting and parity). Findings 16 studies provided data from ~500,000 intended home births for the meta-analyses. There were no reported maternal deaths. When controlling for parity in well-integrated settings we found women intending to give birth at home compared to hospital were less likely to experience: caesarean section OR 0.58(0.44,0.77); operative vaginal birth OR 0.42(0.23,0.76); epidural analgesia OR 0.30(0.24,0.38); episiotomy OR 0.45(0.28,0.73); 3rd or 4th degree tear OR 0.57(0.43,0.75); oxytocin augmentation OR 0.37(0.26,0.51) and maternal infection OR 0.23(0.15,0.35). Pooled results for postpartum haemorrhage showed women intending home births were either less likely or did not differ from those intending hospital birth [OR 0.66(0.54,0.80) and RR 1.30(0.79,2.13) from 2 studies that could not be pooled with the others]. Similar results were found when data were stratified by parity and by degree of integration into health systems. Interpretation Among low-risk women, those intending to birth at home experienced fewer birth interventions and untoward maternal outcomes. These findings along with earlier work reporting neonatal outcomes inform families, health care providers and policy makers around the safety of intended home births. Funding Partial funding: Association of Ontario Midwives open peer reviewed grant.
... Further, no association has been found between outcomes and the number of births occurring in any particular area (Tracy et al., 2005). Similarly, a New Zealand study by Davis et al. (2011) found benefits for low risk women choosing home or a primary facility for birth including fewer intrapartum interventions and caesarean sections, than for women with a similar risk profile who had chosen to give birth in either a secondary or tertiary hospital. Dixon et al. (2014) reviewed the key findings from three of the above studies, the Birthplace in England Collaborative Group study (2011), Davis et al. (2011), andOvergaard et al. (2011), and evaluated their results in respect of the New Zealand midwifery and birth context. ...
... Similarly, a New Zealand study by Davis et al. (2011) found benefits for low risk women choosing home or a primary facility for birth including fewer intrapartum interventions and caesarean sections, than for women with a similar risk profile who had chosen to give birth in either a secondary or tertiary hospital. Dixon et al. (2014) reviewed the key findings from three of the above studies, the Birthplace in England Collaborative Group study (2011), Davis et al. (2011), andOvergaard et al. (2011), and evaluated their results in respect of the New Zealand midwifery and birth context. Despite some differences in the maternity systems for each study setting, the authors concluded that the findings apply to women in the New Zealand context and in addition, home and primary birth settings offer a calmer and more private birth environment. ...
Article
Background: Birth in primary midwife-led maternity units has been demonstrated to be a safe choice for well women anticipating a normal birth. The incidence of serious perinatal outcomes for these women is comparable to similarly low risk women, who choose to birth in hospital. New Zealand women have a choice of Lead Maternity Carer (LMC) and birthplace; home, primary birthing unit, or a base hospital, though not all women may have all these choices available locally. Women in rural and rural remote areas can also choose to birth in their rural primary maternity unit. A percentage of these women (approx. 15-17%) will require transfer during labour, an event which can cause distress and often loss of midwifery continuity of care. Objective: To explore retrospectively the choice of birth place decisions and the labour and birth experiences of a sample of women resident in remotely zoned, rural areas of the lower South Island of New Zealand. Design: A purposive sample of women living in remote rural areas, recruited by advertising in local newspapers and flyers. Individual semi-structured interviews were digitally recorded using a pragmatic interpretive approach. The data (transcripts and field notes) were analysed using thematic and content analysis. Ethical approval was obtained from the Health and Disability Ethics Committee (HEDC) MEC/06/05/045. Participants: Thirteen women consented to participate. Each was resident in a remote rural area having given birth in the previous 18 months. The women had been well during their pregnancies and at the onset of labour had anticipated a spontaneous vaginal birth. Setting: Rural remote zoned areas in Otago and Southland in the South Island of New Zealand FINDINGS: Five women planned to birth in a regional hospital and eight chose their nearest rural primary maternity unit. All of the women were aware of the possibility of transfer and had made their decision about their birthplace based on their perception of their personal safety, and in consideration of their distance from specialist care. Themes included, deciding about the safest place to give birth; making the decision to transfer; experiencing transfer in labour, and reflecting on their birth experience and considering future birthplace choices. Conclusions and implications for practice and policy: The experiences of the women show that for some, distance from a base hospital influences their place of birth decisions in remote rural areas of New Zealand and increases the distress for those needing to transfer over large distances. These experiences can result in women choosing, or needing to make different choices for subsequent births; the consequences of which impact on the future sustainability of midwifery services in remote rural areas, a challenge which resonates with maternity service provision internationally. While choices about birth place cannot be reliably predicted, creative solutions are needed to provide rural midwifery care and birth options for women and more timely and efficient transfer services when required.
... In 2011, 96.9% of women in Australia gave birth in a hospital (Li et al., 2013). Hospital birth, especially in tertiary centers, is associated not only with specialized obstetric care but also with high intervention rates applying to all women using the service (Davis et al., 2011;NSW Health, 2010). Increasing concern has been voiced about these high intervention rates, particularly in the case of healthy women with uncomplicated term pregnancies and spontaneous onset of labor. ...
... To date, there is little research on promoting normal birth, and less on supporting water immersion, in tertiary hospitals (O'Connell & Downe, 2009;Russell, 2011;Russell, Walsh, Scott, & McIntosh, 2014). Although there is evidence that low-risk maternity settings are supporting normal birth effectively, the same is not evident for larger settings suggesting that practices promoting normal birth are not being supported there (Chalmers et al., 2009;Davis et al., 2011;Hodnett, Downe, & Walsh, 2012;O'Connell & Downe, 2009). Given the large number of women birthing in tertiary institutions, a potentially effective way to increase normal birth and lower intervention rates to any significant extent is to target and alter practice in these settings. ...
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PURPOSE: This study aimed to describe and compare the attitudes and practices of midwives and obstetric doctors in a tertiary setting regarding water immersion for labor and birth and to identify strategies for improving bath usage in the facility. DESIGN: A questionnaire consisting of 47 multiple choice and 2 open-ended questions was distributed to midwives and obstetric doctors providing labor care in the facility. FINDINGS: Obstetric doctors were unsupportive. Birth suite midwives, despite assigning value to it, rarely facilitated water immersion. Only continuity midwives routinely facilitated water immersion. The main identified strategies for increasing bath usage in labor were staff training and support, antenatal education, and increased access to continuity of care. CONCLUSION: Providing bath access and supporting guidelines is not sufficient to increase water immersion for labor and birth in a tertiary setting. Additional strategies are needed to incorporate this practice into standard care in the birth suite.
... Although births occur in different hospital settings, such as home-like birth centres, midwifery-led birthing units, and in high intervention hospital birthing facilities. Most of the studies on birthplace has focused on studying the effects of place on the perinatal and maternal outcomes, and the interventions in labour (Brocklehurst et al., 2011;Davis et al., 2011). Findings suggest that planning the place of birth has a significant influence on mode of birth, rates of intrapartum intervention, and on birth experiences (Brocklehurst et al., 2011;Davis et al., 2011;Lindgren, Brink, & Klinberg-Allvin, 2011;Murray-Davis et al., 2012). ...
... Most of the studies on birthplace has focused on studying the effects of place on the perinatal and maternal outcomes, and the interventions in labour (Brocklehurst et al., 2011;Davis et al., 2011). Findings suggest that planning the place of birth has a significant influence on mode of birth, rates of intrapartum intervention, and on birth experiences (Brocklehurst et al., 2011;Davis et al., 2011;Lindgren, Brink, & Klinberg-Allvin, 2011;Murray-Davis et al., 2012). In a recently published review study undertaken to inform WHO intrapartum guidelines of what matter for women during childbirth, environment of care and the atmosphere of the local facility was highlighted (Downe, Finlayson, Oladapo, Bonet, & Gulmezoglu, 2018). ...
Article
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Background: In nursing and midwifery, the concept of environment is considered a meta-concept. Research findings suggest that the location is not the only important factor, as both place and space influence the practices of midwives. Moreover, research on the geography of health suggests a connection between place and health that could be extended to reproductive health. Therefore, to move beyond and expand traditional research expressions, it is beneficial to illuminate the concepts of place and space in relation to childbirth. Purpose: This study was undertaken to produce a synthesis of previous qualitative research of issues in childbirth in relation to the concepts of place and space. Method: In this Critical Interpretive Synthesis (CIS), four electronic databases; CINAHL, Medline, PsycINFO and Sociological abstracts, were used for the literature search. In total 734 papers were screened, and 27 papers met the final inclusion criteria after assessment. Results: The synthesis reveals a need to create a space for childbirth underpinned by four aspects; a homely space, a spiritual space, a safe space, and a territorial space. Conclusion: Findings from this review will provide a basis for useful dialogue in midwifery education and in clinical settings.
... 2010), several letters and articles (Faucon & Brillac, 2013;Gyte, Dodwell, & Macfarlane, 2010a;Keirse, 2010) took issue with the study methodology, noting bias in the selection of studies for inclusion and in the analysis; and comparison of studies using inconsistent definitions to consider neonatal and perinatal mortality (Faucon & Brillac, 2013;Gyte et al., 2010a;Keirse, 2010 In their meta-analysis, Faucon and Brillac (2013) analysed eight studies from five western countries, five of which were among those evaluated by Nove et al., (2012) as having varying adherence to their essential and desirable attributes. Of the three other studies, one smaller study was outside the post-2000 publication limit of Nove et al. 1998), one was a small French study (Munier, 2008), and the third was a New Zealand study comparing mode of birth and intervention rates in four different birth locations (Davis et al., 2011). This was the study with the second largest sample with over 16000 women and no intrapartum mortalities. ...
... This was dealt with by excluding 58.5% of the sample which is a limitation of the study findings. These were that medical interventions and undesirable outcomes occurred less often for the homebirth cohort (Davis et al., 2011). They found no significant difference in neonatal death rates between 24 hours old and the end of the first week of life between births in hospital or home for a subsample of six studies with more than 500,000 births. ...
