PHYSICIAN- AND MIDWIFE-ATTENDED HOME BIRTHS: Effects of Breech,Twin, and Post-Dates Outcome Data on Mortality Rates

The effect of attending breech, twin, and post-date pregnancies on home birth outcomes was assessed. The same form was used to collect data on a convenience sample of 4,361 home births attended by apprentice-trained midwives from 1970 to 1985 and 4,107 home births attended by family physicians from 1969 to 1981. Data sets were compared to find 1,000 pairs of pregnant women, one from each group, who were matched for age, sex, socioeconomic status, race, and medical risk. The perinatal mortality rate for the midwife-attended births was 14 per 1,000 (three fetal deaths before labor, six intrapartum fetal deaths, and five neonatal deaths). The perinatal mortality rate for births attended by family physicians was five per 1,000 (one fetal death before labor, two intrapartum fetal deaths, and two neonatal deaths). The difference was statistically significant; however, the differences disappeared when cases involving post-dates, twin, or breech deliveries were eliminated from the sample. Although the data are more than a decade old, they support the premise that outcomes for low-risk home births are comparably good whether attended by physicians or midwives. However, the findings do raise questions about the safety of attending high-risk births at home.     

OUTCOMES OF 11,788 PLANNED HOME BIRTHS ATTENDED BY CERTIFIED NURSE-MIDWIVES

This study describes the outcomes of 11,788 planned home births attended by certified nurse-midwives (CNMs) from 1987 to 1991. A retrospective survey was used to obtain information about the outcomes of intended home birth, including hospital transfers, as well as practice protocols, risk screening, and emergency preparedness. Ninety nurse-midwifery home birth practices provided data for this report (66.2% of identified nurse-midwifery home birth practices). It is estimated that 60–70% of all CNM-attended home births reported in national statistics data during this period were represented in this survey. The overall perinatal mortality was 4.2 per 1,000, including known third-trimester fetal demises. There were no maternal deaths. The intrapartum and neonatal mortality for those intending home birth at the onset of labor was 2 per 1,000; the overall neonatal mortality rate for this group was 1.3 per 1,000. When deaths associated with congenital anomalies were excluded, the intrapartum and neonatal mortality rate was 0.9 per 1,000; the neonatal mortality was 0.2 per 1,000. The overall transfer rate, including antepartum referrals, was 15.9%. The intrapartum transfer rate for those intending home birth at the onset of labor was 8%. Most responding nurse-midwives used standard risk-assessment criteria, only delivered low-risk women at home, and were prepared with emergency equipment necessary for immediate neonatal resuscitation or maternal emergencies. This study supports previous research indicating that planned home birth with qualified care providers can be a safe alternative for healthy lower risk women.     

Outcomes of 11,788 planned home births attended by certified nurse-midwives A retrospective descriptive study

This study describes the outcomes of 11,788 planned home births attended by certified nurse-midwives (CNMs) from 1987 to 1991: A retrospective survey was used to obtain information about the outcomes of intended home birth, including hospital transfers, as well as practice protocols, risk screening, and emergency preparedness. Ninety nurse-midwifery home birth practices provided data for this report (66.2% of identified nurse-midwifery) home birth practices). It is estimated that 60–70% of all CNM-attended home births reported in national statistics data during this period were represented in this survey. The overall perinatal mortality was 4.2 per 1,000, including known third-trimester fetal demises. There were no maternal deaths. The intrapartum and neonatal mortality for those intending home birth at the onset of labor was 2 per 1,000; the overall neonatal mortality rate for this group was 1.3 per 1,000. When deaths associated with congenital anomalies were excluded, the intrapartum and neonatal mortality rate was 0.9 per 1,000; the neonatal mortality was 0.2 per 1,000. The overall transfer rate, including antepartum referrals, was 15.9%. The intrapartium transfer rate for those intending home birth at the onset of labor was 8%. Most responding nurse-midwives used standard risk-assessment criteria, only delivered low-risk women at home, and were prepared with emergency equipment necessary for immediate neonatal resuscitation or maternal emergencies. This study supports previous research indicating that planned home birth with qualified care providers can be a safe alternative for healthy lower risk women.     

