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

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

Swedish Women's Interest in Home Birth and In‐Hospital Birth Center Care

ABSTRACT:Background: In Sweden, few alternatives to a hospital birth are available, and little is known about consumer interest in alternative birth care. The aim of this study was to determine women's interest in home birth and in‐hospital birth center care in Sweden, and to describe the characteristics of these women. Methods: All Swedish‐speaking women booked for antenatal care during 3 weeks during 1 year were invited to participate in the study. Three questionnaires, completed after the first booking visit in early pregnancy, at 2 months, and 1 year after the birth, asked about the women's interest in two alternative birth options and a wide range of possible explanatory variables. Results: Consent to participate in the study was given by 3283 women (71% of all women eligible). The rates of response to the three questionnaires were 94, 88, and 88 percent, respectively. One percent of participants consistently expressed an interest in home birth on all three occasions, and 8 percent expressed an interest in birth center care. A regression analysis showed five factors that were associated with an interest in home birth: a wish to have the baby's siblings (OR 20.2; 95% CI 6.2–66.5) and a female friend (OR 15.2; 95% CI 6.2–37.4) present at the birth, not wanting pharmacological pain relief during labor and birth (OR 4.7; 95% CI 1.4–15.3), low level of education (OR 4.5; 95% CI 1.8–11.4), and dissatisfaction with medical aspects of intrapartum care (OR 3.6; 95% CI 1.4–9.2). An interest in birth center care was associated with experience of being in control during labor and birth (OR 8.3; 95% CI 3.2–21.6), not wanting pharmacological pain relief (OR 2.3; 95% CI 1.3–4.1), and a preference to have a known midwife at the birth (OR 2.2; 95% CI 1.6–2.9). Conclusion: If Swedish women were offered free choice of place of birth, the home birth rate would be 10 times higher, and the 20 largest hospitals would need to have a birth center. Women interested in alternative models of care view childbirth as a social and natural event, and their needs should be considered. (BIRTH 30:1 March 2003)     

A Randomized,Controlled Trial of Nurse-Midwifery Care

ABSTRACT: Background : In 1990 a pilot nurse-midwifery program was implemented in a tertiary care hospital in a major western Canadian city. A randomized, controlled trial was conducted to determine if when maternal and newborn patient outcomes were compared, the midwifery program was as effective as traditional, low-risk health care available in the city. Methods : All low-risk women who requested and qualified for nurse-midwifery care were randomly assigned to an experimental or control group. Results : One hundred one women received care from nurse-midwives and 93 received standard care from either an obstetrician or family physician. The rate of cesarean delivery in the nurse-midwife group was 4 percent compared with 15.1 percent in the physician group. The episiotomy rate, excluding cesarean deliveries, for the nurse-midwife group was 15.5percent compared with 32.9 percent in the physician group. The rates of epidural anesthesia for pain relief in labor were 12.9 percent and 23.7 percent, respectively. Statistically significant differences were found for ultrasound examinations, amniotomy, intravenous drug administration during labor; dietary supplements, length of hospital stay, and admission of infants to the neonatal intensive care unit. Conclusions : The results clearly support the effectiveness of the pilot nurse-midwifery program and suggest that more extensive participation of midwives in the Canadian health care system is an appropriate use of health care dollars.     

Maternal Satisfaction with Active Management of Labor: A Randomized Controlled Trial

Background: Active management of labor reduces the length of labor and rate of prolonged labor, but its effect on satisfaction with care, within a randomized controlled trial, has not previously been reported. The study objectives were to establish if a policy of active management of labor affected any aspect of maternal satisfaction, and to determine the independent explanatory variables for satisfaction with labor care in a low‐risk nulliparous obstetric population. Methods: Nulliparous women at National Women's Hospital in Auckland, New Zealand, in spontaneous labor at term with singleton pregnancy, cephalic presentation, and without fetal distress were randomized after the onset of labor to active management (n= 320) or routine care (n= 331). Active management included early amniotomy, two‐hourly vaginal assessments, and early use of high dose oxytocin for slow progress in labor. Routine care was not prespecified. Maternal satisfaction with labor care was assessed by postal questionnaire at 6 weeks postpartum. Sensitivity analyses were performed, and logistic regression models were developed to determine independent explanatory variables for satisfaction. Results: Of the 651 women randomized in the trial, 482 (74%) returned the questionnaires. Satisfaction with labor care was high (77%) and did not significantly differ by treatment group. This finding was stable when sensitivity analysis was performed. The first logistic regression model found independent associations between satisfaction and adequate pain relief, one‐to‐one midwifery care, adequate information and explanations by staff, accurate expectation of length of labor, not having a postpartum hemorrhage, and fewer than three vaginal examinations during labor. The second model found fewer than three vaginal examinations and one‐to‐one midwifery care as significant explanatory variables for satisfaction with labor care. Conclusions: Active management did not adversely affect women's satisfaction with labor and delivery care in this trial. Future studies should concentrate on measurement of potential predictors before and during labor.     

