A comparison between midwifery and obstetric care at birth in Spain: Across-sectional study of perinatal outcomes

Analysis of Maternal Positions during the Dilation and Expulsive Phase and Their Relationship with Perineal Injuries in Eutocic Deliveries Attended by Midwives

This cross-sectional descriptive study aimed to analyze the relationship between maternal positions during the expulsion phase and perineal outcomes in 367 eutocic births attended by midwives or midwifery residents at a public hospital in northern Spain in 2018. A total of 94.3% of women opted for horizontal positions. Limited sacral retroversion was observed in 71.7%, potentially influencing perineal outcomes. A low incidence of tears indicated effective management during the expulsive phase, with an episiotomy rate of 15.3%, which was slightly above the 15% standard. Primiparity and maternal age were identified as risk factors associated with episiotomy. Additionally, sacral mobilization and vertical positions during delivery were significantly related to fewer perineal injuries, suggesting benefits for both mother and newborn. The correlation between maternal positions and the need for epidural analgesia highlighted the importance of considering these in pain management during childbirth. Despite limitations, the study provides valuable insight into obstetric practices and advocates for a woman-centered approach that respects autonomy during childbirth. Further research is needed to explore biomechanical parameters and enhance childbirth experiences.

Differences in rates of severe perineal trauma between midwife-led and obstetrician-led care in the Netherlands: A nationwide cohort study

Objective

To investigate trends and rates of severe perineal trauma (SPT), also known as obstetric anal sphincter injury (OASI), between midwife-led and obstetrician-led care in the Netherlands, and factors associated with SPT.

Methods

This nationwide cohort study included registry data from 2000 to 2019 (n = 2,169,950) of spontaneous vaginal births of term, live, cephalic, single infants, without a (previous) caesarean section or assisted vaginal birth.First, trends of SPT and episiotomy were shown. Second, differences in SPT rates between midwife- and obstetrician-led care were assessed. Third, associations of care factors with SPT were examined. Multivariable logistic regression analyses were used to determine which factors were important in the associations. All outcomes were stratified for parity.

Results

Over time, the SPT incidence increased mainly in midwife-led care and episiotomy rates decreased. Compared to midwife-led care, SPT rates were lower in obstetrician-led care among primiparous women (aOR 0.78; 99 % CI 0.74-0.81) and comparable among multiparous women (aOR 1.04; 99 % CI 0.99-1.10). Among women without epidural analgesia, these differences were smaller for primiparous women (aOR 0.88; 99 % CI 0.84-0.92), but the SPT rate was higher in obstetrician-led care among multiparous women (aOR 1.09; 99 % CI 1.03-1.15). Among women without shoulder dystocia, induction, augmentation, and pain medication, SPT rates were comparable among primiparous women, but higher among multiparous women in obstetrician-led care. In midwife-led care, SPT occurred more often among hospital versus home births. In obstetrician-led care, lower SPT incidences were found among births with epidural analgesia and for multiparous women with induction or augmentation.

Conclusions

Iinduction, augmentation, and epidural analgesia in obstetrician-led care may be an explanatory factor for the higher incidence of SPT among primiparous women in midwife-led care. More research is needed to explain differences in SPT rates and to understand how SPT can be prevented, while maintaining a high intact perineum rate.

The outcomes for women planning a VBAC at a private hospital in Australia

BACKGROUND

Rates of cesarean birth (CBs) are steadily increasing and account for 36.7% of all births in New South Wales (NSW), with primary cesareans driving the increase. NSW Health guidelines recommend women attempt a vaginal birth after a previous CB (VBAC); however, rates of VBAC are decreasing, particularly within the private hospital setting. This study aimed to determine the rates of adverse outcomes for women who planned a VBAC (pVBAC) compared with women who planned an elective repeat CB (pERCB) at one private hospital in Sydney, Australia.