Birth outcomes of planned home births in Missouri: a population-based study

We evaluated the birth outcomes of planned home births. We conducted a retrospective cohort study using Missouri vital records from 1989 to 2005 to compare the risk of newborn seizure and intrapartum fetal death in planned home births attended by physicians/certified nurse midwives (CNMs) or non-CNMs with hospitals/birthing center births. The study sample included singleton pregnancies between 36 and 44 weeks of gestation without major congenital anomalies or breech presentation ( N?=?859,873). The adjusted odds ratio (aOR) of newborn seizures in planned home births attended by non-CNMs was 5.11 (95% confidence interval [CI]: 2.52, 10.37) compared with deliveries by physicians/CNMs in hospitals/birthing centers. For intrapartum fetal death, aORs were 11.24 (95% CI: 1.43, 88.29), and 20.33 (95% CI: 4.98, 83.07) in planned home births attended by non-CNMs and by physicians/CNMs, respectively, compared with births in hospitals/birthing centers. Planned home births are associated with increased likelihood of adverse birth outcomes.     

Outcomes Associated with Planned Home and Planned Hospital Births in Low‐Risk Women Attended by Midwives in Ontario,Canada, 2003–2006: A Retrospective Cohort Study

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.     

Contribution of late fetal deaths to US perinatal mortality rates, 1995-1998

We analyzed US fetal death and linked infant birth-death certificate data for 1995-1998 to evaluate perinatal deaths (late fetal deaths [> or = 28 weeks' gestation] and early neonatal deaths [< or = 7 days of life]) by race, Hispanic ethnicity, state of residence, and selected demographic characteristics. We also compared components of perinatal mortality, late fetal deaths, and early neonatal deaths, by birthweight, gestational age, and selected maternal medical conditions during pregnancy. From 1995 through 1998, there were 221,767 fetal deaths at > or = 20 weeks' gestation and infant deaths at less than 1 year. Of these, 113,421 (51%) were perinatal deaths; late fetal deaths accounted for 47% of perinatal deaths. The total perinatal mortality rate declined 5.3%, from 7.5 to 7.1 per 1,000 live births plus late fetal deaths. Blacks experienced higher perinatal mortality rates than whites (rate ratio = 2.1). Among perinatal deaths > or = 28 weeks' gestation, the ratio of fetal to neonatal deaths was 3.4 among blacks and 2.4 among whites. State-specific rates ranged from 5.2 to 13.1 per 1,000 live births plus late fetal deaths. Although late fetal deaths are not included in routine statistics of pregnancy outcomes, these deaths represent a large proportion of adverse pregnancy outcomes. Surveillance of perinatal mortality provides a more complete picture of the health of women, fetuses, and newborns. Improving the quality of surveillance data regarding fetal deaths is essential for more effective use of these data. This information can be used to prevent excess perinatal deaths and reduce disparities in pregnancy outcomes among high-risk subgroups identified by individual and population characteristics.     

Perinatal morbidity and mortality in a regional perinatal network

A study of pregnancy outcome was performed using a 1982-1985 regional network database of 60,456 infants. The perinatal mortality rate was 15.6 deaths per 1,000 births (total, 942), while the antepartum, intrapartum and neonatal mortality rates were 5.3, 1.6 and 8.7, respectively. Seven hundred forty-three multiple gestation pregnancies (1.2%) and 1,632 major congenital anomalies (2.7%) were identified. The corrected perinatal mortality rate was 13.8 deaths per 1,000 births. This study revealed that prematurity, postdatism, congenital anomalies, low Apgar scores and neonatal complications, including respiratory distress syndrome, pneumothorax, persistent fetal circulation, intracerebral hemorrhage and seizure activity, were major factors contributing to mortality. This analysis suggests that a further reduction in mortality should follow a reduction in preterm deliveries and their sequelae and the early identification and management of maternal and fetal antenatal complications.     

Understanding perinatal mortality

The term perinatal death is used to describe antepartum and intrapartum stillbirths, and early neonatal deaths. At term, intrapartum stillbirth and neonatal death are collectively referred to as delivery related perinatal death, and the incidence in nulliparous and multiparous women is approximately one in 1000 and one in 2000 births, respectively. Associated factors include advanced maternal age, small for gestational age, fetal macrosomia, breech labour and previous caesarean delivery. The impact of obstetric interventions in labour on delivery related perinatal death, including rising rates of caesarean delivery, is complex and unclear. The incidence of overall perinatal death is falling mainly as a result of improvements in the management of premature neonates and from decreased deaths secondary to intrapartum anoxia at term. This review will provide an overview of perinatal mortality with a particular emphasis on delivery related perinatal death at term.     

