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)     

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

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

Decision-making regarding place of birth in high-risk pregnancy: a qualitative study

Introduction: Women consider factors including safety and the psychological impact of their chosen location when deciding whether to give birth in hospital or at home. The same is true for women with high-risk pregnancies who may plan homebirths against medical advice. This study investigated women’s decision-making during high-risk pregnancies. Half the participants were planning hospital births and half were planning homebirths.

Methods: A qualitative study using semi-structured interviews set in a hospital maternity department in the UK. Twenty-six participants with high-risk pregnancies, at least 32 weeks pregnant. Results were analysed using systematic thematic analysis.

Results: Three themes emerged: perceptions of birth at home and hospital; beliefs about how birth should be; and the decision process. Both groups were concerned about safety but they expressed different concerns. Women drew psychological comfort from their chosen birth location. Women planning homebirths displayed faith in the natural birth process and stressed the quality of the birth experience. Women planning hospital births believed the access to medical care outweighed their misgivings about the physical environment.

Discussion: Although women from both groups expressed similar concerns about safety they reached different decisions about how these should be addressed regarding birth location. These differences may be related to beliefs about the birth process. Commitment to their decisions may have helped reduce cognitive stress.     

Satisfaction with planned place of birth among midwifery clients in British Columbia

The purpose of this study was to compare satisfaction with the birth experience among a population of women planning birth at home versus in hospital. In British Columbia, Canada, all midwives offer women meeting eligibility requirements for homebirth the choice to give birth in hospital or at home. Therefore, satisfaction can be attributed to planned place of birth, as the caregivers were the same in both settings. The mean overall score on the Labour Agentry Scale among women who had planned a homebirth (n = 550), 188.49 +/- 16.85, was significantly higher than those who planned birth in hospital (n = 108), 176.60 +/- 23.79; P < .001. Overall satisfaction with the birth experience was higher among women planning birth at home, 4.87 +/- 0.42 versus 4.80 +/- 0.49 on a scale of 1 to 5, although this difference was not statistically significant; P = .06. Among women whose actual place of birth was congruent with where they had planned, overall satisfaction was higher in the homebirth group, 4.95 +/- 0.20 versus 4.75 +/- 0.53; P < .001. Although satisfaction with the birth experience was high in both the home and hospital settings, women planning birth at home were somewhat more satisfied with their experience, particularly if they were able to complete the birth at home.     

All that I need exists within me: A qualitative study of nulliparous Norwegian women's experiences with planned home birth

ObjectiveThe aim of this study was to gain knowledge regarding how Norwegian nulliparous women experience planned home birth and why they choose this route of giving birth.DesignA qualitative approach was used, and the study data were derived from semi-structured individual interviews, which were analysed through systematic text condensation.ParticipantsTen Norwegian women aged nineteen to thirty-nine years were interviewed. They had each gone through with a successful planned home birth of their first child within the last two years. These women all resided in the middle, western and eastern areas of Norway. A certified midwife was present throughout the labour and birth, and no transfer to the hospital was necessary.FindingsThe following two main themes were identified: ‘inner motivation’ and ‘giving birth in safe surroundings’. The women in this study had a strong inner faith in the normal physiological processes of labour and birth and had educated and prepared themselves carefully for their planned home birth. To be able to enter one's own inner world was considered crucial for labour, and the trusting relationship they had with their midwife made this possible.Key conclusions and implications for practicePlanned home birth may be experienced as a very positive occurrence for nulliparous women, and the care those women in this study received contained several elements that can help to promote normal labour and birth at a time in which reducing interventions in maternity care is of importance. Their positive birth experiences gave the women confidence both in their transition to motherhood as well as in other aspects of life.     