Thesis
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Homebirth has been established as a safe alternative for low-risk pregnant women in the care of qualified midwives, working within the national assessment and referral guidelines and is more likely than hospital birth to result in fewer interventions and a normal delivery. The aim of this study was to describe the concerns of women living in rural and regional areas who planned homebirth about the possibility of transfer to hospital and how they prepared for this possible event. A qualitative interview and focus group study was conducted of women recruited through the homebirth network of a rural New South Wales (NSW) town. Of the sample of nine women recruited, six were eligible to participate. Three participants gave birth at home; one transferred to hospital in pregnancy and two transferred intra-partum. At the time of transfer, one was an obstetric emergency, the other was not. One of the women who did not transfer in her latest birth had previously experienced a transfer in labour. Three of the sample were multiparas; three were nulliparas. This study found that women in rural NSW who plan homebirth: 1) Do not find hospitals and doctors a helpful source of information about birth options; 2) Strategically prepare for homebirth by developing an open and respectful relationship with their private practice midwife (PPM); 3) Are concerned about the loss of that relationship in the event of transfer to hospital; 4) Are impacted negatively by disrespect for their right to choose place of birth; and 5) Identify preparation as a means to moderate the grief associated with the experience of transfer if it occurs. Those who did require transfer reported a mixture of satisfaction and dissatisfaction with their experience. Improved understanding of the different paradigms for birth in which women choosing homebirth and those choosing hospital birth operate will enhance home to hospital transfer experiences for women. This study is a step towards opening up the necessary dialogue.
... Midwife-led birth settings have been associated with a lower rate of severe adverse maternal morbidity [11]. Additionally, international studies showed a significantly lower risk of episiotomy [12,13], pharmacological pain management [12][13][14][15], assisted vaginal birth [12,13], caesarean section [12,13], and augmentation of labour [12][13][14][15] in birth settings other than obstetric units, although in one study no difference in rate of instrumental births was found [15]. ...
... Midwife-led birth settings have been associated with a lower rate of severe adverse maternal morbidity [11]. Additionally, international studies showed a significantly lower risk of episiotomy [12,13], pharmacological pain management [12][13][14][15], assisted vaginal birth [12,13], caesarean section [12,13], and augmentation of labour [12][13][14][15] in birth settings other than obstetric units, although in one study no difference in rate of instrumental births was found [15]. ...
Article
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Background The use of interventions in childbirth has increased the past decades. There is concern that some women might receive more interventions than they really need. For low-risk women, midwife-led birth settings may be of importance as a counterbalance towards the increasing rate of interventions. The effect of planned place of birth on interventions in the Netherlands is not yet clear. This study aims to give insight into differences in obstetric interventions and maternal outcomes for planned home versus planned hospital birth among women in midwife-led care. Methods Women from twenty practices across the Netherlands were included in 2009 and 2010. Of these, 3495 were low-risk and in midwife-led care at the onset of labour. Information about planned place of birth and outcomes, including instrumental birth (caesarean section, vacuum or forceps birth), labour augmentation, episiotomy, oxytocin in third stage, postpartum haemorrhage >1000 ml and perineal damage, came from the national midwife-led care perinatal database, and a postpartum questionnaire. Results Women who planned home birth more often had spontaneous birth (nulliparous women aOR 1.38, 95 % CI 1.08–1.76, parous women aOR 2.29, 95 % CI 1.21–4.36) and less often episiotomy (nulliparous women aOR 0.73, 0.58–0.91, parous women aOR 0.47, 0.33–0.68) and use of oxytocin in the third stage (nulliparous women aOR 0.58, 0.42–0.80, parous women aOR 0.47, 0.37–0.60) compared to women who planned hospital birth. Nulliparous women more often had anal sphincter damage (aOR 1.75, 1.01–3.03), but the difference was not statistically significant if women who had caesarean sections were excluded. Parous women less often had labour augmentation (aOR 0.55, 0.36–0.82) and more often an intact perineum (aOR 1.65, 1.34–2.03). There were no differences in rates of vacuum/forceps birth, unplanned caesarean section and postpartum haemorrhage >1000 ml. Conclusions Women who planned home birth were more likely to give birth spontaneously and had fewer medical interventions.
... It is these shared characteristics that this study used to define Primary Maternity Units (PMUs). Published research demonstrates that PMUs, compared to secondary or tertiary maternity services, provide safe care in a range of locations with good clinical outcomes for women and infants including: no differences in perinatal mortality (Leeman and Leeman, 2002;Birthplace in England Collaborative Group, 2011;Monk et al., 2014); no differences or improved outcomes for perinatal morbidity (Leeman and Leeman, 2002;Birthplace in England Collaborative Group, 2011;Overgaard et al., 2011); improved outcomes for maternal morbidity (Overgaard et al., 2011); improved outcomes for birth interventions including fewer CS (Leeman and Leeman, 2002;Birthplace in England Collaborative Group, 2011;Davis et al., 2011;Overgaard et al., 2011;Tucker et al., 2013;Monk et al., 2014) and improved neonatal outcomes (Wax et al., 2010;Davis et al., 2011;Dixon et al., 2014;Monk et al., 2014). ...
... It is these shared characteristics that this study used to define Primary Maternity Units (PMUs). Published research demonstrates that PMUs, compared to secondary or tertiary maternity services, provide safe care in a range of locations with good clinical outcomes for women and infants including: no differences in perinatal mortality (Leeman and Leeman, 2002;Birthplace in England Collaborative Group, 2011;Monk et al., 2014); no differences or improved outcomes for perinatal morbidity (Leeman and Leeman, 2002;Birthplace in England Collaborative Group, 2011;Overgaard et al., 2011); improved outcomes for maternal morbidity (Overgaard et al., 2011); improved outcomes for birth interventions including fewer CS (Leeman and Leeman, 2002;Birthplace in England Collaborative Group, 2011;Davis et al., 2011;Overgaard et al., 2011;Tucker et al., 2013;Monk et al., 2014) and improved neonatal outcomes (Wax et al., 2010;Davis et al., 2011;Dixon et al., 2014;Monk et al., 2014). ...
Article
Background: Primary Maternity Units (PMUs) offer less expensive and potentially more sustainable maternity care, with comparable or better perinatal outcomes for normal pregnancy and birth than higherlevel units. However, little is known about how these maternity services operate in rural and remote Australia, in regards to location, models of care, service structure, support mechanisms or sustainability. This study aimed to confirm and describe how they operate. Design: a descriptive, cross-sectional study was undertaken, utilising a 35-item survey to explore current provision of maternity care in rural and remote PMUs across Australia. Data were subjected to simple descriptive statistics and thematic analysis for free text answers. Setting and participants: Only 17 PMUs were identified in rural and remote areas of Australia. All 17 completed the survey. Results: the PMUs were, on average, 56km or 49minutes from their referral service and provided care to an average of 59 birthing women per year. Periodic closures or downgrading of services was common. Low-risk eligibility criteria were universally used, but with some variability. Medically-led care was the most widely available model of care. In most PMUs midwives worked shift work involving both nursing and midwifery duties, with minimal uptake of recent midwifery workforce innovations. Perceived enablers of, and threats to, sustainability were reported. Key conclusions and implications for practice: a small number of PMUs operate in rural Australia, and none in remote areas. Continuing overreliance on local medical support, and under-utilisation of the midwifery workforce constrain the restoration of maternity services to rural and remote Australia.
... Huttonova in sodelavci v rezultatih svoje analize 6.692 porodov na domu v štiriletnem obdobju v primerjavi s skupino nosečnic z nizkim tveganjem, ki so se odločile za porod v porodnišnici, pri prvi skupini ugotavljajo manjše tveganje za porodno izgubo krvi > 1000 mL, epiziotomijo, raztrganine presredka 2. do 4. stopnje, dokončanje poroda s carskim rezom, pospeševanje poroda in uporabo analgetikov.9 Nižjo verjetnost za epiziotomijo, epiduralno ali spinalno analgezijo, umetno predrtje plodovih ovojev, pospeševanje poroda in kirurško dokončanje poroda pri ženskah, ki so rodile doma, navajajo še nekateri drugi avtorji, 8,17,19,22 Wax in sodelavci temu dodajajo še manjšo verjetnost elektronskega nadzora plodovega srčnega utripa in manjšo možnostjo pojava laceracij, poporodne krvavitve, okužb ali zadržane posteljice.22 Novejša nizozemska kohortna raziskava prav tako navaja nižjo incidenco poporodne krvavitve, ročnega luščenja posteljice in nekaterih akutnih stanj pri porodih na reProdukcija človeka domu v primerjavi s porodi v porodnišnici.21 ...
... Po določenih teorijah naj bi medikalizirano okolje porodnišnic povzročilo občutek tesnobnosti in s tem zvišano tvorjenje kateholaminov pri porodnicah, zaradi tega pa posledično zmanjšan pretok krvi proti maternici in tako tudi manjše sproščanje oksitocina, kar vodi v podaljšan porod in nenazadnje tudi fetalni distres ter potrebo po porodniških ukrepanjih. 19 Ženske, ki izberejo porod na domu, naj bi bile bolj motivirane za izogibanje nepotrebnim posegom, prav tako lahko pri izidih poroda na domu pomembno vlogo igra tudi porodno okolje samo.9,18 Poleg nižjega tveganja za medicinske posege pa nosi porod na domu s seboj tudi številne psihosocialne koristi za matere.10 ...
Article
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Background: Home birth is as old as humanity, but still most middle- and high-income countries consider hospitals as the safest birth settings, as perinatal complications are highly unpredictable. Nevertheless, there are a few countries in which home birth is integrated into official healthcare system (the Netherlands, United Kingdom, Canada etc). Home births can be divided into unplanned and planned, and the latter can be further categorized by the presence of birth attendants. This review focuses on the planned home births, which are differently represented throughout the world. In the United States 0.6–1.0 % of all children are born at home, in the United Kingdom 2–3 %, in Canada 1.6 %, in the Netherlands 20–30 %, while in Austria and Germany 1.3 % of all newborns are born outside maternity wards. For Slovenia, the number of planned home births is unknown; however, in 2010, 0.1 % of children were born outside medical facilities. Conclusions: The safety of home birth is still under the debate. While research confirms a lower number of obstetric interventions and some complications in mothers who give birth at home, the data regarding the neonatal and perinatal mortality and morbidity is still conflicting. This confirms the need for large multicentric trials in this field. Current home-birth guidelines emphasize that women should be well informed regarding possible advantages and disadvantages of home births. In addition, the emphasis is on the definition of selection criteria for home birth, indications for intrapartal transfer to the hospital and appropriate education of birth attendants.
... 23 Whilst there is evidence that medically-focussed models of care may impact the provision of 'with woman' care, there is also an emerging proposition that being 'with woman' may actually facilitate movement between all care models and is not risk or birth place dependent. 50 Further research is warranted to enhance understanding about the intersection of midwives being 'with woman' within the context of a variety of care models. ...
