Failed Homebirths: Reasons for Transfer to Hospital and Maternal/Neonatal Outcome

Summary: A review of patients who had been transferred to the Royal Women's Hospital, Brisbane after a failed homebirth was undertaken over a period of 5'/2 years. There were 27 patients identified. The most common reason for transfer was failed progress in labour, although 4 patients were transferred after delivery. Despite the resistance of these patients to medical intervention, the study found that 63% of patients required assistance at delivery, by vacuum extraction, forceps or Caesarean section. The morbidity suffered by the babies was significant (8 were admitted to special and intensive care nursery) but long-term sequelae cannot be determined because of early discharge against medical advice and refusal to be followed-up in some instances.     

A free-standing low-risk maternity unit in the United Kingdom: does it have a role?

This study aimed to evaluate the safety of this birth setting for low-risk deliveries based on our hospital protocol. The study was carried out at Heatherwood Hospital, Ascot (a low-risk unit) and Wexham Park Hospital, Slough, Berkshire (a consultant-led unit). This was a retrospective analysis of the computerised records and statistics of low-risk women delivered at Heatherwood Hospital, Ascot, UK following the unit protocol between July 1995 and December 2001. Women were assessed to be at low risk in accord with the unit protocol. Those who had antenatal and intrapartum care at Heatherwood Hospital and those who were transferred to the consultant unit for delivery were included in this study. We analysed the appropriateness of the structure of the unit with its medical staff input, reviewed the inclusion and exclusion criteria, analysed the perinatal and maternal mortality rates and evaluated the safety of this birth setting. We have had a total of 5468 women delivered at this low-risk maternity unit since the unit was opened. Approximately 1950 women were transferred to consultant care during this period. The intrapartum transfer in the first 18 months was 7.9%. However, since 1997 it has been static at 2.7% as confidence has grown in this model of care. The antenatal transfer rate has been static around 23%. Our emergency caesarean section rate was around 6% and the normal delivery rate was around 85%. For the first time we noted a rise in the emergency caesarean rate in 2001 at 9.5%. There were no maternal deaths. We had no serious postpartum complications accounting for long-term maternal morbidity. The antepartum stillbirths accounted for the majority of the perinatal mortality for 19/23 babies. Intrauterine growth retardation accounted for 4/23 babies in this group. The perinatal mortality rate in this low-risk population was 4.2 per 1000 total births and the stillbirth rate was 3.6 per 1000 total births. We conclude that this birth setting is safe to deliver low-risk women with less intrapartum intervention and a low transfer rate and should be setting an example for any future similar birth centre in this country.     

An ethnographic study of women's experience of partnership caseload midwifery practice: the professional as a friend

OBJECTIVES: To explore the experience of a known midwife for labour and birth as provided through the partnership caseload model of care in women who had a previous baby under an alternative system of care. DESIGN: A qualitative study using an ethnographic approach. Data were collected by tape-recorded interviews. SETTING: The maternity unit at Leicester Royal Infirmary NHS Trust, Leicester, UK in 1998. PARTICIPANTS: 10 multiparous women cared for by Birth Under Midwifery Practice Scheme (BUMPS) midwives were interviewed between eight- and 12 weeks' postpartum. KEY FINDINGS: Women's perceptions and experiences were predominantly influenced by the relationships they had with their midwives who they described as 'friends'. All other themes were filtered through these relationships, including previous negative experiences of maternity care, the valuing of a known midwife for labour and birth, their positive birth experiences, expressions of delight at their care, their liking of home antenatal care, and the appreciation of their existing children and partners meeting their midwives. IMPLICATIONS FOR PRACTICE: Partnership caseload midwifery practice has significant positive impact on women's experience of childbirth. The midwife/woman relationship that has evolved in this context is highly valued by women and challenges traditional professional roles. The model should be explored in other settings to see if its benefits to women are transferable.     

