Self‐Rated “No‐” and “Low‐” Risk Pregnancy: A Comparison of Outcomes for Women in Obstetric‐Led and Midwife‐Led Units in England

ABSTRACT: Background: Debate in the United Kingdom about place of birth often concerns obstetric‐led units and midwife‐led units and relates to notions of risk and safety. Outcomes for these two types of unit are often not comparable because of the restricted selection criteria for midwife‐led units. The purpose of this study was to compare outcomes for women intending to give birth in these different types of unit and whose self‐rated pregnancy risk level was “none” or “low.” Methods: Self‐completion questionnaires were distributed to mothers 8 days after the birth in 9 units (6 midwife led 3 obstetric led) over a 6‐month period. Results: Completed questionnaires were received from 432 women (midwife led = 294, obstetric led = 138). Mothers in midwife‐led units spent shorter times in labor in the unit (p < 0.01), received less analgesia (p < 0.01) and had fewer interventions (p < 0.01), and were more likely to have a normal delivery (p < 0.01) than women in obstetric‐led units. Similar differences were found for both primiparous and multiparous women. In terms of the number of midwives attending each woman, analysis of covariance suggested different models of care depending on type of unit (p < 0.05) and parity (p < 0.01). Conclusions: Since these mothers’ self‐rated risk level was none or low, some comparability of outcomes is permissible. It appears that models of care are significantly different in obstetric‐led units compared with midwife‐led units, leading to greater likelihood of intrapartum intervention, need for analgesia, and assisted or operative delivery. A randomized controlled trial examining such units would permit a conclusive examination of these outcomes. (BIRTH 34:4 December 2007)     

Factors Associated With Non‐Normal Birth Outcomes for Low‐Risk Women in an Inner‐City Hospital

Introduction: The purpose of this study was to examine factors associated with normal versus non‐normal birth outcomes for low‐risk women who were admitted for care in spontaneous labor. Methods: The birth records of 93 women were reviewed. Results: At the completion of the fourth stage of labor, 61% of births (n = 57) met the criteria for normal, while 39% of births (n = 36) had non‐normal outcomes. On bivariate analysis, variables associated with non‐normal outcomes included nulliparity (odds ratio [OR], 9.10; 95% confidence interval [CI], 3–28; P <.0001), lower average centimeters of dilation at admission (t‐score 4.422; P <.001), use of pharmacologic pain relief, including narcotics and epidural anesthesia (OR, 5.03; 95% CI, 2–16; P = .005), and birth attended by a physician versus a certified nurse‐midwife (OR, 3.60; 95% CI, 2–9; P = .004). In a multivariate analysis, nulliparity (OR, 6.07; 95% CI, 2–19; P = .002) and lower average centimeters of dilation at admission (OR, 0.63; 95% CI, 0.5–0.9; P = .005) were independently associated with non‐normal outcome. Discussion: The development of clinical guidelines aimed at reducing admissions of women in early labor may reduce non‐normal outcomes, particularly for nulliparous women.     

Maternal Position at Midwife‐Attended Birth and Perineal Trauma: Is There an Association?

ABSTRACT: Background: Most women will sustain some degree of trauma to the genital tract after vaginal birth. This study aimed to examine the association between maternal position at birth and perineal outcome in women who had a midwife‐attended, spontaneous vaginal birth and an uncomplicated pregnancy at term. Methods: Data from 3,756 births in a major public tertiary teaching hospital were eligible for analysis. The need for sutures in perineal trauma was evaluated and compared for each major factor studied (maternal age, first vaginal delivery, induction of labor, not occipitoanterior, use of regional anesthesia, deflexed head and newborn birthweight >3,500 g). Birth positions were compared against each other. Subgroup analysis determined whether birth positions mattered more or less in each of the major factors studied. The chi‐square test was used to compare categorical variables. Results: Most women (65.9%) gave birth in the semi‐recumbent position. Of the 1,679 women (44.5%) who required perineal suturing, semi‐recumbent position was associated with the need for perineal sutures, whereas all‐fours was associated with reduced need for sutures; these associations were more marked in first vaginal births and newborn birth weight over 3,500 g. When regional anesthesia was used, semi‐recumbent position was associated with a need for suturing, and lateral position associated with a reduced need for suturing. The four major factors significantly related to perineal trauma included first vaginal birth, use of regional anesthesia, deflexed head, and newborn weight more than 3,500 g. Conclusions: Women should be given the choice to give birth in whatever position they find comfortable. Maternity practitioners have a responsibility to inform women of the likelihood of perineal trauma in the preferred birth position. Ongoing audit of all clinicians attending births is encouraged to further determine effects of maternal birth position and perineal trauma, to investigate women's perception of comfortable positioning at birth, and to measure changes to midwifery practice resulting from this study.     

