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)     

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.     

Birth weight centiles,risk of intrapartum compromise,and adverse perinatal outcomes in term infants

Objective: The objective of this study is to evaluate the association between birth weight centiles and the risk of intrapartum compromise and adverse neonatal outcomes in term pregnancies.

Methods: Retrospective study of 32?468 term singleton births at a major tertiary maternity hospital in Australia. Data comprised gestation, mode, and indication for delivery and adverse perinatal outcomes. Fetal sex and gestational age-specific birth weight centiles were the main exposure variable.

Results: Neonates?<21st birth weight centile had an increased risk of intrapartum compromise, the highest risk was in babies?<3rd centile (OR 4.04, 95% CI 3.34–4.89). The risk of adverse perinatal outcomes was increased in neonates?<21st and?>91st birth weight centiles. The highest risk was in those?<3rd centile (OR 2.35, 95% CI 2.00–2.75).

Conclusions: Fetal size measurements near term may be used as part of screening test for identifying fetuses at an increased risk of intrapartum compromise and adverse perinatal outcomes.     

In The Literature: Home Birth: Safe Enough,But Not for the First Baby

The “Birthplace in England” study compared low‐risk pregnancies by planned place of birth at the onset of labor: home, midwifery unit, or obstetric unit. The study showed that childbirth interventions were less frequent in all nonobstetric settings than in obstetric units, confirming what has been noted elsewhere. For parous women, there was no difference in perinatal outcomes by place of birth. For nulliparous women, perinatal outcomes were similar in midwifery and obstetric units, but the frequency of poor outcomes with planned home births was higher. The major strengths of the study are its prospective design and large sample size. The results support providing choices to women, but suggest that women should not be encouraged to give birth at home for their first baby. (BIRTH 39:2 June 2012)     

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

Abstract: Background: 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. Methods: 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. Results: 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. Conclusions: Planned place of birth has a significant influence on mode of birth and rates of intrapartum intervention in childbirth. (BIRTH 38:2 June 2011)     

Outcomes of Free‐Standing,Midwife‐Led Birth Centers: A Structured Review

Abstract: Background : Over the last two decades, childbirth worldwide has been increasingly concentrated in large centralized hospitals, with a parallel trend toward more birth interventions. At the same time in several countries, interest in midwife‐led care and free‐standing birth centers has steadily increased. The objective of this review is to establish the current evidence base for free‐standing, midwife‐led birth centers. Methods : A structured review, based on Cochrane guidelines, was conducted that included nonrandomized studies. The comparative outcomes measured were rates of normal vaginal birth; cesarean section; intact perineum; episiotomy; transfers; and babies remaining with their mothers. Results : Of the 5 controlled studies that met the review criteria, all except one was a single site study. Since no study was randomized, meta‐analysis was not performed. The included studies all raised quality concerns, and significant heterogeneity was observed among them. For the outcomes measured, every study reported a benefit for women intending to give birth in the free‐standing, midwife‐led unit. Conclusions : The benefits shown for women recruited into the included studies who intended to give birth in a free‐standing, midwife‐led unit suggest a question about the efficacy of consultant unit care for low‐risk women. However, the findings cannot be generalized beyond the individual studies. Good quality controlled studies are needed to investigate these issues in the future.     