Fetal death during labor: an epidemiologic indicator of level of obstetric care

The effect of level of perinatal care on rates of intrapartum fetal death was studied in births of infants weighing greater than 1000 gm in New York City in 1976 to 1978. With potential confounding by birth weight, gestational age, and several other variables controlled, intrapartum fetal death rates decreased as intensiveness of care increased. Compared with births in Level 3 maternity units (perinatal intensive care), births in Level 1 units (community hospitals) had a 61% excess risk of intrapartum fetal death (p less than 0.01) and births in Level 2 units (intermediate level of care) had a 35% excess risk (p = 0.06). The effect of hospital level on intrapartum fetal death rates could not be attributed to differences in the classification of fetal deaths during labor across hospital levels, since no compensatory differences in late antepartum fetal death rates were found. Our findings in a total population are compatible with several studies carried out in single hospitals that have reported declines in intrapartum fetal death rates, especially in births more closely attended during labor. Fetal deaths that occur in labor, as contrasted with fetal deaths occurring before labor, constitute a perinatal outcome that is especially sensitive to level of obstetric care.     

Perinatal mortality at King Fahd Hospital of the University Al-Khobar, Saudi Arabia

The perinatal deaths of all singleton births that occurred at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia during a 4-year period are analysed. The causes of death are classified into 12 groups using an extended modification of the Aberdeen classification. There were 165 perinatal deaths in 8057 singleton births, giving a perinatal mortality rate of 20.47 per 1000 total births. Fetal malformations occurred in 29 (17.57%) cases. Of the remaining 136 normal infants, 77 (56.6%) were stillbirths and 59 (43.4%) died within 1 week of delivery. Spontaneous premature labor was the commonest cause of death (23.52%) followed by birth trauma (11%) and maternal diseases (9.55%). The cause of death was not known in 22 (16.17%) cases. In conclusion, prevention of premature labor, better intrapartum fetal monitoring, early recognition of fetal distress and improvement of neonatal care should reduce the perinatal mortality rate.     

Mortality in relation to method of delivery in breech infants

To study the relation of method of delivery to perinatal mortality, we examined information from the deliveries of 1593 breech infants weighing 1000 g or more born in 1976 and 1977. In none of the birthweight groups 1000 g or more was neonatal mortality significantly different between infants delivered vaginally compared with those delivered by cesarean section, although the number of deaths was small. In all the birthweight groups, perinatal mortality was higher in breeches delivered vaginally, but the differences were because all of the infants who died before labor were delivered vaginally. Total mortality (intrapartum plus neonatal deaths) in infants who survived to labor was not significantly different in breech infants delivered by one or the other method at any birthweight. These data suggest that routine cesarean delivery for infants 1000 g or more who are in the breech presentation may not be justified from the standpoint of mortality.     

The National Birth Center Study. Part III--Intrapartum and immediate postpartum and neonatal complications and transfers, postpartum and neonatal care, outcomes, and client satisfaction.

This is the final article of the three-part report of the National Birth Center Study. Eight percent of the mothers or infants had serious complications; 16% were transferred, 12% before and 4% after the deliveries. Fifteen percent of transfers were emergencies. Nulliparous women were much more likely than parous women to experience dystocia, be transferred, or have cesarean sections. Seventy-five percent of the nulliparous women gave birth in the centers, compared with 95% of the parous women. Eighty-four percent of the women had at least one postpartum home or office visit. There were 11,814 mothers, no maternal deaths, and 15 intrapartum/neonatal deaths (1.3/1,000 births, 0.7 excluding congenital anomalies). Postterm deliveries with macrosomic infants, placental abruption, sustained fetal distress, and thick meconium were associated with high mortality. Mortality was very low for those not transferred and much lower for transfers during labor as compared with those after the delivery. Women with no medical/obstetric risk factors had the lowest rates of transfers and serious complications. Except for postterm pregnancies, the intrapartum/neonatal mortality rate for birth center clients was not higher than rates from studies of low-risk hospital births, and the cesarean section rate was lower. There is no evidence that hospitals are a safer place for low-risk births.     