Outcomes of Planned Hospital Birth Attended by Midwives Compared with Physicians in British Columbia

ABSTRACT: Background: The impact of midwifery versus physician care on perinatal outcomes in a population of women planning birth in hospital has not yet been explored. We compared maternal and newborn outcomes between women planning hospital birth attended by a midwife versus a physician in British Columbia, Canada. Methods: All women planning a hospital birth attended by a midwife during the 2‐year study period who were of sufficiently low‐risk status to meet eligibility requirements for home birth as defined by the British Columbia College of Midwives were included in the study group (n =488). The comparison group included women meeting the same eligibility requirements but planning a physician‐attended birth in hospitals where midwives also practiced (n =572). Outcomes were ascertained from the British Columbia Reproductive Care Program Perinatal Registry to which all hospitals in the province submit data. Results: Adjusted odds ratios for women planning hospital birth attended by a midwife versus a physician were significantly reduced for exposure to cesarean section (OR 0.58, 95% CI 0.39–0.86), narcotic analgesia (OR 0.26, 95% CI 0.18–0.37), electronic fetal monitoring (OR 0.22, 95% CI 0.16–0.30), amniotomy (OR 0.74, 95% CI 0.56–0.98), and episiotomy (OR 0.62, 95% CI 0.42–0.93). The odds of adverse neonatal outcomes were not different between groups, with the exception of reduced use of drugs for resuscitation at birth (OR 0.19, 95% CI 0.04–0.83) in the midwifery group. Conclusions: A shift toward greater proportions of midwife‐attended births in hospitals could result in reduced rates of obstetric interventions, with similar rates of neonatal morbidity. (BIRTH 34:2 June 2007)     

Making Choices for Childbirth: A Randomized Controlled Trial of a Decision‐aid for Informed Birth after Cesareana

ABSTRACT: Background: Decision‐making about mode of birth after a cesarean delivery presents challenges to women and their caregivers and requires a balance of risks and benefits according to individual circumstances. The study objective was to determine whether a decision‐aid for women who have experienced previous cesarean birth facilitates informed decision‐making about birth options during a subsequent pregnancy. Method: A prospective multicenter randomized controlled trial of 227 pregnant women was conducted within 3 prenatal clinics and 3 private obstetric practices in New South Wales, Australia. Women with 1 previous cesarean section and medically eligible for trial of vaginal birth were recruited at 12 to 18 weeks’ gestation; 115 were randomized to the intervention group and 112 to the control group. A decision‐aid booklet describing risks and benefits of elective repeat cesarean section and trial of labor was given to intervention group women at 28 weeks’ gestation. Main outcome measures included level of knowledge, decisional conflict score, women's preference for mode of birth, and recorded mode of birth. Results: Women who received the decision‐aid demonstrated a significantly greater increase in mean knowledge scores than the control group (increasing by 2.17 vs 0.42 points on a 15‐point scale)(p < 0.001, 95% CI for difference = 1.15–2.35). The intervention group demonstrated a reduction in decisional conflict score (p < 0.05). The decision‐aid did not significantly affect the rate of uptake of trial of labor or elective repeat cesarean section. Preferences expressed at 36 weeks were not consistent with actual birth outcomes for many women. Conclusion: A decision‐aid for women facing choices about birth after cesarean section is effective in improving knowledge and reducing decisional conflict. However, little evide nce suggested that this process led to an informed choice. Strategies are required to better equip organizations and practitioners to empower women so that they can translate informed preferences into practice. Further work needs to examine ways to enhance women's power in decision‐making within the doctor‐patient relationship. (BIRTH 32:4 December 2005)     