Admission of Term Infants to Neonatal Intensive Care: A Population‐Based Study

ABSTRACT: Background: Neonatal intensive care and special care nurseries provide a level of care that is both high in cost and low in volume. The aim of our study was to determine the rate of admission of term babies to neonatal intensive care in association with each method of giving birth among low‐risk women. Methods: We examined the records of 1,001,249 women who gave birth in Australia during 1999 to 2002 using data from the National Perinatal Data Collection. Among low‐risk women, we calculated the adjusted odds of admission to neonatal intensive care at term separated for each week of gestational age between 37 and 41 completed weeks. We also calculated the odds of admission to neonatal intensive care in association with cesarean section before or after the onset of labor, and vacuum or instrumental birth compared with unassisted vaginal birth at 40 weeks’ gestation. Results: The overall rate of admission to neonatal intensive care of term babies was 8.9 percent for primiparas and 6.3 percent for multiparas. After a cesarean section before the onset of labor, the adjusted odds of admission among low‐risk primiparas at 37 weeks’ gestation were 12.08 (99% CI 8.64–16.89); at 38 weeks, 7.49 (99% CI 5.54–10.11); and at 39 weeks, 2.80 (99% CI 2.02–3.88). At 41 weeks, the adjusted odds were not significantly higher than those at 40 weeks’ gestation. Among low‐risk multiparas who had a cesarean section before the onset of labor, the adjusted odds of admission to neonatal intensive care at 37 weeks’ gestation were 15.40 (99% CI 12.87–18.43); at 38 weeks, 12.13 (99% CI 10.37–14.19); and at 39 weeks, 5.09 (99% CI 4.31–6.00). At 41 weeks’ gestation, the adjusted odds of admission were significantly lower than those at 40 weeks (AOR 0.64, 99% CI 0.47–0.88). Babies born after any operative method of birth were at increased odds of being admitted to neonatal intensive care compared with those born after unassisted vaginal birth at 40 weeks’ gestation. Conclusions: The adjusted odds of admission to neonatal intensive care for babies of low‐risk women were increased after birth at 37 weeks’ gestation. In a climate of rising cesarean sections, this information is important to women who may be considering elective procedures. (BIRTH 34:4 December 2007)     

Operative Deliveries in Low‐Risk Pregnancies in The Netherlands: Primary versus Secondary Care

ABSTRACT: Background: In The Netherlands, 35 percent of births take place in “primary care” to women considered at low risk and during labor, approximately 30 percent are referred to “secondary care.” High‐risk women and some low‐risk women deliver in secondary care. This study sought to compare planned place of birth and incidence of operative delivery among women at low risk of complications at the time of onset of labor. Methods: A retrospective analysis was conducted of data about births in The Netherlands during 2003 that were recorded routinely in the Netherlands Perinatal Registry. Mode of delivery was analyzed for women classified as low risk at labor onset according to their planned place of birth (intention‐to‐treat analysis). The primary outcome was the rate of operative deliveries (vacuum or forceps extraction or cesarean section). Results: Women at low risk who planned to give birth, and therefore labored and delivered in secondary care, had a significantly higher rate of operative deliveries than women who began labor in primary care where they intended to give birth (18% [3,558/19,850] vs 9% [7,803/87,187]) (OR 2.25, 95% CI 2.00–2.52). For cesarean section, the rates were 12 percent (2,419/19,850) versus 3 percent (2,990/87,817) (OR 3.97, 95% CI 3.15–5.01), irrespective of parity. Conclusions: The rate of operative deliveries was significantly lower for low‐risk pregnant women who gave birth in a primary care setting compared with similar women who planned birth in secondary care. As with any retrospective analysis, it was not possible to eliminate bias, such as possible differences between primary and secondary care in assignment of risk status. In addition, known risk factors for interventions, technologies such as induction of labor and fetal monitoring, are only available in secondary care. These findings clearly demonstrate the need for a prospective study to examine the relationship between planned place of birth and mode of delivery and neonatal and maternal outcomes. (BIRTH 35:4 December 2008)     

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.     

Transfers Among Women Intending A Birth Center Delivery in the San Diego Birth Center Study

Using data from the San Diego Birth Center Study that enrolled underserved women between 1994 and 1996, we examined demographic, sociobehavioral, and medical predictors of hospital transfer in a group of women who intended to deliver at a freestanding birth center. Of the 1808 women, 34.6% transferred to the hospital antenatally and 19.6% transferred during labor, while 45.7% delivered at the birth center. Compared with multiparous women who had never had a cesarean and never had a previous hospital delivery, nulliparous women were 2.0 times more likely (95% confidence interval [CI], 1.4–2.7), multiparous women with a previous cesarean were 2.6 times more likely (95% CI, 1.7–3.8), and women without a previous cesarean but who had a previous hospital delivery were 2.1 times more likely (95% CI, 1.5–3.0) to transfer after adjusting for other predictors of transfer. Nulliparity, cesarean history and having a previous hospital delivery were among the strongest predictors of a hospital transfer even after adjusting for demographic, sociobehavioral, and other medical conditions. Understanding predictors of transfer may assist practitioners, patients, and policy makers in considering the appropriateness of individuals for birth center delivery or to target further education to reduce nonmedical transfers.     

