Organisation of maternity care and choices of mode of birth: a worldwide view

Drawing on the findings from a Cochrane systematic review of midwife-led care vs. other models of maternity care, this article discusses maternity organisation of care, women's choice of mode of birth and a global trend in reducing normality of childbirth. The review included 11 trials involving 12,276 women. The results showed that women who received models of midwife led care were less likely to experience fetal loss before 24 weeks' gestation, less likely to have regional analgesia, less likely to have instrumental birth, less likely to have an episiotomy (with no significant differences in perineal lacerations), and were more likely to be attended at birth by a known midwife, more likely to have a spontaneous vaginal birth, initiate breast feeding and more stated to feel in control. In addition, their babies were more likely to have a shorter length of hospital stay. No statistically significant differences were observed in fetal loss/neonatal death of at least 24 weeks or in overall fetal/neonatal death between women who were allocated to the midwifery led care and those in the medical led care. In light of these findings, the interrelationship between social organisation of maternity care, philosophy of care and choice is explored using case examples with high and low rates of caesarean section rates. A worldwide overview of vaginal birth and caesarean section rates as indicators of normality (and lack of it) is also presented. Questions are raised with regard to the fast growing rate of caesarean section rates particularly among middle income countries. The rate of caesarean section is twice as much in private settings compared to public hospitals in these countries. In conclusion, the importance of sharing good practice among countries with particular attention to social location of midwifery, mobilisation of consumer groups as well as education of maternity health-care professionals and women, in facilitation of an effective 'informed choice', is highlighted. Areas for further global research on factors, which may influence women's choice of mode of birth are debated.     

Self‐Rated “No‐” and “Low‐” Risk Pregnancy: A Comparison of Outcomes for Women in Obstetric‐Led and Midwife‐Led Units in England

ABSTRACT: Background: Debate in the United Kingdom about place of birth often concerns obstetric‐led units and midwife‐led units and relates to notions of risk and safety. Outcomes for these two types of unit are often not comparable because of the restricted selection criteria for midwife‐led units. The purpose of this study was to compare outcomes for women intending to give birth in these different types of unit and whose self‐rated pregnancy risk level was “none” or “low.” Methods: Self‐completion questionnaires were distributed to mothers 8 days after the birth in 9 units (6 midwife led 3 obstetric led) over a 6‐month period. Results: Completed questionnaires were received from 432 women (midwife led = 294, obstetric led = 138). Mothers in midwife‐led units spent shorter times in labor in the unit (p < 0.01), received less analgesia (p < 0.01) and had fewer interventions (p < 0.01), and were more likely to have a normal delivery (p < 0.01) than women in obstetric‐led units. Similar differences were found for both primiparous and multiparous women. In terms of the number of midwives attending each woman, analysis of covariance suggested different models of care depending on type of unit (p < 0.05) and parity (p < 0.01). Conclusions: Since these mothers’ self‐rated risk level was none or low, some comparability of outcomes is permissible. It appears that models of care are significantly different in obstetric‐led units compared with midwife‐led units, leading to greater likelihood of intrapartum intervention, need for analgesia, and assisted or operative delivery. A randomized controlled trial examining such units would permit a conclusive examination of these outcomes. (BIRTH 34:4 December 2007)     

Listeriosis in pregnancy

M.G., a 24‐year‐old, healthy, gravida 2, para 1001 had an uncomplicated prenatal course, with a normal first trimester ultrasound and normal values on all routine prenatal labs. At 18 weeks' gestation, she presented to her midwife on labor and delivery complaining of severe abdominal pain and a sudden onset of fever. She was found to be febrile with a temperature of 38.5°C and tachycardic with a pulse of 120 bpm. Using Doppler ultrasound, her nurse identified fetal heart tones. Her midwife noted fetal membranes bulging into the vagina through a dilated cervix on speculum exam. M.G. received fentanyl 100 mcg intravenously for pain. The midwife paged her consulting physician who arrived within 30 minutes. Shortly thereafter, M.G. gave birth to a normally formed fetus appropriate for 18 weeks gestation. The placenta delivered within a few minutes and was sent to the pathology department for culture. The placenta was noted to have a fibrous, exudative coating. M.G. received routine postpartum care and follow‐up for a second‐trimester abortion, including grief counseling. Her febrile illness resolved spontaneously within a day following the birth. The pathology report stated that the placenta had signs of chorioamnionitis and the culture grew Listeria monocytogenes. During postpartum follow‐up, M.G. denied exposure to any of the foods known to be at high risk for L monocytogenes contamination.     