The economic costs of intrapartum care in Tower Hamlets: A comparison between the cost of birth in a freestanding midwifery unit and hospital for women at low risk of obstetric complications

Objectiveto compare the economic costs of intrapartum maternity care in an inner city area for ‘low risk’ women opting to give birth in a freestanding midwifery unit compared with those who chose birth in hospital.Designmicro-costing of health service resources used in the intrapartum care of mothers and their babies during the period between admission and discharge, data extracted from clinical notes.Settingthe Barkantine Birth Centre, a freestanding midwifery unit and the Royal London Hospital's consultant-led obstetric unit, both run by the former Barts and the London NHS Trust in Tower Hamlets, a deprived inner city borough in east London, England, 2007–2010.Participantsmaternity records of 333 women who were resident in Tower Hamlets and who satisfied the Trust's eligibility criteria for using the Birth Centre. Of these, 167 women started their intrapartum care at the Birth Centre and 166 started care at the Royal London Hospital.Measurements and findingswomen who planned their birth at the Birth Centre experienced continuous intrapartum midwifery care, higher rates of spontaneous vaginal delivery, greater use of a birth pool, lower rates of epidural use, higher rates of established breastfeeding and a longer post-natal stay, compared with those who planned for care in the hospital. The total average cost per mother-baby dyad for care where mothers started their intrapartum care at the Birth Centre was £1296.23, approximately £850 per patient less than the average cost per mother and baby who received all their care at the Royal London Hospital. These costs reflect intrapartum throughput using bottom up costing per patient, from admission to discharge, including transfer, but excluding occupancy rates and the related running costs of the units.Key conclusions and implications for practicethe study showed that intrapartum throughput in the Birth Centre could be considered cost-minimising when compared to hospital. Modelling the financial viability of midwifery units at a local level is important because it can inform the appropriate provision of these services. This finding from this study contribute a local perspective and thus further weight to the evidence from the Birthplace Programme in support of freestanding midwifery unit care for women without obstetric complications.     

Outcomes of the first midwife-led birth centre in Italy: 5 years’ experience

Objective To assess the experience of the first 5 years of the first midwife-led birth centre (MLBC) in Italy. Study design Data were prospectively collected to analyse the first 5 years’ experience of the MLBC. MLBC is located alongside a University hospital maternity unit and it offers care to women with a straightforward pregnancy and midwives take primary professional responsibility for care. Women with maternal diseases, complicated obstetric history, height < 150 cm, maternal age > 45, or multiple pregnancy were excluded. Transfer was request in case of antenatal, intrapartum and postpartum pathological conditions. Results During the 5-year period (1 January 2001–31 December 2005), 1,438 low-risk women were admitted in labour to the MLBC. Of these, 203 (14.1%) were transferred during labour to consultant care (138 because of pathologies and 65 because of request of epidural analgesia). Among the transfers, the caesarean sections were 87, corresponding to 6.1% (87/1,438) of the total of women admitted to MLBC, while the operative vaginal deliveries were 14, corresponding to 1.0% (14/1,438) of the total of women admitted to MLBC. Among women who gave birth in the MLBC, episiotomy rate was 17.1%. Conclusions In Italy, in the passed 10 years, the caesarean section rate reached 60%, in some regions. According to our data, the first 5 years of activity of the first MLBC in Italy had been associated with a low rate of medical interventions during labour and birth, with high rates of spontaneous vaginal birth and without signs of complications. We hope that this experience could be taken as a model to improve the quality of maternity care in Italy. Condensation: The experience of the first midwife-led birth centre in Italy in reducing rates of perinatal medical interventions and in increasing rates of spontaneous vaginal birth.     

Perceptions and attitudes of pregnant women towards caesarean section in urban Nigeria

OBJECTIVES: To determine the perceptions and attitudes towards caesarean section [CS] among women attending maternity care at the University of Benin Teaching Hospital in Nigeria. METHODS. Some 413 consecutive women, attending antenatal care in the hospital, were interviewed with a structured questionnaire that solicited information on their socio-demographic characteristics, their previous pregnancy and delivery history, and their knowledge and attitudes towards CS. Additional focus group discussions and in-depth interviews were held with women who recently underwent CS in the hospital, to gain further insights into attitudes and perception about CS in the women. RESULTS: The women had good knowledge of CS; however, only 6.1% were willing to accept CS as a method of delivery, while 81% would accept CS if needed to save their lives and that of their babies. Up to 12.1% of women would not accept CS under any circumstances. Logistic regression showed that women's low level of education, and past successful vaginal and instrumental deliveries, were most likely to be associated with women's non-acceptance of indicated caesarean section. Further analysis showed that this was mainly due to inaccurate cultural perceptions of labour and caesarean section in the cohort of women. CONCLUSION: There is a need for programs to increase women's and community understanding and perceptions of CS as a method of delivery in Nigeria.     