In‐Hospital Birth Center with the Same Medical Guidelines as Standard Care: A Comparative Study of Obstetric Interventions and Outcomes

Background: A challenge of obstetric care is to optimize maternal and infant health outcomes and the mother’s experience of childbirth with the least possible intervention in the normal process. The aim of this study was to investigate the effects of modified birth center care on obstetric procedures during delivery and on maternal and neonatal outcomes. Methods: In a cohort study 2,555 women who signed in for birth center care during pregnancy were compared with all 9,382 low‐risk women who gave birth in the standard delivery ward in the same hospital from March 2004 to July 2008. Odds ratios (OR) were calculated with 95% confidence interval (CI) and adjusted for maternal background characteristics, elective cesarean section, and gestational age. Results: The modified birth center group included fewer emergency cesarean sections (primiparas: OR: 0.69, 95% CI: 0.58–0.83; multiparas: OR: 0.34, 95% CI: 0.23–0.51), and in multiparas the vacuum extraction rate was reduced (OR: 0.42, 95% CI: 0.26–0.67). In addition, epidural analgesia was used less frequently (primiparas: OR: 0.47, 95% CI: 0.41–0.53; multiparas: OR: 0.25, 95% CI: 0.20–0.32). Fetal distress was less frequently diagnosed in the modified birth center group (primiparas: OR: 0.72, 95% CI: 0.59–0.87; multiparas: OR: 0.45, 95% CI: 0.29–0.69), but no statistically significant differences were found in neonatal hypoxia, low Apgar score less than 7 at 5 minutes, or proportion of perinatal deaths (OR: 0.40, 95% CI: 0.14–1.13). Anal sphincter tears were reduced (primiparas: OR: 0.73, 95% CI: 0.55–0.98; multiparas: OR: 0.41, 95% CI: 0.20–0.83). Conclusion: Midwife‐led comprehensive care with the same medical guidelines as in standard care reduced medical interventions without jeopardizing maternal and infant health. (BIRTH 38:2 June 2011)     

Does a Pregnant Woman's Intended Place of Birth Influence Her Attitudes Toward and Occurrence of Obstetric Interventions?

Abstract: Background : A home confinement with midwifery care is still an integral part of Dutch maternity care. It has been argued that the existence of home birth itself influences the course of the birth process positively, which is why obstetric interventions are low in comparison with neighboring countries. This study examined the impact of women's intended place of birth (home or hospital) and the course of pregnancy and labor when attended by midwives. Methods : This is a prospective study of 625 low‐risk pregnant women, gestation 20 to 24 weeks, enrolled in 25 independently working midwifery practices. The course of labor was measured by the frequency of interventions by midwives and obstetricians. Results : A more nontechnological approach to childbirth was observed within the women opting for a home birth compared with the women opting for a hospital birth. Data showed a relationship between interventions and planned birth site: sweeping membranes and amniotomy by midwives were more likely to be conducted in women opting for a home birth. Multiparas opting for hospital birth were more likely to experience consultations and referrals. Within the group of multiparas referred for obstetrician care, women intending to have a home birth experienced fewer interventions (e.g., induction, augmentation, pharmacologic pain relief, assisted delivery, cesarean section) compared with those who had opted for a hospital birth. Conclusions : A large proportion of women desire a home birth. The impact of that choice demonstrated a smoother course of the birth process, compared with women who desired to deliver in the hospital, as measured by fewer obstetric interventions. We suggest that psychological factors (expectation and perceptions) influence both a woman's decision of birthplace and the actual birth process. (BIRTH 31:1 March 2004)     

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)     

First Birth Cesarean and Risk of Antepartum Fetal Death in a Subsequent Pregnancy