Relationship Between Hospital‐Level Percentage of Midwife‐Attended Births and Obstetric Procedure Utilization

Introduction

Research has shown good outcomes among individual low‐risk women who receive perinatal care from midwives, yet little is known about how hospital‐level variation in midwifery care relates to procedure use and maternal health. This study aimed to document the association between the hospital‐level proportion of midwife‐attended births and obstetric procedure utilization.

Methods

This analysis used 2 data sources: Healthcare Cost and Utilization Project State Inpatient Database data for New York in 2014, and New York State Department of Health data on the percentage of midwife‐attended births at hospitals in the state in 2014. Using logistic regression, we estimated the association between the hospital‐level percentage of midwife‐attended births and 4 outcomes among low‐risk women: labor induction, cesarean birth, episiotomy, and severe maternal morbidity.

Results

Hospital‐level percentage of midwife‐attended births was not associated with reduced odds of labor induction or severe maternal morbidity. Women who gave births at hospitals with more midwife‐attended births had lower odds of giving birth by cesarean (eg, adjusted odds ratio [aOR], 0.70; 95% confidence interval [CI], 0.59‐0.82 at a hospital with 15% to 40% of births attended by midwives, compared to no midwife‐attended births) and lower odds of episiotomy (eg, aOR, 0.41; 95% CI, 0.23‐0.74 at a hospital with more than 40% of births attended by midwives, compared to no midwife‐attended births).

Discussion

Our results indicate that hospitals with more midwife‐attended births have lower utilization of some obstetric procedures among low‐risk women; this raises the possibility of improving value in maternity care through greater access to midwifery care.     

Effectiveness of a Counseling Intervention after a Traumatic Childbirth: A Randomized Controlled Trial

Abstract: Adverse childbirth experiences can evoke fear and overwhelming anxiety for some women and precipitate posttraumatic stress disorder. The objective of this study was to assess a midwife‐led brief counseling intervention for postpartum women at risk of developing psychological trauma symptoms. Method : Of 348 women screened for trauma symptoms, 103 met inclusion criteria and were randomized into an intervention (n = 50) or a control (n = 53) group. The intervention group received face‐to‐face counseling within 72 hours of birth and again via telephone at 4 to 6 weeks postpartum. Main outcome measures were posttraumatic stress symptoms, depression, self‐blame, and confidence about a future pregnancy. Results : At 3‐month follow‐up, intervention group women reported decreased trauma symptoms, low relative risk of depression, low relative risk of stress, and low feelings of self‐blame. Confidence about a future pregnancy was higher for these women than for control group women. Three intervention group women compared with 9 control group women met the diagnostic criteria for posttraumatic stress disorder at 3 months postpartum, but this result was not statistically significant. Discussion : A high prevalence of postpartum depression and trauma symptoms occurred after childbirth. Although most women improved over time, the intervention markedly affected participants’ trajectory toward recovery compared with women who did not receive counseling. Conclusions : A brief, midwife‐led counseling intervention for women who report a distressing birth experience was effective in reducing symptoms of trauma, depression, stress, and feelings of self‐blame. The intervention is within the scope of midwifery practice, caused no harm to participants, was perceived as helpful, and enhanced women's confidence about a future pregnancy.     