Article
https://authors.elsevier.com/a/1WjV~6fYC64-d2 Background: Midwives being 'with woman' is embedded in professional philosophy, standards of practice and partnerships with women. In light of the centrality of being 'with woman' to the profession of midwifery, it is timely to review the literature to gain a contemporary understanding of this phenomenon. Aim: This review synthesises research and theoretical literature to report on what is known and published about being 'with woman'. Methods: A five step framework for conducting an integrative literature reviews was employed. A comprehensive search strategy was utilised that incorporated exploration in electronic databases CINAHL, Scopus, Proquest, Science Direct and Pubmed. The initial search resulted in the retrieval of 2057 publications which were reduced to 32 through a systematic process. Findings: The outcome of the review revealed three global themes and corresponding subthemes that encompassed 'with woman': (1) philosophy, incorporated two subthemes relating to midwifery philosophy and philosophy and models of care; (2) relationship, that included the relationship with women and the relationship with partners; and (3) practice, that captured midwifery presence, care across the childbirth continuum and practice that empowers women. Conclusion: Research and theoretical sources support the concept that being 'with woman' is a fundamental construct of midwifery practice as evident within the profession's philosophy. Findings suggest that the concept of midwives being 'with woman' is a dynamic and developing construct. The philosophy of being 'with woman' acts as an anchoring force to guide, inform and identify midwifery practice in the context of the rapidly changing modern maternity care landscapes. Gaps in knowledge and recommendations for further research are made.
... The results of the study support the provision of care in FMUs as an alternative to high risk settings for women with low risk pregnancies-with FMUs associated with similar or reduced odds of intrapartum interventions (including caesarean section) and similar or improved odds of indicators of neonatal wellbeing (Monk et al., 2014). These findings concur with a broad range of international evidence that supports the provision of primary birthing services to women with low risk pregnancies (Birthplace in England Collaborative Group, 2011;Davis et al., 2011;Overgaard et al., 2011). ...
Article
Background: the viability of freestanding midwifery units in Australia is restricted, due to concerns over their safety, particularly for women and babies who, require transfer. Aim: to compare the maternal and neonatal birth outcomes of women who planned, to give birth at freestanding midwifery units and subsequently, transferred to a tertiary maternity unit to the maternal and neonatal, outcomes of a low-risk cohort of women who planned to give birth in, tertiary maternity unit. Methods: a descriptive study compared two groups of women with low-risk singleton, pregnancies who were less than 28 weeks pregnant at booking: women who, planned to give birth at a freestanding midwifery unit (n=494) who, transferred to a tertiary maternity unit during the antenatal, intrapartum or postnatal periods (n=260) and women who planned to give, birth at a tertiary maternity unit (n=3157). Primary outcomes were mode, of birth, Apgar score of less than 7 at 5minutes and admission to, special care nursery or neonatal intensive care. Key findings: the proportion of women who experienced a caesarean section was lower, among the freestanding midwifery unit women who transferred during the, intrapartum/postnatal period compared to women in the tertiary maternity, unit group (16.1% versus 24.8% respectively). Other outcomes were, comparable between the cohorts. Rates of primary outcomes in relation to, stage of transfer varied when stratified by parity. Discussion: these descriptive results support the provision of care in freestanding, midwifery units as an alternative to tertiary maternity units for women, with low risk pregnancies at the time of booking. A larger study, powered, to determine statistical significance of any differences in outcomes, is, required.
... 6-9 25 The other New Zealand research had the highest caesarean section rate differential reported to date (relative risk 4.62). 9 This difference may be due to the small size of the current study or by differences in the timing of the identification of the cohorts. The retrospective Davis et al 9 (2011) study is the only one to identify the cohorts by intended birthplace in labour, whereas the cohorts in each of the other studies were established antenatally (on hospital booking or study entry). ...
Article
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Objective To compare maternal and neonatal birth outcomes and morbidities associated with the intention to give birth in a freestanding primary level midwife-led maternity unit (PMU) or tertiary level obstetric-led maternity hospital (TMH) in Canterbury, Aotearoa/New Zealand. Design Prospective cohort study. Participants 407 women who intended to give birth in a PMU and 285 women who intended to give birth at the TMH in 2010–2011. All of the women planning a TMH birth were ‘low risk’, and 29 of the PMU cohort had identified risk factors. Primary outcomes Mode of birth, Apgar score of less than 7 at 5 min and neonatal unit admission. Secondary outcomes: labour onset, analgesia, blood loss, third stage of labour management, perineal trauma, non-pharmacological pain relief, neonatal resuscitation, breastfeeding, gestational age at birth, birth weight, severe morbidity and mortality. Results Women who planned a PMU birth were significantly more likely to have a spontaneous vaginal birth (77.9%vs62.3%, adjusted OR (AOR) 1.61, 95% CI 1.08 to 2.39), and significantly less likely to have an instrumental assisted vaginal birth (10.3%vs20.4%, AOR 0.59, 95% CI 0.37 to 0.93). The emergency and elective caesarean section rates were not significantly different (emergency: PMU 11.6% vs TMH 17.5%, AOR 0.88, 95% CI 0.55 to 1.40; elective: PMU 0.7% vs TMH 2.1%, AOR 0.34, 95% CI 0.08 to 1.41). There were no significant differences between the cohorts in rates of 5 min Apgar score of <7 (2.0%vs2.1%, AOR 0.82, 95% CI 0.27 to 2.52) and neonatal unit admission (5.9%vs4.9%, AOR 1.44, 95% CI 0.70 to 2.96). Planning to give birth in a primary unit was associated with similar or reduced odds of intrapartum interventions and similar odds of all measured neonatal well-being indicators. Conclusions The results of this study support freestanding midwife-led primary-level maternity units as physically safe places for well women to plan to give birth, with these women having higher rates of spontaneous vaginal births and lower rates of interventions and their associated morbidities than those who planned a tertiary hospital birth, with no differences in neonatal outcomes.
... This result is consistent with the findings of the extensive Birthplace in England study and the research on freestanding midwifery units in Quebec [8,44]. The result is likewise in line with the reduced use of interventions for all women generally documented by studies of care in FMUs [59]. It is increasingly being recognised that the mode of delivery in the first birth influences delivery mode and outcomes in subsequent births [19, 49-53, 60, 61]. ...
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Open acess: http://link.springer.com/article/10.1186/s12884-016-1208-1 Abstract Background Intrapartum complications and the use of obstetric interventions are more common in primiparous childbirth than in multiparous childbirth, leading to concern about out of hospital birth for primiparous women. The purpose of this study was to determine whether the effect of birthplace on perinatal and maternal morbidity and the use of obstetric interventions differed by parity among low-risk women intending to give birth in a freestanding midwifery unit or in an obstetric unit in the North Denmark Region. Methods The study is a secondary analysis of data from a matched cohort study including 839 low-risk women intending birth in a freestanding midwifery unit (primary participants) and 839 low-risk women intending birth in an obstetric unit (individually matched control group). Analysis was by intention-to-treat. Conditional logistic regression analysis was applied to compute odds ratios and effect ratios with 95% confidence intervals for matched pairs stratified by parity. Results On no outcome did the effect of birthplace differ significantly between primiparous and multiparous women. Compared with their counterparts intending birth in an obstetric unit, both primiparous and multiparous women intending birth in a freestanding midwifery unit were significantly more likely to have an uncomplicated, spontaneous birth with good outcomes for mother and infant and less likely to require caesarean section, instrumental delivery, augmented labour or epidural analgesia (although for caesarean section this trend did not attain statistical significance for multiparous women). Perinatal outcomes were comparable between the two birth settings irrespective of parity. Compared to multiparas, transfer rates were substantially higher for primiparas, but fell over time while rates for multiparas remained stable. Conclusions Freestanding midwifery units appear to confer significant advantages over obstetric units to both primiparous and multiparous mothers, while their infants are equally safe in both settings. Our findings thus support the provision of care in freestanding midwifery units as an alternative to care in obstetric units for all low-risk women regardless of parity. In view of the global rise in caesarean section rates, we consider it an important finding that freestanding midwifery units show potential for reducing first-birth caesarean.
... Although there are strengths to the research design used, there are also limitations to any observational research design, particularly with respect to bias and confounding. 46 For example, although this was a prospective study, with careful consideration given to variables included, it is possible that variables were not included that would have influenced the results obtained, for example, continuity of care model, or accoucheur experience were not accounted for and could have had an impact on outcomes. In addition, although great effort was made to reduce errors during data collection and entry, the possibility of some recorder or transcriber error cannot be ruled out. ...
Article
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Introduction Research to understand factors associated with normal physiologic birth (unassisted vaginal birth, spontaneous labor onset without epidural analgesia, spinal, or general anesthetic, without episiotomy) is required. Laboring and/or giving birth in water has been shown to be associated with a high proportion of physiologic birth but with little understanding of factors that may influence this outcome. This study explored factors associated with normal physiologic birth for women who labored in water. Methods We conducted a secondary analysis of a UK-based prospective observational study of 8064 women at low risk of childbirth complications who labored in water. Consecutive women were recruited from birth settings in England, Scotland, and Northern Ireland. Planned place of birth, maternal characteristics, intrapartum events, and maternal and neonatal outcomes were measured. Univariable and multivariable logistic regression modelling explored factors associated with normal physiologic birth. Results In total, 5758 (71.4%) of women who labored in water had a normal physiologic birth. Planned birth in the community (adjusted odds ratio [aOR], 2.58; 95% CI, 2.22-2.99) or at an alongside midwifery unit (aOR, 1.21; 95% CI, 1.04-1.41) was positively associated with normal physiologic birth compared with planned birth in an obstetric unit. Duration of second stage (aOR, 0.66; 95% CI, 0.62-0.70), duration in the pool [aOR, 0.93; 95% CI, 0.90-0.96), and birth weight of the neonate (aOR, 0.74; 95% CI, 0.65-0.85) were negatively associated with normal physiologic birth. Parity was not associated with normal physiologic birth in multivariate analyses. Discussion Our findings largely reflected wider research, both in and out of water. We found midwifery-led birth settings may increase the likelihood of normal physiologic birth among healthy women who labor in water, irrespective of parity. This association supports growing evidence demonstrating the importance of planned place of birth on reducing intervention rates and adds to research on labor and birth in water.
... It is unlikely that women say to each other " I felt confident, you can too " . Yet the other stories we have heard in two rounds of data collection related to this birthing centre (X, 2011; XXX., 2012; Smythe et al., 2009) showed us women who had birthed in this centre exuding confidence. We heed the words: " Depending on the quality of her matrescent, a woman may be greatly enlarged or diminished, for during this time, she is both vulnerable and powerful " (Thomas, 2001, p. 90). ...
