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

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

Characteristics and practices of birth centres in Australia

Background: Around 2% of women who give birth in Australia each year give birth in a birth centre. There is currently no standard definition of a birth centre in Australia.
Aims: This study aimed to locate all birth centres nationally, describe their characteristics and procedures, and develop a definition.
Methods: Surveys were sent to 23 birth centres. Questions included: types of procedures, equipment and pain relief available, staffing, funding, philosophies, physical characteristics and transfer procedures. Of the birth centres, 19 satisfied the inclusion criteria and 16 completed surveys.
Results: Three constructs of a birth centre were identified. A 'commitment to normality of pregnancy and birth' was most commonly reported as the most important philosophy (44%). The predominant model of care was group practice/caseload midwifery (63%).
Thirteen birth centres were located within/attached to a hospital, two were on a hospital campus and one was freestanding. The distance to the nearest labour ward ranged from 2 m to 15 km. Reported intrapartum transfer rates ranged from 7% to 29%. Thirteen centres had a special care nursery or neonatal intensive care unit onsite, or both.
Eight centres undertook artificial rupture of membranes for induction of labour, while two administered oxytocin or prostaglandins. All centres offered nitrous oxide and local anaesthetic. Twelve centres had systemic opioids available and one offered pudendal analgesia. Fetal monitoring was used in all birth centres. Only three centres conducted instrumental deliveries, while 15 performed episiotomies.
Conclusion: Birth centres vary in their philosophies, characteristics and service delivery.     

Experiences of women who planned birth in a birth centre compared to alternative planned places of birth. Results of the Dutch Birth Centre Study

Objectiveto assess the experiences with maternity care of women who planned birth in a birth centre and to compare them to alternative planned places of birth, by using the responsiveness concept of the World Health Organization.Designthis study is a cross-sectional study using the ReproQ questionnaire filled out eight to ten weeks after birth. The primary outcome was responsiveness of birth care. Secondary outcomes included overall grades for birth care and experiences with the birth centre services. Regression analyses were performed to compare experiences among the planned places of birth. The study is part of the Dutch Birth Centre Study.Settingthe women were recruited by 82 midwifery practices in the Netherlands, within the study period 1 August 2013 and 31 December 2013.Participantsa total of 2162 women gave written consent to receive the questionnaire and 1181 (54.6%) women completed the questionnaire.Measurements and findingswomen who planned to give birth at a birth centre:(1) had similar experiences as the women who planned to give birth in a hospital receiving care of a community midwife.(2) had significantly less favourable experiences than the women who planned to give birth at home. Differences during birth were seen on the domains dignity (OR=1.58, 95% CI=1.09–2.27) and autonomy (OR=1.77, 95% CI=1.25–2.51), during the postpartum period on the domains social considerations (OR=1.54, 95% CI=1.06–2.25) and choice and continuity (OR=1.43, 95% CI=1.00–2.03).(3) had significantly better experiences than the women who planned to give birth in a hospital under supervision of an obstetrician. Differences during birth were seen on the domains dignity (OR=0.51, 95% CI=0.31–0.81), autonomy (OR=0.59, 95% CI=0.35–1.00), confidentiality (OR=0.57, 95% CI=0.36–0.92) and social considerations (OR=0.47, 95% CI=0.28–0.79). During the postpartum period differences were seen on the domains dignity (OR=0.61, 95% CI=0.38–0.98), autonomy (OR=0.52, 95% CI=0.31–0.85) and basic amenities (OR=0.52, 95% CI=0.30–0.88). More than 80% of the women who received care in a birth centre rated the facilities, the moment of arrival/departure and the continuity in the birth centre as good.Key conclusions and implications for practicein the last decades, many birth centres have been established in different countries, including the United Kingdom, Australia, Sweden and the Netherlands. For women who do not want to give birth at home a birth centre is a good choice: it leads to similar experiences as a planned hospital birth. Emphasis should be placed on ways to improve autonomy and prompt attention for women who plan to give birth in a birth centre as well as on the improvement of care in case of a referral.     

The relationship between women-centred care and women's birth experiences: a comparison between birth centres, clinics, and hospitals in Japan

Objective

the goal of women-centred care (WCC) is respect, safety, holism, partnership and the general well-being of women, which could lead to women's empowerment. The first step in providing WCC to all pregnant women is to describe women's perceptions of WCC during pregnancy in different health facilities. The objectives of this study were to ask (a) what are the perceptions and comparison of WCC at Japanese birth centres, clinics, and hospitals and (b) what are the relationships between WCC and three dimensions of women's birth experience: (1) satisfaction with care they received during pregnancy and birth, (2) sense of control during labour and birth, and (3) attachment to their new born babies.