Does Team Midwife Care Increase Satisfaction with Antenatal,Intrapartum, and Postpartum Care? A Randomized Controlled Trial

Background: Although policymakers have suggested that improving continuity of midwifery can increase women's satisfaction with care in childbirth, evidence based on randomized controlled trials is lacking. New models of care, such as birth centers and team midwife care, try to increase the continuity of care and caregiver. The objective of this study was to evaluate the effect of a new team midwife care program in the standard clinic and hospital environment on satisfaction with antenatal, intrapartum, and postpartum care in low‐risk women in early pregnancy. Methods: Women at Royal Women's Hospital in Melbourne, Australia, were randomly allocated to team midwife care (n = 495) or standard care (n = 505) at booking in early pregnancy. Doctors attended most women in standard care, and continuity of the caregiver was lacking. Satisfaction was measured by means of a postal questionnaire 2 months after the birth. Results: Team midwife care was associated with increased satisfaction, and the differences between the groups were most noticeable for antenatal care, less noticeable for intrapartum care, and least noticeable for postpartum care. The study found no differences between team midwife care and standard care in medical interventions or in women's emotional well‐being 2 months after the birth. Conclusion: Conclusions about which components of team midwife care were most important to increased satisfaction with antenatal care were difficult to draw, but data suggest that satisfaction with intrapartum care was related to continuity of the caregiver.     

Outcomes of Free‐Standing,Midwife‐Led Birth Centers: A Structured Review

Abstract: Background : Over the last two decades, childbirth worldwide has been increasingly concentrated in large centralized hospitals, with a parallel trend toward more birth interventions. At the same time in several countries, interest in midwife‐led care and free‐standing birth centers has steadily increased. The objective of this review is to establish the current evidence base for free‐standing, midwife‐led birth centers. Methods : A structured review, based on Cochrane guidelines, was conducted that included nonrandomized studies. The comparative outcomes measured were rates of normal vaginal birth; cesarean section; intact perineum; episiotomy; transfers; and babies remaining with their mothers. Results : Of the 5 controlled studies that met the review criteria, all except one was a single site study. Since no study was randomized, meta‐analysis was not performed. The included studies all raised quality concerns, and significant heterogeneity was observed among them. For the outcomes measured, every study reported a benefit for women intending to give birth in the free‐standing, midwife‐led unit. Conclusions : The benefits shown for women recruited into the included studies who intended to give birth in a free‐standing, midwife‐led unit suggest a question about the efficacy of consultant unit care for low‐risk women. However, the findings cannot be generalized beyond the individual studies. Good quality controlled studies are needed to investigate these issues in the future.     

Recent Trends in Clinicians Providing Care to Pregnant Women in the United States