Introduction: To examine the relationship between first birth by cesarean and antepartum fetal death in a subsequent pregnancy in a large, hospital‐based population. Methods : Data for this retrospective cohort study were taken from a database of all women who gave birth at Brigham and Women's Hospital during 4 waves of data collection beginning in 1994 and ending in 2002. We calculated the risk of antepartum fetal death in the subsequent pregnancy for women whose first birth was by cesarean compared to women with a vaginal first birth. Survival analysis was used to examine the influence of gestational age at birth. Results: Of 10,996 women who met inclusion criteria, 22% (n = 2450) had first births by cesarean, and 78% (n = 8546) had vaginal first births. The risk of antepartum fetal death in the subsequent pregnancy for women whose first birth was by cesarean was significantly greater than the risk for women whose first birth was vaginal (odds ratio 2.6; 95% confidence interval, 1.1‐6.2). The relationship between first birth cesarean and antepartum fetal death in a subsequent pregnancy differed by gestational age at birth, with no excess risk among women with a previous cesarean birth who gave birth before 34 weeks’ gestation but with a substantially increased risk for women who gave birth at 34 or more weeks’ gestation (unadjusted hazard ratio = 5.6; 95% confidence interval, 1.6‐19.8). Hazard ratio estimates for the association remained significant in bivariate models when adjusted for maternal height, weight, age, hypertension, and diabetes. Discussion: In these data, first birth by cesarean was associated with an increased risk of antepartum fetal death in a subsequent pregnancy. Our findings suggest that antepartum fetal deaths in subsequent pregnancies might be prevented by avoiding primary cesarean birth.     

Giving Birth in Two Maternity Hospitals in Lithuania

Abstract: Background: In many hospitals in former Soviet countries, traditional Soviet perinatal policies remain in place, although in others reforms have been introduced. This study explores women’s experiences during labor and birth in two Lithuanian maternity hospitals. The hospitals differed in that one (S) followed traditional Soviet era maternity practices whereas the other (P) had been exposed to World Health Organization‐Euro practices and policies with respect to more up‐to‐date evidence‐based and family‐centered care. Methods: Consecutive women giving birth in the two maternity hospitals were asked to participate in a survey. Completed responses were obtained from 416 women in one hospital (P) and 304 in the other hospital (S) representing 92.4 and 67.5 percent response rates, respectively. Results: Rates of interventions in both hospitals were similarly high with, however, P hospital being more likely to be sensitive to women’s psychosocial needs, such as being allowed to eat and drink more often during labor, and to have their husband or partner with them for labor and birth. Conclusion: It appears that in Lithuania, as in many parts of the world, introducing changes to the clinical care of birth takes time, and psychosocial changes may be easier to introduce than alterations in clinical practice. (BIRTH 37:2 June 2010)     

A description of the management and outcomes of vaginal birth after cesarean birth in the homebirth setting

Our objective was to describe the outcomes of intended home birth among 57 women with a previous cesarean birth. Data were drawn from a larger prospective study of intended homebirth in nurse-midwifery practice. Available data included demographics, perinatal risk information, and outcomes of prenatal, intrapartum, postpartum, and neonatal care. The hospital course was reviewed for those transferred to the hospital setting. Fifty-three of 57 women (93%) had a spontaneous vaginal birth, 1 had a vacuum-assisted birth, and 3 (5.3%) had a repeat cesarean birth. Thirty-one of 32 (97%) women who had a previous vaginal birth after cesarean birth (VBAC) had a successful VBAC; 22 of 25 (88%) women without a history of VBAC successfully delivered vaginally. Fifty (87.7%) of these women delivered in the home setting, whereas 7 (12.3%) delivered in the hospital setting. None of the women experienced uterine rupture or dehiscence. One infant was stillborn. This event was attributed to a postdates pregnancy with meconium. Certified nurse-midwives with homebirth practices must be knowledgeable about the risks for mother and baby, screen clientele appropriately, and be able to counsel patients with regard to potential adverse outcomes. Given what is presently known, VBAC is not recommended in the homebirth setting. It is imperative in the light of current evidence and practice climate to advocate for the availability of certified nurse-midwife services and woman-centered care in the hospital setting.