A Mirage of Change: Family‐Centered Maternity Care in Practice

Abstract: Background: Since the 1970s, the movement to “humanize” birth in North America has evolved into “family‐centered maternity care,” which has focused on providing evidence‐based maternity care that is responsive to the needs of women and their families. The objective of this research was to explore women’s birth experiences within the context of the numerous changes that have occurred in perinatal care and to determine how information and knowledge acquired about pregnancy and birth influenced women’s birth experiences. Methods: Semi‐structured interviews were conducted in prenatal health clinics in Montreal and Vancouver with 36 women before and after birth. Results: Most study participants were unaware of the range of available providers and birth settings. Of the women who were more aware of their options, those selecting a birth center or home birth and midwives had different notions of risk than those who planned a hospital birth. Study participants felt generally well informed, but thought that information sharing, collaborative decision making, or both were inadequate during labor and birth within the hospital setting. Conclusions: Despite positive changes in recent years, family‐centered maternity care in Canada still needs to be improved. Women’s ability to use their acquired prenatal knowledge to feel satisfied by their birth experience continues to be undermined by a system of care that does not prioritize women’s informed choice. Further systemic change is required to align maternity care with the needs of Canadian birthing women and their families. (BIRTH 37:2 June 2010)     

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.     

Birth place preferences and women’s expectations and experiences regarding duration and pain of labor

Introduction: We know a great deal about how childbirth is affected by setting; we know less about how the experience of birth is shaped by the attitudes women bring with them to the birthing room. In order to better understand how women frame childbirth, we examined the relationship between birth place preference and expectations and experiences regarding duration of labor and labor pain in healthy nulliparous women.

Methods: A prospective cohort study (2007–2011) of 454 women who preferred a home birth (n?=?179), a midwife-led hospital birth (n?=?133) or an obstetrician-led hospital birth (n?=?142) in the Netherlands. Data were collected using three questionnaires (before 20 weeks gestation, 32 weeks gestation and 6 weeks postpartum) and medical records. Analyses were performed according to the initial preferred place of birth.

Results: Women who preferred a home birth were significantly less likely to be worried about the duration of labor (OR 0.5, 95%CI 0.2–0.9) and were less likely to expect difficulties with coping with pain (OR 0.4, 95%CI 0.2–0.8) compared with women who preferred an obstetrician-led birth. We found no significant differences in postpartum accounts of duration of labor. When compared to women who preferred an obstetrician-led birth, women who preferred a home birth were significantly less likely to experience labor pain as unpleasant (OR 0.3, 95%CI 0.1–0.7). Women who preferred a midwife-led birth – either home or hospital – were more likely to report that it was not possible to make their own choices regarding pain relief compared to women who preferred obstetrician-led care (OR 4.3, 95%CI 1.9–9.8 resp. 3.4, 95%CI 1.5–7.7). Compared to women who preferred a midwife-led hospital birth, women who preferred a home birth had an increased likelihood of being dissatisfied about the management of pain relief (OR 2.5, 95%CI 1.1–6.0).

Discussion: Our findings suggest a more natural orientation toward birth with the acceptance of labor pain as part of giving birth in women with a preference for a home birth. Knowledge about women’s expectations and experiences will help caregivers to prepare women for childbirth and will equip them to advise women on birth settings that fit their cognitive frame.     

Maternal factors and the probability of a planned home birth

OBJECTIVES: In the Netherlands, approximately one-third of births are planned home births, mostly supervised by a midwife. The relationship between maternal demographic factors and home births supervised by midwives was examined. DESIGN: Cross-sectional study. Setting Dutch national perinatal registries of the year 2000. POPULATION: All women starting their pregnancy care under the supervision of a midwife, because these women have the possibility of having a planned home birth. METHODS: The possible groups of birth were as follows: planned home birth or short stay hospital birth, both under the supervision of a midwife, or hospital birth under the supervision of an obstetrician after referral from the midwife during pregnancy or birth. The studied demographic factors were maternal age, parity, ethnicity and degree of urbanisation. Probabilities of having a planned home birth were calculated for women with different demographic profiles. MAIN OUTCOME MEASURE: Place of birth. RESULTS: In all age groups, the planned home birth percentage in primiparous women was lower than in multiparous women (23.5%vs 42.8%). A low home birth percentage was observed in women younger than 25 years. Dutch and non-Dutch women showed almost similar percentages of obstetrician-supervised hospital births but large differences in percentage of planned home births (36.5%vs 17.3%). Fewer home births were observed in large cities (30.5%) compared with small cities (35.7%) and rural areas (35.8%). CONCLUSIONS: This study demonstrates a clear relationship between maternal demographic factors and the place of birth and type of caregiver and therefore the probability of a planned home birth.     