Article
Objective: to ponder afresh what makes a good birth experience in a listening manner. Design: a hermeneutic approach that first explores the nature of how to listen to a story that is already familiar to us and then draws on Heidegger's notion of the fourfold to seek to capture how the components of a'good birth' come together within experience. Setting: primary birthing centre, New Zealand Participants: the focus of this paper is the story of one participant. It was her second birth; her first birth involved a lot of medical intervention. She had planned to travel one hour to the tertiary birthing unit but in labour chose to stay at the Birth Centre. Her story seems to portray a 'very good birth'. Findings: in talking of birth, the nature of a research approach is commonly to focus on one aspect: the place, the care givers, or the mode of care. In contrast, we took on the challenge of first listening to all that was involved in one woman's story. We came to see that what made her experience 'good' was'everything' gathered together in a coherent and supportive oneness. Heidegger's notion of the fourfold helped reveal that one cannot talk about one thing without at the same time talking about all the other things as well. Confidence was the thread that held the story together. Key conclusions: there is value in putting aside the fragmented approach of explicating birth to recognise the coming together of place, care, situation, and the mystery beyond explanation. Women grow a confidence in place when peers and community encourage the choice based on their own experience. Confidence of caregiver comes in relationship. Feeling confident within 'self' is part of the mystery. When confidence in the different dimensions holds together, birth is 'good'. IMPLICATIONS OR PRACTICE: one cannot simply build a new birthing unit and assume it will offer a good experience of birth. Experience is about so much more. Being mindful of the dimensions of confidence that need to be built up and sheltered is a quest for wise leaders. Protecting the pockets where we know 'good birth' already flourishes is essential.
... The place where the birth takes place is not only an important factor of the childbearing women's experience (Davis et al, 2011;Ida et al, 2011) but it also has an impact on the practice and number of interventions performed by health care professionals (Freeman et al., 2006;Hunter, 2003;Janssen et al, 2009;Page, 2004). Similarly, public policies can also influence practices and even marginalize them (like those of midwives) without regard for their excellence or their efficiency (Goodman, 2007). ...
... For example, a study conducted in New Zealand reported that women who gave birth at tertiary institutions are at a higher risk of unnecessary intrapartum interventions such as assisted birth and caesarean delivery than those who have had homebirth. 39 This suggests that medicalising birth may have an adverse effect on the labour process and its outcome than we might think. The movement is already taking a shape that women are seeing childbirth as normal-not a disease conditionthat they are starting to prefer homebirth to facility births. ...
Article
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Objective: This study aimed at reviewing identifying reasons for home delivery preference, determining the status of homebirth in Ethiopia, and identifying socio-demographic factors predicting home delivery in Ethiopia. Methods: A systematic literature review regarding the status of homebirth, reasons why women preferred homebirth and socio-demographic determinants of home deliveries was performed using CINAHL, MEDLINE, Google Scholar and Maternity and Infant Care. Keywords and phrases such as home birth, home delivery, childbirth, prevalence, determinants, predictors, women and Ethiopia were included in the search. Results: A total of 10 studies were included in this review. The mean proportion of homebirth was 73.5%. Maternal age, ANC visits, maternal level of education, distance to facilities, and previous facility birth were significantly associated with homebirth. Perceived poor quality of service, distant location of facilities, homebirth as customary in the society and perceived normalness of labour were identified as reasons for choosing homebirth. Conclusion: Despite the significance of skilled birth attendants in reducing maternal and newborn morbidity and mortality, unattended homebirth remains high. By identifying and addressing socio-demographic enablers of home deliveries, maternal health service uptake can be improved.
... The POHD group had the lowest percentage of children who needed hospital visits due to infection by seven years of age. Mothers who deliver at home as planned are more often older [8][9][10][11][12][13][14][15][16][17][18], non-smokers [12,[18][19][20], and married [14,17,21]. In addition, socioeconomic status and/or education are usually higher among these women [10,12,14,17,22,23]. ...
Article
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Background and aims Compared to in-hospital births, the long-term outcome of children born out-of-hospital, planned or unplanned, is poorly studied. This study aimed to examine mortality and morbidity by seven years of age in children born out-of-hospital compared to those born in-hospital. Methods This study was registered retrospectively and included 790 136 children born in Finland between 1996 and 2013. The study population was divided into three groups according to birth site: in-hospital (n = 788 622), planned out-of-hospital (n = 176), and unplanned out-of-hospital (n = 1338). Data regarding deaths, hospital visits, reimbursement of medical expenses, and disability allowances was collected up to seven years of age or by the year-end of 2018. The association between birth site and childhood morbidity was determined using multivariable-adjusted Cox hazard regression analysis. Results No deaths were reported during the first seven years after birth in the children born out-of-hospital. The percentage of children with hospital visits due to infection by seven years of age was lower in those born planned out-of-hospital and in the combined planned out-of-hospital and unplanned out-of-hospital group compared to those born in-hospital. Furthermore, the percentage of children with hospital visits and who received disability allowances due to neurological or mental disorders was higher among those born unplanned out-of-hospital and out-of-hospital in total when compared to those born in-hospital. In the multivariable-adjusted Cox proportional hazard regression analysis, the hazard ratio for hospital visits due to asthma and/or allergic diseases (HR 0.84; 95% CI 0.72–0.98) was lower in children born out-of-hospital when compared to those born in-hospital. A similar decreased risk was found due to infections (HR 0.76; 95% CI 0.68–0.84). However, the risk for neurological or mental health disorders was similar between the children born in-hospital and out-of-hospital. Conclusions Morbidity related to asthma or allergic diseases and infections by seven years of age appeared to be lower in children born out-of-hospital. Birth out-of-hospital seemed to not be associated with increased risk for neurological morbidity nor early childhood mortality. Our study groups were small and heterogeneous and because of this the results need to be interpreted with caution.
... A study in Northern Nigeria showed that utilization of antenatal care services does not necessarily equate to delivery at the orthodox 7 health facility . Yet, planned place of childbirth has been shown to have a significant influence on mode of birth and rates of intrapartum 8 intervention in childbirth .The present study was therefore designed to ascertain the preferred place of childbirth by pregnant women who were attending antenatal clinic in a rural secondary health facility in southern Nigeria. ...
... durante a gestação, parto e pós-parto. A assistência hospitalar está prevista para os casos de possíveis distócias ou em situações de alto risco(KOOY et al., 2017;DAVIS et al., 2011).Nesse sentido, compete a esses profissionais de saúde: realizar a triagem de riscos durante o pré-natal, acompanhar partos fisiológicos, atuar em emergências, reconhecer partos difíceis e encaminhar a gestante para o serviço de retaguarda hospitalar, bem como manter um relacionamento de confiança com a família da gestante. Além disso, cabe a esses profissionais a provisão e organização dos materiais e equipamentos específicos para a assistência ao parto fisiológico e para as emergências.Outro aspecto a ser considerado no planejamento do parto domiciliar é o acesso ao hospital em tempo hábil e oportuno. ...
... Another Australian study 16 and one in New Zealand also found higher rates of perineal trauma in birth centres. 28 However, other research found no significant differences in perineal outcomes, for example in studies in Norway, 29 30 Denmark, 31 Australia 32 or England. 33 The higher rate of severe perineal trauma may be related to the use of birth stools, more common in Australian birth centres but less frequently in hospitals or at home. ...
Article
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Objective To compare perinatal and maternal outcomes for Australian women with uncomplicated pregnancies according to planned place of birth, that is, in hospital labour wards, birth centres or at home. Design A population-based retrospective design, linking and analysing routinely collected electronic data. Analysis comprised χ ² tests and binary logistic regression for categorical data, yielding adjusted ORs. Continuous data were analysed using analysis of variance. Setting All eight Australian states and territories. Participants Women with uncomplicated pregnancies who gave birth between 2000 and 2012 to a singleton baby in cephalic presentation at between 37 and 41 completed weeks’ gestation. Of the 1 251 420 births, 1 171 703 (93.6%) were planned in hospital labour wards, 71 505 (5.7%) in birth centres and 8212 (0.7%) at home. Main outcome measures Mode of birth, normal labour and birth, interventions and procedures during labour and birth, maternal complications, admission to special care/high dependency or intensive care units (mother or infant) and perinatal mortality (intrapartum stillbirth and neonatal death). Results Compared with planned hospital births, the odds of normal labour and birth were over twice as high in planned birth centre births (adjusted OR (AOR) 2.72; 99% CI 2.63 to 2.81) and nearly six times as high in planned home births (AOR 5.91; 99% CI 5.15 to 6.78). There were no statistically significant differences in the proportion of intrapartum stillbirths, early or late neonatal deaths between the three planned places of birth. Conclusions This is the first Australia-wide study to examine outcomes by planned place of birth. For healthy women in Australia having an uncomplicated pregnancy, planned births in birth centres or at home are associated with positive maternal outcomes although the number of homebirths was small overall. There were no significant differences in the perinatal mortality rate, although the absolute numbers of deaths were very small and therefore firm conclusions cannot be drawn about perinatal mortality outcomes.
... 3,[17][18][19][20][21] There are also several observational studies into AMUs, with comparison OU outcomes. 19,22,23 The limited contemporary research into the comparative clinical outcomes for FMUs and OUs includes prospective studies, 24-26 a retrospective study 27 and population-based cohort studies. 19,28 There are also studies reporting only MU clinical outcomes, with no OU comparison outcomes from the same context. ...
Technical Report
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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.
... durante a gestação, parto e pós-parto. A assistência hospitalar está prevista para os casos de possíveis distócias ou em situações de alto risco(KOOY et al., 2017;DAVIS et al., 2011).Nesse sentido, compete a esses profissionais de saúde: realizar a triagem de riscos durante o pré-natal, acompanhar partos fisiológicos, atuar em emergências, reconhecer partos difíceis e encaminhar a gestante para o serviço de retaguarda hospitalar, bem como manter um relacionamento de confiança com a família da gestante. Além disso, cabe a esses profissionais a provisão e organização dos materiais e equipamentos específicos para a assistência ao parto fisiológico e para as emergências.Outro aspecto a ser considerado no planejamento do parto domiciliar é o acesso ao hospital em tempo hábil e oportuno. ...
... The place where the birth takes place is not only an important factor of the childbearing women's experience (Davis et al, 2011;Ida et al, 2011) but it also has an impact on the practice and number of interventions performed by health care professionals (Freeman et al., 2006;Hunter, 2003;Janssen et al, 2009;Page, 2004). Similarly, public policies can also influence practices and even marginalize them (like those of midwives) without regard for their excellence or their efficiency (Goodman, 2007). ...
