Outcomes, safety, and resource utilization in a collaborative care birth center program compared with traditional physician-based perinatal care

An implementation analysis of a quality improvement project to reduce cesarean section in Brazilian private hospitals

BACKGROUND

Brazil has one of the highest prevalence of cesarean sections in the world. The private health system is responsible for carrying out most of these surgical procedures. A quality improvement project called Adequate Childbirth Project ("Projeto Parto Adequado"- PPA) was developed to identify models of care for labor and childbirth, which place value on vaginal birth and reduce the frequency of cesarean sections without a clinical indication. This research aims to evaluate the implementation of PPA in private hospitals in Brazil.

METHOD

Evaluative hospital-based survey, carried out in 2017, in 12 private hospitals, including 4,322 women. We used a Bayesian network strategy to develop a theoretical model for implementation analysis. We estimated and compared the degree of implementation of two major driving components of PPA-"Participation of women" and "Reorganization of care" - among the 12 hospitals and according to type of hospital (belonging to a health insurance company or not). To assess whether the degree of implementation was correlated with the rate of vaginal birth data we used the Bayesian Network and compared the difference between the group "Exposed to the PPA model of care" and the group "Standard of care model".

RESULTS

PPA had a low degree of implementation in both components "Reorganization of Care" (0.17 - 0.32) and "Participation of Women" (0.21 - 0.34). The combined implementation score was 0.39-0.64 and was higher in hospitals that belonged to a health insurance company. The vaginal birth rate was higher in hospitals with a higher degree of implementation of PPA.

CONCLUSION

The degree of implementation of PPA was low, which reflects the difficulties in changing childbirth care practices. Nevertheless, PPA increased vaginal birth rates in private hospitals with higher implementation scores. PPA is an ongoing quality improvement project and these results demonstrate the need for changes in the involvement of women and the care offered by the provider.

Vaginal Birth at Term - Part 1. Guideline of the DGGG, OEGGG and SGGG (S3-Level, AWMF Registry No. 015/083, December 2020)

Purpose This guideline aims to summarize the current state of knowledge about vaginal birth at term. The guideline focuses on definitions of the physiological stages of labor as well as differentiating between various pathological developments and conditions. It also assesses the need for intervention and the options to avoid interventions. This first part presents recommendations and statements about patient information and counselling, general patient care, monitoring of patients, pain management and quality control measures for vaginal birth. Methods The German recommendations largely reproduce the recommendations of the National Institute for Health and Care Excellence (NICE) CG 190 guideline "Intrapartum care for healthy women and babies". Other international guidelines were also consulted in specific cases when compiling this guideline. In addition, a systematic search and analysis of the literature was carried out using PICO questions, if this was considered necessary, and other systematic reviews and individual studies were taken into account. For easier comprehension, the assessment tools of the Scottish Intercollegiate Guidelines Network (SIGN) were used to evaluate the quality of the additionally consulted studies. Otherwise, the GRADE system was used for the NICE guideline and the evidence reports of the IQWiG were used to evaluate the quality of the evidence. Recommendations Recommendations and statements were formulated based on identified evidence and/or a structured consensus.

Should case management be considered a component of obstetrical interventions for pregnancies at risk of preterm birth?

Preterm birth remains the leading cause of morbidity and mortality among nonanomalous neonates in the United States. Unfortunately, preterm birth rates remain high despite current medical interventions such as progestogen supplementation and cerclage placement. Case management, which encompasses coordinated care aimed at providing a more comprehensive and supportive environment, is a key component in improving health and reducing costs in other areas of medicine. However, it has not made its way into the general lexicon and practice of obstetrical care. Case management intended for decreasing prematurity or ameliorating its consequences may include specialty clinics, social services, coordination of specialty services such as nutrition counseling, home visits or frequent phone calls by specially trained personnel, and other elements described herein. It is not currently included in nor is it advocated for as a recommended prematurity prevention approach in the American College of Obstetricians and Gynecologists or Society for Maternal-Fetal Medicine guidelines for medically indicated or spontaneous preterm birth prevention. Our review of existing evidence finds consistent reductions or trends toward reductions in preterm birth with case management, particularly among individuals with high a priori risk of preterm birth across systematic reviews, metaanalyses, and randomized controlled studies. These findings suggest that case management has substantial potential to improve the environmental, behavioral, social, and psychological factors with patients at risk of preterm birth.

A maternity care home model of enhanced prenatal care to reduce preterm birth rate and NICU use

BACKGROUND

Centers for Medicare & Medicaid Services (CMS) funded 182 US health care sites to reduce preterm birth rates by enhancing prenatal care for at-risk women. As a funded site, the enhanced prenatal care maternity care home (MCH) model was implemented from 2013 to 2018 for 1042 Medicaid-eligible pregnant women.

METHODS

This retrospective study evaluated the impact of enhanced services on preterm birth risk reduction. Certified community health workers provided enhanced services from enrollment through six weeks postpartum. Participants attending enhanced intake and third-trimester prenatal visits comprised the Active Group (N = 632). Participants missing third-trimester visits, but participating in enhanced intake and postpartum visits, comprised the Inactive Group (N = 128). Lost Group participants attended only intake visits (N = 282). Data were collected through CMS-developed intake, third-trimester, postpartum, and exit forms. Descriptive analysis, analysis of variance, and the chi-square tests analyzed the impact of risk factors, participant characteristics, and program participation on birth outcomes.

RESULTS

Active Group compared with Inactive and Lost Group participants experienced significantly lower preterm birth rates (7.64% vs 22.48% and 15.82%, P < 0.001) and therefore a significantly lower NICU admission rate compared with Inactive and Lost Groups (2.82% vs 11.85% and 5.47%, P < 0.001).

CONCLUSIONS

The MCH model of enhanced prenatal care reduced preterm birth and NICU admission rates for Active Group participants. The Black Active Group participant preterm birth rate was not significantly different than other Active Group rates, but was lower than Black Inactive and Lost Group rates.

Optimal outcome factors in maternity and newborn care for inpatient (hospital maternity ward-HMW) and outpatient deliveries (outhospital maternity clinics -OMC)

BACKGROUND AND OBJECTIVES

The aim of the study was to use the United States Optimality Index (OI-US) to assess the feasibility of its application in making decisions for more optimal methods of delivery and for more optimal postpartum and neonatal outcomes. Numerous worldwide associations support the option of women giving birth at maternity outpatient clinics and also at home. What ought to be met is the assessments of requirements and what could be characterized as the birth potential constitute the basis for making the right decision regarding childbirth.

