Maternity Care in The Netherlands: The Changing Home Birth Rate

In 1965 two-thirds of all births in The Netherlands occurred at home. In the next 25 years, that situation became reversed with more than two-thirds of births occurring in hospital and fewer than one-third at home. Several factors have influenced that change, including the introduction of short-stay hospital birth, hospital facilities for independent midwives, increased referral rates from primary to secondary care, changes in the share of the different professionals involved in maternity care, medical technology, and demographic changes. After a decline up to 1978 and a period of relative stability between 1978 and 1988, the home birth rate started to decline further, to the extent that it might destabilize the Dutch maternity care system and the role of midwives in it. The Dutch maternity care system depends heavily on primary caregivers, midwives and general practitioners who are responsible for the care of women with low-risk pregnancies, and on obstetricians who provide care for high-risk pregnancies. Its preservation requires a high level of cooperation among the different caregivers, and a functional selection system to ensure that all women receive the type of care that is best suited to their needs. Preserving the home birth option in the Dutch maternity care system necessitates the maintenance of high training and postgraduate standards for midwives, the continued provision of maternity home care assistants, and giving women with uncomplicated pregnancies enough confidence in themselves and the system to feel safe in choosing a home birth. (BIRTH 25:3 September 1998)     

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)     

Outcomes of surrogate pregnancies in California and hospital economics of surrogate maternity and newborn care

AIM: To describe maternity and newborn charges for an economic analysis of surrogate pregnancies on the health care resource utilization. METHODS: A retrospective chart review of all women identified as being surrogates and the infants born from these pregnancies was performed between January 1, 2012 and December 31, 2013. Selected maternity diagnoses, mode of delivery, duration of hospitalization, and hospital charges were collected together with infants’ birth weights, gestational age, length of hospital stay, and hospital charges. Charges associated with the in vitro fertilization cycles, artificial insemination, or embryo(s) transfer into the surrogate were not considered in the maternity charges. A ratio contrasting the maternity hospital charges for the surrogate carrier was compared as a ratio to the mean charges for 2540 infants delivered in 2013 after natural conception and adjusted to the baseline hospital charges for both maternity and newborn care. RESULTS: Analysis of sixty-nine infants delivered from both gestational and traditional surrogate women found an increased in multiple births, NICU admission, and length of stay with hospital charges several multiples beyond that of a term infant conceived naturally and provided care in our nursery. Among singletons and twins (per infant) hospital charges were increased 26 times (P < 0.001) and in triplets charges were increased 173 times (P < 0.0001) when compared to a term infant provided care in a normal nursery at our center. CONCLUSION: Maternity costs for surrogates exceed those of women who conceive naturally, and these costs are especially magnified in women with triplets and multiple births.     

Outcomes Associated with Planned Home and Planned Hospital Births in Low‐Risk Women Attended by Midwives in Ontario,Canada, 2003–2006: A Retrospective Cohort Study

Background: Midwives in Ontario, Canada, provide care in the home and hospital and are required to submit data for all births to the Ontario Ministry of Health database. The purpose of this study was to compare maternal and perinatal/neonatal mortality and morbidity and intrapartum intervention rates for women attended by Ontario midwives who planned a home birth compared with similar low‐risk women who planned a hospital birth between 2003 and 2006. Methods: The database provided outcomes for all women planning a home birth at the onset of labor (n = 6,692) and for a cohort, stratified by parity, of similar low‐risk women planning a hospital birth. Results: The rate of perinatal and neonatal mortality was very low (1/1,000) for both groups, and no difference was shown between groups in perinatal and neonatal mortality or serious morbidity (2.4% vs 2.8%; relative risk [RR], 95% confidence intervals [CI]: 0.84 [0.68–1.03]). No maternal deaths were reported. All measures of serious maternal morbidity were lower in the planned home birth group as were rates for all interventions including cesarean section (5.2% vs 8.1%; RR [95% CI]: 0.64 [0.56, 0.73]). Nulliparas were less likely to deliver at home, and had higher rates of ambulance transport from home to hospital than multiparas planning home birth and had rates of intervention and outcomes similar to, or lower than, nulliparas planning hospital births. Conclusions: Midwives who were integrated into the health care system with good access to emergency services, consultation, and transfer of care provided care resulting in favorable outcomes for women planning both home or hospital births.     

