A Randomized Controlled Study of Birth Center Care versus Standard Maternity Care: Effects on Women's Health

ABSTRACT: Background : The safety of birth center care for low-risk women is an important issue, but it has not yet been studied in randomized controlled trials. Our purpose was to evaluate the effect of birth center care on women's health during pregnancy, birth, and 2 months postpartum by comparing the outcomes with those of women experiencing standard maternity care in the greater Stockholm area. Methods : Of 1860 women, 928 were randomly allocated to birth center care and 932 to standard antenatal, intrapartum, and postpartum care. Information about medical procedures and health outcomes was collected from clinical records, and a questionnaire was mailed to women 2 months after the birth. Analysis was by “intention to treat;” that is, all antenatal, intrapartum, and postpartum transfers were included in the birth center group. Results : During pregnancy, birth center women made fewer visits to midwives and doctors, experienced fewer tests, and reported fewer health problems. No statistical difference occurred in hospital admissions (4.8%) compared with the control group (4.7%). During labor, birth center women used more alternative birth positions, had longer labors, and did not differ inperineal lacerations. In both groups 1.7 percent of women developed complications, requiring more than 7 days of hospital care after the birth. During the first 2 postpartum months, about 20 percent of women in both groups saw a doctor for similar types of health problems, and no statistical difference occurred in hospital readmissions, 1.4 and 0.8 percent in the birth center and control groups, respectively, Conclusion : The results suggest that birth center care is effective in identifying signijicant maternal complications and as safe for women as standard maternity care.     

Maternity Care in The Netherlands: The Changing Home Birth Rate

In 1965 two-thirds of all births in The Netherlands occurred at home. In the next 25 years, that situation became reversed with more than two-thirds of births occurring in hospital and fewer than one-third at home. Several factors have influenced that change, including the introduction of short-stay hospital birth, hospital facilities for independent midwives, increased referral rates from primary to secondary care, changes in the share of the different professionals involved in maternity care, medical technology, and demographic changes. After a decline up to 1978 and a period of relative stability between 1978 and 1988, the home birth rate started to decline further, to the extent that it might destabilize the Dutch maternity care system and the role of midwives in it. The Dutch maternity care system depends heavily on primary caregivers, midwives and general practitioners who are responsible for the care of women with low-risk pregnancies, and on obstetricians who provide care for high-risk pregnancies. Its preservation requires a high level of cooperation among the different caregivers, and a functional selection system to ensure that all women receive the type of care that is best suited to their needs. Preserving the home birth option in the Dutch maternity care system necessitates the maintenance of high training and postgraduate standards for midwives, the continued provision of maternity home care assistants, and giving women with uncomplicated pregnancies enough confidence in themselves and the system to feel safe in choosing a home birth. (BIRTH 25:3 September 1998)     

MOM Survey: Maternity Options for Mothers—What Do Women Want in Maternity Care?

ABSTRACT: As part of planning a new maternity wing of a Boulder, Colorado hospital, a telephone interview survey of 645 women who delivered within one year at this hospital was made to determine their preferences for 49 different options in maternity care. The sample was divided into 210 women chosen at random, 230 from La Leche League groups, and 205 women from prepared childbirth classes. The most important areas of concern to these new mothers were similar in all three groups and revolved around maintaining family closeness and obtaining help from hospital staff rather than desire for new or different facilities. Proposals resulting from this study were for the new maternity service to provide 1) combined labor-delivery-recovery rooms; 2) most post-partum rooms to be private; 3) father unrestricted in visiting throughout; 4) sibling visitation; 5) inservice training for medical and nursing staff in childbirth and breastfeeding techniques; 6) family-centered cesarean births; 7) alternative birth arrangement with early discharge.     

Neonatal Outcomes in the Birth Center Setting: A Systematic Review

Introduction

This systematic review investigates the effect of the birth center setting on neonatal mortality in economically developed countries to aid women and clinicians in decision making.

Methods

We searched the Google Scholar, CINAHL, and PubMed databases using key terms birth/birthing center or out of hospital with perinatal/neonatal outcomes. Ancestry searches identified additional studies, and an alert was set for new publications. We included primary source studies in English, published after 1980, conducted in a developed country, and researching planned birth in centers with guidelines similar to American Association of Birth Centers standards. After initial review, we conducted a preliminary analysis, assessing which measures of neonatal health, morbidity, and mortality were included across studies.

Results

Neonatal mortality was selected as the sole summary measure as other measures were sporadically reported or inconsistently defined. Seventeen studies were included, representing at least 84,500 women admitted to a birth center in labor. There were substantial differences of study design, sampling techniques, and definitions of neonatal outcomes across studies, limiting conclusive statements of the effect of intrapartum care in a birth center. No reviewed study found a statistically increased rate of neonatal mortality in birth centers compared to low‐risk women giving birth in hospitals, nor did data suggest a trend toward higher neonatal mortality in birth centers. As in all birth settings, nulliparous women, women aged greater than 35 years, and women with pregnancies of more than 42 weeks’ gestation may have an increased risk of neonatal mortality.