MATERIALS AND METHODS

The study is based on a prospective follow-up of pregnant women and new mothers (100 participants) who were monitored and gave birth at the hospital maternity ward (HMW) and pregnant women and new mothers (100 participants) who were monitored and gave birth at the outhospital maternity clinics (OMC). Selected patients were classified according to the criteria of low and medium-risk and each of the parameters of the OI and the total OI were compared.

RESULTS

The results of this study confirm the benefits of intrapartum and neonatal outcome, when delivery was carried out in an outpatient setting. The median OI of intrapartum components was significantly higher in the outpatient setting compared to the hospital maternity ward (97 range from 24 to 100 vs 91 range from 3 to 100). The median OI of neonatal components was significantly higher in the outpatient compared to the inpatient delivery. (99 range from 97 to 100 vs 96 range from 74 to 100). Certain components from the intrapartum and neonatal period highly contribute to the significantly better total OI in the outpatient conditions in relation to hospital conditions.

CONCLUSION

Outpatient care and delivery provide multiple benefits for both the mother and the newborn.

Comparison of vaginal birth outcomes in midwifery-led versus physician-led setting: A propensity score-matched analysis

BACKGROUND

Experts in many countries are recommending a scaling up midwifery-led care as a model to improve maternal and newborn outcomes, reduce rates of unnecessary interventions, realise cost savings, and facilitate normal spontaneous vaginal birth.

OBJECTIVE

The aim of this study was to compare midwifery-led and obstetrician-gynaecologist-led care-related vaginal birth outcomes.

PARTICIPANTS

Pregnant women in Kaunas city maternity care facilities.

METHODS

A propensity score-matched case-control study of midwifery-led versus physician-led low-risk birth outcomes. Patient characteristics and outcomes were compared between the groups. Continuous variables are presented as mean ± standard deviation and analysed using the Mann-Whitney U test. Categorical and binary variables are presented as frequency (percentage), and differences were analysed using the chi-square test. Analyses were conducted separately for the unmatched (before propensity score matched [PSM]) and matched (after PSM) groups.

RESULTS

After adjusting groups for propensity score, postpartum haemorrhage differences between physician-led and midwifery-led labours were significantly different (169.5 and 152.6 mL; p = 0.026), same for hospital stay duration (3.3 and 3.1 days, p = 0.042). Also, in matched population, significant differences were seen for episiotomy rates (chi2 = 4.8; p = 0.029), newborn Apgar 5 min score (9.58 and 9.76; p = 0.002), and pain relief (chi2 = 14.9; p = 0.002). Significant differences were seen in unmatched but not confirmed in matched population for obstetrical procedures used during labour, breastfeeding, birth induction, newborn Apgar 1 min scores, and successful vaginal birth as an overall spontaneous vaginal birth success measure.

CONCLUSION

The midwifery-led care model showed significant differences from the physician-led care model in episiotomy rates, hospital stay duration and postpartum haemorrhage, and newborn Apgar 5 min scores. Midwifery-led care is as safe as physician-led care and does not influence the rate of successful spontaneous vaginal births.

The effect of structured delivery preparation education on birth preference

OBJECTIVE

To demonstrate the effect of the health belief model on the birth preferences of an education program that is applicable, sustainable, structured by all health personnel, and evaluating the woman as a whole, based on Bandura's Social Learning Theory.

METHODS

Our research is a controlled intervention study. Central stratified randomization was used, and each group consists of eight centers. Control and intervention groups were formed from an equal number of people, and 160 people participated in the study. The participants were given structured delivery preparation education, and breathing exercises were performed. The data of the study were evaluated using χ² test, and logistic regression analysis was used. A P value <0.05 was considered significant.

RESULTS

Forty-five (56.3%) of the responders in the control group and 60 (75.0%) of the responders in the intervention group had vaginal deliveries (p = 0.013). According to the results of multiple analyses of the factors affecting the delivery method performed by the participants, women in the control group had 2.41 times (95% confidence interval 1.07-5.41) more cesarean deliveries than women in the intervention group.

CONCLUSION

It has been shown that structured delivery preparation education increases vaginal delivery rates.

Freestanding Midwife-Led Units: A Narrative Review

Background

Strengthening of midwives' position and support for freestanding birth centers, frequently referred to as Freestanding Midwife-led Units (FMUs), raise hopes for a return to humanized labor. Our study aimed to review published evidence regarding FMUs to systematize the knowledge of their functioning and to identify potential gaps in this matter.

Materials and Methods

A structured integrative review of theoretical papers and empirical studies was conducted. The literature search included MEDLINE, Cochrane, Scopus, and Embase databases. The analysis included papers published in 1977-2017. Relevant documents were identified using various combinations of search terms and standard Boolean operators. The search included titles, abstracts, and keywords. Additional records were found through a manual search of reference lists from extracted papers.

Results

Overall, 56 out of 107 originally found articles were identified as eligible for the review. Based on the critical analysis of published data, six groups of research problems were identified and discussed, namely, 1) specifics of FMUs, 2) costs of perinatal care at FMUs, 3) FMUs as a place for midwife education, 4) FMUs from midwives' perspective, 5) perinatal, maternal, and neonatal outcomes, and 6) FMUs from the perspective of a pregnant woman.

Conclusions

FMUs offers a home-like environment and complex midwifery support for women with uncomplicated pregnancies. Although emergency equipment is available as needed, FMU birth is considered a natural spontaneous process. Midwives' supervision over low-risk labors may provide many benefits, primarily related to lower medicalization and fewer medical interventions than in a hospital setting.

Factors influencing utilisation of ‘free-standing’ and ‘alongside’ midwifery units for low-risk births in England: a mixed-methods study

Background

Midwifery-led units (MUs) are recommended for ‘low-risk’ births by the National Institute for Health and Care Excellence but according to the National Audit Office were not available in one-quarter of trusts in England in 2013 and, when available, were used by only a minority of the low-risk women for whom they should be suitable. This study explores why.

Objectives

To map the provision of MUs in England and explore barriers to and facilitators of their development and use; and to ascertain stakeholder views of interventions to address these barriers and facilitators.