Improving Quality and Safety in Maternity Care: The Contribution of Midwife‐Led Care

This article draws on findings from a recent Cochrane systematic review of midwife‐led care and discusses its contribution to the safety and quality of women's care in the domains of safety, effectiveness, woman‐centeredness, and efficiency. According to the Cochrane review, women who received models of midwife‐led care were nearly eight times more likely to be attended at birth by a known midwife, were 21% less likely to experience fetal loss before 24 weeks' gestation, 19% less likely to have regional analgesia, 14% less likely to have instrumental birth, 18% less likely to have an episiotomy, and significantly more likely to have a spontaneous vaginal birth, initiate breastfeeding, and feel in control. In addition to normalizing and humanizing birth, the contribution of midwife‐led care to the quality and safety of health care is substantial. The implications are that policymakers who wish to improve the quality and safety of maternal and infant care, particularly around normalizing and humanizing birth, should consider midwife‐led models of care and how financing of midwife‐led services can support this. Suggestions for future research include exploring why fetal loss is reduced under 24 weeks' gestation in midwife‐led models of care, and ensuring that the effectiveness of midwife‐led models of care on mothers' and infants' health and well‐being are assessed in the longer postpartum period.     

Randomized Controlled Trial of Hands‐and‐Knees Positioning for Occipitoposterior Position in Labor

ABSTRACT: Background: Hands‐and‐knees positioning during labor has been recommended on the theory that gravity and buoyancy may promote fetal head rotation to the anterior position and reduce persistent back pain. A Cochrane review found insufficient evidence to support the effectiveness of this intervention during labor. The purpose of this study was to evaluate the effect of maternal hands‐and‐knees positioning on fetal head rotation from occipitoposterior to occipitoanterior position, persistent back pain, and other perinatal outcomes. Methods: Thirteen labor units in university‐affiliated hospitals participated in this multicenter randomized, controlled trial. Study participants were 147 women laboring with a fetus at ≥37 weeks’ gestation and confirmed by ultrasound to be in occipitoposterior position. Seventy women were randomized to the intervention group (hands‐and‐knees positioning for at least 30 minutes over a 1‐hour period during labor) and 77 to the control group (no hands‐and‐knees positioning). The primary outcome was occipitoanterior position determined by ultrasound following the 1‐hour study period and the secondary outcome was persistent back pain. Other outcomes included operative delivery, fetal head position at delivery, perineal trauma, Apgar scores, length of labor, and women's views with respect to positioning. Results: Women randomized to the intervention group had significant reductions in persistent back pain. Eleven women (16%) allocated to use hands‐and‐knees positioning had fetal heads in occipitoanterior position following the 1‐hour study period compared with 5 (7%) in the control group (relative risk 2.4; 95% CI 0.88–6.62; number needed to treat 11). Trends toward benefit for the intervention group were seen for several other outcomes, including operative delivery, fetal head position at delivery, 1‐minute Apgar scores, and time to delivery. Conclusions: Maternal hands‐and‐knees positioning during labor with a fetus in occipitoposterior position reduces persistent back pain and is acceptable to laboring women. Given this evidence, hands‐and‐knees positioning should be offered to women laboring with a fetus in occipitoposterior position in the first stage of labor to reduce persistent back pain. Although this study demonstrates trends toward improved birth outcomes, further trials are needed to determine if hands‐and‐knees positioning promotes fetal head rotation to occipitoanterior and reduces operative delivery. (BIRTH 32:4 December 2005)     

Systematic Review of Nulliparous Women’s Views of Planned Cesarean Birth: The Missing Component in the Debate about a Term Cephalic Trial