Design

this was a cross-sectional study using self-completed retrospective questionnaires.

Setting

three types of health facility: birth centres (n=7), clinics (n=4), and hospitals (n=2).

Participants

participants were women who had a singleton birth and were admitted to one of the study settings. Women who were seriously ill were excluded. Data were analysed on 482 women.

Measurements

instrumentation included: a researcher-developed WCC-pregnancy questionnaire, Labour Agentry Scale, Maternal Attachment Questionnaire, and a researcher-developed Care Satisfaction Scale.

Findings

among the three types of settings, women who delivered at birth centres rated WCC highly and were satisfied with care they received compared to those who gave birth at clinics and hospitals. WCC was positively associated with women's satisfaction with the care they received.

Key conclusions

women giving birth at birth centres had the most positive perceptions of WCC. This was related to the respectful communication during antenatal checkups and the continuity of care by midwives, which were the core elements of WCC.

Implications for practice

health-care providers should consider the positive correlation of WCC and women's perception of satisfaction. Every woman should be provided continuity of care with respectful communication, which is a core element of WCC.     

Nature works best when allowed to run its course. The experience of midwives promoting normal births in a home birth setting

Objectiveto gain a deeper understanding of how midwives promote a normal birth in a home birth setting in Norway.Design/settinga qualitative approach was chosen for data collection. In-depth interviews were conducted with nine midwives working in a home birth setting in different areas in Norway. The transcribed interviews were analysed with the help of systematic text condensation.Findingsthe analysis generated two main themes: «The midwife's fundamental beliefs» and «Working in line with one's ideology». The midwives had a fundamental belief that childbirth is a normal event that women are able to manage. It is important that this attitude is transferred to the woman in order for her to believe in her own ability to give birth. The midwives in the study were able to work according to their ideology when promoting a normal birth at home. To avoid disturbing the natural birth process was described as an important factor. Also crucial was to approach the work in a patient manner. Staying at home in a safe environment and establishing a close relationship with the midwife also contributed positively to a normal birth.Key conclusionsthe midwife's attitude is important when trying to promote a normal birth. Patience was seen as essential to avoid interventions. Being in a safe environment with a familiar midwife provides a good foundation for a normal birth. The attitude of the midwives towards normal childbirth ought to be more emphasised, also in the context of maternity wards.     

Birth preparedness and place of birth in rural Mysore,India: A prospective cohort study

BackgroundIndia accounts for almost a third of the global deaths among newborns on their first day of birth. In spite of making significant progress in increasing institutional births, large numbers of rural Indian women are still electing to give birth at home. The aim of this study was to identify factors associated with place of birth among women who had recently given birth in rural Mysore, India.MethodsBetween January 2009 and 2011, 1675 rural pregnant women enrolled in a prospective cohort study in Mysore District completed interviewer-administered questionnaires on maternity care services. Ethical approval of the original study was obtained from the Institutional Review Boards of Vikram Hospital and Florida International University. Logistic regression analyses were conducted to identify factors associated with place of birth among the 1654 (99%) women that were successfully followed up after childbirth.FindingsThe median age of the women was 20 years; the majority were educated (87%), low-income (52%), and multiparous (56%). The prevalence of home births was low (4%). Half of the women giving birth at home did not adequately plan for transportation (55%), finances (48%), or birthing with a skilled provider (55%). Multiparous women had greater odds of giving birth at home compared to public (adjusted odds ratio [AOR]=7.83, p<0.001) and private institutions (AOR=7.05, p<0.001). Women attending ≥4 antenatal consultations had greater odds of giving birth at public (AOR=2.53, p=0.036) and private institutions (AOR=3.58, p=0.010). Those with higher scores of birth preparedness also had greater odds of giving birth at public (AOR=2.53, p<0.001) and private institutions (AOR=3.00, p<0.001).Conclusions and implicationsAs a means to reduce newborn mortality, maternal health interventions in India and similar populations should focus on increasing birth preparedness and institutional births among rural women, particularly among those from lower socio-economic status.     