Deliveries in maternity homes in Norway: results from a 2-year prospective study

BACKGROUND: The study aims to report the short-term outcome for the mothers and newborns for all pregnancies accepted for birth at maternity homes in Norway. METHODS: A 2-year prospective study of all mothers in labor in maternity homes, i.e. all births including women and newborns transferred to hospital intra partum or the first week post partum. RESULTS: The study included 1275 women who started labor in the maternity homes in Norway; 1% of all births in Norway during this period. Of those who started labor in a maternity home, 1217 (95.5%) also delivered there while 58 (4.5%) women were transferred to hospital during labor. In the post partum period there were 57 (4.7%) transferrals of mother and baby. Nine women had a vacuum extraction, one had a forceps and three had a vaginal breech (1.1% operative vaginal births in the maternity homes). Five babies (0.4%) had an Apgar score below 7 at 5 min. There were two (0.2%) neonatal deaths; both babies were born with a serious group B streptococcal infection. CONCLUSION: Midwives and general practitioners working in the districts can identify a low-risk population (estimated at 35%) of all pregnant women in the catchment areas who can deliver safely at the maternity homes in Norway. Only 4.5% of those who started labor in the maternity homes had to be transferred to hospital during labor.     

Midwife-led maternity services and consumer 'choice' in an Australian metropolitan region

OBJECTIVE: Identify the factors determining women's support for midwife-led maternity care in an Australian metropolitan region, and identify the implications for the role of midwives and for the expansion of options for childbearing women. DESIGN: A two-stage research design was utilised. In the first stage a sample of women were surveyed regarding their choice of maternity service provider and site of provision of maternity services. In the second stage, in-depth interviews were used to collect the birthing narratives of a sample of 50 women involved in the first stage of the research. SETTING: A metropolitan region of Adelaide, South Australia. PARTICIPANTS: Women who had given birth to a live baby in the 1991 calendar year, who lived within a designated region and who gave birth at one of four hospitals in or near the region. In the first stage of the study, 519 women returned surveys, giving a response rate of 61.7%. Sixty-four per cent of these women expressed an interest in being involved in further research, and fifty of these were randomly selected for interview. FINDINGS: Despite recent calls in Australia to increase the choices available to childbearing women, these choices are limited by, amongst other things, insufficient information about midwife-led maternity services. The work of midwives remains silenced and invisible to many women pregnant for the first time, who have little idea about what midwives can do. This research shows that women's main source of information about midwife care is developed through the actual experience of it, particularly in giving birth. This experience leads to an extremely positive recognition and appraisal of the work of midwives, such that the majority of women indicate that they would be happy with midwife care for subsequent births. First-time mothers are significantly disadvantaged in terms of choices available to them because of this lack of information about midwife-led maternity care. IMPLICATIONS: In the interests of providing childbearing women with real choices for maternity care, strategic interventions to better publicise the role of midwives and of midwife-led services are needed.     

The Royal Women''s Hospital Family Birth Centre: The First 10 Years Reviewed

In reviewing the first 10 years experience of the Royal Women's Hospital Family Birth Centre (FBC), we examined the outcomes of pregnancy and labour in a group of women who requested alternative birthing care and who were identified antenatally as being a 'low-risk' population. This study is a retrospective analysis of 5,365 women booked with the birth centre between 1980 and 1989. Over 16% of women developed antenatal complications precluding further care there, while a further 16% developed complications in labour requiring transfer out to conventional labour wards. Thus 67% of those originally booked delivered in the FBC. The instrumental delivery rate was 11%, and the Caesarean section rate was 4%. Of the women who delivered in the FBC, 3.1% had a postpartum haemorrhage and 1.8% required manual removal of placenta. Approximately 4% of babies born in the FBC required some resuscitation, and 0.8% needed admission to the neonatal nursery. Two perinatal deaths occurred in women admitted in labour to the FBC with a live baby, whilst 2 other women presented in labour with a fetal death in utero (perinatal mortality 0.89 per 1,000).     