The Experience of Pregnancy and Birth with Midwives: Results from the Canadian Maternity Experiences Survey

Abstract: Background: In Canada maternity care is publicly funded, and although women may choose their care providers, choices may be limited. The purpose of this study was to compare perceptions of maternity outcomes and experiences of those who received care from midwives with those who received care from other providers. Methods: Based on the 2006 Canadian census, a random sample of women (n = 6,421) who had recently given birth in Canada completed a computer‐assisted telephone interview for the Maternity Experiences Survey. The sample was stratified according to province or territory where birth occurred, age, rural or urban residence, and presence of other children in the home. Those who were 15 years of age and older, gave birth to a singleton baby, and were living with their infant were eligible for inclusion. Results: Women whose primary prenatal providers were midwives had fewer ultrasounds and were more likely to attend prenatal classes and have at least five or more prenatal visits. They were also more likely to rate satisfaction with their maternity experience as “very positive” and be satisfied with information provided on a variety of pregnancy and birth topics if their primary prenatal provider was a midwife. They were almost half as likely to experience induction and 7.33 times more likely to experience a medication‐free delivery. They were more likely to initiate and maintain breastfeeding at 3 and 6 months. Conclusions: Evidence shows that midwifery outcomes and levels of satisfaction meet or exceed Canadian maternity care standards. Facilitation of the continuing integration of midwives as autonomous practitioners throughout Canada is recommended. (BIRTH 38:3 September 2011)     

Women's experiences of continuity of midwifery care in a randomised controlled trial in Australia

OBJECTIVE: to compare the experiences of women who received a new model of continuity of midwifery care with those who received standard hospital care during pregnancy, labour, birth and the postnatal period. DESIGN: a randomised controlled trial was conducted. One thousand and eighty-nine women were randomly allocated to either the new model of care, the St George Outreach Maternity Project (STOMP), or standard care. Women completed a postal questionnaire eight to ten weeks after the birth. PARTICIPANTS: women in the trial were of mixed obstetric risk status and more than half the sample were born in a non-English speaking country. FINDINGS: questionnaires were returned from 69% of consenting women. STOMP women were significantly more likely to have talked with their midwives and doctors about their personal preferences for childbirth and more likely to report that they knew enough about aspects of labour and birth, particularly induction of labour, pain relief and caesarean section. Almost 80% of women in the STOMP group experienced continuity of care, that is, one of their team midwives was present, during labour and birth. STOMP women reported a significantly higher 'sense of control during labour and birth'. Sixty-three per cent of STOMP women reported that they 'knew' the midwife who cared for them during labour compared with 21% of control women. In a secondary analysis, women who had a midwife during labour who they felt that they knew, had a significantly higher sense of 'control' and a more positive birth experience compared with women who reported an unknown midwife. Postnatal care elicited the greatest number of negative comments from women in both the STOMP and the control group. CONCLUSION: The reorganisation of maternity services to enable women to receive continuity of care has benefits for women. The benefits of a known labour midwife needs further research.     

Variation in home-birth rates between midwifery practices in The Netherlands

OBJECTIVE: To examine the reasons for the variation in home-birth rates between midwifery practices. METHOD: Multi-level analysis of client and midwife associated, case-specific and structural factors in relation to 4420 planned and actual home or hospital births in 42 midwifery practices. FINDINGS: Women's choice of birth location and the occurrence of complications that lead to referral to specialist care before or during labour, were found to be the main determinants of the home-birth rate. Yet, about 64% of the variation between midwifery practices is explained by midwife and practice characteristics. Higher home-birth rates were associated with a positive attitude to home-birth, a critical attitude to hospital birth for non-medical reasons, and good co-operation between midwifery practices and hospital obstetricians. CONCLUSIONS: The proportions of planned hospital birth and of referral to specialist care are the most important predictors of the actual hospital-birth rate of women receiving midwifery care. Both can be influenced by the midwife through a positive attitude to home-birth, a critical approach to non-medical reasons for hospital birth, and good co-operation with specialist obstetricians. It is, therefore, important for midwives to be aware of the influence that their own attitudes may have on the choices their clients make about home or hospital birth.     