Abstract: Background: The suggestion that planned cesarean birth is gaining acceptance among women has led some physicians to advocate the need for a trial of primary planned cesarean section versus planned vaginal birth in healthy women with singleton cephalic pregnancies at term. This paper reviews published studies of nulliparous women’s views of mode of birth collected in the antenatal period, examining why women may express a preference for cesarean birth and exploring implications for the debate about the need for a trial. Methods: A systematic literature review was undertaken of Cochrane, CINAHL, EMBASE, MEDLINE, and PsycINFO using the MeSH heading “cesarean section” and four free text spellings of “cesarean,” or “birth” or “delivery,” near truncated synonyms of 17 words meaning expressed preference. Studies of nulliparous women with a medical indication for cesarean birth, studies where a woman’s preference for mode of birth was reported in the postpartum period, surveys of midwives or obstetricians, and opinion and non‐English language papers were all excluded. Results: Nine papers were included in the review, which reported rates of women expressing a preference for cesarean birth that ranged from 0 to 100 percent at recruitment. However, the papers raised specific methodological, conceptual, and cultural issues that may have influenced women’s preferences for mode of birth in the populations studied. These issues included the timing and frequency of data collection, complexity of factors determining individual women’s decision making, and influence of societal norms. Conclusions: Little evidence is available that an increasing cultural acceptance of cesarean delivery will bring about support for a trial among pregnant nulliparous women. Further qualitative research investigating the influence of both obstetric and psychosocial factors on women’s views of vaginal and cesarean birth is required. (BIRTH 33:3 September 2006)     

Birth Centers in Australia: A National Population‐Based Study of Perinatal Mortality Associated with Giving Birth in a Birth Center

ABSTRACT: Background: Perinatal mortality is a rare outcome among babies born at term in developed countries after normal uncomplicated pregnancies; consequently, the numbers involved in large databases of routinely collected statistics provide a meaningful evaluation of these uncommon events. The National Perinatal Data Collection records the place of birth and information on the outcomes of pregnancy and childbirth for all women who give birth each year in Australia. Our objective was to describe the perinatal mortality associated with giving birth in “alongside hospital” birth centers in Australia during 1999 to 2002 using nationally collected data. Methods: This population‐based study included all 1,001,249 women who gave birth in Australia during 1999 to 2002. Of these women, 21,800 (2.18%) gave birth in a birth center. Selected perinatal outcomes (including stillbirths and neonatal deaths) were described for the 4‐year study period separately for first‐time mothers and for women having a second or subsequent birth. A further comparison was made between deaths of low‐risk term babies born in hospitals compared with deaths of term babies born in birth centers. Results: The total perinatal death rate attributed to birth centers was significantly lower than that attributed to hospitals (1.51/1,000 vs 10.03/1,000). The perinatal mortality rate among term births to primiparas in birth centers compared with term births among low‐risk primiparas in hospitals was 1.4 versus 1.9 per 1,000; the perinatal mortality rate among term births to multiparas in birth centers compared with term births among low‐risk multiparas in hospitals was 0.6 versus 1.6 per 1,000. Conclusions: This study using Australian national data showed that the overall rate of perinatal mortality was lower in alongside hospital birth centers than in hospitals irrespective of the mother’s parity. (BIRTH 34:3 September 2007)     

Transfers in Planned Home Births Related to Midwife Availability and Continuity: A Nationwide Population‐Based Study

ABSTRACT: Background: Planning a home birth does not necessarily mean that the birth will take place successfully at home. The object of this study was to describe reasons and risk factors for transfer to hospital during or shortly after a planned home birth. Methods: A nationwide study including all women who had given birth at home in Sweden between January 1, 1992, and July 31, 2005. A total of 735 women had given birth to 1,038 children. One questionnaire for each planned home birth was sent to the women. Of the 1,038 questionnaires, 1,025 were returned. Reasons for transfer and obstetric, socioeconomic, and care‐related risk factors for being transferred were measured using logistic regression. Results: Women were transferred in 12.5 percent of the planned home births. Transfers were more common among primiparas compared with multiparas (relative risk [RR] 2.5; 95% CI 1.8–3.5). Failure to progress and unavailability of the chosen midwife at the onset of labor were the reasons for 46 and 14 percent of transfers, respectively. For primiparas, the risk was four times greater if a midwife other than the one who carried out the prenatal checkups assisted at the birth (RR 4.4; 95% CI 2.1–9.5). A pregnancy exceeding 42 weeks increased the risk of transfer for both primiparas (RR 3.0; 95% CI 1.1–9.4) and multiparas (RR 3.4; 95% CI 1.3–9.0). Conclusions: The most common reasons for transfer to hospital during or shortly after delivery were failure to progress followed by the midwife’s unavailability at the onset of labor. Primiparas whose midwife for checkups during pregnancy was different from the one who assisted at the home birth were at increased risk of being transferred. (BIRTH 35:1 March 2008)     