Design

Mixed methods – first, MU access and utilisation across England was mapped; second, local media coverage of the closure of free-standing midwifery units (FMUs) were analysed; third, case studies were undertaken in six sites to explore the barriers and facilitators that have an impact on the development of MUs; and, fourth, by convening a stakeholder workshop, interventions to address the barriers and facilitators were discussed.

Setting

English NHS maternity services.

Participants

All trusts with maternity services.

Interventions

Establishing MUs.

Main outcome measures

Numbers and types of MUs and utilisation of MUs.

Results

Births in MUs across England have nearly tripled since 2011, to 15% of all births. However, this increase has occurred almost exclusively in alongside units, numbers of which have doubled. Births in FMUs have stayed the same and these units are more susceptible to closure. One-quarter of trusts in England have no MUs; in those that do, nearly all MUs are underutilised. The study findings indicate that most trust managers, senior midwifery managers and obstetricians do not regard their MU provision as being as important as their obstetric-led unit provision and therefore it does not get embedded as an equal and parallel component in the trust’s overall maternity package of care. The analysis illuminates how provision and utilisation are influenced by a complex range of factors, including the medicalisation of childbirth, financial constraints and institutional norms protecting the status quo.

Limitations

When undertaking the case studies, we were unable to achieve representativeness across social class in the women’s focus groups and struggled to recruit finance directors for individual interviews. This may affect the transferability of our findings.

Conclusions

Although there has been an increase in the numbers and utilisation of MUs since 2011, significant obstacles remain to MUs reaching their full potential, especially FMUs. This includes the capacity and willingness of providers to address women’s information needs. If these remain unaddressed at commissioner and provider level, childbearing women’s access to MUs will continue to be restricted.

Future work

Work is needed on optimum approaches to improve decision-makers’ understanding and use of clinical and economic evidence in service design. Increasing women’s access to information about MUs requires further studies of professionals’ understanding and communication of evidence. The role of FMUs in the context of rural populations needs further evaluation to take into account user and community impact.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 12. See the NIHR Journals Library website for further project information.

Effectiveness of a Collaborative Nursing Care Model for the Treatment of Patients with Diabetic Foot Disease by Transverse Tibial Bone Transport Technique: A Pilot Study

PURPOSE

Medical staff shortages remain a serious challenge, particularly to medical administrators. We aimed to analyze the effectiveness of a collaborative nursing care model in treatment of diabetic foot.

DESIGN

A quasi-experimental pilot study.

METHODS

Twenty-eight patients with diabetic foot treated by transverse tibial bone transport between January 2017 and March 2018 were randomized. The observational group received collaborative nursing care, while the control group received usual nursing care. Postoperative dorsal foot skin temperature, visual analog scale, self-rating anxiety scale (SAS) score, and other endpoints were assessed.

FINDINGS

Postoperative dorsal foot skin temperature was significantly higher in the observation group than in the control group. Visual analog scale and SAS scores were significantly lower in the observational group than in the control group.

CONCLUSIONS

The collaborative nursing care model enhanced collaboration between patient and health care providers, shortened hospital stay, and relieved postoperative pain and anxiety.

[New childbirth practices and the challenges for the humanization of health care in southern and southeastern Brazil]

The humanization of care in childbirth and the choice of performing cesarean or vaginal delivery have long been discussed in Brazil and worldwide. The complexities of the factors surrounding this issue range from the quality of obstetric care through to the significance of childbirth for women. A new proposal for humanization of delivery was introduced by the Brazilian Ministry of Health, the objectives of which were to make changes to the current system of delivery practices regarding, access, care, quality and resolution, in order to make it a more human and less technical experience. The Sofia Feldman Hospital, in Belo Horizonte - MG, is a benchmark in the adoption of best practices in care during childbirth, according to the Brazilian National Health Agency. However, for the humanization to become a national reality, there are still many challenges to be overcome within the public health system and the private partnerships. The most important problems are related with the current education system that continues to prepare health professionals to act in an interventional way, focused on the physician figure. This study aims to provide an overview about the different humanized care practices focused on pregnancy and childbirth, conducted in southern and southeastern Brazil.

A Planning Checklist for Interprofessional Consultations for Women in Midwifery Care

Team-based, interprofessional models of maternity care can allow women to receive personalized care based on their health needs and personal preferences. However, involvement of multiple health care providers can fragment care and increase communication errors, which are a major cause of preventable maternal morbidity and mortality. In order to improve communication within one health system, a community-engaged approach was used to develop a planning checklist for the care of women who began care with midwives but developed risks for poor perinatal outcomes. The planning checklist was constructed using feedback from women, nurses, midwives, and physicians in one interprofessional, collaborative network. In feasibility testing during 50 collaborative visits, the planning checklist provided a prompt to generate a comprehensive plan for maternity care and elucidate the rationale for interventions to women and future health care providers. In interviews after implementation of the checklist within a new collaborative format of prenatal physician consultations, women were pleased with the information received, and nurses, midwives, and physicians were positive about improved communication. This tool, developed with stakeholder input, was easy to implement and qualitatively beneficial to satisfaction and health system function. This article details the creation, implementation, and qualitative evaluation of the planning checklist. The checklist is provided and can be modified to meet the needs of other health systems.

Reduced prevalence of small-for-gestational-age and preterm birth for women of low socioeconomic position: a population-based cohort study comparing antenatal midwifery and physician models of care

OBJECTIVE

Our aim was to investigate if antenatal midwifery care was associated with lower odds of small-for-gestational-age (SGA) birth, preterm birth (PTB) or low birth weight (LBW) compared with general practitioner (GP) or obstetrician (OB) models of care for women of low socioeconomic position.

SETTING

This population-level, retrospective cohort study used province-wide maternity, medical billing and demographic data from British Columbia, Canada.

PARTICIPANTS

Our study included 57 872 pregnant women, with low socioeconomic position, who: were residents of British Columbia, Canada, carried a singleton fetus, had low to moderate medical/obstetric risk, delivered between 2005 and 2012 and received medical insurance premium assistance.

PRIMARY AND SECONDARY OUTCOME MEASURES

We report rates, adjusted ORs (aOR), and 95% CIs for the primary outcome, SGA birth (<the 10th percentile), and secondary outcomes, PTB (<37 weeks' completed gestation) and LBW (<2500 g).