The Components of Women's Satisfaction with Maternity Care

Abstract: For a better understanding of how women's satisfaction with maternity care is affected, a representative sample of 1790 women from the Montreal area who had delivered four to seven months earlier were mailed a postal questionnaire; 938 (52.4%) completed and returned it. With factor analysis, we determined five dimensions to women's satisfaction: (a) the delivery itself, (b) medical care, (c) nursing care, (d) information received and participation in the decision-making process, and (e) physical aspects of the labor and delivery rooms. Multiple regression analysis was used to determine explicative factors for each of these dimensions of satisfaction. Items relative to the delivery process such as pain intensity, complications, and length of labor were the most important for the delivery experience itself. Participation in the decision-making process was the first component of satisfaction with medical care. Information received appeared to be the major component of their satisfaction with nursing care. The physical environment did not affect women's satisfaction with obstetric care.     

Satisfaction with Team Midwifery Care for Low‐ and High‐Risk Women: A Randomized Controlled Trial

ABSTRACT:Background: In 1996 a new model of maternity care characterized by continuity of midwifery care from early pregnancy through the postpartum period was implemented for women attending Monash Medical Centre, a tertiary level obstetric service, in Melbourne, Australia. This study's purpose was to assess the impact of this model on women's views and experiences of care during the antenatal, intrapartum, and postpartum periods compared with views of women receiving standard maternity care. Methods: One thousand low‐ and high‐risk women who booked at the antenatal clinic and met the eligibility criteria were randomly allocated to continuity of midwifery care from a group of seven midwives in collaboration with medical staff, or to standard care from a variety of midwives and medical staff. Women's views of care were measured by means of a postal questionnaire at four months after the birth. Results: Team midwifery care was associated with increased satisfaction with antenatal, intrapartum, and some aspects of postpartum care. The differences were most obvious for antenatal care. Conclusions: Continuity of midwifery care is realistically achievable in a tertiary obstetric referral service and is associated with increased satisfaction. (BIRTH 30:1 March 2003)     

Satisfaction with Postpartum Care: Opportunities for Bonding,Reconstructing the Birth and Instruction

ABSTRACT: The declining length of postpartum stay in hospitals has made it more difficult for staff to provide the kind of care recommended in the nursing literature. This study examines the association between satisfaction with care and three clinical procedures—parent-infant bonding, reconstructing birth events and instruction in care of self and baby. Data taken from an Arizona statewide survey of women who recently gave birth indicated little dissatisfaction with care. However, contingency table analysis revealed that level of satisfaction is associated with the provision of opportunities for parent-infant bonding, review of birthing experience and instruction in care of mother and newborn. Strategies for increasing level of satisfaction are discussed.     

Transfer Rates From Freestanding Birth Centers: A Comparison with the National Birth Center Study

This article reviews retrospective data derived from Sharp The BirthPlace, San Diego for 1993–94 and from the University of California, Irvine, Birthing Center for 1994 and compares these findings to data obtained from the National Birth Center Study (NBCS). The focus of this article is on intrapartum transfer rates from the two freestanding birth centers as a critical clinical indicator. Cause-specific transfer rates were calculated for eight clinical conditions. Data suggest that cause-specific intrapartum transfer rates are influenced by factors such as risk profile of the client population, distance to the referral center and mechanisms of transfer, definitions and diagnostic criteria used, and clinical practice guidelines. Reports from the literature, such as NBCS data, might serve as points of reference, but are likely not appropriate baseline indicators (benchmarks of “best practice”) for clinical events, against which individual performance can be measured; rather, these benchmarks should be individually defined, based on characteristics unique to each birth center.     

Satisfaction With Care in Labor and Birth: A Survey of 790 Australian Women

ABSTRACT: Data on satisfaction with care in labor and birth were gathered in a survey conducted in conjunction with a review of maternity services in Victoria, Australia. All women who gave birth in one week in 1989 (>1000) were mailed questionnaires eight to nine months after the birth, with a response rate of 790 (71.4%). When adjusted for parity in a logistic regression model, the following factors were highly related to dissatisfaction with intrapartum care: lack of involvement in decision making (p < 0.001), insufficient information (p < 0.001), a higher score for obstetric intervention (p = 0.015), and perception that caregivers were unhelpful (p = 0.04). No association was found between satisfaction and maternal age, marital status, total family income, country of birth, or health insurance status. The survey results were influential in shaping final recommendations of the Ministerial Review of Birthing Services by countering stereotypes about women who become dissatisfied with their care, providing evidence of far greater dissatisfaction with intrapartum than antenatal care, and demonstrating the importance of information, participation in decision making, and relationships with caregivers to women's overall satisfaction with intrapartum care.     