Perinatal Outcomes of Women Intending to Give Birth in Birth Centers in Australia

Abstract: Background: A recent Australian study showed perinatal mortality was lower among women who gave birth in a birth center than in a comparable low‐risk group of women who gave birth in a hospital. The current study used the same large population database to investigate whether perinatal outcomes were improved for women intending to give birth in a birth center at the onset of labor, regardless of the actual place of birth. Methods: Data were obtained from the National Perinatal Data Collection (NPDC) in Australia. The study included 822,955 mothers who gave birth during the 5‐year period, 2001 to 2005, and their 836,919 babies. Of these, 22,222 women (2.7%) intended to give birth in a birth center at the onset of labor. Maternal and perinatal factors and outcomes were compared according to the intended place of birth. Data were not available on congenital anomalies, or cause, or timing of death. Results: Women intending to give birth in a birth center at the onset of labor had lower rates of intervention and of adverse perinatal outcomes compared with women intending to give birth in a hospital, including less preterm birth and low birthweight. No statistically significant difference was found in perinatal mortality for term babies of mothers intending to give birth in a birth center compared with term babies of low‐risk women intending to give birth in a hospital (1.3 per 1,000 births [99% CI = 0.66, 1.95] vs 1.7 per 1,000 births [99% CI = 1.50, 1.80], respectively). Conclusions: Term babies of women who intended to give birth in a birth center were less likely to be admitted to a neonatal intensive care unit or special care nursery, and no significant difference was found in other perinatal outcomes compared with term babies of low‐risk women who intended to give birth in a hospital labor ward. Birth center care remains a viable option for eligible women giving birth at term. (BIRTH 37:1 March 2010)     

Behavior Change Following Implementation of Home‐Based Life‐Saving Skills in Liberia,West Africa

Introduction: Home‐Based Life‐Saving Skills (HBLSS) has been fully integrated into Liberia's long‐term plan to decrease maternal and newborn mortality and morbidity, coordinated through the Ministry of Health and Social Welfare. The objective of this article is to disseminate evaluation data from project monitoring and documentation on translation of knowledge and skills obtained through HBLSS into behavior change at the community level. Methods: One year after completion of HBLSS training, complication audits were conducted with 434 postpartum women in 1 rural county in Liberia. Results: Sixty‐two percent (n = 269) of the women were attended during birth by an HBLSS‐trained traditional midwife or family member, while 38% (n = 165) were attended by a traditional midwife or family member who did not receive HBLSS training. Home‐Based Life‐Saving Skills–trained birth attendants performed significantly more first actions (life‐saving actions taught to be performed after every birth) than the attendants not HBLSS trained. Fourteen percent of our sample (n = 62) reported too much bleeding following the birth. Of these women, approximately half (n = 29) were attended by an HBLSS‐trained traditional midwife or family member. There was a significant difference in secondary actions (those actions taught to be performed when a woman experiences too much bleeding following childbirth) that were reported to have been performed by HBLSS‐trained attendants (mean 5.26, standard deviation [SD] 1.88) and untrained attendants (mean 2.73, SD 1.97; P < .0001). Discussion: Our findings suggest that HBLSS knowledge is being transferred into behavior change and used at the community level by traditional midwives and family members.     