METHOD

This retrospective data review evaluated patient records over a 10-year period (2010-2019). Records (n = 2039) were divided into four groups: pVBAC, pVBAC + EMCB, labor + ERCB (lab + ERCB), and pERCB. The incidence of adverse maternal and neonatal outcomes is reported as counts and percentages. Regression and chi-squared tests were used to compare groups. Significance was determined at a p-value of <0.05.

RESULTS

Overall, very low rates (N = 148, 7.3%) of women had a VBAC compared with a repeat CB at this private hospital over the 10-year period. The incidence of adverse outcomes was low regardless of study group. Outcomes differed significantly between groups for postpartum hemorrhage (pERCB seven times less likely than VBAC group) and special care nursery admission (pVBAC + EMCB is 4.6 times more likely than in the VBAC group).

CONCLUSION

Overall, it is safe to attempt a VBAC at this private hospital, and labor after a cesarean should be recommended, yet very few women had a VBAC at the study site. The incidence of adverse outcomes was low compared with other published research.

Expanding midwifery care in the United States: Implications for clinical outcomes and cost

BACKGROUND

This study compared clinical and financial outcomes for low-risk birthing people between those attended by midwives and those attended by obstetricians during hospital births.

METHODS

We conducted a retrospective cohort analysis of births from January 1, 2016 to December 31, 2020 at hospitals participating in a perinatal quality improvement collaborative, Obstetrical Care Outcomes Assessment Program (OB COAP), in the Northwest region of the United States and estimated risk ratios using a multivariate regression approach with a modified Poisson binomial for mode of delivery, labor interventions, and newborn outcomes comparing midwife-led to obstetrician-led care. Using publicly available data on average costs of vaginal and cesarean births, we then extrapolated the cost differences in care between midwives and obstetricians.

RESULTS

Births in the midwife group were less likely to be associated with induction (17.6% vs. 20.3% RR 0.74; 95% CI 0.70-0.78), epidural use (58.9% vs. 76.3% RR 0.78; 95% CI 0.77-0.80), and episiotomy (2.2% vs. 3.4% RR 0.68; 95% CI 0.58-0.81). Cesarean birth was also lower in the midwifery group (7.8% vs. 12.3% RR 0.68, 95% CI 0.62-0.73), without a corresponding increase in risk in adverse neonatal outcomes. We estimated that expanding midwifery care to 100% of low-risk births across the United States could save as much as $340 million per year.

CONCLUSIONS

Midwifery care is associated with a lower risk of cesarean birth and other interventions versus care provided by obstetricians and is therefore likely lower-cost.

Assessment of the Quality of Obstetric Services From the Perspective of Maternity Patients and Service Providers in a Tertiary Care Obstetric Unit in Lithuania

Although largely focused on the patient, the provision of healthcare services is a 2-way process and its success hinges on the interactions between patients and physicians. Given the growing role of subjective, patient-dependent assessment of the quality of care received, which is increasingly influenced by the individual aspects of the interaction between patients and care providers, in addition to the explicitly measurable, objective assessment of the quality of care received based on clinical indicators, quality assessment of services should especially consider and explore the attitudes, needs and dynamics of all the parties involved in the healthcare process. This study was designed to assess the attitudes of maternity patients and healthcare providers towards the quality of obstetric care. A quantitative questionnaire survey was conducted in a tertiary level healthcare facility providing obstetric services in Lithuania. Research findings suggested that maternity patients rate both the technical and functional quality of obstetric services higher than the staff providing it. Midwives and obstetricians-gynaecologists view quality assurance as a complex process, rather than focus solely on quantitative indicators. Since midwives were rated slightly higher than physicians in terms of services they provide, it may be appropriate to ensure and encourage a wider use of midwife-only deliveries in low-risk births. A comprehensive assessment of the quality assurance aspects as viewed by the patients and the staff should be included in the regular quality assessments of healthcare facilities as one of the most informative assessment tools on the service quality.