Discussion

There are substantial flaws in the literature concerning the effect of birth center care on neonatal outcomes. More research is needed on subgroups at risk of poor outcomes in the birth center environment. To expedite research, consistent use of national and international definitions of perinatal and neonatal mortality within data registries and greater detail on adverse outcomes would be beneficial.     

Maternity Care Practices: Implications for Breastfeeding

Background: Many United States mothers never breastfeed their infants or do so for very short periods. The Baby‐Friendly Hospital Initiative was developed to help make breastfeeding the norm in birthing environments, and consists of specific recommendations for maternity care practices. The objective of the current study was to assess the impact of the type and number of Baby‐Friendly practices experienced on breastfeeding. Methods: A longitudinal mail survey (1993–1994) was administered to women prenatally through 12 months postpartum. The study focused on the 1085 women with prenatal intentions to breastfeed for more than 2 months who initiated breastfeeding, using data from the prenatal and neonatal periods. Predictor variables included indicators of the absence of specific Baby‐Friendly practices (late breastfeeding initiation, introduction of supplements, no rooming‐in, not breastfeeding on demand, use of pacifiers), and number of Baby‐Friendly practices experienced. The main outcome measure was breastfeeding termination before 6 weeks. Results: Only 7 percent of mothers experienced all five Baby‐Friendly practices. The strongest risk factors for early breastfeeding termination were late breastfeeding initiation and supplementing the infant. Compared with mothers experiencing all five Baby‐Friendly practices, mothers experiencing none were approximately eight times more likely to stop breastfeeding early. Additional practices decreased the risk for early termination. Conclusion: Increased Baby‐Friendly Hospital Initiative practices improve the chances of breastfeeding beyond 6 weeks. The need to work with hospitals to increase adoption of these practices is illustrated by the small proportion of mothers who experienced all five practices measured in this study.     

Outcomes and Procedures in Low Risk Birth: A Comparison of Hospital and Birth Center Settings

ABSTRACT: Two retrospectively matched groups of low-risk women were studied, one that chose to give birth in an out-of-hospital birth center staffed and run by nurse-midwives, and another that labored and delivered in a tertiary care teaching hospital. The groups were matched for low risk status at 37 weeks. Although outcomes for both groups were similar, the use of almost all interventions during labor and delivery was significantly more frequent in the hospital group. These findings are consistent with studies of other settings in which the place of birth was shown to have an impact on childbirth experience, thus demonstrating that birth centers can oversee childbirth as safely and with less intervention than do hospitals. Larger comparative studies are needed to explore the impact and safety of hospital and out-of-hospital birth settings.     

Women's Satisfaction with Birth Center Care: A Randomized,Controlled Study

This randomized, controlled trial compared women's satisfaction with care at an in-hospital birth center with standard obstetric care in Stockholm. Subjects were 1230 women with an expected date of birth between October 1989 and February 1992, who expressed interest in birth center care, and who were medically low risk. The intervention was the random allocation of maternity care at the birth center or standard obstetric care. Birth center women expressed greater satisfaction with antenatal, intrapartum, and postpartum care, especially psychological aspects of care. Of these women, 63 percent thought that the antenatal care had raised their self-esteem, versus 18 percent of the control group. Eighty-nine percent of the experimental group would prefer birth center care for any future birth, and 46 percent of the control group would prefer standard care. Birth center care successfully meets the needs of women who are interested in natural childbirth and active involvement in their own care, and are concerned about the psychological aspects of birth.     

Maternity Care and Outcomes in a High-Risk Service: The North Central Bronx Hospital Experience

ABSTRACT: The maternity service of the North Central Bronx Hospital, a New York City municipal hospital for the medically indigent, has demonstrated that good maternal and infant outcomes can be obtained in an unselected population of disadvantaged women by using obstetric interventions only when medically indicated. Approximately 70 percent of the mothers cared for in the service are considered at risk or high risk. Of the 3287 deliveries in 1988, 86.1 percent were performed by the midwives on staff. Midwives were the primary providers of prenatal, intrapartum, and postpartum care for all low-risk mothers, and comanaged with the attending obstetricians the care of all high-risk mothers. The cesarean section rate was 11.8 percent, and the rate of instrumental delivery was 0.3 percent, with minimal use of oxytocin augmentation (6.4%). Among the 3323 infants delivered in 1988, the last full year before an obstetric residency program was established, the rate of those requiring special or intensive care was 11.1 percent, and neonatal mortality was 9.2 per 1000 live births for all birth weights and 3.7 per 1000 for infants over 1000 g. The experience gained from 10 years and over 25,000 births suggests that the maternity care of both high- and low-risk mothers could be improved by minimizing obstetric intervention whenever possible.