Introduction: Health care needs of pregnant women are met by a variety of clinicians in a changing policy and practice environment. This study documents recent trends in types of clinicians providing care to pregnant women in the United States. Methods: We used a repeat cross‐sectional design and data from the Integrated Health Interview Series (2000‐2009), a nationally representative data set, for respondents who reported being pregnant at the time of the survey (N = 3204). Using longitudinal logistic regression models, we analyzed changes over time in pregnant women's reported use of care from 1) obstetrician‐gynecologists; 2) midwives, nurse practitioners (NPs), or physician assistants (PAs); or 3) both an obstetrician‐gynecologist and a midwife, NP, or PA. Results: The percentage of pregnant women who reported seeing an obstetrician‐gynecologist (87%) remained steady from 2000 through 2009. After controlling for demographic and clinical variables, the percentage who reported receiving care from a midwife, NP, or PA increased 4% annually (yearly adjusted odds ratio [AOR] 1.04; P < .001), indicating a cumulative increase of 48% over the decade. The percentage of pregnant women who received care from both an obstetrician‐gynecologist and a midwife, NP, or PA also increased (AOR 1.027; P < .001), for a cumulative increase of 30%. Discussion: The increasing role of midwives, NPs, and PAs in the provision of maternity care suggests changes in the perinatal workforce and practice models that may promote collaborative care and quality improvement. However, better data collection is required to gather detailed information on specific provider types, these trends, and their implications.     

Patient Safety in Midwifery Care for Low‐Risk Women: Instrument Development

Introduction: Few studies have examined the safety of midwife‐led care for low‐risk childbearing women. While most women have a low‐risk profile at the start of pregnancy, validated measures to detect patient safety risks for this population are needed. The increased interest of midwife‐led care for childbearing women to substitute for other models of care requires careful evaluation of safety aspects. In this study, we developed and tested an instrument for safety assessment of midwifery care. Methods: A structured approach was followed for instrument development. First, we reviewed the literature on patient safety in general and obstetric and midwifery care in particular. We identified 5 domains of patient risk: organization, communication, patient‐related risk factors, clinical management, and outcomes. We then developed a prototype to assess patient records and, in an iterative process, reviewed the prototype with the help of a review team of midwives and safety experts. The instrument was pilot tested for content validity, reliability, and feasibility. Results: Trained reviewers with clinical midwifery expertise applied the instrument. We were able to reduce the original 100‐item screening instrument to 32 items and applied the instrument to patient records in a reliable manner. With regard to the validity of the instrument, review of the literature and the validation procedure produced good content validity. Discussion: A valid and feasible instrument to assess patient safety in low‐risk childbearing women is now available and can be used for quantitative analyses of patient records and to identify unsafe situations. Identification and analysis of patient safety incidents required clinical judgment and consultation with the panel of safety experts. The instrument allows us to draw conclusions about safety and to recommend steps for specific, domain‐based improvements. Studies on the use of the instrument for improving patient safety are recommended.     

Admission of Term Infants to Neonatal Intensive Care: A Population‐Based Study

ABSTRACT: Background: Neonatal intensive care and special care nurseries provide a level of care that is both high in cost and low in volume. The aim of our study was to determine the rate of admission of term babies to neonatal intensive care in association with each method of giving birth among low‐risk women. Methods: We examined the records of 1,001,249 women who gave birth in Australia during 1999 to 2002 using data from the National Perinatal Data Collection. Among low‐risk women, we calculated the adjusted odds of admission to neonatal intensive care at term separated for each week of gestational age between 37 and 41 completed weeks. We also calculated the odds of admission to neonatal intensive care in association with cesarean section before or after the onset of labor, and vacuum or instrumental birth compared with unassisted vaginal birth at 40 weeks’ gestation. Results: The overall rate of admission to neonatal intensive care of term babies was 8.9 percent for primiparas and 6.3 percent for multiparas. After a cesarean section before the onset of labor, the adjusted odds of admission among low‐risk primiparas at 37 weeks’ gestation were 12.08 (99% CI 8.64–16.89); at 38 weeks, 7.49 (99% CI 5.54–10.11); and at 39 weeks, 2.80 (99% CI 2.02–3.88). At 41 weeks, the adjusted odds were not significantly higher than those at 40 weeks’ gestation. Among low‐risk multiparas who had a cesarean section before the onset of labor, the adjusted odds of admission to neonatal intensive care at 37 weeks’ gestation were 15.40 (99% CI 12.87–18.43); at 38 weeks, 12.13 (99% CI 10.37–14.19); and at 39 weeks, 5.09 (99% CI 4.31–6.00). At 41 weeks’ gestation, the adjusted odds of admission were significantly lower than those at 40 weeks (AOR 0.64, 99% CI 0.47–0.88). Babies born after any operative method of birth were at increased odds of being admitted to neonatal intensive care compared with those born after unassisted vaginal birth at 40 weeks’ gestation. Conclusions: The adjusted odds of admission to neonatal intensive care for babies of low‐risk women were increased after birth at 37 weeks’ gestation. In a climate of rising cesarean sections, this information is important to women who may be considering elective procedures. (BIRTH 34:4 December 2007)     

