Birth centre confinement at the Queen Victoria Medical Centre. I. Obstetric and neonatal outcome

Obstetric risks and outcomes: birth centre compared with conventional labour ward

Birth centres in Australia provide an option for women and their professional advisors when choosing the setting for childbirth. It is important that empirical information about the risks is available to enable informed decisions to be made. The purpose of this study was to compare the obstetric outcomes for women admitted to the Birth Centre at Royal Hospital for Women in Sydney with outcomes for women admitted to the conventional labour ward, controlling for prenatal and intrapartum risk. The findings indicate that, with the existing back-up provided by the conventional service, the outcomes for women admitted to the Birth Centre were at least as good as those of the other women. The study also shows that there are differences between the two settings in the management of the intrapartum period. The rate of intervention is substantially higher for women admitted to the Labour Ward, after risk is taken into consideration. The evaluation indicates that the Birth Centre offers a viable choice for women with relatively low obstetric risk.

A systematic review comparing continuity of midwifery care with standard maternity services

OBJECTIVE

To review randomised controlled trials of alternative maternity services characterised by continuity of midwifery care.

METHODS

A systematic review of randomised controlled trials, analysed on an intention to treat basis, in which the study intervention was characterised by a midwife or small group of midwives providing care from early pregnancy to the postnatal period (defined as that provided on the postnatal ward); and the controls by standard maternity care as practised in the place where the trial was conducted. The seven trials identified included 9148 women. Main outcome measures were interventions during labour, maternal outcomes and infant outcomes.

RESULTS

The alternative models with continuity of midwifery care were associated with less use of obstetric interventions during labour (eg, induction, augmentation of labour, electronic fetal monitoring, obstetric analgesia, instrumental vaginal delivery and episiotomy). However, the caesarean section rate did not differ statistically between the trial groups (OR 0.91; 95% CI 0.78 to 1.05). The lower episiotomy rate in the alternative models of care (OR 0.69; 95% CI 0.61 to 0.77) was associated with a significantly higher rate of perineal tears in the pooled alternative groups (OR 1.15; 95% CI 1.05 to 1.26). The percentage of intact perineums was very similar for the two groups (OR 1.11; 95% CI 1.00 to 1.24). There was no maternal death, and rates of maternal complications based on unpooled estimates did not show any statistically significant differences. The proportion of babies with an Apgar score < 7 at five minutes after the birth was approximately the same in the pooled alternative groups as in the control groups (OR 1.13 95% CI 0.69 to 1.84). Admission to intensive care or special care baby unit was similar (OR 0.86; 95% CI 0.71 to 1.04). The difference in perinatal deaths was bordering on statistical significance (OR 1.60; 95% CI 0.99 to 2.59).

CONCLUSION

Continuity of midwifery care is associated with lower intervention rates than standard maternity care. No statistically significant differences were observed in maternal and infant outcomes. However, more research is necessary to make definite conclusions about safety, for the infant as well as for the mother. This review illustrates the variation in the different models of alternative and standard maternity care, and thus the problems associated with pooling data from different trials.

Women's satisfaction with antenatal and postnatal care: an analysis of individual and organisational factors

A local study of consumer views of maternity services was initiated because of major shifts in the patterns of maternity service provision and use in a metropolitan region. Women who had given birth to a live infant at one of four hospitals in and near the region in the 1991 calendar year were surveyed about their satisfaction with their antenatal and postnatal care. Questionnaires were sent to 866 women and 519 responded, for an overall response rate of 62 per cent; in the second stage of the study, in-depth interviews were conducted with 50 of the women. Analyses were conducted according to the hospital and to individual sociodemographic characteristics. There were statistically significant differences in satisfaction according to women's sociodemographic characteristics and the type of hospital at which they gave birth. Women who were best off in terms of economic, educational and other social resources reported the highest levels of satisfaction. Analyses by hospital revealed important differences between different types of public hospital, and between public and private hospitals. The results suggest that changing some of the organisational features of antenatal and postnatal care provision may make a significant difference to women's experience of, and satisfaction with, maternity services; most of the organisational changes identified suggest an enhanced or extended role for midwives in the provision of antenatal and postnatal services.

Continuity of care by a midwife team versus routine care during pregnancy and birth: a randomised trial

OBJECTIVE

To compare continuity of care from a midwife team with routine care from a variety of doctors and midwives.

DESIGN

A stratified, randomised controlled trial.

PARTICIPANTS AND SETTING

814 women attending the antenatal clinic of a tertiary referral, university hospital.