BIRTH SETTING FOR LOW-RISK PREGNANCIES

This article reviews the literature on birth settings for women with low-risk pregnancies. Methodological issues of the existing research include nonrandom designs, small samples, selection differences, data limitations, and confounding bias. Studies for four birth sites are summarized: the home, freestanding birth centers, in-hospital birthing centers or birthing rooms, and traditional hospital settings. Despite the methodological limitations, nontraditional birth settings present advantages for low-risk women as compared with traditional hospital settings: lower costs for maternity care, and lower use of childbirth procedures, without significant differences in perinatal mortality.     

Birth Centers in Australia: A National Population‐Based Study of Perinatal Mortality Associated with Giving Birth in a Birth Center

ABSTRACT: Background: Perinatal mortality is a rare outcome among babies born at term in developed countries after normal uncomplicated pregnancies; consequently, the numbers involved in large databases of routinely collected statistics provide a meaningful evaluation of these uncommon events. The National Perinatal Data Collection records the place of birth and information on the outcomes of pregnancy and childbirth for all women who give birth each year in Australia. Our objective was to describe the perinatal mortality associated with giving birth in “alongside hospital” birth centers in Australia during 1999 to 2002 using nationally collected data. Methods: This population‐based study included all 1,001,249 women who gave birth in Australia during 1999 to 2002. Of these women, 21,800 (2.18%) gave birth in a birth center. Selected perinatal outcomes (including stillbirths and neonatal deaths) were described for the 4‐year study period separately for first‐time mothers and for women having a second or subsequent birth. A further comparison was made between deaths of low‐risk term babies born in hospitals compared with deaths of term babies born in birth centers. Results: The total perinatal death rate attributed to birth centers was significantly lower than that attributed to hospitals (1.51/1,000 vs 10.03/1,000). The perinatal mortality rate among term births to primiparas in birth centers compared with term births among low‐risk primiparas in hospitals was 1.4 versus 1.9 per 1,000; the perinatal mortality rate among term births to multiparas in birth centers compared with term births among low‐risk multiparas in hospitals was 0.6 versus 1.6 per 1,000. Conclusions: This study using Australian national data showed that the overall rate of perinatal mortality was lower in alongside hospital birth centers than in hospitals irrespective of the mother’s parity. (BIRTH 34:3 September 2007)     

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.     

Perinatal Outcomes of Women Intending to Give Birth in Birth Centers in Australia

Abstract: Background: A recent Australian study showed perinatal mortality was lower among women who gave birth in a birth center than in a comparable low‐risk group of women who gave birth in a hospital. The current study used the same large population database to investigate whether perinatal outcomes were improved for women intending to give birth in a birth center at the onset of labor, regardless of the actual place of birth. Methods: Data were obtained from the National Perinatal Data Collection (NPDC) in Australia. The study included 822,955 mothers who gave birth during the 5‐year period, 2001 to 2005, and their 836,919 babies. Of these, 22,222 women (2.7%) intended to give birth in a birth center at the onset of labor. Maternal and perinatal factors and outcomes were compared according to the intended place of birth. Data were not available on congenital anomalies, or cause, or timing of death. Results: Women intending to give birth in a birth center at the onset of labor had lower rates of intervention and of adverse perinatal outcomes compared with women intending to give birth in a hospital, including less preterm birth and low birthweight. No statistically significant difference was found in perinatal mortality for term babies of mothers intending to give birth in a birth center compared with term babies of low‐risk women intending to give birth in a hospital (1.3 per 1,000 births [99% CI = 0.66, 1.95] vs 1.7 per 1,000 births [99% CI = 1.50, 1.80], respectively). Conclusions: Term babies of women who intended to give birth in a birth center were less likely to be admitted to a neonatal intensive care unit or special care nursery, and no significant difference was found in other perinatal outcomes compared with term babies of low‐risk women who intended to give birth in a hospital labor ward. Birth center care remains a viable option for eligible women giving birth at term. (BIRTH 37:1 March 2010)     