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.     

Birth Outcomes Associated with Receipt of Group Prenatal Care Among Low‐Income Hispanic Women

Introduction: Although Hispanic women in the United States have preterm birth and low‐birth‐weight rates comparable to non‐Hispanic white women, their rates fall short of 2010 Healthy People goals, with variability found across states. This study examined the effectiveness of the CenteringPregnancy group prenatal care model in reducing preterm birth and low‐birth‐weight rates for Hispanic women. Methods: Pregnant Hispanic women at less than or equal to 20 weeks, gestation initiating prenatal care between January 2008 to July 2009 at 2 Palm Beach County, Florida, public health clinics selected either group or traditional prenatal care. Data on neonatal birth weight and gestational age were obtained through abstraction of Palm Beach County Health Department medical records. Records were abstracted for 97% of CenteringPregnancy (n = 150) and 94% of traditional care (n = 66) participants. Results: A statistically significant difference was found in the percentage of women giving birth to preterm neonates (5% group prenatal care vs 13% traditional care; P= .04). There were no statistically significant differences in the percentage of women having a low‐birth‐weight neonate when group and traditional care participants were compared. Discussion: The CenteringPregnancy model holds promise for improving the birth outcomes of Hispanic women. Future research should be conducted with larger sample sizes to replicate study findings using experimental designs and incorporating formal cost‐effectiveness analyses.     

Playing Second Fiddle Is Okay–Swedish Fathers' Experiences of Prenatal Care

Introduction: In Sweden, prospective fathers are encouraged and welcome to attend prenatal visits, and pregnant women assess their partners' involvement in prenatal care as very important. The aim of this study was to describe expectant fathers' experiences of and involvement in prenatal care in Sweden. Methods: Data were drawn from a 1‐year cohort study of 827 Swedish‐speaking fathers recruited during their partners' midpregnancy and followed up 2 months after childbirth. Results: The participants reported that the most important issues in prenatal care were the woman's physical and emotional well‐being and the support she received from her midwife. However, care was identified as deficient in nearly all aspects of information, medical care, and fathers' involvement. “Excessive” care was also reported and related to how the father was treated by the midwife, mainly in terms of attention to his emotional well‐being. Discussion: Although fathers prioritize the needs of their pregnant partners, it is important for caregivers to assess fathers' needs and incorporate a family‐oriented approach to prenatal care.     

Syphilis in pregnancy

A 28‐year‐old African American woman pregnant with her first child presented for her initial prenatal visit at 16 weeks' gestation. Her routine prenatal labs were within normal limits, except for a reactive venereal research laboratory test (VDRL) with a titer of 1:16. A fluorescent treponemal antibody‐absorption (FTA‐ABS) was requested and found to be positive. She did not have any history of syphilis and had never been tested for syphilis. She was asymptomatic, and her physical exam was within normal limits with no signs of syphilis. Tests for HIV, chlamydia, gonorrhea, and hepatitis B were all negative. A wet mount was negative for trichomonas. Based on her history, physical exam, and laboratory results, her diagnosis was syphilis of unknown duration because she had no documented VDRL in the preceding year, no history of the disease, and no symptoms. The midwife prescribed a course of benzathine penicillin 2.4 million units intramuscularly every week for 3 weeks, instructed her to refer her partner for testing and treatment, and counseled her about the potential effects of syphilis on her body and her baby. She was advised that she needed repeat serology at 6, 12, and 24 months post‐treatment. After treatment, she had a level two ultrasound, which was not suspicious for congenital syphilis. Her VDRL was repeated at 28 weeks' gestation and was nonreactive. At 40 2/7 weeks' gestation, she gave birth to a healthy baby boy with Apgar scores of 9 and 9. Initial exam of the newborn was grossly within normal limits, and his serology was nonreactive for syphilis.     