The effect of delivery route on outcome in breech presentation

This study was undertaken to determine the effect of choice of birth route on infant outcome in fetal breech presentation. The study group excluded infants who were footling breeches and infants with major congenital anomalies. The mothers were in labor with the fetal heartbeat present at entry into the labor room. Outcome variables were intrapartum and neonatal deaths and neonatal neurological morbidity. Delivery route was not significantly associated with neonatal death in the 500 to 999 gm (p = 0.43) and 1,000 to 2,499 gm (p = 0.43) categories. Over 2,500 gm, there were no neonatal deaths. In similar manner, delivery route was not significantly associated with neonatal neurological morbidity. In both neonatal death and morbidity, birth weight and modified Dubowitz score explained the largest proportion of the variance for outcome in breech presentation.     

Licensed Midwife-Attended,Out-of-Hospital Births in Washington State: Are They Safe?

ABSTRACT: The safety of out-of-hospital births attended by midwives who are licensed according to international standards has not been established in the United States. To address this issue, outcomes of births attended out of hospital by licensed midwives in Washington state were compared with those attended by physicians and certified nurse-midwives in hospital and certified nurse-midwives out of hospital between 1981 and 1990. Outcomes measured included low birthweight, low five-minute Apgar scores, and neonatal and postneonatal mortality. Associations between attendant and outcomes were measured using odds ratios to estimate relative risks. Multivariate analysis using logistic regression controlled for confounding variables. Overall, births attended by licensed midwives out of hospital had a significantly lower risk for low birthweight than those attended in hospital by certified nurse-midwives, but no significant differences were found between licensed midwives and any of the comparison groups on any other outcomes measured. When the analysis was limited to low-risk women, certified nurse-midwives were no more likely to deliver low-birthweight infants than were licensed midwives, but births attended by physicians had a higher risk of low birthweight. The results of this study indicate that in Washington state the practice of licensed nonnurse-midwives, whose training meets standards set by international professional organizations, may be as safe as that of physicians in hospital and certified nurse-midwives in and out of hospital.     

Outcome of very-low-birth-weight infants: does antepartum versus neonatal referral have a better impact on mortality, morbidity, or long-term outcome?

To evaluate the effect of aggressive intrapartum and early neonatal resuscitation on perinatal mortality, neonatal morbidity, and long-term outcome, we evaluated two groups of low-birth-weight infants who received different intrapartum and early neonatal care. One group of infants was delivered at a university-based regional perinatal center offering both high-risk obstetric and tertiary neonatal care. The second population consisted of infants from five community hospitals with level I nurseries. These two groups were selected because they differed in the ability to provide intrapartum and early neonatal care and because a total base population could be evaluated. During the 4-year study period, 174 infants with birth weights of 500 to 1499 gm were delivered at the university center and 297 infants were delivered at the community hospitals. At the university center, there was a significant reduction in fetal deaths, a delay in the time of neonatal deaths, and a reduction in hyaline membrane disease. Neonatal mortality rates at the university center were not reduced, and the incidence of sequelae was not affected. These data suggest that for the smallest infant, intrapartum and immediate neonatal care at a tertiary center may decrease fetal mortality and neonatal morbidity rates. Neonatal mortality and long-term outcome, however, may be less affected.     

Examining Autonomy’s Boundaries: A Follow‐up Review of Perinatal Mortality Cases in UK Independent Midwifery

Abstract: Background: An earlier matched cohort study in the United Kingdom found a significantly higher perinatal mortality rate for births booked under an independent midwife compared with births in National Health Service units (1.7% [25/1,508] vs 0.6% [45/7,366]). This study examined independent midwives’ management and decision making in the 15 instances of perinatal death that occurred at term. Methods: Thematic analysis of independent midwives’ case notes was performed in instances of perinatal mortality. Semi‐structured interviews were conducted with the midwives concerned. Results: Home birth was attempted in 13 of the 15 cases. Significant (often multiple) antenatal risk factors were identified in 13 cases, including twin pregnancy, planned vaginal births after cesarean section, breech presentations, and maternal illness. Several women had declined some or all routine antenatal screening. Three deaths occurred before labor onset. Postmortem results were known in only four cases; many causes of death remained unexplained. Professional consensus was that seven deaths were unpreventable; elective cesarean section may have changed the outcome in eight cases. However, the pregnant women had declined this option; some were reported to be avoiding National Health Service care because of previous bad experiences. Transfer to hospital care, when it occurred, was often problematic. Care management was judged to be clinically acceptable within the parameters set by the mothers’ choices. Conclusions: Information about clinical processes (and outcomes) is essential if informed decisions are to be made. The women in this review had reportedly accepted the potential consequences of their high‐risk situations. If reality is to match rhetoric about “patient” autonomy, such decision making in high‐risk situations must be accepted. (BIRTH 37:4 December 2010)     