RESULTS

Our sample included 4705 midwifery patients, 45 114 GP patients and 8053 OB patients. Odds of SGA birth were reduced for patients receiving antenatal midwifery versus GP (aOR 0.71, 95% CI 0.62 to 0.82) or OB care (aOR 0.59, 95% CI 0.50 to 0.69). Odds of PTB were lower for antenatal midwifery versus GP (aOR 0.74, 95% CI 0.63 to 0.86) or OB patients (aOR 0.53, 95% CI 0.45 to 0.62). Odds of LBW were reduced for midwifery versus GP (aOR 0.66, 95% CI 0.53 to 0.82) or OB patients (aOR 0.43, 95% CI 0.34 to 0.54).

CONCLUSION

Antenatal midwifery care in British Columbia, Canada, was associated with lower odds of SGA birth, PTB and LBW, for women of low socioeconomic position, compared with physician models of care. Results support the development of policy to ensure antenatal midwifery care is available and accessible for women of low socioeconomic position. Future research is needed to determine the underlying mechanisms linking midwifery care to better birth outcomes for women of low socioeconomic position.

Outcomes for the First Year of Ontario's Birth Center Demonstration Project

INTRODUCTION

In 2014, Ontario opened 2 stand-alone midwifery-led birth centers. Using mixed methods, we evaluated the first year of operations for quality and safety, client experience, and integration into the maternity care community. This article reports on our study of safety and quality of care.

METHODS

This descriptive evaluation focused on women admitted to a birth center at the beginning of labor. For context, we matched this cohort (on a 1:4 basis) with similar low-risk midwifery clients giving birth in a hospital. Data sources included Ontario's Better Outcomes Registry and Network (BORN) Information System, the Canadian Institute for Health Information, Ontario census data, and birth center records.

RESULTS

Of 495 women admitted to a birth center, 87.9% experienced a spontaneous vaginal birth, regardless of the eventual location of birth, and 7.7% had a cesarean birth. The transport rate to a hospital was 26.3%. When compared with midwifery clients with a planned hospital birth, rates of intervention (epidural analgesia, labor augmentation, assisted vaginal birth, and cesarean birth) were significantly lower in the planned birth center group, even when controlled for previous cesarean birth and body mass index. Markers of potential morbidity were identified in about 10% of birth center births; however, there were no short-term health impacts up to discharge from midwifery care at 6 weeks postpartum. Care was low in intervention and safe (minimal negative outcomes and transport rates comparable to the literature).

DISCUSSION

In the first year of operation, care was consistent with national guidelines, and morbidity and mortality rates and intervention rates were low for women with low-risk pregnancies seeking a low-intervention approach for labor and birth. Further evaluation to confirm these findings is required as the number of births grows.

Providers' Reports of Environmental Conditions and Resources at Births in the United States

Environmental conditions and resources that may influence provider's behaviors have been investigated in birth environments focusing on location rather than conditions and available resources. Using a descriptive, cross sectional design, we surveyed a random sample of certified nurse-midwives (CNMs), obstetricians, family practice physicians, and certified professional midwives (CPMs) to describe conditions, resources, and workforce present during U.S. births. In all, 1,243 midwives and physicians reported most environmental resources were present at almost 100% of births they attended. Conditions varied: room noise acceptability restriction of phone calls/texts from any source and lighting kept to a minimum. Trainees were present at most births regardless of setting and provider type. The impact of room noise, phone calls/texting, and lighting on outcomes should be determined. The roles and impact of personnel, including trainees, should be described. The extent to which clusters of resources are associated with outcomes might provide new directions for interventions that improve care.

Effects of midwife-led maternity services on postpartum wellbeing and clinical outcomes in primiparous women under China's one-child policy

BACKGROUND

The Midwife-led maternity services have been implemented in China in response to the high rates of primiparous women and Caesarean Sections (CS) which may be related to China's one-child policy. However, few studies in China have been reported on the effectiveness of Midwife-led Care at Delivery (MCD) and the Continuity of Midwife-led Care (CMC) on postpartum wellbeing and other clinical outcomes. Therefore, evidence-based clinical validation is needed to develop an optimal maternity service for childbearing women in China.

METHODS

A concurrent cohort study design was conducted with 1730 pregnant women recruited from 9 hospitals in Shanghai. Among the 1730 participants at baseline, 1568 participants completed the follow-up questionnaire, with a follow-up rate of 90.6%.

RESULTS

Compared with the routine Obstetrician-led Maternity Care (OMC), Midwife-led Care at Delivery (MCD) was associated with CS rate (OR were 0.16; 95%CI: 0.11 to 0.25) and a higher total score of postpartum wellbeing (βwere 2.70; 95%CI: 0.70 to 4.70) when adjusting for the baseline differences and other confounders during delivery or postpartum period. Moreover, continuity of Midwife-led Care (CMC) was associated with CS rate (OR were 0.30; 95%CI: 0.23 to 0.41), as well as increased rate of breastfeeding within the first 24 h (OR were 2.49; 95% CI: 1.47 to 4.23), higher postpartum satisfaction (β = 4.52; 95% CI: 1.60 to 12.68), lower anxiety (βwere 0.66; 95% CI: 0.16 to 1.17), increased self-control (βwere 0.39; 95% CI: 0.02 to 0.76) and a higher total score of postpartum wellbeing (βwere 3.14; 95% CI: 1.54 to 4.75).

CONCLUSION

CMC is the optimal service for low-risk primiparous women under China's one-child policy, and is worthwhile for a general implementation across China.

The experiences of midwives and nurses collaborating to provide birthing care: a systematic review

BACKGROUND

Collaboration has been associated with improved health outcomes in maternity care. Collaborative relationships between midwives and physicians have been a focus of literature regarding collaboration in maternity care. However despite the front line role of nurses in the provision of maternity care, there has not yet been a systematic review conducted about the experiences of midwives and nurses collaborating to provide birthing care.

OBJECTIVE

The objective of this review was to identify, appraise and synthesize qualitative evidence on the experiences of midwives and nurses collaborating to provide birthing care.Specifically, the review question was: what are the experiences of midwives and nurses collaborating to provide birthing care?

INCLUSION CRITERIA

This review considered studies that included educated and licensed midwives and nurses with any length of practice. Nurses who work in labor and delivery, postpartum care, prenatal care, public health and community health were included in this systematic review.This review considered studies that investigated the experiences of midwives and nurses collaborating during the provision of birthing care. Experiences, of any duration, included any interactions between midwives and nurses working in collaboration to provide birthing care.Birthing care referred to: (a) supportive care throughout the pregnancy, labor, delivery and postpartum, (b) administrative tasks throughout the pregnancy, labor, delivery and postpartum, and (c) clinical skills throughout the pregnancy, labor, delivery and postpartum. The postpartum period included the six weeks after delivery.The review considered English language studies that focused on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.This review considered qualitative studies that explored the experiences of collaboration in areas where midwives and nurses work together. Examples of these areas included: hospitals, birth centers, client homes, health clinics and other public or community health settings. These settings were located in any country, cultural context, or geographical location.