Women's perceptions of informed choice in maternity care

OBJECTIVE: to describe the extent to which women using maternity services perceive that they have exercised informed choice. SETTING: twelve maternity units in Wales. DESIGN: postal survey of women using maternity services, covering women's views of the extent to which they exercised informed choice overall, and at eight decision points during their care. PARTICIPANTS: 1386 women at approximately 28 weeks gestation (antenatal sample) and 1741 women at approximately 8 weeks post delivery (postnatal sample). MEASUREMENTS AND FINDINGS:54% of women perceived that they exercised informed choice overall in the antenatal sample (95% CI: 51-57%) and 54% overall in the postnatal sample (95% CI: 52-56%). Perceptions of informed choice differed by decision point, varying between 31% for fetal heart monitoring during labour and 73% for the screening test for Down's syndrome and spina bifida in the baby. There were differences by maternity unit, even when the characteristics of women attending these units were taken into account. Multiparous women, women from manual occupations and women with lower educational status were more likely to feel that they exercised informed choice during antenatal care. These sub-groups of women were also more likely to report a preference for not sharing decision-making with health professionals. CONCLUSIONS: a large minority of women felt that they had not exercised informed choice overall in their maternity care. The perception of informed choice differed by decision point, maternity unit and characteristics of the woman. IMPLICATIONS FOR PRACTICE: attaining informed choice is more of a challenge for some decision points in maternity care than others, particularly fetal monitoring. The difference in levels of informed choice between maternity units highlights the importance of maternity unit policy in the promotion of informed choice.     

Childbirth policies and practices in Ireland and the journey towards midwifery-led care

OBJECTIVE: To describe the dominant policies and practices that have governed childbirth in Ireland, and to outline the progress made towards the introduction of midwifery-led care in one health region. LITERATURE REVIEW: A review of maternity-care policies in Ireland was conducted using government and regional health-authority documents and two historical reviews of government policies. A search was also carried out in PubMed and cinahl databases, using the keywords 'maternity care', 'childbirth', 'policy', 'midwifery-led', 'Ireland/Irish', with relevant Boolean and string operands. Childbirth as a social process is influenced by the model of care, and affects the physical and psychological outcomes for the woman and her family. In Ireland, routine intervention in labour is common, but, since the early 1990s, some changes in the Irish maternity services have taken place. Pilot projects on community midwifery have been introduced in some areas. Challenges to the provision of maternity care in the Health Service Executive, North Eastern area (formerly the North-Eastern Health Board) led to the production of the Kinder report, which included a recommendation to introduce pilot midwifery-led units (MLUs). THE INTRODUCTION OF MIDWIFERY-LED CARE: A Maternity Services Taskforce was established in January 2002 with a wide remit, including facilitation of the establishment of MLUs in Cavan General Hospital, Cavan and Our Lady of Lourdes Hospital, Drogheda, Co. Louth. The MLUs are being evaluated within the context of a randomised trial known as 'the MidU study', which compares midwife-led care with the present system of medical-led care for women who are at low risk of complications during pregnancy and labour. CONCLUSION: The journey to midwifery-led care in Ireland has been a long one. The phased introduction of MLUs, which are subject to rigorous evaluation, will provide quality evidence upon which to base the future development of maternity care across Ireland.     

Induction of Labour: Does Internal Tocography Result in Better Obstetric Outcome than External Tocography

Summary: A prospective randomized study was undertaken to evaluate the benefit of intrauterine catheters in induced labour. Two hundred and thirty nine women who had induced labour were studied. The patients in one group had intrauterine catheters inserted and oxytocin was titrated to achieve the 75th percentile of uterine activity observed in spontaneous normal labour according to parity. Contractions were assessed by external tocography in the other group and oxytocin was titrated to achieve 6 to 7 contractions per 15 minutes each lasting >40 seconds. Mean maximum dose of oxytocin, mode of delivery, Apgar score < 7 at 5 minutes, cord arterial blood pH < 7.15 and admission to neonatal intensive care unit did not differ significantly in the 2 groups. In conclusion, women who had intrauterine catheters did not have a shorter duration of labour, lower dose of oxytocin, fewer operative deliveries or fewer babies in poor condition at birth compared with those who had external tocography in induced labour.     