Does Team Midwife Care Increase Satisfaction with Antenatal,Intrapartum, and Postpartum Care? A Randomized Controlled Trial

Background: Although policymakers have suggested that improving continuity of midwifery can increase women's satisfaction with care in childbirth, evidence based on randomized controlled trials is lacking. New models of care, such as birth centers and team midwife care, try to increase the continuity of care and caregiver. The objective of this study was to evaluate the effect of a new team midwife care program in the standard clinic and hospital environment on satisfaction with antenatal, intrapartum, and postpartum care in low‐risk women in early pregnancy. Methods: Women at Royal Women's Hospital in Melbourne, Australia, were randomly allocated to team midwife care (n = 495) or standard care (n = 505) at booking in early pregnancy. Doctors attended most women in standard care, and continuity of the caregiver was lacking. Satisfaction was measured by means of a postal questionnaire 2 months after the birth. Results: Team midwife care was associated with increased satisfaction, and the differences between the groups were most noticeable for antenatal care, less noticeable for intrapartum care, and least noticeable for postpartum care. The study found no differences between team midwife care and standard care in medical interventions or in women's emotional well‐being 2 months after the birth. Conclusion: Conclusions about which components of team midwife care were most important to increased satisfaction with antenatal care were difficult to draw, but data suggest that satisfaction with intrapartum care was related to continuity of the caregiver.     

Economic Implications of Home Births and Birth Centers: A Structured Review

ABSTRACT: Background: It is widely perceived that home births and birth centers may help decrease the costs of maternity care for women with uncomplicated pregnancies and deliveries. This structured review examines the literature relating to the economic implications of home births and birth center care compared with hospital maternity care. Methods: The bibliographic databases MEDLINE (from 1950), CINAHL (from 1982), EMBASE (from 1980), and an “in‐house” database, Econ2, were searched for relevant English language publications using MeSH and free text terms. Data were extracted with respect to the study design, inclusion criteria, clinical and cost results, and details of what was included in the cost calculations. Results: Eleven studies were included from the United Kingdom, United States, Australia, and Canada. Two studies focused on home births versus other forms and locations of care, whereas nine focused on birth centers versus other forms and locations of care. Resource use was generally lower for women cared for at home and in birth centers due to lower rates of intervention, shorter lengths of stay, or both. However, this fact did not always translate into lower costs because, in the U.K. where many studies were conducted, more midwives of a higher grade were employed to manage the birth centers than are usually employed in maternity units, and because of costs of converting existing facilities into delivery rooms. The quality of much of the literature was poor, although no studies were excluded for this reason. Selection bias was likely to be a problem in those studies not based on randomized controlled trials because, even where birth center eligibility was applied throughout, women who choose to deliver at home or in a birth center are likely to be different in terms of expectations and approach from women choosing to deliver in hospital. Conclusions: This review highlights the paucity of economic literature relating to home births and birth centers. Differences in results between studies may be attributed to differences in health care systems, differences in methods used, and differences in costs included. Further economic research that involves detailed bottom‐up costing of alternative options for place of birth and measures multiple outcomes, including women’s preferences, would help address the question of whether out‐of‐hospital birth is beneficial in economic terms. (BIRTH 35:2 June 2008)     

Midwife-led care unit for ‘low risk’ pregnant women in a Japanese hospital

Objectives.?To examine the obstetric outcomes of our ‘low risk’ pregnant women under the midwife-led delivery care compared with those under the obstetric shared care.

Methods.?A retrospective cohort study compared outcomes of labor under midwife ‘primary’ care with those under obstetric shared care. The factors examined were: maternal age, parity, gestational age at delivery, length of labor, augmentation of labor pains, delivery mode, episiotomy, perineal laceration, postpartum hemorrhage, neonatal birth weight, Apgar score, and umbilical artery pH. In this study, pregnant women were initially considered ‘low risk’ at admission when they had no history of medical, gynecological, or obstetric problems and no complications during the present pregnancy.

Results.?There were 1031 pregnant women initially considered ‘low risk’ at admission. At admission, 878 of them (85%) requested to give birth under midwife care; however 364 of these women (42%) were transferred to obstetric shared care during labor. The average length of labor under the midwife ‘primary’ care was significantly longer than that under the obstetric shared care. However, there were no significant differences in the rate of prolonged labor (≥24?h). There were no significant differences in other obstetric or neonatal outcomes between the two groups.