SEARCH STRATEGY

A three-step search strategy was used to identify relevant published and unpublished studies. English papers from 1981 onwards were considered. The following databases were searched: Anthrosource, CENTRAL (The Cochrane Library), CINAHL, EMBASE, PsycINFO, PubMed, Social Services Abstracts and Sociological Abstracts. In addition to the databases, several grey literature sources were searched.

METHODOLOGICAL QUALITY

Papers that were selected for retrieval were independently assessed for inclusion in the review by two JBI-trained reviewers. The two reviewers used a standardized critical appraisal instrument from the Joanna Briggs Institute Qualitative Assessment and Review Instrument.

DATA EXTRACTION

Qualitative data were extracted from papers included in the review using the standardized data extraction tool from the Joanna Briggs Institute Qualitative Assessment and Review Instrument.

DATA SYNTHESIS

Once qualitative studies were assessed using the the Joanna Briggs Institute Qualitative Assessment and Review Instrument critical appraisal tool, findings of the included studies were extracted. These findings were aggregated into categories according to their similarity in meaning. These categories were then subjected to a meta-synthesis to produce a comprehensive set of synthesized findings.

RESULTS

Five studies were included in the review. Thirty-eight findings were extracted from the included studies and were aggregated into five categories. The five categories were synthesized into two synthesized findings. The two synthesized findings were:Synthesized finding1: Negative experiences of collaboration between nurses and midwives may be influenced by distrust, lack of clear roles, or unprofessional or inconsiderate behavior.Synthesized finding 2: If midwives and nurses have positive experiences collaborating thenthere is hope that the challenges of collaboration can be overcome.

CONCLUSIONS

Qualitative evidence about the experiences of midwives and nurses collaborating to provide birthing care was identified, appraised and synthesized. Two synthesized findings were created from the findings of the five included studies. Midwives and nurses had negative experiences of collaboration which may be influenced by: distrust, unclear roles, or a lack of professionalism or consideration. Midwives and nurses had positive experiences of teamwork which can be a source of hope for overcoming the challenges of sharing care.There is clearly a gap in the literature about the collaborative experiences of midwives and nurses, given that only five studies were located for inclusion in the systematic review. More qualitative research exploring collaboration as a process and the interactional dynamics of midwives and nurses in a variety of practice and professional contexts is required.Distrust, unclear roles, and lack of professionalism and consideration must all be addressed. Strategies that address and minimize the occurrences of these three elements need to be developed and implemented in an effort to reduce negative collaborative experiences for midwives and nurses. Postive experiences of teamwork must be acknowleged and celebrated, and the challenges that sharing care present must be understood as a part of the collaborative process.More qualitative research is required to explore the collaborative process between midwives and nurses. Further exploration of their interactional dynamics, their relationship between power and collaboration, and the experiences of collaboration in a variety of professional and practice contexts is recommended.

Competitive effects of scope of practice restrictions: Public health or public harm?

The demand for healthcare professionals is predicted to grow significantly over the next decade. Securing an adequate workforce is of primary importance to ensure the health and wellbeing of the population in an efficient manner. Occupational licensing laws and related restrictions on scope of practice (SOP) are features of the market for healthcare professionals and are also controversial. At issue is a balance between protecting the public health and removing anticompetitive barriers to entry and practice. In this paper, we examine the case of SOP restrictions for certified nurse midwives (CNMs) and evaluate the effects of changes in states' SOP laws on markets for CNMs and on maternal and infant outcomes. We find that SOP laws are neither helpful nor harmful in regards to health outcomes but states that have no SOP-based barriers have lower rates of induced labor and Cesarean section births. We discuss the implications for state policy.

Intervention of the obstetrician during childbirth in a supposedly low-risk population and influence of parity

OBJECTIVE

Compare obstetrician intervention and calling rates during labour and delivery between low-risk and high-risk women and study the influence of parity on these rates.

MATERIAL AND METHODS

Descriptive retrospective study conducted on 227 patients in a university maternity unit (level 3 university hospital maternity unit) between 1st and 30th January 2014. The low- and high-risk populations were characterised according to the French National Authority for Health (HAS) and NICE guidelines. The obstetrician intervention criteria were: Caesarean section, instrumental vaginal delivery, artificial delivery/uterus examination and postpartum haemorrhage. The obstetrical team also had to call the obstetrician in case of foetal heart rate abnormalities, scalp blood pH measurement, third and/or fourth degree perineal tears, labour dystocia, or any other severe event occurring during labour or delivery.

RESULTS

In univariate analysis, the obstetrician intervention rates were respectively 44.5% and 34.4% in the high- and low-risk groups (P=0.13). The obstetrician calling rates were similar between the two groups. Using logistic regression model including parity, the obstetrician intervention rate became significantly higher in the "high-risk" group (OR 2.044, 95% CI 1.129-3.703, P=0.018). In the low-risk population, the intervention rate was significantly increased for nulliparous women compared with multiparas (47.5% versus 9.7%, P<0.001, OR=8.2, CI 95% 2.2 to 46.9).

CONCLUSION

One third of the women defined as low-risk patients appear to need an obstetrician intervention during labour and delivery, with a major influence of parity.

Birth Care Providers' Experiences and Practices in a Brazilian Alongside Midwifery Unit: An Ethnographic Study

The implementation of a new birthing facility in a country such as Brazil requires an extensive in-depth analysis of the challenges faced. The aim of this study was to explore beliefs, values, experiences, and practices related to the provision of birthing and neonatal care with the implementation of a new birth care facility structure called alongside midwifery units in Brazil. The study utilizes an ethnographic method to evaluate members of a Brazilian public hospital’s midwifery unit. The ethnographic study focuses on the cultural theme of “between the proposed and the possible”: the following birthing care guidelines require overcoming numerous obstacles, and four other cultural subthemes toward revealing the analyzed birth care team’s perspectives. The study found that prior training and preparation of all members of the care team, as well as the provision of adequate institutional infrastructure are essential for the implementation of a new and innovative birthing care center.