INTERVENTION

Women were randomly allocated to team care from a team of six midwives, or routine care from a variety of doctors and midwives.

MAIN OUTCOME MEASURES

Antenatal, intrapartum and neonatal events; maternal satisfaction; and cost of treatment.

RESULTS

405 women were randomly allocated to team care and 409 to routine care; they delivered 385 and 386 babies, respectively. Team care women were more likely to attend antenatal classes (OR, 1.73; 95% CI, 1.23-2.42); less likely to use pethidine during labour (OR, 0.32; 95% CI, 0.22-0.46); and more likely to labour and deliver without intervention (OR, 1.73; 95% CI, 1.28-2.34). Babies of team care mothers received less neonatal resuscitation (OR, 0.59; 95% CI, 0.41-0.86), although there was no difference in Apgar scores at five minutes (OR, 0.86; 95% CI, 0.29-2.57). The stillbirth and neonatal death rate was the same for both groups of mothers with a singleton pregnancy (three deaths), but there were three deaths (birthweights of 600 g, 660 g, 1340 g) in twin pregnancies in the group receiving team care. Team care was rated better than routine care for all measures of maternal satisfaction. Team care meant a cost reduction of 4.5%.

CONCLUSION

Continuity of care provided by a small team of midwives resulted in a more satisfying birth experience at less cost than routine care and fewer adverse maternal and neonatal outcomes. Although a much larger study would be required to provide adequate power to detect rare outcomes, our study found that continuity of care by a midwife team was as safe as routine care.

Women's satisfaction with birth center care: a randomized, controlled study

This randomized, controlled trial compared women's satisfaction with care at an in-hospital birth center with standard obstetric care in Stockholm. Subjects were 1230 women with an expected date of birth between October 1989 and February 1992, who expressed interest in birth center care, and who were medically low risk. The intervention was the random allocation of maternity care at the birth center or standard obstetric care. Birth center women expressed greater satisfaction with antenatal, intrapartum, and postpartum care, especially psychological aspects of care. Of these women, 63 percent thought that the antenatal care had raised their self-esteem, versus 18 percent of the control group. Eighty-nine percent of the experimental group would prefer birth center care for any future birth, and 46 percent of the control group would prefer standard care. Birth center care successfully meets the needs of women who are interested in natural childbirth and active involvement in their own care, and are concerned about the psychological aspects of birth.

The safety of team midwifery: the first decade of the Monash Birth Centre

OBJECTIVE

To review the safety of team midwifery care, in terms of perinatal mortality, for pregnant women assessed at their first visit as being at low risk of complications.

DESIGN

A cohort study.

SETTING

Team midwifery unit (Birth Centre) in a tertiary hospital.

PATIENTS

All women who made a booking and met the selection criteria at their first antenatal visit (3085), excluding those with spontaneous or induced fetal loss before 20 weeks (89) and those who withdrew at their own request to seek an alternative form of care (138); the 2858 remaining women gave birth to 2874 infants.

MAIN OUTCOME MEASURES

Perinatal mortality rate; and birthweight specific perinatal mortality ratio with reference values being specific rates for birthweight in Victoria for 1984-1985.

RESULTS

The perinatal mortality rate was 7.7 per 1000 births (95% confidence interval [CI] 4.8-11.6) for the whole cohort; for women beginning labour in the Birth Centre it was 1.3 per 1000 births (95% CI, 0.3-3.9). The birthweight standardised perinatal mortality ratio was 80 (95% CI, 50-122).

CONCLUSION

Within this setting, with explicit criteria for booking and referral, and a framework for consultation, team midwifery care is as safe as the standard maternity care provided within the State.

Birth centre confinement at the Queen Victoria Medical Centre: four years' experience

A review of the first four years of the functioning of the birth centre at the Queen Victoria Medical Centre is presented. In that time, 1040 pregnant women were accepted for confinement there. Of these, 52 withdrew for non-obstetric reasons, while 470 were transferred to alternative obstetrical care--274 because of antepartum complications and 196 because of intrapartum problems. Therefore, 518 women were delivered in the birth centre. The care of the women is entrusted almost entirely to a team of midwives and this review demonstrates an enviable safety record.

Family births at the Royal Women's Hospital, Melbourne

A controlled study comparing clinical aspects of birthing unit confinement with orthodox obstetric care in a major obstetric hospital is detailed. The results confirm that this centre provides an acceptable and safe alternative for those who desire such an environment.