Willingness of pregnant women to participate in a birth cohort study in China

Objective

To determine the willingness of pregnant women in Guangzhou, China, to participate in a large-scale birth cohort study.

Methods

A cross-sectional survey was conducted of 526 pregnant women who attended their first prenatal class at Guangzhou Women and Children’s Medical Center, Guangzhou, China, between September 21 and November 15, 2011. Information on demographic characteristics, willingness to participate, and preferences regarding collection procedures and incentives were analyzed.

Results

In all, 47.9% of the women were willing to participate in a birth cohort study, whereas 23.0% refused and 29.1% were unsure. The majority of the women willing to participate (95.2%–98.4%) accepted the use of non-invasive data collection methods except for stool collection, and 85.9% would allow their offspring to participate in long-term follow-up. Willingness to participate rose to 85.2% when non-monetary incentives were offered. The most popular incentive was assessment of child development.

Conclusion

The willingness of pregnant Chinese women to participate in long-term observational research was similar to that reported in high-income countries. Non-monetary incentives improved their level of willingness, a finding that might inform future maternal and child health research in low- and middle-income countries.     

‘Reacting to the unknown’: experiencing the first birth at home or in hospital in Australia

Objective

to explore the experiences of a small group of first-time mothers giving birth at home or in hospital.

Design

a grounded theory methodology was used. Data were generated from in-depth interviews with women in their own homes.

Setting

Sydney, Australia.

Participants

19 women were interviewed. Seven women who gave birth for the first time in a public hospital and seven women who gave birth for the first time at home were interviewed, and their experiences were contrasted with two mothers who gave birth for the first time in a birth centre, one mother who gave birth for the first time in a private hospital and two women who had given birth more than once.

Results

these women shared common experiences of giving birth as ‘novices’. Regardless of birth setting, they were all ‘reacting to the unknown’. As they entered labour, the women chose different levels of responsibility for their birth. They also readjusted their expectations when the reality of labour occurred, reacted to the ‘force’ of labour, and connected or disconnected from the labour and eventually the baby.

Implications for practice

knowing that first-time mothers, irrespective of birth setting, are essentially ‘reacting to the unknown’ as they negotiate the experience of birth, could alter the way in which care is provided and increase the sensitivity of midwives to women's needs. Most importantly, midwives need to be aware of the need to help women adjust their expectations during labour and birth. Identifying the ‘novice’ status of first-time mothers also better explains previous research that reports unrealistic expectations and fear that may be associated with first-time birthing.     

Maternal psychosocial stress and children’s ADHD diagnosis: a prospective birth cohort study

Objective: Examine the association of mothers’ psychosocial stressors before and during pregnancy with their children’s diagnosis of attention deficit hyperactivity disorder (ADHD).

Methods: This study included 2140 mother–child pairs who had at least one postnatal pediatric visit at the Boston Medical Center between 2003 and 2015. Child ADHD was determined via International Classification of Diseases, Ninth Revision (ICD-9) codes documented in electronic medical records. Latent factors of maternal stress and social support and measures of the physical home environment and psychosocial adversities were constructed using exploratory factor analysis. The association between the latent factors and child ADHD diagnosis was examined using multiple logistic regression, controlling for known risk factors for ADHD.

Results: Children were 1.45 (95% CI: 1.06, 1.99) and 3.03 (95% CI: 2.19, 4.20) times more likely to receive an ADHD diagnosis if their mother experienced a major stressful event during pregnancy or reported a high level of perceived stress, respectively. The number of family adversities increases the risk of ADHD diagnosis [second quartile: OR?=?1.90; CI (1.31, 2.77); third quartile: OR?=?1.96?CI (1.34, 2.88); fourth quartile: OR?=?2.89?CI (2.01, 4.16)] compared to first quartile.

Conclusions: In this prospective, predominantly urban, low-income, minority birth cohort, mothers’ psychosocial stress before and during pregnancy appears to be an independent risk factor for the development of ADHD in their children.     

Risky Health Behaviors of Teenage Mothers and Infant Outcomes in the Japan Environment and Children's Study: A Nationwide Cohort Study

Study Objective

Few studies have investigated the risky health behaviors and psychosocial characteristics of teenage mothers in countries with a low teenage birth rate, like Japan. We examined the differences in maternal prenatal risky health behaviors and psychosocial characteristics, and birth weight of infants between teenage and adult mothers.