Are freestanding midwifery units a safe alternative to obstetric units for low-risk, primiparous childbirth? An analysis of effect differences by parity in a matched cohort study

Background

Intrapartum complications and the use of obstetric interventions are more common in primiparous childbirth than in multiparous childbirth, leading to concern about out of hospital birth for primiparous women. The purpose of this study was to determine whether the effect of birthplace on perinatal and maternal morbidity and the use of obstetric interventions differed by parity among low-risk women intending to give birth in a freestanding midwifery unit or in an obstetric unit in the North Denmark Region.

Methods

The study is a secondary analysis of data from a matched cohort study including 839 low-risk women intending birth in a freestanding midwifery unit (primary participants) and 839 low-risk women intending birth in an obstetric unit (individually matched control group). Analysis was by intention-to-treat. Conditional logistic regression analysis was applied to compute odds ratios and effect ratios with 95% confidence intervals for matched pairs stratified by parity.

Results

On no outcome did the effect of birthplace differ significantly between primiparous and multiparous women. Compared with their counterparts intending birth in an obstetric unit, both primiparous and multiparous women intending birth in a freestanding midwifery unit were significantly more likely to have an uncomplicated, spontaneous birth with good outcomes for mother and infant and less likely to require caesarean section, instrumental delivery, augmented labour or epidural analgesia (although for caesarean section this trend did not attain statistical significance for multiparous women). Perinatal outcomes were comparable between the two birth settings irrespective of parity. Compared to multiparas, transfer rates were substantially higher for primiparas, but fell over time while rates for multiparas remained stable.

Conclusions

Freestanding midwifery units appear to confer significant advantages over obstetric units to both primiparous and multiparous mothers, while their infants are equally safe in both settings. Our findings thus support the provision of care in freestanding midwifery units as an alternative to care in obstetric units for all low-risk women regardless of parity. In view of the global rise in caesarean section rates, we consider it an important finding that freestanding midwifery units show potential for reducing first-birth caesarean.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1208-1) contains supplementary material, which is available to authorized users.

Cesarean Outcomes in US Birth Centers and Collaborating Hospitals: A Cohort Comparison

INTRODUCTION

High rates of cesarean birth are a significant health care quality issue, and birth centers have shown potential to reduce rates of cesarean birth. Measuring this potential is complicated by lack of randomized trials and limited observational comparisons. Cesarean rates vary by provider type, setting, and clinical and nonclinical characteristics of women, but our understanding of these dynamics is incomplete.

METHODS

We sought to isolate labor setting from other risk factors in order to assess the effect of birth centers on the odds of cesarean birth. We generated low-risk cohorts admitted in labor to hospitals (n = 2527) and birth centers (n = 8776) using secondary data obtained from the American Association of Birth Centers (AABC). All women received prenatal care in the birth center and midwifery care in labor, but some chose hospital admission for labor. Analysis was intent to treat according to site of admission in spontaneous labor. We used propensity score adjustment and multivariable logistic regression to control for cohort differences and measured effect sizes associated with setting.

RESULTS

There was a 37% (adjusted odds ratio [OR], 0.63; 95% confidence interval [CI], 0.50-0.79) to 38% (adjusted OR, 0.62; 95% CI, 0.49-0.79) decreased odds of cesarean in the birth center cohort and a remarkably low overall cesarean rate of less than 5% in both cohorts.

DISCUSSION

These findings suggest that low rates of cesarean in birth centers are not attributable to labor setting alone. The entire birth center care model, including prenatal preparation and relationship-based midwifery care, should be studied, promoted, and implemented by policy makers interested in achieving appropriate cesarean rates in the United States.

Is model of care associated with infant birth outcomes among vulnerable women? A scoping review of midwifery-led versus physician-led care

This scoping review investigates if, over the last 25 years in high resource countries, midwives' patients of low socioeconomic position (SEP) were at more or less risk of adverse infant birth outcomes compared to physicians' patients. Reviewers identified 917 records in a search of 12 databases, grey literature, and citation lists. Thirty-one full documents were assessed and nine studies met inclusion criteria. Eight studies were assessed as moderate in quality; one study was given a weak rating. Of the moderate quality studies, the majority found no statistical difference in outcomes according to model of care for preterm birth, low or very low birth weight, or NICU admission. No study reported a statistically significant difference for small for gestational age birth (2 studies), or mean or low Apgar score (4 studies). However, one study found a reduced risk of preterm birth (AOR=0.70, p<0.01), and heavier mean infant birth weight (3325 g vs. 3282 g, p<0.01) for midwifery patients. Another study reported lower risk of low (RR=0.59, 95% CI: 0.46, 0.73) and very low birthweight (RR=0.44, 95% CI: 0.23, 0.85) for midwifery care. And, a third study reported a decrease in stays (1-3 days) in NICU (Adjusted Risk Difference=-1.8, 95% CI: -3.9, 0.2) for midwifery patients, though no overall difference in NICU admission of any duration. Other studies reported significant differences favoring midwifery care for mean birth weight (3598 g vs. 3407.3 g, p<0.05; 3233 g vs. 3089 g, p<0.05; 2 studies) and very low birth weight (OR=0.35, 95% CI:0.1, 0.9), for sub-groups within the larger study populations. This scoping review documented heterogeneity in study designs and analytical methods, inconsistent findings, moderate methodological quality, and lack of currency. There is a need for new studies to definitively establish if and how a midwifery-led model of care influences birth outcomes for women of low SEP.

Measuring the cost-effectiveness of midwife-led versus physician-led intrapartum teams in developing countries

International agencies have advocated scaling-up of midwifery resources as an important method for improving maternal health and reducing maternal mortality rates (MMR). The cost-effectiveness of midwife-led versus physician-led intrapartum care is an important consideration in the human resource planning required to reduce MMR. Studies suggest that midwife-led teams can achieve comparable effectiveness and outcomes using less medically intensive care compared with physician-led teams. In the absence of adequate medical cost data, decision makers should consider the substantially lower average costs for three main drivers: salaries, benefits and incentives (≥two-times lower); preservice training (three-times lower) and attrition (two-times lower) necessary to deliver intrapartum care at the level of midwife competencies. This suggests that scale-up of midwifery resources is a less expensive and more cost-effective way to reduce MMRs and could potentially increase access to skilled intrapartum care.