Midwife or doctor: a study of pregnant women making delivery decisions

Eighty-eight women from diverse educational backgrounds were interviewed as they made several important and related life decisions during their pregnancies. In this article, the focus is on the choice of birth attendant. There were few differences between those women who did and did not consider a midwife. Women who selected a midwife reported feeling more knowledgeable about birth attendants, more in control over the birth attendant decision, more satisfied about their delivery decisions, more in control of and satisfied with pain medication decisions, more autonomous in their pregnancy decision making, and more in agreement with "alternative birth" philosophies. and less in agreement with "conventional birth" philosophies. The participants also reported receiving more approval from spouse/significant other and friends, were more likely to use "gut instinct" and previous experience or habit to make pregnancy decisions, and were more ready to make these decisions than were women who had not selected a midwife as their primary birth attendant.     

Childbirth at home: A qualitative study exploring perceptions of risk and risk management among Baloch women in Iran

Objective

to explain how women who choose to give birth at home perceive and manage the risks related to childbirth.

Design

a qualitative, methodological approach drawing upon the principles of grounded theory. Data were gathered by in-depth interviews with women who had given birth at home.

Setting

the study was conducted in Zahedan, the capital of Sistan and Balochestan province in southeast Iran.

Participants

21 Baloch women aged 13–39 years who had a planned home birth were interviewed. Nine had been attended by university-educated midwives, eight by trained midwives, and four by traditional birth attendants.

Findings

concerning perceived risks, women perceived giving birth in hospital to be risky because of medical interventions, routines and ethical considerations. The perceived risks for home birth were acute medical conditions. Women made their decision to give birth at home based on existing verbal, visual, and intuitive information. The following two categories related to risk management were identified: (1) psychological preparation and (2) medical and logistican preparation. All of the women relied on their own intuition, their midwife and the sociopsychological support of their families to transfer them to hospital in the case of complications.

Key conclusions and implications for practice

the women who chose to give birth at home accepted that there was a risk of complications, but perceived these to be due to fate. Technical risks were considered to be a consequence of the decision to give birth in hospital, and were perceived to be avoidable. In addition, the women considered ethical issues as risks that are sometimes more important than medical complications. Women's perceptions of risk, and the ways in which they prepare to manage risk, are central issues to help providers and policy makers adjust services to women's expectations in order to respond to the individuality of each woman.     

Outcomes of a Rural Sonoma County Home Birth Practice: 1976–1982

ABSTRACT: Of 741 women who appeared for orientation by an obstetrician/lay midwife, 521 were delivered by them. Of 258 primiparae, 191 had planned home births while 24 were transported to the hospital during labor, and 42 had planned hospital births. Of the multiparae, 233 delivered at home; 2 were transported to the hospital after birth and 3 during labor. Hospital births were planned by 25 multiparae. The cesarean rate was 6.1 per cent. There were 4 premature births (all in hospital and all with normal outcomes), 6 minor malformations, and 3 postpartum infections. The 3 perinatal deaths included a prepartum death at 34 weeks, a stillborn double footling breech with a prolapsed cord, and an infant who was resuscitated at home but died after two weeks of intensive care.     

Deciding on home or hospital birth: Results of the Ontario choice of birthplace survey

Objective

decision-making autonomy regarding where to give birth is associated with maternal satisfaction with childbirth but how women decide their location of birth is poorly understood. The aim of this study was to understand how pregnant women in Ontario, Canada decide to give birth at home or hospital and why they choose one birthplace over another.

Design

a mixed methods survey completed by midwifery clients in Ontario pertaining to sources of information about choice of birthplace and decision-making priorities.

Findings

decisions about choice of birthplace are made before becoming pregnant or during the first trimester. Books and research are important sources of information for women when deciding where to give birth. Women who planned home birth wanted to avoid interventions and felt most comfortable at home. Those who planned hospital birth wanted access to pain medication and found the idea of home birth stressful. Questions about the safety of home birth are a critical barrier to those who are undecided about where to give birth.

Key conclusions

beliefs and values about birth and the desire for pain relief options play significant roles in women?s decisions, but are balanced with views of safety and risk. Regardless of where they have their baby, midwifery clients believe that birth is a natural process.

Implications for practice

the findings provide health care providers and women with a deeper understanding of the factors for consideration when deciding where to give birth.