Directive Versus Supportive Approaches Used by Midwives When Providing Care During the Second Stage of Labor

Introduction: Although the risks associated with using sustained and forceful maternal bearing‐down efforts during the second stage of labor have been well documented, most women who give birth in the United States bear down in response to direction from care providers about when and how to push rather than in response to their own physiologic urges. The purpose of this study was to describe the practices used by certified nurse‐midwives/certified midwives (CNMs/CMs) in response to maternal bearing‐down efforts when caring for women in second‐stage labor and to identify factors associated with the use of supportive approaches to second‐stage labor care. Methods: A national survey of 705 CNMs/CMs was conducted using mailed questionnaires. The instrument was an 84‐item, fixed‐choice questionnaire using Likert type scales that had been validated. A 72.6% response rate was achieved, and 375 of the respondents cared for women during the second stage of labor. Results: Most CNMs/CMs (82.4%) often or almost always supported women without epidural anesthesia to initiate bearing‐down efforts only when the woman felt an urge to do so. When caring for women without an epidural, most of the respondents (67%) reported that they often or almost always supported a woman's spontaneous bearing‐down efforts without providing direction. Most participants reported using more directive practices when caring for women with epidural anesthesia. Whether caring for women with or without an epidural, most respondents (77.1% and 79.6%, respectively) often or almost always provided more direction as the fetal head emerged and the final stretching of the perineum was taking place. A change in fetal heart tones that led the midwife to believe the birth needed to occur quickly was the circumstance that had the greatest degree of influence on the participant's (90.6%) decision to provide more direction during bearing‐down efforts. Many participants indicated that they also were influenced to provide more direction when women in labor asked for more direction (73.3%) or appeared to be fatigued (74.6%). Discussion: The majority of CNMs/CMs use supportive approaches to bearing‐down efforts during second‐stage labor care and most used directive approaches as an intervention aimed at avoiding potential problems.     

Care for infants born at 23 weeks gestational age: 5 years' experience from a large medical center

Objectives: Assessing parental choice regarding care of infants born at 23 weeks' gestation.

Methods: Neonatal records review.

Results: During 2010–2014, of 26 births (33 infants), 13 families (17 newborns) conceded comfort care only with no survivors, while 13 families (16 babies) requested full medical care and three survived. With birth year, gender, multi-fetal pregnancy, assisted reproductive technology, religious background and specialization of physician counseling at delivery as independent variables, none significantly affected parental decision; yet, that decision impacted outcome.

Conclusions: Parental choice regarding infants born at 23 weeks' gestation cannot be predicted from demographics; counseling should concentrate on local experience/outcome.     

The motivation and capacity to go ‘above and beyond’: Qualitative analysis of free-text survey responses in the M@NGO randomised controlled trial of caseload midwifery