Low birth weight and prenatal care in Colombia: a cross-sectional study

Background

Low birth weight (LBW) is one of the most important factors affecting child morbidity and mortality worldwide; approximately one third of neonatal deaths are attributable to it. Most research and public health policy on LBW arise from developed nations, despite that most cases (96.5%) take place in developing countries. The specific features of prenatal care that prevent LBW in developing countries are unclear. This study aims to identify the characteristics of prenatal care associated with LBW in a developing country as Colombia.

Methods

Observational cross-sectional study using data from the Colombian Demographic and Health Survey 2010. A total of 10,692 children were included. Descriptive statistics were calculated, followed by bivariate regressions of LBW with all other study variables. Finally, stepwise logistic binomial regression analyses were done.

Results

A LBW prevalence of 8.7% was found. Quality of prenatal care (95%CI: 0.33, 0.92; OR = 0.55), number of prenatal visits (95%CI: 0.92, 0.93; OR = 0.92), and first prenatal visits during pregnancy (95%CI: 1.02, 1.07; OR = 1.08) were associated with LBW even after controlling for all the studied variables. The health care provider conducting prenatal checkup, and insurance coverage, were not associated with LBW.

Conclusion

This research provides information on the characteristics of prenatal care (quality, number of visits, and gestational age at first prenatal visit) which may strengthen LBW prevention in Colombia and possibly in countries with similar socioeconomic characteristics.

A multicenter, randomized, controlled trial of osteopathic manipulative treatment on preterms

Background

Despite some preliminary evidence, it is still largely unknown whether osteopathic manipulative treatment improves preterm clinical outcomes.

Materials and Methods

The present multi-center randomized single blind parallel group clinical trial enrolled newborns who met the criteria for gestational age between 29 and 37 weeks, without any congenital complication from 3 different public neonatal intensive care units. Preterm infants were randomly assigned to usual prenatal care (control group) or osteopathic manipulative treatment (study group). The primary outcome was the mean difference in length of hospital stay between groups.

Results

A total of 695 newborns were randomly assigned to either the study group (n= 352) or the control group (n=343). A statistical significant difference was observed between the two groups for the primary outcome (13.8 and 17.5 days for the study and control group respectively, p<0.001, effect size: 0.31). Multivariate analysis showed a reduction of the length of stay of 3.9 days (95% CI -5.5 to -2.3, p<0.001). Furthermore, there were significant reductions with treatment as compared to usual care in cost (difference between study and control group: 1,586.01€; 95% CI 1,087.18 to 6,277.28; p<0.001) but not in daily weight gain. There were no complications associated to the intervention.

Conclusions

Osteopathic treatment reduced significantly the number of days of hospitalization and is cost-effective on a large cohort of preterm infants.

Caesarean section and neonatal outcomes in private hospitals in Brazil: comparative study of two different perinatal models of care

This study aims at comparing caesarean section rates and neonatal outcomes of two perinatal models of care provided in private hospitals in Brazil. Birth in Brazil data, a national hospital-based cohort conducted in the years 2011/2012 was used. We analysed 1,664 postpartum women and their offspring attended at 13 hospitals located in the South-east region of Brazil, divided into a "typical"--standard care model and "atypical"--Baby-Friendly hospital with collaborative practices between nurse-midwives and obstetricians on duty to attend deliveries in an alternative labour ward. The Robson's classification system was used to compare caesarean sections, which was lower in the atypical hospital (47.8% vs. 90.8%, p<0.001). Full term birth, early skin-to-skin contact, breastfeeding in the first hour, rooming-in care, and discharge in exclusive breastfeeding were more frequent in the atypical hospital. Neonatal adverse outcome did not differ significantly between hospitals. The atypical hospital's intervention should be further evaluated since it might reduce caesarean section prevalence and increase good practices in neonatal care.

Two practice models in one labor and delivery unit: association with cesarean delivery rates

OBJECTIVE

The objective of the study was to examine the association between labor and delivery practice model and cesarean delivery rates at a community hospital.

STUDY DESGIN

This was a retrospective cohort study of 9381 singleton live births at 1 community hospital, at which women were provided labor and delivery care under 1 of 2 distinct practice models: a traditional private practice model and a midwife-physician laborist practice model. Cesarean rates were compared by practice model, adjusting for potential sociodemographic and clinical confounders. Statistical comparisons were performed using the χ(2) test and multivariable logistical regression.

RESULTS

Compared with women managed under the midwife/laborist model, women in the private model were significantly more likely to have a cesarean delivery (31.6% vs 17.3%; P < .001; adjusted odds ratio [aOR], 2.11; 95% confidence interval [CI], 1.73-2.58). Women with nulliparous, term, singleton, vertex gestations also were more likely to have a cesarean delivery if they were cared for in the private model (29.8% vs 15.9%; P < .001; aOR, 1.86; 95% CI, 1.33-2.58) as were women who had a prior cesarean delivery (71.3% vs 41.4%; P < .001; aOR, 3.19; 95% CI, 1.74-5.88).

CONCLUSION

In this community hospital setting, a midwife-physician laborist practice model was associated with lower cesarean rates than a private practice model.

Midwife-physician collaboration: a conceptual framework for interprofessional collaborative practice

INTRODUCTION

Since the passage of the Affordable Care Act, collaborative practice has been cited as one method of increasing access to care, decreasing costs, and improving efficiency. How and under what conditions might these goals be achieved? Midwives and physicians have built effective collaborative practice models over a period of 30 years. Empirical study of interprofessional collaboration between midwives and physicians could be useful in guiding professional education, regulation, and health policy in women's health and maternity care.

METHODS

Construction of a conceptual framework for interprofessional collaboration between midwives and physicians was guided by a review of the literature. A theory derivation strategy was used to define dimensions, concepts, and statements of the framework.

RESULTS

Midwife-physician interprofessional collaboration can be defined by 4 dimensions (organizational, procedural, relational, and contextual) and 12 concepts (trust, shared power, synergy, commitment, and respect, among others). The constructed framework provides the foundation for further empirical study of the interprofessional collaborative process.

DISCUSSION

The experiences of midwife-physician collaborations provide solid support for a conceptual framework of the collaborative process. A conceptual framework provides a point from which further research can increase knowledge and understanding about how successful outcomes are achieved in collaborative health care practices. Construction of a measurement scale and validation of the model are important next steps.