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.     

Immigrant Women's Views About Care During Labor and Birth: An Australian Study of Vietnamese,Turkish, and Filipino Women

ABSTRACT: Background: Few studies of immigrant women's views of maternity care in their new homelands have been conducted. In Victoria, Australia, approximately 1 woman in 7 giving birth was born overseas in a non‐English speaking country. This paper examines the views of three groups of immigrant women about the care they received in hospital for the birth of their babies and compares the findings with a population‐based statewide survey. Methods: Mothers in a New Country was a study of 318 Vietnamese, Turkish, and Filipino women interviewed about their maternity care experiences by bicultural interviewers 6 months after giving birth in Melbourne, Australia. The interview schedule was adapted from the 1994 Victorian Survey of Recent Mothers, a population‐based postal survey of 1336 women. Results: Of the 3 groups, 27 percent of Vietnamese, 48 percent of Turkish, and 39 percent of Filipino women reported their care during labor and birth as “very good,” figures significantly lower than for the statewide survey, in which 61 percent of women experiencing similar models of care described their care as “very good.” This significant differential in views about care was also present for many individual aspects of care. In the current study of mothers in a new country, comments about aspects of care with which women were particularly happy and unhappy highlighted their appreciation of care that was safe, kind, supportive, and respectful, and conversely, illustrated how distressed women were when care failed to meet these basic standards. Conclusions: What immigrant women wanted from their maternity care proved to be extremely similar to what Australian‐born women—and women the world over—want. Unfortunately, immigrant women were much less likely to experience care that gave them what they wanted. (BIRTH 29:4 December 2002)     

Acceptability and Feasibility of Early Palliative Care Among Women with Advanced Epithelial Ovarian Cancer: A Randomized Controlled Pilot Study

ObjectiveTo evaluate the acceptability of early palliative care (EPC) among patients with advanced ovarian cancer and to determine the feasibility of larger-scale phase III trials.MethodsWe performed a randomized controlled pilot study of adult women (>18 years) with pathologically confirmed epithelial ovarian cancer that had recurred or progressed on first-line therapy and had no immediate need for palliative care. We randomly assigned patients to either EPC or standard oncologic care (SOC), and collected patient-reported outcomes (PRO) at baseline, 3 months, and 6 months; end-of-life care quality indicators were collected at study completion. Study endpoints were rates of enrollment, EPC adherence, and PRO completion.ResultsOf 32 eligible patients approached, 23 enrolled (72%; 95% CI 53–86) and were randomly assigned to either EPC (n = 12) or SOC (n = 11). At baseline, participants had poor physical and emotional wellbeing, high rates of depression (65%), and understood that their disease was not curable (87%). Eleven patients (92%; 95% CI 62–100) attended their EPC consultation, and all visits took place within 4 weeks of enrollment. However, PRO completion was low due to deaths by 3 (5/23) and 6 months (9/23).ConclusionPatients had accurate perceptions of their disease status, were willing to be randomly assigned to EPC, and attended scheduled appointments. However, a definitive trial in this group is not feasible without major adjustments to eligibility criteria and a multicentre, international effort. We propose that EPC be considered routinely at progression or recurrence given patients’ symptom burden and clear acceptance of the intervention, as well as evidence of benefit from adequately powered trials in other malignancies.     

College Women's Expectations About Pregnancy,Childbirth, and Infant Care: A Prospective Study

A prospective study of 103 women undergraduate students explored expectations and knowledge about pregnancy, childbirth, and newborn care. Participants completed a 35-item questionnaire based on a planned pregnancy. Most women (68%) thought they were extremely likely to become pregnant in their lives and planned to have an average of 2.6 children. Positive emotions about pregnancy were most frequently excited, happy, and proud, and negative emotions were most frequently nervous, scared, and anxious. Women expected that pregnancy and parenting would interfere most with work or education plans. Choices of birthplace were hospital delivery room (54.4%), in-hospital birthing room (35%), out-ofhospital birth center (3.9%), and home (2.9%). One-half of the women planned to breastfeed, 35 percent had not decided, and 10.7 percent would not breastfeed. Positive feelings about pregnancy were correlated with positive feelings about labor and birth (r = 0.48, P < 0.001). Negative feelings about pregnancy were correlated with a low self-assessment of ability to care for an infant (r = 0.27, P < 0.01). Some college women's expectations are similar to those held by pregnant women, and suggest the need for further education of young women in areas such as prenatal health care and breastfeeding.     