Preprint
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Midwives, who are specially trained to favour normal birth, are deeply concerned about the constantly increasing rate of cesareans in many countries of the world. Since training has a long-lasting impact on professionals, the one received by midwives is then of particular importance. How can midwives make a difference in maternity care when their training and place of practice are often colonized by the medical paradigm? There is something particular about the situation in Québec: the clinical training of student midwives mostly takes place in midwifery-led Birthing centres, out of hospitals and funded by the public health care system. In our opinion, this situation constitutes a key for teaching autonomy and confidence, two elements that are essential to midwives for the promotion and protection of normal birth. In order to understand the roots of the status and professional culture of midwives in Québec, it's necessary to first evoke the sociopolitical elements of the history of the emergence of midwives and birthing centres in the province. The progressive training given by midwife preceptors in these centres allows student midwives to develop their autonomy and confidence in the exercise of their clinical and communication skills, as well as learn the art of «being» a midwife. The Birthing centre is a place for birthing. In Québec it is also a place for the birth of midwives.
... Similar large-scale studies examining outcomes by place of birth have been conducted in other high-income countries, including England (2), the Netherlands (3-6), Nordic countries (7,8), Canada (9)(10)(11)(12), the United States (13)(14)(15) and New Zealand (16,17). Although previous Australian research has investigated outcomes related to place of birth in single states (18)(19)(20), none has attempted to examine outcomes for women nation-wide. ...
Article
Background: Data linkage offers a powerful mechanism for examining healthcare outcomes across populations and can generate substantial robust datasets using routinely collected electronic data. However, it presents methodological challenges, especially in Australia where eight separate states and territories maintain health datasets. This study used linked data to investigate perinatal and maternal outcomes in relation to place of birth. It examined data from all eight jurisdictions regarding births planned in hospitals, birth centres and at home. Data linkage enabled the first Australia-wide dataset on birth outcomes. However, jurisdictional differences in data collection created challenges in obtaining comparable cohorts of women with similar low-risk pregnancies in all birth settings. The objective of this paper is to describe the techniques for managing previously linked data, and specifically for ensuring the resulting dataset contained only low-risk pregnancies. Methods: This paper indicates the procedures for preparing and merging linked perinatal, inpatient and mortality data from different sources, providing technical guidance to address challenges arising in linked data study designs. Results: We combined data from eight jurisdictions linking four collections of administrative healthcare and civil registration data. The merging process ensured that variables were consistent, compatible and relevant to study aims. To generate comparable cohorts for all three birth settings, we developed increasingly complex strategies to ensure that the dataset eliminated women with pregnancies at risk of complications during labour and birth. It was then possible to compare birth outcomes for comparable samples, enabling specific examination of the impact of birth setting on maternal and infant safety across Australia. Conclusions: Data linkage is a valuable resource to enhance knowledge about birth outcomes from different settings, notwithstanding methodological challenges. Researchers can develop and share practical techniques to address these challenges. Study findings suggest that jurisdictions develop more consistent data collections to facilitate future data linkage.
... All rights reserved. alternative to standard hospital care for both mother and baby and are associated with lower rates of caesarean section and obstetric intervention ( Brocklehurst et al., 2011, Catling-Paull et al., 2013, Davis et al., 2011, de Jonge et al., 2013, Hutton et al., 2019, Olsen and Clausen, 2013, Scarf et al., 2018, Homer et al., 2019. ...
Article
Objective The aim of the study was to explore hospital-based midwives' experiences of providing publicly-funded homebirth services in Australia. Design A qualitative descriptive study using a constructivist grounded theory methodology was undertaken. Setting Five different states or territories of Australia where publicly-funded homebirth services were operating. Participants Interviews were conducted with 21 midwives and midwifery managers from 8 different public hospitals who had recent experience of working in, or with, publicly-funded homebirth models. Findings Witnessing undisturbed birth in the home setting transformed midwives' attitudes towards birth. Following exposure to homebirth, many midwives felt they were seeing undisturbed birth for the first time. This led them to question their current understanding of physiological birth and develop a new awareness of the powerful influence that the environment has on labouring women. This new understanding resulted in changes to their practice. Key Conclusions For midwives accustomed to working in hospital settings, exposure to homebirth deepened their understanding of physiological birth, resulting in a perspective transformation and subsequent shift in practice. Implications for practice: Exposure to homebirth may motivate midwives to alter their practice in both home and hospital settings in order to shift the power dynamic between women and caregivers and protect women from unnecessary disturbance during labour.
... Background A woman's chosen place of birth impacts not only the type of birth, but also the number of unnecessary interventions that the mother and baby are exposed to during their labour and birth [1][2][3][4] . Women who give birth in a midwife-led unit or at home, rather than an obstetric unit, experience lower rates of unnecessary interventions. ...
Preprint
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Background: A woman’s choice of birth place does not only influence her birth experience, but also impacts on maternal and neonatal outcomes. For healthy women who have had a straightforward pregnancy, a planned home birth supported by midwives and other maternity care providers, is now a recognised choice within their individual country’s health care system. However, there is limited evidence on women’s actual experiences of engaging with maternity care providers to plan for a home birth, especially within the context of middle to high-income countries where there is integration of maternity care services. Therefore, this systematic review will synthesise findings from previous studies, which have reported on women’s experiences of planning a home birth in consultation with maternity care providers, in middle to high-income countries. Methods: Using a systematic approach, we will develop a search strategy to identify relevant research studies on women’s experiences of planning a home birth, with the support of their maternity care providers. Search terms will be iteratively developed using text words derived from the review aim, the PICO framework and database-indexed terms. In May 2020, the searches will be conducted on seven bibliographic databases: Ovid Medline, Embase, PsycInfo, and CINAHL plus, Scopus, ProQuest and Cochrane (Central and Library) from January 2015 to 26th May 2020. Supplementary searches will also be undertaken to identify additional articles. At least two reviewers will do the screening, quality appraisal, data extraction and analysis. Included studies will be appraised using a quality appraisal tool suited to the study design. Data will be analysed using either a narrative or thematic synthesis depending on the methodological design of the studies included. Discussion: Review findings will provide useful recommendations to improve care and support provided for women when planning a home birth. We will publish review findings in a peer-reviewed journal and present it at relevant conferences while also sharing summaries with maternity care providers and service users via social media fora. PROSPERO registration ID: CRD42018095042
Chapter
The purpose of this study was to analyze the main topics of media reports reported in the last 15 years (2005–2019) regarding low birthrates. To this end, 70,488 related news reports reported in 15 years were used. By applying the LDA technique, we extracted the topic of low fertility phenomenon and analyzed the major issues every 5 years. As a result of the study, the main words cited in the low birthrate media articles were fertility rates, children, housing, jobs, services, etc., and divided into three cycles divided into 5 year cycles from 2005. The second cycle passes women, children, gender equality, and future society, but the third cycle expands into an aging society, life cycle, and jobs, and it can be seen that the contents related to low birthrate gradually expand to problems related to life in general. It was found that women-related problems were prominent, and that this suggests that the low birthrate policy is a national system that improves human happiness and the quality of life throughout life, beyond simply supporting child care.
Article
A woman has many important decisions to make once discovering a pregnancy. One of those decisions with significant implications is where the birth will take place. The primary consideration for the majority of pregnant women when making a decision about birth environment is safety. However, other factors such as attitudes of family and friends, religious reasons, and confidence in the body's ability to give birth play a factor in the choice of birth environment. It is recommended that birth attendants use the process of shared decision making to assist pregnant women in making choices related to the birth environment. This process empowers the pregnant woman and provides a woman-centered and evidence-based approach to choices related to obstetrical care.
Article
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Background: Over the past two decades, 14 publicly-funded homebirth models have been established in Australian hospitals. Midwives working in these hospitals now have the opportunity to provide homebirth care, despite many having never been exposed to homebirth before. The transition to providing homebirth care can be daunting for midwives who are accustomed to practising in the hospital environment. Aim: To explore midwives' experiences of transitioning from providing hospital to homebirth care in Australian public health systems. Methods: A descriptive, exploratory study was undertaken. Data were collected through in-depth interviews with 13 midwives and midwifery managers who had recent experience transitioning into and working in publicly-funded homebirth programs. Thematic analysis was conducted on interview transcripts. Findings: Six themes were identified. These were: skilling up for homebirth; feeling apprehensive; seeing birth in a new light; managing a shift in practice; homebirth-the same but different; and the importance of mentoring and support. Discussion: Midwives providing homebirth work differently to those working in hospital settings. More experienced homebirth midwives may provide high quality care in a relaxed environment (compared to a hospital setting). Midwives acceptance of homebirth is influenced by their previous exposure to homebirth. Conclusion: The transition from hospital to homebirth care required midwives to work to the full scope of their practice. When well supported by colleagues and managers, midwives transitioning into publicly-funded homebirth programs can have a positive experience that allows for a greater understanding of and appreciation for normal birth.
Article
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Objective: described the maternal results of the care with planned home births provided by the Hanami Team in 2002-2012. Method: this transversal study It includes home and hospital births (212). Descriptive analysis was undertaken, with CI 95%, using the SAS/9.1.3 software. Results: the rate of amniotomy was 9.9% (CI 95% 5.9-13.9), of episiotomy was 0.5% (CI 95% 0.5-1.5), the amniotic fluid remained clear in 95.2% (CI 95% 92.4-98), there was no change in fetal heartbeat in 94.3% (CI 95% 92-96.6). The vaginal tears perineal trauma were exclusively of first degree (64.7%; CI 95% 57.8-71.6) and second degree (7.0%; CI 95% 3.4-10.8), it being the case that almost half did not need suturing (46.8%; CI 95% 41.1-52.6). The rate of transfer to hospital was 7.4%, all these cases occurring during labor (CI 95% 3.8 - 11.0). The rate of cesareans in the sample was 9.9%. Conclusions: the women assisted at home undergo few interventions. Rates of complications and transfers to hospital for obstetric reasons were low.
Article
Background: In Australia, more than 20% of women giving birth are 35 years or older. Advanced maternal age (AMA) is a risk factor for stillbirth, and many clinicians now recommend induction of labour (IOL) at around term gestation. The aim of this study is to determine if AMA is associated with emergency caesarean section (CS) following IOL. Methods: A retrospective cohort study was undertaken using routinely collected de-identified data. Live-born, singleton, cephalic, non-anomalous pregnancies undergoing IOL between 37 + 0 and 42 + 0 weeks were included. Previous CS and privately insured admission status were excluded. Mode of delivery was compared for women ≥38 years (AMA) and women <38 years. The primary outcome was birth by CS. Bivariate and multivariate logistic regression analyses were undertaken. Results: A total of 7459 women were included (≥38 years n = 718, 9.6%; <38 years n = 6741, 90.4%). AMA women had similar rates of unassisted vaginal births (OR 1.15, 95% CI 0.98-1.35, P = 0.080) and CS (OR 1.08, 95% CI 0.90-1.30, P = 0.407) but fewer instrumental deliveries (OR 0.69, 95% CI 0.55-0.87, P = 0.002) compared to women <38 years. When controlled for confounders, AMA was independently associated with a two-fold increase in birth by CS following IOL (adjusted OR 2.29; 95% CI 1.64-3.20; P < 0.001). There were no differences in neonatal outcomes. Conclusion: Following IOL, AMA was associated with a two-fold increased likelihood of birth by CS in both nulliparous and multiparous women. However, the majority of AMA women birthed vaginally. Clinicians may find this information useful when counselling older women who are undergoing term IOL.