Birth setting for low-risk pregnancies. An analysis of the current literature

This article reviews the literature on birth settings for women with low-risk pregnancies. Methodological issues of the existing research include nonrandom designs, small samples, selection differences, data limitation, and confounding bias. Studies for four birth sites are summarized: the home, freestanding birth centers, in-hospital birthing centers or birthing rooms, and traditional hospital settings. Despite the methodological limitations, nontraditional birth settings present advantages for low-risk women as compared with traditional hospital settings: lower costs for maternity care, and lower use of childbirth procedures, without significant differences in perinatal mortality.     

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

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

THE NATIONAL BIRTH CENTER STUDY

This is the first of three articles that will report on the complete findings from the National Birth Center Study (NBCS). This article describes the study methodology, compares the entire group of NBCS subjects with all women who gave birth in the United States in 1986, describes the prenatal care and prenatal referral practices of birth centers in the study, and describes the women who were admitted to the birth centers for intrapartum care with regard to characteristics known or thought to be associated with perinatal risk. Nearly 18,000 women were included in the study; two-thirds of them (n = 11,814) were admitted to the birth centers for intrapartum care. Although medical and obstetric complications were the most common reason for discontinuing birth center care, they accounted for less than half of the women who were not admitted to the birth centers for labor and delivery; many women left for a variety of other reasons. In addition to describing birth center clients, birth center care providers, and birth center care, the NBCS provides detailed information about the characteristics and experiences during pregnancy of a large population of essentially low-risk women receiving a low-intervention style of maternity care.     

Relationship Between Hospital‐Level Percentage of Midwife‐Attended Births and Obstetric Procedure Utilization

Introduction

Research has shown good outcomes among individual low‐risk women who receive perinatal care from midwives, yet little is known about how hospital‐level variation in midwifery care relates to procedure use and maternal health. This study aimed to document the association between the hospital‐level proportion of midwife‐attended births and obstetric procedure utilization.

Methods

This analysis used 2 data sources: Healthcare Cost and Utilization Project State Inpatient Database data for New York in 2014, and New York State Department of Health data on the percentage of midwife‐attended births at hospitals in the state in 2014. Using logistic regression, we estimated the association between the hospital‐level percentage of midwife‐attended births and 4 outcomes among low‐risk women: labor induction, cesarean birth, episiotomy, and severe maternal morbidity.

Results

Hospital‐level percentage of midwife‐attended births was not associated with reduced odds of labor induction or severe maternal morbidity. Women who gave births at hospitals with more midwife‐attended births had lower odds of giving birth by cesarean (eg, adjusted odds ratio [aOR], 0.70; 95% confidence interval [CI], 0.59‐0.82 at a hospital with 15% to 40% of births attended by midwives, compared to no midwife‐attended births) and lower odds of episiotomy (eg, aOR, 0.41; 95% CI, 0.23‐0.74 at a hospital with more than 40% of births attended by midwives, compared to no midwife‐attended births).

Discussion

Our results indicate that hospitals with more midwife‐attended births have lower utilization of some obstetric procedures among low‐risk women; this raises the possibility of improving value in maternity care through greater access to midwifery care.     