Safety of the Stockholm Birth Center Study: A Critical Review

Abstract: This paper critically appraised the validity and generalizability of the safety of the Stockholm Birth Center care study to determine if it can be relied on to answer the question, “Is primiparous labor and birth in a birth center as safe for babies as standard medical care?” The retrospective cohort study is summarized, and statistical and methodological aspects are evaluated. Errors that were identified include selection bias and two forms of performance bias, both involving the independent variable. Nondefinition and lack of control of the independent variable and minor statistical errors were also noted. More serious concerns relate to the validity of an intention‐to‐treat analysis. Some methodological problems reduced validity of the study and ability to generalize the findings to other birth centers. Birth center care is a desirable and established birth option. A more useful approach to improving maternity care provision could involve comparing multiple birth center sites with each other to find best practice so that it can be analyzed and duplicated. (BIRTH 32:2 June 2005)     

Team Midwifery Care in a Tertiary Level Obstetric Service: A Randomized Controlled Trial

Background: In 1996 a new model of maternity care characterized by continuity of midwifery care from early pregnancy through to the postpartum period was implemented for women attending Monash Medical Centre, a tertiary level obstetric service, in Melbourne, Australia. The objective of this study was to compare the new model of care with standard maternity care. Methods: In a randomized controlled trial, 1000 women who booked at the antenatal clinic and met the eligibility criteria were randomly allocated to receive continuity of midwifery care (team care) from a group of seven midwives in collaboration with obstetric staff, or care from a variety of midwives and obstetric staff (standard care). The primary outcome measures were procedures in labor, maternal outcomes, neonatal outcomes, and length of hospital stay. Results: Women assigned to the team care group experienced less augmentation of labor, less electronic fetal monitoring, less use of narcotic and epidural analgesia, and fewer episiotomies but more unsutured tears. Team care women stayed in hospital 7 hours less than women in standard care. More babies of standard care mothers were admitted to the special care nurseries for more than 5 days because of preterm birth, and more babies of team care mothers were admitted to the nurseries for more than 5 days with intrauterine growth retardation. No differences occurred in perinatal mortality between the two groups. Conclusions: Continuity of midwifery care was associated with a reduction in medical procedures in labor and a shorter length of stay without compromising maternal and perinatal safety. Continuity of midwifery care is realistically achievable in a tertiary obstetric referral service.     

A Randomized Controlled Trial to Improve Outcomes Utilizing Various Warming Techniques during Cesarean Birth

ObjectiveTo examine the effect of various warming methods during cesarean birth (CB) on maternal core body temperature, maternal hypothermia, and other maternal and neonatal outcomes.DesignThree‐arm randomized controlled trial.SettingPerinatal unit in a large community hospital in the mid‐Atlantic United States.ParticipantsTwo hundred twenty‐six (226) pregnant women undergoing planned CB.MethodsWomen were randomly assigned to one of three groups (usual care, warmed fluids, or warmed underbody pad). Warming treatments began preoperatively and continued for 2 hours postoperatively. Study nurses measured outcomes at defined intervals.ResultsBoth warming techniques affected maternal temperatures and the incidence of hypothermia. The warmed fluids group had significantly higher temperatures in the operating room, whereas the warmed underbody pad group had significantly higher temperatures in the recovery room. Although none of the other outcomes was statistically different among groups, the findings have implications for practice. Apgar scores were proportionately lower in the usual care group, and maternal request for additional warming was proportionately higher in the usual care group.ConclusionThis study adds information on ways to maintain maternal normothermia during surgery. By understanding maternal hypothermia during CB, nurses can use best practice to obtain optimal maternal and neonatal outcomes.     

Patient Satisfaction with IUD Services in a School-Based Health Center: A Pilot Study

Study ObjectiveWe aimed to determine the acceptability to and satisfaction of high school students receiving an intrauterine device (IUD) at a school-based health center (SBHC).Design, Setting, Participants, Interventions, and Main Outcome MeasuresIn this prospective pilot study at a Bronx SBHC, adolescent patients who had an IUD inserted in the SBHC between November 2010 and June 2013 completed a self-administered survey on the day of IUD insertion and a follow-up survey within 6 months. The initial survey addressed patient sexual and contraceptive history, reasons for choosing the IUD, and the insertion experience, whereas the follow-up survey addressed IUD continuation and side effects.ResultsIn all, 104 of 139 (75%) eligible patients agreed to participate, and 75 (72%) of those completed the follow-up survey. Respondents chose IUDs because they were long-lasting, effective, private, and easy to remember, and chose the SBHC for services because it was convenient, recommended, free, and a trusted setting. Participants rated their interactions with SBHC staff highly, and almost all described their procedure experience as somewhat or very acceptable. Of the respondents, 92% were still using the IUD at the time of the follow-up survey, with 32% stating that they were somewhat satisfied and 65% stating they were very satisfied with this method of contraception.ConclusionOur research demonstrates that IUD services can be integrated into the SBHC setting with high rates of acceptability and satisfaction. Furthermore, SBHCs provide a unique and acceptable option for providing these services and have the potential to increase adolescents’ contraceptive access and choice.