Objectiveto explore whether women allocated to caseload care characterise their midwife differently to those allocated to standard care.Designmulti-site unblinded, randomised, controlled, parallel-group trial.Settingthe study was conducted in two metropolitan teaching hospitals across two Australian cities.Populationwomen of all obstetric risk were eligible to participate. Inclusion criteria were: 18 years or older, less than 24 week’s gestation with a singleton pregnancy. Women already booked with a care provider or planning to have an elective caesarean section were excluded.Interventionsparticipants were randomised to caseload midwifery or standard care. The caseload model provided antenatal, intrapartum and postnatal care from a primary midwife or ‘back-up’ midwife; as well as consultation with obstetric or medical physicians as indicated by national guidelines. The standard model included care from a general practitioner and/or midwives and obstetric doctors.Measurements and findingsparticipants’ responses to open-ended questions were collected through a 6-week postnatal survey and analysed thematically. A total of 1748 women were randomised between December 2008 – May 2011; 871 to caseload midwifery and 877 to standard care. The response rate to the 6-week survey including free text items was 52% (n=901). Respondents from both groups characterised midwives as Informative, Competent and Kind. Participants in the caseload group perceived midwives with additional qualities conceptualised as Empowering and ‘Endorphic’. These concepts highlight some of the active ingredients that moderated or mediated the effects of the midwifery care within the M@NGO trial.Key conclusioncaseload midwifery attracts, motivates and enables midwives to go Above and Beyond such that women feel empowered, nurtured and safe during pregnancy, labour and birth.Implications for practicethe concept of an Endorphic midwife makes a useful contribution to midwifery theory as it enhances our understanding of how the complex intervention of caseload midwifery influences normal birth rates and experiences. Defining personal midwife attributes which are important for caseload models has potential implications for graduate attributes in degree programs leading to registration as a midwife and selection criteria for caseload midwife positions.     

Expanding Access to Midwifery Care: Using One Practice's Success to Create Community Change

Starting in 1991, Marin's County Certified Nurse‐Midwife‐Physician Collaborative Practice has proven to be a successful model of care for underinsured women. Functioning within the same hospital as traditional physician‐led practices, the practice displayed excellent clinical outcomes and gained respect within the community. Twenty years later, the Marin obstetric community decided to restructure its programs to incorporate the care of underinsured and privately insured women into one system. The goal was to design a system that would be patient‐centered, financially and professionally sustainable, and accessible to all women and would provide evidence‐based care with excellent outcomes. The community agreed, based on its own experience and on current literature, that continuing and expanding the midwife‐led model of care was a way to achieve these goals. Here we describe the history, practice, and outcomes of Marin's county practice and the factors that contributed to extending the availability of midwifery care to privately insured women.     

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 Model of Group Prenatal Care for Patients with Prenatally Diagnosed Fetal Anomalies

The model of group prenatal care was initially developed to include peer support and to improve education and health‐promoting behaviors during pregnancy. This model has since been adapted for populations with unique educational needs. Mama Care is an adaptation of the CenteringPregnancy Model of prenatal care. Mama Care is situated within a national and international referral center for families with prenatally diagnosed fetal anomalies. In December 2013, the Center for Fetal Diagnosis and Treatment at Children's Hospital of Philadelphia began offering a model of group prenatal care to women whose pregnancies are affected by a prenatal diagnosis of a fetal anomaly. The model incorporates significant adaptations of CenteringPregnancy in order to accommodate these women, who typically transition their care from community‐based settings to the Center for Fetal Diagnosis and Treatment in the late second or early third trimester. Unique challenges associated with caring for families within a referral center include a condensed visit schedule, complex social needs such as housing and psychosocial support, as well as an increased need for antenatal surveillance and frequent preterm birth. Outcomes of the program are favorable and suggest group prenatal care models can be developed to support the needs of patients with prenatally diagnosed fetal anomalies.     

Outcomes from extremely preterm births

Extremely preterm birth is associated with significant mortality and morbidity. Survival has improved in recent years with 29% of babies admitted for neonatal care at 23 weeks' gestation now surviving to 3 years, increasing to 78% at 26 weeks' gestation. Neurodevelopmental impairment and physical problems do however cause short and long term morbidity in survivors. Risk-lowering strategies which substantially improve outcomes include in utero transfer to a level three centre, antenatal provision of magnesium sulphate and antenatal provision of steroids. A multidisciplinary approach to managing delivery and clear communication between the obstetric and neonatal teams are essential to optimise delivery conditions.