THE NATIONAL BIRTH CENTER STUDY

This is the final article of the three-part report of the National Birth Center Study. Eight percent of the mothers or infants had serious complications; 16% were transferred, 12% before and 4% after the deliveries. Fifteen percent of transfers were emergencies. Nulliparous women were much more likely than parous women to experience dystocia, be transferred, or have cesarean sections. Seventy-five percent of the nulliparous women gave birth in the centers, compared with 95% of the parous women. Eighty-four percent of the women had at least one postpartum home or office visit. There were 11,814 mothers, no maternal deaths, and 15 intrapartum/neonatal deaths (1.3/1,000 births, 0.7 excluding congenital [Text missing in PDF]omalies). Postterm deliveries with macrosomic infants, placental abruption, sustained fetal distress, and thick meconium were associated with high mortality. Mortality was very low for those not transferred and much lower for transfers during labor as compared with those after the delivery. Women with no medical/obstetric risk factors had the lowest rates of transfers and serious complications. Except for postterm pregnancies, the intrapartum/neonatal mortality rate for birth center clients was not higher than rates from studies of low-risk hospital births, and the cesarean section rate was lower. There is no evidence that hospitals are a safer place for low-risk births.     

Perinatal Mortality in Bahrain

A review of 583 perinatal deaths at the Ministry of Health hospitals in Bahrain, during the years 1985-1987 revealed a perinatal mortality rate of 19.6 per 1,000 total births. Lethal congenital malformations accounted for 145 (24.9%) deaths. Of the 438 normally formed infants there were 42.2% antepartum, 115 (26.3%) intrapartum and 138 (31.5%) early neonatal deaths; in 82.7% of cases the death was considered to be unavoidable. The population of Bahrain for 1986 according to the Central Statistics Organization (1) was 435,065, the majority of which was served by the Ministry of Health Maternity Service with approximately 10,000 deliveries per annum. The Ministry of Health provides maternity services through one main maternity hospital and 2 peripheral hospitals with consultant obstetric care. In addition to these, there are 3 maternity units run by midwives. High risk cases are usually delivered in the main hospital as there is a neonatal intensive care unit attached to it. The latter also acts as a referral centre for all sick babies in Bahrain. An analysis of the causes of perinatal deaths is an effective way of assessing the efficiency of maternity services. The objective of this study was to identify and improve the various factors influencing perinatal mortality in Bahrain.     

Balancing the risks of planned cesarean section and trial of vaginal delivery for the mature, selected, singleton breech presentation

The experience of mature, singleton, vaginal breech delivery over the last decade in our hospital is reviewed. This constitutes the largest series of breech delivery reported for over twelve years. Unlike all but two previous reports, we analyze our results by management policy; elective cesarean section, trial of vaginal breech delivery and cesarean section as soon as the diagnosis of breech delivery was made on labor ('expedite' cesarean operations). Six intrapartum or neonatal deaths occurred among 613 patients selected for trial of vaginal delivery--a rate of one per cent. There were none following 217 elective or 69 expedite cesarean sections. A detailed review of the literature over the last decade confirms that trial of vaginal delivery is more dangerous to the fetus and results in about one perinatal death of a normally formed infant in 200 deliveries. Apgar scores were slightly lower following trial of vaginal delivery and there were more irritable or injured babies in this group. The last intrapartum or neonatal death occurred in 1981. However, the elective cesarean section rate has increased from 14 to 33 per cent over this time period. Similarly the rate of failed trial of vaginal breech delivery has increased from 15 to 31 per cent. The proportion of failed trials was highest where the fetus was large but clinicians were poor at estimating fetal weight. Decision theory is used to examine the maternal utility of trial of vaginal breech delivery versus elective cesarean section when the intrapartum cesarean rate rises to these levels. It is shown that, from the point of view of maternal mortality and morbidity in the current pregnancy, trial of vaginal delivery maybe the more dangerous maternal option. Thus a low threshold for cesarean section in labor leads to greater fetal safety at the mother's expense. It is nevertheless concluded that maternal attitude and the long-term effects of a uterine scar should be considered in the final decision.