Article
Background: This study investigates maternal and perinatal outcomes for women with low-risk pregnancies laboring in free-standing birth centers compared with laboring in a hospital maternity unit in a large New Zealand health district. Methods: The study used observational data from 47 381 births to women with low-risk pregnancies in South Auckland maternity facilities 2003-2010. Adjusted odds ratios with 95% confidence intervals were calculated for instrumental delivery, cesarean section, blood transfusion, neonatal unit admission, and perinatal mortality. Results: Labor in birth centers was associated with significantly lower rates of instrumental delivery, cesarean section and blood transfusion compared with labor in hospital. Neonatal unit admission rates were lower for infants of nulliparous women laboring in birth centers. Intrapartum and neonatal mortality rates for birth centers were low and were not significantly different from the hospital population. Transfers to hospital for labor and postnatal complications occurred in 39% of nulliparous and 9% of multiparous labors. Risk factors identified for transfer were nulliparity, advanced maternal age, and prolonged pregnancy ≥41 weeks' gestation. Conclusions: Labor in South Auckland free-standing birth centers was associated with significantly lower maternal intervention and complication rates than labor in the hospital maternity unit and was not associated with increased perinatal morbidity.
Article
Objective: To increase understanding of integrative power in decision-making in home-like childbirth from midwives' and women's perspectives. Design: A qualitative multiple case study. Setting: Two regions of Switzerland, a French and a German-speaking. Participants: Twenty interviews with midwives and 20 with women and some partners who had experienced complications in home-like births. Methods: Data were collected from in-depth interviews relevant for casestudy. Four cases during second stage of labour were carefully selected using literal replication logic. Interview transcripts were analysed in developing case descriptions and in interpreting mechanisms related to perception of power in making decision. Findings: The analysis of each case and a cross-case comparison showed that mechanisms for building integrative power, such as creation of relationships, cooperation, loyalty, legitimacy and respect, were highly visible in midwifery decision-making activities. Key conclusions and implications for practice: The study highlighted the visibility of integrative power mechanisms in decision-making in homelike settings. Until now, mechanisms of positive power in midwifery have been poorly described in literature. Integrative power could be a promising strategy to reinforce decision-making strategies. Therefore, clinical and policy measures explicitly addressing the positive aspects of power should be developed and evaluated.
Article
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PURPOSE: To determine traits related to pregnancy and delivery, length of stay, health care cost, postpartum discomfort, and satisfaction with medical service of puerperas giving birth in midwifery clinic and hospitals. METHODS: This study used a comparative survey design. Data were collected from a total of 140 postpartum mothers composed of 70 mothers who gave births in two hospitals and another 70 mothers who delivered in one midwifery clinic. RESULTS: Delivery in midwifery clinic had higher Apgar score at 1 minute and 5 minutes after birth than hospital. Those who delivered in midwifery clinic had shorter stay in the clinic, fewer health care cost, less postpartum discomfort in physical, environmental, social, and cultural areas, higher satisfaction with medical services than those who delivered in hospitals. CONCLUSION: Results of this study can be used as a basis for studies on giving birth in midwifery clinic and hospitals. They might increase the autonomy of women in giving birth with positive effect on the delivery experience of the mother and her spouse.
Article
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.
Article
Objective: To discuss the concept of ‘transcendent birth’, an as yet poorly articulated and under recognised psychosocial wellness phenomenon of childbirth. Design: an auto-ethnographical examination of the primary authors’ journaled experiences as a student midwife and childbearing woman. Setting: three maternity care units in South Eastern Australia as well as the home of the primary author. Findings: The phenomenon of transcendent birth is linked with physiologic birth. Maternity care can hinder or facilitate physiologic birth, and therefore transcendent birth. Key conclusions: Transcendent birth is more likely in maternity care models which value the childbearing woman and physiologic birth. Implications for practice: Women's access to transcendent birth is demarcated by women's position in society, cultural knowledge of transcendent birth and the valuing of transcendent birth as a maternity care outcome.
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Objective: To assess procedures and outcomes in deliveries planned at home versus those planned in hospital among women choosing the place of delivery. Design: Follow up study of matched pairs. Setting: Antenatal clinics and reference hospitals in Zurich between 1989 and 1992. Subjects: 489 women opting for home delivery and 385 opting for hospital delivery; the women comprised all those attending members of the study team for antenatal care and those attending the reference hospital for antenatal care who could be matched with the women planning home confinement. Main outcome measures: Need for medication and incidence of interventions during delivery (caesarean section, forceps, vacuum extraction, episiotomy), duration of labour, occurrence of severe perineal lesions, maternal blood loss, and perinatal morbidity and death. Results: All women were followed up from their first antenatal visit till three months after delivery. Referrals during pregnancy (n = 37) and labour (70), changes of mind (15 home to hospital, eight hospital to home), and 17 miscarriages resulted in 369 births occurring at home and 486 in hospital. During delivery the home birth group needed significantly less medication and fewer interventions whereas no differences were found in durations of labour, occurrence of severe perineal lesions, and maternal blood loss. Perinatal death was recorded in one planned hospital delivery and one planned home delivery (overall perinatal mortality 2.3/1000). There was no difference between home and hospital delivered babies in birth weight, gestational age, or clinical condition. Apgar scores were slightly higher and umbilical cord pH lower in home births, but these differences may have been due to differences in clamping and the time of transportation. Conclusion: Healthy low risk women who wish to deliver at home have no increased risk either to themselves or to their babies. Key messages Interventions (induction, caesarean section, medication, forceps, or vacuum extraction) may be considerably less frequent in women who originally opt for home deliveryThere are no obvious disadvantages of home delivery for mother or child when the mother opts for home deliveryMore studies are needed to look into the small risks of death, serious bleeding, and complications of interventions, which could not be evaluated in this study owing to limited power
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OBJECTIVE: To compare perinatal mortality and severe perinatal morbidity between planned home and planned hospital births, among low-risk women who started their labour in primary care. DESIGN: A nationwide cohort study. SETTING: The entire Netherlands. POPULATION: A total of 529,688 low-risk women who were in primary midwife-led care at the onset of labour. Of these, 321,307 (60.7%) intended to give birth at home, 163,261 (30.8%) planned to give birth in hospital and for 45,120 (8.5%), the intended place of birth was unknown. METHODS: Analysis of national perinatal and neonatal registration data, over a period of 7 years. Logistic regression analysis was used to control for differences in baseline characteristics. MAIN OUTCOME MEASURES: Intrapartum death, intrapartum and neonatal death within 24 hours after birth, intrapartum and neonatal death within 7 days and neonatal admission to an intensive care unit. RESULTS: No significant differences were found between planned home and planned hospital birth (adjusted relative risks and 95% confidence intervals: intrapartum death 0.97 (0.69 to 1.37), intrapartum death and neonatal death during the first 24 hours 1.02 (0.77 to 1.36), intrapartum death and neonatal death up to 7 days 1.00 (0.78 to 1.27), admission to neonatal intensive care unit 1.00 (0.86 to 1.16). CONCLUSIONS: This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system
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This report surveys and evaluates the scientific research on evidence-based healthcare design and extracts its implications for designing better and safer hospitals. It builds on a literature review conducted by researchers in 2004. Research teams conducted a new and more exhaustive search for rigorous empirical studies that link the design of hospital physical environments with healthcare outcomes. The review followed a two-step process, including an extensive search for existing literature and a screening of each identified study for the relevance and quality of evidence. This review found a growing body of rigorous studies to guide healthcare design, especially with respect to reducing the frequency of hospital-acquired infections. Results are organized according to three general types of outcomes: patient safety, other patient outcomes, and staff outcomes. The findings further support the importance of improving outcomes for a range of design characteristics or interventions, including single-bed rooms rather than multibed rooms, effective ventilation systems, a good acoustic environment, nature distractions and daylight, appropriate lighting, better ergonomic design, acuity-adaptable rooms, and improved floor layouts and work settings. Directions for future research are also identified. The state of knowledge of evidence-based healthcare design has grown rapidly in recent years. The evidence indicates that well-designed physical settings play an important role in making hospitals safer and more healing for patients, and better places for staff to work.
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Midwives in Ontario, Canada, provide care in the home and hospital and are required to submit data for all births to the Ontario Ministry of Health database. The purpose of this study was to compare maternal and perinatal/neonatal mortality and morbidity and intrapartum intervention rates for women attended by Ontario midwives who planned a home birth compared with similar low-risk women who planned a hospital birth between 2003 and 2006. The database provided outcomes for all women planning a home birth at the onset of labor (n = 6,692) and for a cohort, stratified by parity, of similar low-risk women planning a hospital birth. The rate of perinatal and neonatal mortality was very low (1/1,000) for both groups, and no difference was shown between groups in perinatal and neonatal mortality or serious morbidity (2.4% vs 2.8%; relative risk [RR], 95% confidence intervals [CI]: 0.84 [0.68-1.03]). No maternal deaths were reported. All measures of serious maternal morbidity were lower in the planned home birth group as were rates for all interventions including cesarean section (5.2% vs 8.1%; RR [95% CI]: 0.64 [0.56, 0.73]). Nulliparas were less likely to deliver at home, and had higher rates of ambulance transport from home to hospital than multiparas planning home birth and had rates of intervention and outcomes similar to, or lower than, nulliparas planning hospital births. Midwives who were integrated into the health care system with good access to emergency services, consultation, and transfer of care provided care resulting in favorable outcomes for women planning both home or hospital births.