Aromatherapy in childbirth: a pilot randomised controlled trial

Objectives  We aimed to determine the feasibility of conducting a randomised controlled trial (RCT) on the use of aromatherapy during labour as a care option that could improve maternal and neonatal outcomes.
Design  RCT comparing aromatherapy with standard care during labour.
Setting  District general maternity unit in Italy.
Sample  Two hundred and fifty-one women randomised to aromatherapy and 262 controls.
Methods  Participants randomly assigned to administration of selected essential oils during labour by midwives specifically trained in their use and modes of application.
Main outcome measures  Intrapartum outcomes were the following: operative delivery, spontaneous delivery, first- and second-stage augmentation, pharmacological pain relief, artificial rupture of membranes, vaginal examinations, episiotomy, labour length, neonatal wellbeing (Apgar scores) and transfer to neonatal intensive care unit (NICU).
Results  There were no significant differences for the following outcomes: caesarean section (relative risk [RR] 0.99, 95% CI: 0.70–1.41), ventouse (RR 1.5, 95% CI: 0.31–7.62), Kristeller manoeuvre (RR 0.97, 95% CI: 0.64–1.48), spontaneous vaginal delivery (RR 0.99, 95% CI: 0.75–1.3), first-stage augmentation (RR 1.01, 95% CI: 0.83–1.4) and second-stage augmentation (RR 1.18, 95% CI: 0.82–1.7). Significantly more babies born to control participants were transferred to NICU, 0 versus 6 (2%), P = 0.017. Pain perception was reduced in aromatherapy group for nulliparae. The study, however, was underpowered.
Conclusion  This study demonstrated that it is possible to undertake an RCT using aromatherapy as an intervention to examine a range of intrapartum outcomes, and it provides useful information for future sample size calculations.     

A randomized controlled trial comparing midwife-managed care and obstetrician-managed care for women assessed to be at low risk in the initial intrapartum period.

OBJECTIVE: To compare the efficacy of midwife-managed care and obstetrician-managed care for women assessed to be at low risk in the initial intrapartum period. METHODS: 1,050 women assessed to be at low risk on admission to labour ward in the Prince of Wales Hospital participated in this study. By computer-generated random allocation, 563 (54%) women were assigned to Group A (experimental) under midwifery care, and 487 (46%) women to Group B (control) under obstetrician care. The outcomes and complications between the 2 groups were compared. Data were analyzed by 2 x 2 contingency tables and Chi-square. RESULTS: 150 (26.6%) women in the experimental group were taken over by the obstetricians. 46 (30.7%) women were transferred to obstetrician-management for the preference of epidural analgesia. The other reasons for taken over the remaining 104 (69.3%) women were fetal distress, poor progress of labour, complications in first or second stage of labour. The experimental group had less oxytocic augmentation (Chi-square = 7.49, p = 0.006) and the insertion of intravenous infusion (Chi-square = 5.34, p = 0.02). Both groups had similar outcomes on normal delivery, operative vaginal delivery, caesarean section and complications. CONCLUSIONS: Midwife-managed care is as safe as obstetrician-managed care for women who were assessed to be at low risk in the intrapartum period. Routine visit by obstetrician is not necessary and the midwives are able to detect complications in the course of labour and alert the obstetrician for taking the necessary action.     

The experience of pregnancy, labour and birth of Thai women in Australia.

OBJECTIVE: To identify the perceptions and experience of pregnancy care, labour and birth of Thai women in Melbourne, Australia. DESIGN: An ethnographic interview and participant observation with women in relation to pregnancy, labour and birth. SETTING: Melbourne Metropolitan Area, Victoria, Australia. PARTICIPANTS: 30 Thai women who are now living in Melbourne. FINDINGS: Thai women saw antenatal care as an important aspect of their pregnancy and sought care as soon as they suspected they were pregnant. They were more concerned about the well-being of their babies than their own health, therefore they attended all antenatal appointments. In general, these women were satisfied with care during labour, but some also had negative experiences with their caregivers and hospital routine. When asked to compare maternity services between Thailand and Australia, most of the women believed that services in Australia were better. However, women who had had good experiences of childbirth in Thailand, tended to have negative feelings about the Australian experience. There was also evidence in this study that most of these Thai women did not receive adequate information about care. IMPLICATIONS FOR PRACTICE: Women's perceptions and experiences of antenatal care, labour and birth deserve attention, if appropriate and sensitive care is to be provided to women in Australia and elsewhere. It is only when women's voices are heard in all aspects of health-care delivery that we may see better and appropriate health services for women in childbirth.     