Oxytocin administered during labor and breast-feeding: a retrospective cohort study

Abstract

Objective: The relationship between labor physiology and the onset of lactation leads to assess the potential correlation between oxytocin administration during labor and duration of breast-feeding.

Methods: This study was designed as a retrospective cohort study where patients given synthetic oxytocin during labor induction were considered as the exposed cohort, and patients not given oxytocin formed the non-exposed cohort. Four hundred of the 7465 children born at our maternity during 2006 were randomly selected. Information about breast-feeding was available for 316 of these children. Eventual confounding or adjustment factors were analyzed using stratified and multivariate analysis.

Results: Oxytocin was used for delivery of 189 (59.8%) newborns, multiplying the risk of bottle-feeding by 1.451 (95% CI 1.28–1.63). The best-fit regression model of oxytocin use effect on bottle-feeding included sex and gestational age of the newborn. The use of oxytocin also multiplies the risk of breast-feeding withdrawal at 3 months by 2.29 (95% CI 1.41–3.74). This effect is confounded by maternal age, being higher for mothers under 27 years.

Conclusion: Oxytocin administration during labor had some impact on both onset and duration of breast-feeding, particularly in mothers under 27 years of age and newborns delivered at term. Clinical Study registered at U.S. NIH, ID: NCT01951040.     

Caesarean delivery and risk of stillbirth in subsequent pregnancy: a retrospective cohort study in an English population

OBJECTIVE: Two recent studies indicate an increased risk of stillbirth in the pregnancy that follows a pregnancy delivered by caesarean section. In this study, we report an analysis designed to test the hypothesis that delivery by caesarean section is a risk factor for explained or unexplained stillbirth in any subsequent pregnancy. We also report on the proportion of stillbirths in our study population, which may have been attributable to previous delivery by caesarean section. DESIGN: Retrospective cohort study. POPULATION: Linked statistical data set of 81 784 singleton deliveries registered in Oxfordshire and West Berkshire between 1968 and 1989. METHODS: The crude and adjusted hazard ratios for stillbirth in deliveries following a previous delivery by caesarean section, compared with no previous caesarean, were estimated using Cox regression. MAIN OUTCOME MEASURE: Stillbirth. RESULTS: The unadjusted hazard ratios for all, explained, and unexplained stillbirths were 1.54 (95% CI 1.04-2.29); 2.13 (1.22-3.72); and 1.19 (0.68-2.09), respectively. After adjustment for maternal age, parity, social class, previous adverse outcome of pregnancy, body mass indexand smoking the hazard ratios were 1.58 (0.95-2.63), 2.08 (1.00-4.31) and 1.24 (0.60-2.56). CONCLUSIONS: Pregnancies in women following a pregnancy delivered by caesarean section are at an increased risk of stillbirth. In our study, the risk appears to be mainly concentrated in the subgroup of explained stillbirths. However, there are sufficient inconsistencies in the developing literature about stillbirth risk that further research is needed.     

Clinical outcomes of the first midwife-led normal birth unit in China: a retrospective cohort study

Aims

to report the clinical outcomes of the first six months of operation of an innovative midwife-led normal birth unit (MNBU) in China in 2008, aiming to facilitate normal birth and enhance midwifery practice.

Setting

an urban hospital with 2000–3000 deliveries per year.

Method

this study was part of a major action research project that led to implementation of the MNBU. A retrospective cohort and a questionnaire survey were used. The data were analysed thematically.

Participants

the outcomes of the first 226 women accessing the MNBU were compared with a matched retrospective cohort of 226 women accessing standard care. In total, 128 participants completed a satisfaction questionnaire before discharge.

Main outcome measure

mode of birth and model of care.

Findings

the vaginal birth rate was 87.6% in the MNBU compared with 58.8% in the standard care unit. All women who accessed the MNBU were supported by both a midwife and a birth companion, referred to as ‘two-to-one’ care. None of the women labouring in the standard care unit were identified as having a birth companion.

Discussion

the concept of ‘two-to-one’ care emerged as fundamental to women’s experiences and utilisation of midwives’ skills to promote normal birth and decrease the likelihood of a caesarean section.

Conclusion

the MNBU provides an environment where midwives can practice to the full extent of their role. The high vaginal birth rate in the MNBU indicates the potential of this model of care to reduce obstetric intervention and increase women’s satisfaction with care within a context of extraordinary high caesarean section rates.

Implications for practice

midwife-led care implies a separation of obstetric care from maternity care, which has been advocated in many European countries.