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Studies of planned home births attended by registered midwives have been limited by incomplete data, nonrepresentative sampling, inadequate statistical power and the inability to exclude unplanned home births. We compared the outcomes of planned home births attended by midwives with those of planned hospital births attended by midwives or physicians. We included all planned home births attended by registered midwives from Jan. 1, 2000, to Dec. 31, 2004, in British Columbia, Canada (n = 2889), and all planned hospital births meeting the eligibility requirements for home birth that were attended by the same cohort of midwives (n = 4752). We also included a matched sample of physician-attended planned hospital births (n = 5331). The primary outcome measure was perinatal mortality; secondary outcomes were obstetric interventions and adverse maternal and neonatal outcomes. The rate of perinatal death per 1000 births was 0.35 (95% confidence interval [CI] 0.00-1.03) in the group of planned home births; the rate in the group of planned hospital births was 0.57 (95% CI 0.00-1.43) among women attended by a midwife and 0.64 (95% CI 0.00-1.56) among those attended by a physician. Women in the planned home-birth group were significantly less likely than those who planned a midwife-attended hospital birth to have obstetric interventions (e.g., electronic fetal monitoring, relative risk [RR] 0.32, 95% CI 0.29-0.36; assisted vaginal delivery, RR 0.41, 95% 0.33-0.52) or adverse maternal outcomes (e.g., third- or fourth-degree perineal tear, RR 0.41, 95% CI 0.28-0.59; postpartum hemorrhage, RR 0.62, 95% CI 0.49-0.77). The findings were similar in the comparison with physician-assisted hospital births. Newborns in the home-birth group were less likely than those in the midwife-attended hospital-birth group to require resuscitation at birth (RR 0.23, 95% CI 0.14-0.37) or oxygen therapy beyond 24 hours (RR 0.37, 95% CI 0.24-0.59). The findings were similar in the comparison with newborns in the physician-assisted hospital births; in addition, newborns in the home-birth group were less likely to have meconium aspiration (RR 0.45, 95% CI 0.21-0.93) and more likely to be admitted to hospital or readmitted if born in hospital (RR 1.39, 95% CI 1.09-1.85). Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.
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We studied 11,814 women admitted for labor and delivery to 84 free-standing birth centers in the United States and followed their course and that of their infants through delivery or transfer to a hospital and for at least four weeks thereafter. The women were at lower-than-average risk of a poor outcome of pregnancy, according to many but not all of the recognized demographic and behavioral risk factors. Among the women, 70.7 percent had only minor complications or none; 7.9 percent had serious emergency complications during labor and delivery or soon thereafter, such as thick meconium or severe shoulder dystocia. One woman in six (15.8 percent) was transferred to a hospital; 2.4 percent had emergency transfers. Twenty-nine percent of nulliparous women and only 7 percent of parous women were transferred, but the frequency of emergency transfers was the same. The rate of cesarean section was 4.4 percent. There were no maternal deaths. The overall intrapartum and neonatal mortality rate was 1.3 per 1000 births. The rates of infant mortality and low Apgar scores were similar to those reported in large studies of low-risk hospital births. We conclude that birth centers offer a safe and acceptable alternative to hospital confinement for selected pregnant women, particularly those who have previously had children, and that such care leads to relatively few cesarean sections.
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Records on recovery after cholecystectomy of patients in a suburban Pennsylvania hospital between 1972 and 1981 were examined to determine whether assignment to a room with a window view of a natural setting might have restorative influences. Twenty-three surgical patients assigned to rooms with windows looking out on a natural scene had shorter postoperative hospital stays, received fewer negative evaluative comments in nurses' notes, and took fewer potent analgesics than 23 matched patients in similar rooms with windows facing a brick building wall.
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To examine whether intrapartum care and delivery of low risk women in a midwife managed delivery unit differs from that in a consultant led labour ward. Pragmatic randomised controlled trial. Subjects were randomised in a 2:1 ratio between the midwives unit and the labour ward. Aberdeen Maternity Hospital, Grampian. 2844 low risk women, as defined by existing booking criteria for general practitioner units in Grampian. 1900 women were randomised to the midwives unit and 944 to the labour ward. Maternal and perinatal morbidity. Of the women randomised to the midwives unit, 647 (34%) were transferred to the labour ward antepartum, 303 (16%) were transferred intrapartum, and 80 (4%) were lost to follow up. 870 women (46%) were delivered in the midwives unit. Primigravid women (255/596, 43%) were significantly more likely to be transferred intrapartum than multi-gravid women (48/577, 8%). Significant differences between the midwives unit and labour ward were found in monitoring, fetal distress, analgesia, mobility, and use of episiotomy. There were no significant differences in mode of delivery or fetal outcome. Midwife managed intrapartum care for low risk women results in more mobility and less intervention with no increase in neonatal morbidity. However, the high rate of transfer shows that antenatal criteria are unable to determine who will remain at low risk throughout pregnancy and labour.
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To study whether hospitals of different levels are equally safe places to give birth in a regionalised system of care. This was a population based, cross sectional survey comparing birth outcomes in nationwide catchment areas of different levels of hospital care. All women and low risk women were examined separately. The study population comprised all women who gave birth in Finland in 1987-88. The data were obtained from the Finnish Medical Registry, complemented by official data. No statistically significant differences were found in crude or birthweight specific perinatal mortality rates between the catchment areas, nor did the other outcomes studied favour tertiary care compared with other levels of care in the area based analysis. In a regionalised system of birth care with a proper referral system, small local hospitals are as safe places to give birth as tertiary care hospitals.
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Should there be a trial ofhome versus hospital delivery in the United Kingdom? We received a letterfrom Dowswell and colleagues on thefeasibility ofconducting a trial to compare the effects of birth at home and in hospital. We asked a midwife, an epidemiologist, a generalpractitioner, the director ofthe National Childbirth Trust, and an obstetrician for their comments. Measuring outcomes other than safety is feasible T Dowswell, JG Thornton, J Hewison, RJL Lilford Two recent expert groups' 2 have concluded that the evidence for the relative safety of home compared with hospital delivery3 does not justify a general recommendation for hospital delivery. Although the evidence has been disputed,4 safety is not testable in a randomised controlled trial because of the numbers required and will have to be assessed as well as possible by other methods. Nevertheless, another uncertainty underlying the debate is the effect of place of delivery on psychological outcomes and infant feeding.5 The hypotheses that home birth results in less anxiety and higher rates of breast feeding are testable in a ran-domised controlled trial of only modest size. For example, if breast feeding rates were 50% in hospital a trial of 100 women per group would have the power to exclude a 20% increase among women offered home delivery (alpha 0.05). Most experts we consulted told us, however, that women would decline being randomly allocated to home or hospital delivery in such a trial, and so we performed a small feasibility study.
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To assess procedures and outcomes in deliveries planned at home versus those planned in hospital among women choosing the place of delivery. Follow up study of matched pairs. Antenatal clinics and reference hospitals in Zurich between 1989 and 1992. 489 women opting for home delivery and 385 opting for hospital delivery; the women comprised all those attending members of the study team for antenatal care and those attending the reference hospital for antenatal care who could be matched with the women planning home confinement. Need for medication and incidence of interventions during delivery (caesarean section, forceps, vacuum extraction, episiotomy), duration of labour, occurrence of severe perineal lesions, maternal blood loss, and perinatal morbidity and death. All women were followed up from their first antenatal visit till three months after delivery. Referrals during pregnancy (n = 37) and labour (70), changes of mind (15 home to hospital, eight hospital to home), and 17 miscarriages resulted in 369 births occurring at home and 486 in hospital. During delivery the home birth group needed significantly less medication and fewer interventions whereas no differences were found in durations of labour, occurrence of severe perineal lesions, and maternal blood loss. Perinatal death was recorded in one planned hospital delivery and one planned home delivery (overall perinatal mortality 2.3/1000). There was no difference between home and hospital delivered babies in birth weight, gestational age, or clinical condition. Apgar scores were slightly higher and umbilical cord pH lower in home births, but these differences may have been due to differences in clamping and the time of transportation. Healthy low risk women who wish to deliver at home have no increased risk either to themselves or to their babies.
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Over the past few centuries childbirth has become increasingly influenced by medical technology, and now medical intervention is the norm in most Western countries. Richard Johanson and colleagues argue here that perhaps normal birth has become too "medicalised" and that higher rates of normal birth are in fact associated with beliefs about birth, implementation of evidence based practice, and team working.
Article
Over the past few centuries childbirth has become increasingly influenced by medical technology, and now medical intervention is the norm in most Western countries. Richard Johanson and colleagues argue here that perhaps normal birth has become too “medicalised” and that higher rates of normal birth are in fact associated with beliefs about birth, implementation of evidence based practice, and team working Until the 17th century, birth in most parts of the world was firmly in the exclusively female domestic arena, and hospital birth was uncommon before the 20th century, except in a few major cities. 1 2 Before the invention of forceps, men had been involved only in difficult deliveries, using destructive instruments with the result that babies were invariably not born alive and the mother too would often die. Instrumental delivery with forceps became the hallmark of the obstetric era. In the 19th and 20th centuries, medical influence was extended further by the development of new forms of analgesia, anaesthesia, caesarean section, and safe blood transfusion. The introduction first of antiseptic and aseptic techniques and later of sulphonamides, coupled with changes in the severity of puerperal sepsis, lowered the maternal mortality that had made hospitals dangerous places in which to give birth.3 #### Summary points Obstetricians play an important role in preserving lives when there are complications of pregnancy or labour In developed countries, however, obstetrician involvement and medical interventions have become routine in normal childbirth, without evidence of effectiveness Factors associated with increased obstetric intervention seem to include private practice, medicolegal pressures, and not involving women fully in decision making Emerging evidence suggests that higher rates of normal births are linked to beliefs about birth, implementation of evidence based practice, and team working Maternal mortality in the West fell substantially during the 20th century. The World Health Organization and Unicef …
Article
Design and use of space are critical features of contemporary healthcare facilities, but there is often pressure on available space. The drive to minimize the ‘institutional’ feel of maternity units has led to the move to make them more ‘homely’. This first of three results papers presents findings from a three-year nine-site study in England examining maternity unit design and its impact on women giving birth there. Data from a questionnaire survey of 559 mothers and 227 ward-based staff are augmented by analysis of follow-up focus groups. For mothers perceptions of spaciousness were strongly associated with overall satisfaction with surroundings and facilities (p<.01), as well as with care received (p<.01). Mothers' perceived ability to move themselves or room furniture around during labour varied across units and was not associated with overall room size. Among midwives the belief that they provided good quality care was moderately correlated with positive responses concerning ward layout (p<.01) and a comfortable working environment (p<.01).