An economic evaluation of daycare in the management of hypertension in pregnancy.

OBJECTIVE: To evaluate the efficiency of daycare in the management of hypertension in pregnancy compared with inpatient management with prior domiciliary visits. DESIGN: Comparative study. SETTING: Two maternity teaching hospitals, Glasgow Royal Maternity Hospital which has an established daycare unit and Aberdeen Maternity Hospital with no daycare unit. MAIN OUTCOME MEASURES: Pregnancy outcomes in terms of maternal hypertensive complications, gestation at delivery, mode of delivery, birthweight, Apgar scores, admission rates and length of admission to special care baby unit. RESULTS: There was no significant difference in any of the measured pregnancy outcomes between the two hospitals. The average cost of treating a women with mild hypertension was 154.91 pounds in Glasgow and 136.59 pounds in Aberdeen. The average cost of treating women with a single episode of hypertension and women with a past history of hypertension was 88.65 pounds and 214.12 pounds in Glasgow and 31.18 pounds and 28.28 pounds in Aberdeen, respectively. If these two groups are excluded, the average cost of treating women with mild hypertension was 172.32 pounds in Glasgow and 201.13 pounds in Aberdeen. The majority of women were willing to attend daycare five times per week to avoid admission. CONCLUSION: Daycare management of hypertension in pregnancy is more efficient than inpatient care with prior domiciliary visits for most women, but less efficient for women with transient or previous hypertension. It is very acceptable to women. Domiciliary checking of women with hypertension found at outpatient clinics would reduce resource use.     

A comparison of partnership caseload midwifery care with conventional team midwifery care: labour and birth outcomes

OBJECTIVES: to compare the effects of partnership caseload midwifery care, with conventional team midwifery care. Comparisons of labour interventions and birth outcomes were made between the two models of care. DESIGN: a prospective, non-randomised clinical trial. SETTING: Women's Hospital at Leicester Royal Infirmary, Leicester, UK in 1998. PARTICIPANTS: 303 women from the experimental group and 308 from the control group (611 in total) matched for age, ethnicity, marital status, parity, gravida and height who gave birth between April 1997 and August 1998. INTERVENTION: the control group received conventional team midwifery care during pregnancy, labour and birth, and the experimental group received care from midwives working in partnerships that provided continuity of care during pregnancy, labour and birth. KEY FINDINGS: 21% of women in the experimental group had an epidural compared with 32% of the controls (OR 0.56 95%, CI 0.39-0.81, P=0.002). The normal vaginal birth rate (74% v 66%, OR 1.45, 95% CI 1.02-2.05, P=0.038), upright birth posture rate (60% v 14%, OR 9.64, 95% CI 5.96-15.61, P= or <0.001), intact perineum rate (40% v 30%, OR 1.57, 95% CI 1.05-2.35, P=0.027), and physiological third stage rate (37% v 1.5%, OR 38.69, 95% CI 11.98-124.89, P= or <0.001) were significantly higher in the experimental group. The induction of labour rate (16% v 23%, OR 0.66, 95% CI 0.44-0.98, P=0.042) was significantly lower in the experimental group. Women in the experimental group had more home births (17% v 1.3%, OR 15.38. 95% CI 5.48-43.14, P= or <0.001); used the midwife-led birthing suite more often (28% v 12%, OR 2.77, 95% CI 1.82-4.22, P= or <0.001); were more likely to take an early discharge (two to six hours) from hospital following birth (25% v 3%, OR 11.32. 95% CI 5.55-23.06, P= or <0.001); and were attended in birth more often by either their named midwife (67% v 5%, OR 39.65, 95% CI 22.38-70.25, P= or <0.001) or her partner (known midwife) (84% v 14%, OR 32.74, CI 20.96-51.14, P= or <0.001). IMPLICATIONS FOR PRACTICE: partnership caseload midwifery care resulted in less interventionist labour and more normal birth than conventional team midwifery care. Women in the experimental group had more home births, birth in a midwife-led suite and opted for early discharge home postnatally more often than the controls. They also experienced much higher levels of continuity, particularly of a known midwife during labour and birth. The study findings should encourage other maternity units in the UK to pilot and evaluate the model to see if these benefits are transferable.