Conclusions.?There was no evidence indicating that midwife ‘primary’ care is unsafe for ‘low risk’ pregnant women. Therefore, midwifery care is recommended for ‘low risk’ pregnant women.     

Use of Hyaluronidase to Prevent Perineal Trauma During Spontaneous Births: A Randomized,Placebo‐Controlled,Double‐blind,Clinical Trial

Introduction: The purpose of this study was to compare the frequency and severity of perineal trauma during spontaneous birth with or without perineal injections of hyaluronidase (HAase). Methods: A randomized, placebo‐controlled, double‐blind clinical trial was conducted in a midwife‐led, in‐hospital birth center in São Paulo, Brazil. Primiparous women (N = 160) were randomly assigned to an experimental (n = 80) or control (n = 80) group. During the second stage of labor, women in the experimental group received an injection of 20.000 turbidity‐reducing units of HAase in the posterior region of the perineum, and those in the control group received a placebo injection. The assessment of perineal outcome was performed by 2 independent nurse‐midwives. A 1‐tailed Fisher exact test was performed, and a P value < .025 was considered statistically significant. Results: Perineal integrity occurred in 34.2% of the experimental group and in 32.5% of the control group, which was not a statistically significant difference (P= .477). First‐degree laceration was the most common trauma in the posterior region of the perineum in women in both groups (experimental = 56%, control = 42.6%). Severe perineal trauma occurred in 28.9% of the experimental group and 38.8% of the control group, which also was not a statistically significant difference (P= .131). The depth of second‐degree perineal lacerations in the experimental and control groups, measured by the Peri‐Rule, was 1.9 cm and 2.3 cm, respectively. An episiotomy was performed in 11 women (experimental group = 3, control group = 8), and 4 (all in control group) had third‐degree lacerations. Discussion: The use of injectable HAase did not increase the proportion of intact perineum and did not reduce the proportion of severe perineal trauma in our sample.     

The kaleidoscopic midwife: A conceptual metaphor illustrating first-time mothers' perspectives of a good midwife during childbirth. A grounded theory study

BackgroundThe literature review reveals general information about a good midwife from a range of perspectives and what childbearing women generally value in a midwife, but there is a lack of information around mothers’ perspectives of what makes a good midwife specifically during labour and birth, and even less in the context of different places of birth.AimTo conceptualise first-time mothers’ expectations and experiences of a good midwife during childbirth in the context of different birthplaces.DesignQualitative Straussian grounded theory methodology.SettingThree National Health Service Trusts in England providing maternity care that offered women the possibility of giving birth in different settings (home, freestanding midwifery unit and obstetric unit).ParticipantsFourteen first-time mothers in good general health with a straightforward singleton pregnancy anticipating a normal birth.MethodsEthical approval was gained. Data were collected through two semi-structured interviews for each participant (before and after birth). Data analysis included the processes of coding and conceptualising data, with constant comparison between data, literature and memos.FindingsThe model named ‘The kaleidoscopic midwife: a conceptual metaphor illustrating first-time mothers’ perspectives of a good midwife during childbirth’ was developed. The model is dynamic and woman-centred, and is operationalised as the midwife adapts to each woman's individual needs in the context of each specific labour. Four pillars of intrapartum care were identified for a good midwife in the labour continuum: promoting individuality; supporting embodied limbo; helping to go with the flow; providing information and guidance. The metaphor of a kaleidoscopic figure is used to describe a midwife who is ‘multi-coloured’ and ever changing in the light of the woman's individual needs, expectations and labour journey, in order to create an environment that enables her to move forward despite the uncertainty and the expectations-experiences gap. The following elements are harmonised by the kaleidoscopic midwife: relationship-mediated being; knowledgeable doing; physical presence; immediately available presence.ConclusionThe model presented has relevance to contemporary debates about quality of care and place of birth and can be used by midwives to pursue excellence in caring for labouring mothers. Independently from the place of birth, when the woman is cared for by a midwife demonstrating the above characteristics, she is likely to have an optimum experience of birth. Future research is necessary to tease out individual components of the model in a variety of practice settings.