Cross-Cultural Adaptation and Validation of the Perceptions of Empowerment in Midwifery Scale in the Spanish Context (PEMS-e)

Midwifery empowerment is an important topic. The most widely used instrument to measure the perceived empowerment of midwives is the Perceptions of Empowerment in Midwifery Scale (PEMS), which has not been validated in Spain. The aim of this study was to translate and adapt the PEMS to the Spanish context. This research was carried out in two phases; Phase 1: Methodological study; translation, backtranslation and cross-cultural adaptation of the PEMS and pilot study on the target population (10 midwives) for evaluation of face validity. Phase 2: Cross-sectional observational study to obtain a sample for construct validation by Exploratory Factor Analysis and measurement of PEMS-e reliability. Additionally, an inferential analysis was carried out to study the possible association between several collected variables and PEMS-e subscale-scores. A total of 410 midwives from 18 Spanish regions participated in the study through an online questionnaire. An initial Spanish version of the PEMS scale was produced, demonstrating adequate face validity. A final model was produced for the PEMS-e, which included 17 items classified into two subscales ("Organizational support" and "Own skills and teamwork") with fit indexes RMSEA = 0.062 (95%CI: 0.048-0.065) and AGFI = 0.985 (95%CI: 0.983-0.989) and Cronbach's alpha 0.922 for the total scale. Results showed that one in four midwives had considered abandoning the profession in the last 6 months (p ≤ 0.001). This research suggests that Spanish midwives perceive their empowerment level as low. The PEMS-e is a valid tool with solid psychometric properties that can be used in future research to identify factors that contribute to increased empowerment among Spanish midwives and inform strategies to improve job satisfaction and retention in the profession.

Individual and country-level variables associated with the medicalization of birth: Multilevel analyses of IMAgiNE EURO data from 15 countries in the WHO European region

OBJECTIVE

To investigate potential associations between individual and country-level factors and medicalization of birth in 15 European countries during the COVID-19 pandemic.

METHODS

Online anonymous survey of women who gave birth in 2020-2021. Multivariable multilevel logistic regression models estimating associations between indicators of medicalization (cesarean, instrumental vaginal birth [IVB], episiotomy, fundal pressure) and proxy variables related to care culture and contextual factors at the individual and country level.

RESULTS

Among 27 173 women, 24.4% (n = 6650) had a cesarean and 8.8% (n = 2380) an IVB. Among women with IVB, 41.9% (n = 998) reported receiving fundal pressure. Among women with spontaneous vaginal births, 22.3% (n = 4048) had an episiotomy. Less respectful care, as perceived by the women, was associated with higher levels of medicalization. For example, women who reported having a cesarean, IVB, or episiotomy reported not feeling treated with dignity more frequently than women who did not have those interventions (odds ratio [OR] 1.37; OR 1.61; OR 1.51, respectively; all: P < 0.001). Country-level variables contributed to explaining some of the variance between countries.

CONCLUSION

We recommend a greater emphasis in health policies on promotion of respectful and patient-centered care approaches to birth to enhance women's experiences of care, and the development of a European-level indicator to monitor medicalization of reproductive care.

“Mix of Races, Bad Uterus”: Obstetric Violence in the Experiences of Afro-Brazilian Migrants in Portugal

In this article, I address the issues of obstetric violence and racism in the Portuguese setting of obstetric care. Based on data collected through interviews and participatory artistic creation, I analyze the perception of three Afro-Brazilian migrants about their perinatal experiences of obstetric care in the Portuguese public sector between 2013 and 2019. These women’s experiences have much in common with experiences of obstetric violence as narrated by Portuguese, non-racialized women. Despite this, certain aspects of their experience are related to their particular identification as Brazilian, migrant, and Black, such as xenophobic discrimination and their placement in systems of stratified reproduction, including a supposed tendency for birth by caesarean section, as well as self-policing behaviors because of the stereotype of Brazilian women as flirty. I consider a range of manifestations of obstetric violence and racism, from more overt forms to more covert ones, to analyze how, in a country where racism and obstetric violence are only slowly beginning to be recognized as the norm, multiple discriminations intersect and have an impact on the experiences of women of their bodies in pregnancy, birth, and postpartum, including breastfeeding.