Outcomes of planned home birth: an integrative review

Current evidence indicates the critical importance of several factors that contribute to improved perinatal outcomes: a facilitating environment at the place of birth, skilled birth attendance, and the continuum of perinatal care for women and newborns. This level of care is often referred to as "first-level" care, and is most readily provided in birthing centers and primary level health facilities. However, there is a body of evidence that has been compiled over the past several decades that addresses the safety of planned home birth, under circumstances that emulate these elements of "first-level" care. These studies demonstrate a remarkable consistency in the generally favorable results of maternal and neonatal outcomes, both over time and among diverse population groups. These outcomes are also favorable when viewed in comparison to various reference groups (birth center births, planned hospital births, and vital statistics). These data should influence policy in support of planned home birth, including policy that endorses building or sustaining a home birth infrastructure in parallel to the efforts to build capacity for facility-based birth. Such public policy would also be in keeping with the fundamental right of women to have choice in childbirth, particularly when options are equally good.     

The cost-effectiveness of home birth

As health care costs increase and a growing number of women are without insurance, the one health service that every family needs deserves further attention. Even for the 40% of births covered by Medicaid, safe birthing alternatives that permit a reduction in the $150 billion Medicaid burden would allow the United States to devote more resources to other urgent priorities. Informed birthing decisions cannot be made without information on costs, success rates, and any necessary tradeoffs between the two. This article provides the relevant information for hospital, home, and birth center births. The average uncomplicated vaginal birth costs 68% less in a home than in a hospital, and births initiated in the home offer a lower combined rate of intrapartum and neonatal mortality and a lower incidence of cesarean delivery.     

Giving Birth in Two Maternity Hospitals in Lithuania

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

Birth centers Economy,safety, and empowerment

The first three-quarters of this century saw births in the United States shift dramatically from the home toward hospital-based, physician-oriented care. More recently, the establishment and proliferation of modern birth centers and the increased numbers of certified nurse-midwives in this country have expanded birth alternatives for women but not without controversy. The objectives of this article are as follows: 1) to review literature comparing modern birth centers with hospital and physician-attended births in terms of safety, rates of complications, number of invasive procedures, cost-effectiveness, and patient satisfaction, and then 2) to explicate models of empowerment as applied to birth centers and consider how they may manifest in individuals and in the community. Findings: comprehensive data have clearly demonstrated that birth centers are as safe as hospitals for low-risk births, do fewer invasive procedures and cesarean sections, are less expensive, and have high rates of patient satisfaction. Furthermore, birth centers effectively shift the locus of control of the pregnancy from physician to mother, and conform closely to ideal models of empowerment structures described in the literature. Conclusions: For low-risk pregnancies, birth centers confer many advantages over conventional hospital-based births without compromising the safety of the mother or infant and in the process can empower women to transform their lives and their community.     

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.     

Factors Associated with the Choice of Delivery without Epidural Analgesia in Women at Low Risk in France

ABSTRACT: Background: Regional anesthesia is used for three‐fourths of the deliveries in France. Epidural analgesia during labor is supposed to be available to all women at low risk. The purpose of our study was to examine how the choice of delivery without an epidural varied in this context according to women’s characteristics, prenatal care, and type of maternity unit. Methods: The 2003 National Perinatal Survey in France collected data about a representative sample of births. We selected 8,233 women who were at low risk and therefore should have been able to choose whether or not to deliver without epidural analgesia. Women were interviewed in the maternity unit after delivery. The factors associated with women’s choice to deliver without epidural analgesia were studied with multivariable analyses. Results: Of the 2,720 women who gave birth without epidural analgesia, 37 percent reported that they had not wanted one; other reasons were labor occurring too quickly (43.9%), medical contraindication (3.3%), and unavailability of an anesthesiologist (2.8%). The reported decision to deliver without epidural analgesia was closely associated with high parity. It was also more frequent among women in an unfavorable social situation (not cohabiting, no or low‐qualified job) and among women who gave birth in nonuniversity public hospitals, in small‐ or medium‐sized maternity units, and in maternity units without an anesthesiologist always on site. Conclusions: Unfavorable social situation and organizational factors are associated with the reported choice to give birth without epidural analgesia. This finding suggests that women are not always in a position to make a real choice. It would be useful to improve the understanding of how pregnant women define their preferences and to know how these preferences change during pregnancy and labor. (BIRTH 35:3 September 2008)