[Concept for a department of intensive care]

BACKGROUND

Demographic change and increasing complexity are among the reasons for high-tech critical care playing a major and increasing role in today's hospitals. At the same time, intensive care is one of the most cost-intensive departments in the hospital.

PREREQUISITES

To guarantee high-quality care, close cooperation of specialised intensive care staff with specialists of all other medical areas is essential. A network of the intensive care units within the hospital may lead to synergistic effects concerning quality of care, simultaneously optimizing the use of human and technical resources.

GOAL

Notwithstanding any organisational concepts, development and maintenance of the highest possible quality of care should be of overriding importance.

Maternal morbidity of women receiving birth center care in New South Wales: a matched-pair analysis using linked health data

BACKGROUND

Around 2 percent of women who give birth in Australia each year do so in a birth center. New South Wales, Australia's largest state, accounts for almost half of these births. Previous studies have highlighted the need for better quality data on maternal morbidity and mortality, to fully evaluate the safety of birth center care.

AIMS

This study aimed to examine maternal morbidity related to birth center care for women in New South Wales.

METHODS

A retrospective cohort study with matched-pairs was conducted using linked health data for New South Wales. Maternal outcomes were compared for women who intended to give birth in a birth center, matched with women who intended to give birth in the co-located hospital labor ward.

RESULTS

Rates of maternal outcomes, including postpartum hemorrhage, retained placenta, and postpartum infection, were significantly lower in the birth center group, after controlling for demographic and institutional factors. Interventions such as cesarean section and episiotomy were also significantly lower in these women, and the rate of breastfeeding at discharge was higher. There existed no difference in length of stay, admission to ICU, or maternal mortality.

CONCLUSIONS

Birth centers are a safe option for low-risk women; however, further research is required for some rare maternal outcomes.

Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues

Cesarean delivery is the most commonly performed surgical procedure in the United States, and cesarean rates are increasing. Working with 2009 data from 593 US hospitals nationwide, we found that cesarean rates varied tenfold across hospitals, from 7.1 percent to 69.9 percent. Even for women with lower-risk pregnancies, in which more limited variation might be expected, cesarean rates varied fifteenfold, from 2.4 percent to 36.5 percent. Thus, vast differences in practice patterns are likely to be driving the costly overuse of cesarean delivery in many US hospitals. Because Medicaid pays for nearly half of US births, government efforts to decrease variation are warranted. We focus on four promising directions for reducing these variations, including better coordinating maternity care, collecting and measuring more data, tying Medicaid payment to quality improvement, and enhancing patient-centered decision making through public reporting.

Maternal Obesity and the First Birth: A Case for Targeted Contemporary Maternity Care

BACKGROUND: Obesity in childbearing women is associated with poorer pregnancy and birth outcomes, particularly caesarean section, compared with normal-weight women. The high caesarean section rate may reflect care and outcomes which occur at the time surrounding the first birth.

AIM: To describe the birth outcomes of extremely obese pregnant women (body mass index [BMI] of 40 or more) experiencing their first birth.

METHODS: Clinical audit was used to systematically review the care and birth outcomes of all extremely obese pregnant women experiencing their birth at one study site during a 2-year period in 2009 and 2010. Fifty participants birthed during the study period. Data were collected from booking to discharge from the maternity service and included variables such as model of care, number of appointments, and obstetric and neonatal outcomes. Descriptive statistics were used to describe and synthesize the data. Inferential statistics were used to draw inferences about the population.

RESULTS: Obese women rarely had contact with a midwife, except at booking, receiving a standard model of care provided by numerous caregivers, most often inexperienced medical staff. More than half of the obese women experienced a caesarean section (56%), 2.3 times that of normal-weight primiparous women who birthed at the study site during the same period (24.2%). This was despite 64% experiencing normal pregnancy free from any complication. For women who planned to labor, birth intervention including induction of labor, augmentation for slow labor, epidural, and continuous cardiotocography was high. Caesarean occurred most often for “failure to progress” and “failed induction.”

CONCLUSION: Clinical audit was useful in determining information, which suggests current maternity care provision is not meeting the needs of extremely obese women experiencing their first birth.

IMPLICATIONS FOR PRACTICE: The development of effective, targeted antenatal care designed to meet the needs of extremely obese women is recommended as are strategies to keep birth normal.

A midwifery-led in-hospital birth center within an academic medical center: successes and challenges

The University of California San Diego Community Women's Health Program (CWHP) has emerged as a successful and sustainable coexistence model of women's healthcare. The cornerstone of this midwifery practice is California's only in-hospital birth center. Located within the medical center, this unique and physically separate birth center has been the site for more than 4000 births. With 10% cesarean delivery and 98% breast-feeding rates, it is an exceptional example of low-intervention care. Integrating this previously freestanding birth center into an academic center has brought trials of mistrust and ineffectual communication. Education, consistent leadership, and development of multidisciplinary guidelines aided in overcoming these challenges. This collaborative model provides a structure in which residents learn to be respectful consultants and appreciate differences in medical practice. The CWHP and its Birth Center illustrates that through persistence and flexibility a collaborative model of maternity services can flourish and not only positively influence new families but also future generations of providers.

Physician-led, hospital-linked, birth care centers can decrease cesarean section rates without increasing rates of adverse events

BACKGROUND

This study compares outcomes at a hospital-linked, physician-led, birthing center to a traditional hospital labor and delivery service.

METHODS

Using de-identified electronic medical records, a retrospective cohort design was employed to evaluate 32,174 singleton births during 1998-2005.

RESULTS

Compared with hospital service, birth care center delivery was associated with a lower rate of cesarean sections (adjusted Relative Risk = 0.73, 95% confidence interval 0.59-0.91; p < 0.001) without an increased rate of operative vaginal delivery (adjusted Relative Risk = 1.04, 95% confidence interval 0.97-1.13; p = 0.25) and a higher initiation of breastfeeding (adjusted Relative Risk = 1.28, 95% confidence interval 1.25-1.30; p ≤ 0.001). A maternal length of stay greater than 72 hours occurred less frequently in the birth care center (adjusted Relative Risk = 0.60, 95% confidence interval 0.55-0.66; p < 0.001). Comparing only women without major obstetrical risk factors, the differences in outcomes were reduced but not eliminated. Adverse maternal and infant outcomes were not increased at the birth care center.

CONCLUSION

A hospital-linked, physician-led, birth care center has the potential to lower rates of cesarean sections without increasing rates of operative vaginal delivery or other adverse maternal and infant outcomes.