Article
Objective: To estimate the cost of 'the cascade' of obstetric interventions introduced during labour for low risk women. Design: A cost formula derived from population data. Setting: New South Wales, Australia. Population: All 171,157 women having a live baby during 1996 and 1997. Methods: Four groups of interventions that occur during labour were identified. A cost model was constructed using the known age-adjusted rates for low risk women having one of three birth outcomes following these pre-specified interventions. Costs were based on statewide averages for the cost of labour and birth in hospital. Main outcome measures: The outcome measure is an 'average cost unit per woman' for low risk women, predicted by the level of intervention during labour. Obstetric care is classified as either private obstetric care in a private or public hospital, or routine public hospital care. Results: The relative cost of birth increased by up to 50% for low risk primiparous women and up to 36% for low risk multiparous women as labour interventions accumulated. An epidural was associated with a sharp increase in cost of up to 32% for some primiparous low risk women, and up to 36% for some multiparous low risk women. Private obstetric care increased the overall relative cost by 9% for primiparous low risk women and 4% for multiparous low risk women. Conclusions: The initiation of a cascade of obstetric interventions during labour for low risk women is costly to the health system. Private obstetric care adds further to the cost of care for low risk women
Article
Objective: To study the association between volume of hospital births per annum and birth outcome for low risk women. Design: Population-based study using the National Perinatal Data Collection (NPDC). Setting: Australia. Participants: Of 750,491 women who gave birth during 1999-2001, there were 331,147 (47.14%) medically 'low risk' including 132,696 (40.07%) primiparae and 198,451 (59.93%) multiparae. Methods: The frequency of each birth and infant outcome was described according to the size of the hospital where birth took place. We investigated whether unit size (defined by volume) was an independent risk factor for each outcome factor using public hospitals with greater than 2000 births per annum as a reference point. Main outcome measures: Rates of intervention at birth and neonatal mortality for low risk women in relation to hospitals with <100, 100-500, 501-1000, 1001-2000 and >2001 births per annum. Results: Neonatal death was less likely in hospitals with less than 2000 births per annum regardless of parity. For multiparous low risk women in hospitals of 100 and 500 births per annum compared with hospitals of >2000 births per annum the adjusted odds of neonatal mortality [adjusted odds ratio (AOR) 0.36; 99% confidence interval (CI) 0.14-0.93]. For low risk primiparous women in hospitals with less than 100 births per annum, there were lower rates of induction of labour (AOR 0.62; 99% CI 0.54-0.73); intrathecal analgesia/anaesthesia (AOR 0.34; 99% CI 0.28-0.42); instrumental birth (AOR 0.80; 99% CI 0.69-0.93); caesarean section after labour (AOR 0.59; 99% CI 0.49-0.72) and admission to a neonatal unit (AOR 0.15; 99% CI 0.10-0.22) and for low risk multiparous women in hospitals with less than 100 births per annum: induction (AOR 0.69; 99% CI 0.62-0.76); intrathecal analgesia/anaesthesia (AOR 0.32; 99% CI 0.29-0.36); instrumental birth (AOR 0.52; 99% CI 0.41-0.67); caesarean section after labour (AOR 0.41; 99% CI 0.33-0.52); and admission to a neonatal unit (AOR 0.09; 99% CI 0.07-0.12). Conclusions: In Australia, lower hospital volume is not associated with adverse outcomes for low risk women. -® RCOG 2006 BJOG An International Journal of Obstetrics and Gynaecology
Article
A place designed for childbirth should nowadays guarantee the security offered by technology without denying freedom of expression to the woman. This article will discuss the conflict between the humanization of the hospital birth environment and the spatial requirements imposed by a pathological definition of birth. Traditional institutional birth settings will be analyzed and new models, which support the active participation of women in the birth process, will be described.
Article
OBJECTIVE: To determine the incidence of placenta previa based on available epidemiologic evidence, and to quantify the risk of previa based on the presence and number of cesarean deliveries as well as a history of spontaneous and induced abortions. STUDY DESIGN: We reviewed studies on placenta previa published between 1950 and 1995 based on a comprehensive literature search using MEDLINE and by identifying studies cited in the references of published reports. Data on the incidence of previa, and its associations with previous cesarean delivery and abortions were abstracted. Studies were grouped based on design (case-control versus cohort studies). Statistical methods employed for the meta-analysis included the fixed-effects logistic regression model, while potential sources of heterogeneity among studies was evaluated by fitting random-effects models. RESULTS: The tabulation of 37 studies identified a total of 3.7 million pregnant women of whom 13,992 patients were diagnosed with placenta previa. The reported incidence of placenta previa ranged between 0.28% to 1.0%, or approximately 1 in 200 deliveries. No discernible trends over time in the incidence of previa were apparent. Women with at least one prior cesarean delivery were 2.6 (95% confidence interval (CI) 2.3-3.0) times at greater risk of developing placenta previa in a subsequent pregnancy. The results varied by study design, with case-control studies showing a stronger relative risk (RR=3.8,'95% U 2.3-6.4) than cohort studies (RR-2.4, 95% CI 2.1-2.8). Four studies encompassing 170,640 pregnant women showed a dose-response pattern for the risk of previa based on the number of prior cesarean deliveries. Relative risks were 4.5 (95% CI 3.6-5.5) for one, 7.4 (95% CI 7.1-7.7) for two, 6.5 (95% CI 3.6-11.6) for three, and 44.9 (95% CI 13.5-149.5) for four or more prior cesarean deliveries. Women with a prior history of spontaneous or induced abortion had a risk of previa of 1.6 (95% CI 1.0-2.6) and 1.7 (95% CI 1.0-2.9), respectively. Substantial heterogeneity in the results of the meta-analysis was noted among studies. CONCLUSION: There is a strong association between having a previous cesarean deliver)', spontaneous, or induced abortion and the subsequent development of placenta previa. The risk increases with number of prior cesarean deliveries. Pregnant women with a history of cesarean delivery or abortion must be regarded as high risk for placenta previa and must be monitored carefully. This study provides yet another reason for reducing the primary cesarean delivery rate, and for advocating vaginal birth for women with prior cesarean delivery.
Article
Background: Midwives in Ontario, Canada, provide care in the home and hospital and are required to submit data for all births to the Ontario Ministry of Health database. The purpose of this study was to compare maternal and perinatal/neonatal mortality and morbidity and intrapartum intervention rates for women attended by Ontario midwives who planned a home birth compared with similar low-risk women who planned a hospital birth between 2003 and 2006. Methods: The database provided outcomes for all women planning a home birth at the onset of labor (n = 6, 692) and for a cohort, stratified by parity, of similar low-risk women planning a hospital birth. Results: The rate of perinatal and neonatal mortality was very low (1/1,000) for both groups, and no difference was shown between groups in perinatal and neonatal mortality or serious morbidity (2.4% vs 2.8%; relative risk (RR), 95% confidence intervals (CI): 0.84 (0.68-1.03)). No maternal deaths were reported. All measures of serious maternal morbidity were lower in the planned home birth group as were rates for all interventions including cesarean section (5.2% vs 8.1%; RR (95% CI): 0.64 (0.56, 0.73)). Nulliparas were less likely to deliver at home, and had higher rates of ambulance transport from home to hospital than multiparas planning home birth and had rates of intervention and outcomes similar to, or lower than, nulliparas planning hospital births. Conclusions: Midwives who were integrated into the health care system with good access to emergency services, consultation, and transfer of care provided care resulting in favorable outcomes for women planning both home or hospital births. (BIRTH 36:3 September 2009)
Article
This article explores the interrelations between the corporeal, the social and the spatial as they operate to shape the discursive and material realities of childbirth in the obstetric hospital setting. It draws on interviews conducted with midwives throughout New Zealand and embodies key insights derived from the work of Michel Foucault and Elizabeth Grosz. The obstetric hospital is theorised as a product of particular socio-political relations that privilege biomedical constructions of the body and childbirth. Midwives, however, proffer an alternative construction of childbirth and the space/place it is enacted. It is one that requires a woman to actively engage with a variety of birth spaces and take up a range of subject positions that enable her to be a more active agent in the process of parturition. The limited and limiting spatial and discursive arrangements of the obstetric hospital, it is argued, shape the behaviour, subjectivity and corporeality of the maternal body confined within it and therefore the practises of midwives. Unfortunately, and as this article demonstrates, the opportunity to take up such an alternative is limited in the obstetric hospital despite some recent cosmetic attempts to render it more welcoming.
Article
Summary Haemorrhage associated with childbirth continues to be a significant cause of morbidity and mortality. Despite recommendations in the Report on Confidential Enquiries into Maternal Deaths, obstetric haemorrhage ranks in the top three leading causes of death and is associated with many of the other fatalities studied in these reports. The aim of this study was to look for risk factors that are associated with significant obstetric haemorrhage. The case notes and blood transfusion records of all women delivering after 25 completed weeks gestation who suffered obstetric haemorrhage and required at least 6 units of blood to be transfused were identified and then studied in detail. Over the six year period January 1984 to December 1989, there were 38 480 deliveries at the hospital of which 34 446 were considered as part of this study cohort. The incidence of major obstetric haemorrhage in this population was 1:931 deliveries. Most obstetric units can therefore expect to see at least two or three cases per year. The incidence of postpartum hysterectomy was 1:4306. Our figures show a trend towards a greater incidence of haemorrhage in parous women and, strikingly, 17 of these 24 (71 per cent) parous patients had a prior caesarean section. The high risk status of such should be recognised, treatment of any haemorrhage should be prompt and aggressive.
Article
Birthing centre care offers women with a low risk of complication in pregnancy an alternative to conventional care for the birthing of their baby It is important these two forms of care are appropriately assessed. A randomised controlled trial comparing the newly opened birthing centre with the established conventional delivery suite was conducted at the then Queen Victoria Hospital, Adelaide, South Australia. The outcomes measured included maternal satisfaction, costs and clinical outcomes both for mother and baby which related to the need for Caesarean section, episiotomy or tear rate and method of feeding. Two hundred and one women attending the hospital's antenatal clinic were randomly allocated to either birthing centre or delivery suite care. One hundred women were allocated to the birthing centre. No differences were found in either group related to clinical outcomes or costs. The only difference in maternal satisfaction was the choice women made for their next birth. More women in the birthing centre group felt they were encouraged to breastfeed immediately after birth. While the numbers in this study were too small to detect any but large differences in outcome, birthing centre care should remain an option for women and further studies undertaken with larger numbers.
Article
RESULTS: Planned home births were associated with fewer maternal interventions including epidural analgesia, electronic fetal heart rate monitoring, episiotomy, and operative delivery. These women were less likely to experience lacerations, hemorrhage, and infections. Neonatal outcomes of planned home births revealed less frequent prematurity, low birthweight, and assisted newborn ventilation. Although planned home and hospital births exhibited similar perinatal mortality rates, planned home births were associated with significantly elevated neonatal mortality rates. CONCLUSION: Less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate.