First alongside midwifery led unit in a high complexity public hospital in Spain: Maternal and neonatal outcomes

PROBLEM

Midwifery led units are rare in Spain.

BACKGROUND

Midwife-Led Care (MLC) is a widely extended model of care and, within this, the alongside midwifery-led units (AMLU) are those hospital-based and located in close connection with obstetric units. In Spain, CL is the first center belonging to the National Health System of these characteristics.

AIM

To evaluate the first year of activity of this pioneering unit.

METHODS

An observational cross-sectional study was carried out to assess maternal and neonatal outcomes of births facilitated at CL by comparing with those births that fulfilled the criteria to be admitted at the AMLU but were assisted at the standard obstetric care unit of the hospital.

FINDINGS

174 (20,3%) women and birthing people decided to give birth at CL, whereas 684 (79,7%) gave birth at the Obstetric Unit of the Hospital. Women assisted at the AMLU had lower intervention rates (episiotomy, epidural analgesia) and a higher rate of breastfeeding practice. There were no statistical differences in maternal outcomes (postpartum hemorrhage, third-or-four-degree laceration) or neonatal outcomes (Apgar< 7 at 5 min; birth weight < 2500 gr; macrosomia; shoulder dystocia, neonatal care transfer).

DISCUSSION

There were differences in transfers from MLU to OU between nulliparous and multiparous; the main reason for transfer is the request for analgesia. Epidural analgesia should be considered when analyzing maternal outcomes.

CONCLUSION

An alongside midwifery-led unit is a safe option with a low incidence of complications. This model of care can be positively implemented at the Public Healthcare System.

Perceptions of quality of care in Midwife-led Birth Centres (MLBCs) in Uganda: Why do women choose MLBCs over other options?

BACKGROUND

Midwife-led birth centres (MLBCs) are associated with reduced childbirth interventions, higher satisfaction rates, and improved birth outcomes. The evidence on quality of care in MLBCs from low and middle-income countries (LMIC) is limited.

AIM

This study aimed to explore the perceptions of women and midwives regarding the quality of care in four MLBCs in Uganda.

METHODS

A qualitative study was conducted in four MLBCs in Uganda. We conducted interviews with women and midwives in the MLBCs to explore their perceptions and experiences related to care in the MLBCs. The study obtained ethical approval. Deductive thematic analysis was used for data analysis.

RESULTS

Three key themes were identified regarding the perceptions of women and midwives about the quality of care in the MLBCs: providing respectful, and dignified care; a focus on woman-centred care; and reasons for choosing care in the MLBC. Women valued the respectful and humane care characterised by dignified and non-discriminatory care, non-abandonment, privacy, and consented care. The woman-centred care in the MLBC involved individualised holistic care, providing autonomy and empowerment, continuity of care, promoting positive birth experience, confidence in the woman's own abilities, and responsive providers. Women chose MLBCs because the services were perceived to be available, accessible, affordable, with comprehensive and effective referral mechanisms.

CONCLUSION

Women perceived care to be respectful, woman-centred, and of good quality. Global attention should be directed to scaling up the establishment of MLBCs, especially in LMIC, to improve the positive childbirth experience and increase access to care.

A prospective observational cohort study

PROBLEM

It is yet unknown whether shifting antenatal cardiotocography (aCTG) from obstetrician-led to midwife-led care leads to a safe reduction in referrals.

BACKGROUND

ACTG is used to assess fetal well-being. In the Netherlands, the procedure has until now been performed as part of obstetrician-led care. Developments in E-health facilitates the performance of aCTG outside the hospital in midwife-led care, hereby increasing continuity of care.

AIM

To evaluate 1) process outcomes of implementing aCTG for specific indications in primary midwife-led care; 2) maternal and perinatal outcomes of pregnant women receiving aCTG in midwife-led care; 3) serious adverse events (with outcomes, causes, avoidability, and potential prevention strategies) that have occurred during the innovation project 'aCTG in midwife-led care'.

METHODS

Prospective observational cohort study and a case series study of serious adverse events.

FINDINGS

A total of 1584 pregnant women with a specific aCTG indication were included in this cohort study for whom 1795 aCTGs were performed in midwife-led care. 1591 aCTGs(89.7%) were classified as reassuring. Referral to obstetrician-led care occurred for 234 women(13.0%) after an aCTG in midwife-led care of whom 202(86%) were referred back. Severe neonatal morbidity occurred in 27 neonates (1.7%). In the 5736 aCTGs included in the case series study, one case with a serious neonatal outcome was assessed as a serious adverse event attributable to human factors.

DISCUSSION

ACTGs performed in midwife-led care increased continuity of care. In this innovation project, maternal and perinatal outcomes were in the expected range for women in midwife-led care.

Costs and intermediate outcomes for the implementation of evidence-based practices of midwifery under a MIDWIZE framework in an urban health facility in Nairobi, Kenya

BACKGROUND

Three evidence-based midwife-led care practices: dynamic birth positions (DBP), immediate skin-to-skin contact (SSC) with zero separation between mother and newborn, and delayed cord clamping (DCC), were implemented in four sub-Saharan African countries after an internet-based capacity building program for midwifery leadership in quality improvement (QI). Knowledge on costs of this QI initiative can inform resource mobilization for scale up and sustainability.

METHODS

We estimated the costs and intermediate outcomes from the implementation of the three evidence-based practices under the midwife-led care (MIDWIZE) framework in a single facility in Kenya through a pre- and post-test implementation design. Daily observations for the level of practice on DBP, SSC and DCC was done at baseline for 1 week and continued during the 11 weeks of the training intervention. Three cost scenarios from the health facility perspective included: scenario 1; staff participation time costs ($515 USD), scenario 2; staff participation time costs plus hired trainer time costs, training material and logistical costs ($1318 USD) and scenario 3; staff participation time costs plus total program costs for the head trainer as the QI leader from the capacity building midwifery program ($8548 USD).

RESULTS

At baseline, the level of DBP and SSC practices per the guidelines was at 0 % while that of DCC was at 80 %. After 11 weeks, we observed an adoption of DBP practice of 36 % (N = 111 births), SSC practice of 79 % (N = 241 births), and no change in DCC practice. Major cost driver(s) were midwives' participation time costs (56 %) for scenario 1 (collaborative), trainers' material and logistic costs (55 %) in scenario 2(collaborative) and capacity building program costs for the trainer (QI lead) (94 %) in scenario 3 (programmatic). Costs per intermediate outcome were $2.3 USD per birth and $0.5 USD per birth adopting DBP and SSC respectively in Scenario 1; $6.0 USD per birth adopting DBP and $1.4 USD per birth adopting SSC in Scenario 2; $38.5 USD per birth adopting DBP and $8.8 USD per birth adopting SSC in scenario 3. The average hourly wage of the facility midwife was $4.7 USD.

CONCLUSION

Improving adoption of DBP and SSC practices can be done at reasonable facility costs under a collaborative MIDWIZE QI approach. In a programmatic approach, higher facility costs would be needed. This can inform resource mobilization for future QI in similar resource-constrained settings.

Maternal health leaders' perceptions of barriers to midwife-led care in Ethiopia, Kenya, Malawi, Somalia, and Uganda

OBJECTIVE

To identify and examine barriers to midwife-led care in Eastern Africa and how these barriers can be reduced DESIGN: A qualitative inductive study with online focus group discussions and semi-structured interviews using content analysis SETTING: The study examines midwife-led care in Ethiopia, Malawi, Kenya, Somalia, and Uganda -five African countries with an unmet need for midwives and a need to improve maternal and neonatal health outcomes.

PARTICIPANTS

Twenty-five participants with a health care profession background and current position as a maternal and child health leader from one of the five study countries.

FINDINGS

The findings demonstrate barriers to midwife-led care connected to organisational structures, traditional hierarchies, gender disparities, and inadequate leadership. Societal and gendered norms, organisational traditions, and differences in power and authority between professions are some factors explaining why the barriers persist. A focus on intra- and multisectoral collaborations, the inclusion of midwife leaders, and providing midwives with role models to leverage their empowerment are examples of how to reduce the barriers.

KEY CONCLUSIONS

This study provides new knowledge on midwife-led care from the perspectives of health leaders in five African countries. Transforming outdated structures to ensure midwives are empowered to deliver midwife-led care at all healthcare system levels is crucial to moving forward.

IMPLICATIONS FOR PRACTISE

This knowledge is important as enhancing the midwife-led care provision is associated with substantially improved maternal and neonatal health outcomes, higher satisfaction of care, and enhanced utilisation of health system resources. Nevertheless, the model of care is not adequately integrated into the five countries' health systems. Future studies are warranted to further explore how reducing barriers to midwife-led care can be adapted at a broader level.

Barriers and facilitators to the implementation of midwife-led care for childbearing women in low- and middle-income countries: A mixed-methods systematic review

BACKGROUND

Evidence from high-income countries demonstrate improvements in maternal and neonatal health with midwife-led care. Midwife-led care is pivotal to meet the United Nations' Sustainable Development Goals. Despite this, successful implementation of midwife-led care in low- and middle-income countries (LMICs) has been limited. It is therefore necessary to understand the factors that influence the implementation of midwife-led care.

AIM

This systematic review aimed to synthesize the evidence on barriers and facilitators to the implementation of midwife-led care for childbearing women in LMICs from the perspectives of care recipients, providers and wider stakeholders.

METHODS

A mixed-methods systematic review was conducted of primary research studies that expressed the views of those involved in or affected by the implementation of midwife-led care in LMICs. Reporting followed PRISMA guidelines. MEDLINE, EMBASE, PsychINFO, CINAHL, Maternity and Infant Care database (MIDIRS), Global Health and Web of Science databases were systematically searched. Methodological quality was assessed using the Mixed Methods Appraisal Tool (MMAT). Data was analysed and synthesized using the Supporting the Use of Research Evidence (SURE) framework to identify barriers and enabling factors to implementing midwife-led care.

FINDINGS

A total of 31 studies from 21 LMICs were included. At the care recipient level, women need adequate knowledge and confidence about midwife-led care to utilise services. At the care provider level, strengthening midwifery education and practice by employing experienced educators and supervisors is essential. Findings also suggest that increased collaboration between funders, professional organisations, practitioners, communities, and the government is necessary for successful implementation. However, adequate and sustained funding for midwife-led care programs is often lacking and political instability contributes to poor implementation in LMICs.

CONCLUSION AND IMPLICATIONS FOR PRACTICE AND RESEARCH

There are several enabling factors which increase the success and sustainability of the midwife-led model of care in LMICs. However, current practice guidelines and strategic frameworks need to better reflect the infrastructure and resource limitations of health settings in LMICs.

Midwifery continuity of care for women with complex pregnancies in Australia: An integrative review

BACKGROUND

All women require access to quality maternity care. Continuity of midwifery care can enhance women's experiences of childbearing and is associated with positive outcomes for women and infants. Much research on these models has been conducted with women with uncomplicated pregnancies; less is known about outcomes for women with complexities.

AIM

To explore the outcomes and experiences for women with complex pregnancies receiving midwifery continuity of care in Australia.

METHODS

This integrative review used Whittemore and Knafl's approach. Authors searched five electronic databases (PubMed/MEDLINE, EMBASE, CINAHL, Scopus, and MAG Online) and assessed the quality of relevant studies using the Critical Appraisal Skills Programme (CASP) appraisal tools.

FINDINGS

Fourteen studies including women with different levels of obstetric risk were identified. However, only three reported outcomes separately for women categorised as either moderate or high risk. Perinatal outcomes reported included mode of birth, intervention rates, blood loss, perineal trauma, preterm birth, admission to special care and breastfeeding rates. Findings were synthesised into three themes: 'Contributing to safe processes and outcomes', 'Building relational trust', and 'Collaborating and communicating'. This review demonstrated that women with complexities in midwifery continuity of care models had positive experiences and outcomes, consistent with findings about low risk women.

DISCUSSION

The nascency of the research on midwifery continuity of care for women with complex pregnancies in Australia is limited, reflecting the relative dearth of these models in practice.

CONCLUSION

Despite favourable findings, further research on outcomes for women of all risk is needed to support the expansion of midwifery continuity of care.

The MIDWIZE conceptual framework: a midwife-led care model that fits the Swedish health care system might after contextualization, fit others

OBJECTIVE

Familiarity with the unique tradition and experience of Swedish midwives during the more than 300 years in which midwife-led care has contributed to one of the lowest maternal and neonatal mortality and morbidity ratio in the world might encourage professionals in other countries to follow the Swedish example. The framework described below, reflecting the midwife's role in the Swedish health care system, might, after implementation, strengthen maternal and neonatal outcomes if contextualized to other settings.

RESULTS

Using a four-step procedure we identified our topic, made a literature review, identified the key components and their internal relationship, and finally developed the MIDWIZE conceptual framework. In this framework, the midwives in collaboration with obstetricians, provide evidence-based care with continuous quality improvements during the whole reproductive life cycle. Teamwork including specialists for referral and a responsive, relational, trust-based practice is the foundation for provision of midwife-led care for healthy women with a normal pregnancy. The well-educated midwife, of high academic standard, promoting gender equality and equity is the hub in the team and the primary care provider.

Women's experience of receiving team-midwifery care in Japan: A qualitative descriptive study

BACKGROUND

Team-midwifery care remains limited in Japan. To introduce changes to the midwifery system, an in-depth understanding of women's perception of receiving team-midwifery care is crucial.

AIM

This study aimed to describe women's experience of receiving team-midwifery care in Japan and to understand the central essence of this form of care.

METHODS

This study used a descriptive research design and involved focus group interviews in a birth clinic in central Tokyo. This birth clinic provided continuous team-midwifery care involving five to six midwives in one team from pregnancy to the postpartum period. Interview data were analysed by content analysis. The ethical review board of St. Luke's International Hospital, Tokyo approved this study (12-R178).

FINDINGS

Thirteen women who gave birth within 19 months were included. The women's experience of receiving team-midwifery care was described as "feelings of becoming closer and connected through a warm mutual relationship" with the midwives. The women felt that the midwives genuinely focused on their care and noticed their desire for their family to be involved. A trusting relationship was built through regular meetings. The women also described their experience as "a lasting feeling of ease and security". The midwives' continuity of care empowered the women even after their discharge.

CONCLUSION

The underlying assumption for the women's empowerment was the continuity of woman-centred care built through a trusting relationship between the women and the midwives. These important elements constitute the central essence of team-midwifery care which can be adopted regardless of the care system.

The comparison of the interpersonal action component of woman-centred care reported by healthy pregnant women in different sized practices in the Netherlands: A cross-sectional study

BACKGROUND

The number of interventions is lower, and the level of satisfaction is higher among women who receive midwife-led primary care from one or two midwives, compared to more midwives. This suggests that midwives in small-sized practices practice more women-centred. This has yet to be explored.

OBJECTIVE

To examine pregnant women's perceptions, of the interpersonal action component of woman-centred care by primary care midwives, working in different sized practices.

METHODS

A cross-sectional study using the Client Centred Care Questionnaire (CCCQ), administered during the third trimester of pregnancy among Dutch women receiving midwife-led primary care from midwives organised in small-sized practices (1-2 midwives), medium-sized (3-4 midwives) and large-sized practices (≥5 midwives). A Welch ANOVA with post hoc Bonferroni correction was performed to examine the differences.

RESULTS

553 completed questionnaires were received from 91 small-sized practices/104 women, 98 medium-sized practices/258 women and 65 large-sized practices/191 women. The overall sum scores varied between 57-72 on a minimum/maximum scoring range of 15-75. Women reported significantly higher woman-centred care scores of midwives in small-sized practices (score 70.7) compared with midwives in medium-sized practices (score 63.6) (p<.001) and large-sized practices (score 57.9) (p<.001), showing a large effect (d .88; d 1.56). Women reported statistically significant higher woman-centred care scores of midwives in medium-sized practices compared with large-sized practices (p<.001), showing a medium effect (d .69).

CONCLUSION

There is a significant variance in woman-centred care based on women's perceptions of woman-midwife interactions in primary care midwifery, with highest scores reported by women receiving care from a maximum of two midwives. Although the CCCQ scores of all practices are relatively high, the significant differences in favour of small-sized practices may contribute to moving woman-centred care practice from 'good' to 'excellent' practice.

Tensions and interplay: A qualitative study of access to patient-centered birth counseling of maternal cesarean requests in Norway

OBJECTIVE

This study aimed to explore women's access to patient-centered counseling for concerns initiating cesarean requests in absence of obstetric indications in pregnancy, and to identify tensions, barriers and facilitators affecting such care.

DESIGN, SETTING AND INFORMANTS

This qualitative study (June 2016 to August 2017) obtained data through semi-structured in-depth interviews with 17 women requesting planned C-section during birth counseling at a university hospital in Norway and focus group discussions with 20 caregivers (9 midwives and 11 obstetricians) employed at the same hospital. Analysis was carried out by systematic text condensation, a method for thematic analysis in medical research, presented within the frames of Levesque and colleagues' conceptual framework of access to patient-centered care.

FINDINGS

The analysis revealed that there were considerable tensions in care seeking and provision of counseling for maternal requests for C-section. There was a prominent culture of vaginal delivery among caregivers and women. The appropriateness of CS on maternal request was debated and caregivers revealed diverging attitudes and practices when agreement with women was not reached. Women's views on their entitlement to choose were divided, but the majority of women did not support complete maternal choice. Midwife-led counseling were highly appreciated among woman as well as obstetricians.

IMPLICATIONS FOR PRACTICE

Tensions and barriers in care seeking and provision of counseling for women requesting C-section for non-obstetric reasons, call for standardized counseling in order for equal and adequate care to be provided across health care institutions and providers. Dialogue-based decision-making and midwife-led care may improve satisfaction of care, enhance spontaneous vaginal deliveries and avoid future conflicts.

Maternal and neonatal outcome of births planned in alongside midwifery units: a cohort study from a tertiary center in Germany

Background

For healthy women entering birth after uneventful pregnancy, midwife-led models of care have the potential to reduce interventions and increase the vaginal birth rate. In Germany, 98.4% of women are giving birth in consultant-led obstetric units. Alongside midwifery units (AMU) have been established in 2003. We compared the outcome of women registered for planned birth in the AMU at our hospital with a matched group of low-risk women who gave birth in standard obstetric care during the same period of time.

Methods

We used a retrospective cohort study design. The study group consisted of all women admitted to labor ward who had registered for birth in AMU from 2010 to 2017. For the control group, low-risk women were selected; additionally, matching was performed for parity. Mode of birth was chosen as primary outcome parameter for the mother. For the neonate, a composite primary outcome (5-min Apgar < 7 or umbilical cord arterial pH < 7.10 or transfer to specialist neonatal care) was defined. Secondary outcomes included epidural anesthesia, duration of the second stage of labor, episiotomy, obstetric injury, and postpartum hemorrhage. Non-inferiority was assessed, and multiple logistic regression analysis was performed.

Results

Six hundred twelve women were admitted for labor in AMU, the control group consisted of 612 women giving birth in standard obstetric care. Women in the study group were on average older and had a higher body mass index (BMI); birthweight was on average 95 g higher. Non-inferiority could be established for the primary outcome parameters. Epidural anesthesia and episiotomy rates were lower, and the mean duration of the second stage of labor was shorter in the study group; second-degree perineal tears were less common, higher-order obstetric lacerations occurred more frequently.

Overall, 50.3% of women were transferred to standard obstetric care. Regression analysis revealed effects of parity, age and birthweight on the chance of transfer.

Conclusion

Compared to births in our consultant-led obstetric unit, the outcome of births planned in the AMU was not inferior, and intervention rates were lower. Our results support the integration of AMU as a complementary model of care for low-risk women.

Maternity service organisational interventions that aim to reduce caesarean section: a systematic review and meta-analyses

Background

Caesarean sections (CSs) are associated with increased maternal and perinatal morbidity, yet rates continue to increase within most countries. Effective interventions are required to reduce the number of non-medically indicated CSs and improve outcomes for women and infants. This paper reports findings of a systematic review of literature related to maternity service organisational interventions that have a primary intention of improving CS rates.

Method

A three-phase search strategy was implemented to identify studies utilising organisational interventions to improve CS rates in maternity services. The database search (including Cochrane CENTRAL, CINAHL, MEDLINE, Maternity and Infant Care, EMBASE and SCOPUS) was restricted to peer-reviewed journal articles published from 1 January 1980 to 31 December 2017. Reference lists of relevant reviews and included studies were also searched. Primary outcomes were overall, planned, and unplanned CS rates. Secondary outcomes included a suite of birth outcomes. A series of meta-analyses were performed in RevMan, separated by type of organisational intervention and outcome of interest. Summary risk ratios with 95% confidence intervals were presented as the effect measure. Effect sizes were pooled using a random-effects model.

Results

Fifteen articles were included in the systematic review, nine of which were included in at least one meta-analysis. Results indicated that, compared with women allocated to usual care, women allocated to midwife-led models of care implemented across pregnancy, labour and birth, and the postnatal period were, on average, less likely to experience CS (overall) (average RR 0.83, 95% CI 0.73 to 0.96), planned CS (average RR 0.75, 95% CI 0.61 to 0.93), and episiotomy (average RR 0.84, 95% CI 0.74 to 0.95). Narratively, audit and feedback, and a hospital policy of mandatory second opinion for CS, were identified as interventions that have potential to reduce CS rates.

Conclusion

Maternity service leaders should consider the adoption of midwife-led models of care across the maternity episode within their organisations, particularly for women classified as low-risk. Additional studies are required that utilise either audit and feedback, or a hospital policy of mandatory second opinion for CS, to facilitate the quantification of intervention effects within future reviews.

PROSPERO registration

CRD42016039458; prospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2351-2) contains supplementary material, which is available to authorized users.

Factors influencing decision-making for caesarean section in Sweden - a qualitative study

BACKGROUND

Rising rates of caesarean section (CS) are a concern in many countries, yet Sweden has managed to maintain low CS rates. Exploring the multifactorial and complex reasons behind the rising trend in CS has become an important goal for health professionals. The aim of the study was to explore Swedish obstetricians' and midwives' perceptions of the factors influencing decision-making for CS in nulliparous women in Sweden.

METHODS

A qualitative design was chosen to gain in-depth understanding of the factors influencing the decision-making process for CS. Purposive sampling was used to select the participants. Four audio-recorded focus group interviews (FGIs), using an interview guide with open ended questions, were conducted with eleven midwives and five obstetricians from two selected Swedish maternity hospitals after obtaining written consent from each participant. Data were managed using NVivo© and thematically analysed. Ethical approval was granted by Trinity College Dublin.

RESULTS

The thematic analysis resulted in three main themes; 'Belief in normal birth - a cultural perspective'; 'Clarity and consistency - a system perspective' and 'Obstetrician makes the final decision, but...', and each theme contained a number of subthemes. However, 'Belief in normal birth' emerged as the core central theme, overarching the other two themes.

CONCLUSION

Findings suggest that believing that normal birth offers women and babies the best possible outcome contributes to having and maintaining a low CS rate. Both midwives and obstetricians agreed that having a shared belief (in normal birth), a common goal (of achieving normal birth) and providing mainly midwife-led care within a 'team approach' helped them achieve their goal and keep their CS rate low.

A ten-year study of midwife-led care at an Austrian tertiary care center: a retrospective analysis with special consideration of perineal trauma

BACKGROUND

In contrast to other countries, Austria rarely offers alternative models to medical led-care. In an attempt to improve the facilities, a midwife-led care service was incorporated within the Department of Obstetrics and Fetomaternal Medicine. The aim of the present study was to analyze the maternal and neonatal outcomes of this approach.

METHODS

Over a 10-years period, a total of 2123 low-risk women receiving midwife-led care were studied. Among these women, 148 required obstetric referral. Age- and parity matched low-risk women with spontaneous vaginal birth overseen by an obstetrician-led team were used as controls to ensure comparability of data.

RESULTS

Midwife-led care management demonstrated a significant decrease in interventions, including oxytocin use (p < 0.001), medical pain relief (p < 0.001), and artificial rupture of membranes (ARM) (p < 0.01) as well as fewer episiotomies (p < 0.001), as compared with obstetrician-led care. Moreover, no negative effects on maternal or neonatal outcomes were observed. The mean length of the second stage of labor, rate of perineal laceration and APGAR scores did not differ significantly between the study groups (p > 0.05). Maternal age (p < 0.01), head diameter (p < 0.001), birth weight (p < 0.001) and the absence of midwife-led care (p < 0.05) were independent risk factors for perineal trauma. The overall referral rate was low (7%) and was most commonly caused by pathologic cardiotocography (CTG) and prolonged first- and second-stage of labor. Most referred mothers nevertheless had spontaneous deliveries (77%), and there were low rates of vaginal operative deliveries and cesarean sections (vacuum extraction, 16%; cesarean section, 7%).

CONCLUSIONS

The present study confirmed that midwife-led care confers important benefits and causes no adverse outcomes for mother and child. The favorable obstetrical outcome clearly highlights the importance of the selection of obstetric care, on the basis of previous risk assessment. We therefore fully support the recommendation that midwife-led care be offered to all low-risk women and that mothers should be encouraged to use this option. However, to increase the numbers of midwife-led care deliveries in Austria in the future, it will be necessary to expand this care model and to establish new midwife-led care units within hospital facilities.

Comparison of midwife-led care and obstetrician-led care on maternal and neonatal outcomes in Singapore: A retrospective cohort study

OBJECTIVES

to examine the maternal and neonatal outcomes of low-risk women receiving midwife-led care and obstetrician-led care. DESIGN, SETTING,&PARTICIPANTS: a retrospective cohort study design was used. Data were collected from a large tertiary maternity hospital in Singapore. This involved a medical record review of 368 women who had singleton, normal to low-risk, term pregnancy, and received midwife-led care and obstetrician-led care between 2013 to 2014.

MEASUREMENTS

a data extraction tool was used to solicit information on the outcome measures, including duration of labour, mode of delivery, episiotomy, and 5-minutes Apgar score (<7). Descriptive statistics were used to summarise the women's 'characteristics. χ² and independent sample t-test were used to assess the differences in demographics and birth outcomes. Multiple linear and logistic regressions were used to examine the difference between the two comparison groups after adjusted for potential confounders.

FINDINGS

statistically significant differences (p<0.05) between the midwife-led care group and the obstetrician-led care group in terms of the total duration of labour and total antenatal visits were found. No statistically significant differences were observed for mode of delivery, episiotomy, intrapartum pain management, labour augmentation, labour induction, postpartum haemorrhage, perineal trauma, birth status, 5-minutes Apgar score (<7), low birth weight (<2500g), and neonatal admission to intensive care units between the midwife-led care group and the obstetrician-led care group.

KEY CONCLUSIONS

while interventions such as episiotomies and labour augmentation were more common in the midwife-led care group, no significant differences were found for most of the outcome measures between the two maternity groups except for total antenatal visits and duration of labour. Findings suggest that midwife-led care is as safe and effective as obstetrician-led care in achieving optimal birth outcomes, with no higher risk of adversities for low-risk women. Additional studies are necessary to continuously evaluate midwife-led care and to promote normal birth and reduce excessive use of obstetric procedures.

IMPLICATIONS FOR PRACTICE

the provision of midwife-led care should continue to be extended as an additional choice in maternity care for women with low-risk pregnancies. Professional staff development with continuous education is needed to clear misconceptions about midwife-led care and to promote awareness in current practice guidelines. Prospective evaluation of midwife-led care will be beneficial in informing policies and practise guidelines.

Quality of care provided in two Scottish rural community maternity units: a retrospective case review

Background

Women in Scotland with uncomplicated pregnancies are encouraged by professional bodies and national guidelines to access community based models of midwife-led care for their labour and birth. The evidence base for these guidelines relates to comparisons of predominantly urban birth settings in England. There appears to be little evidence available about the quality of the care during the antenatal, birth and post birth periods available for women within the Scottish Community Maternity Unit (CMU) model.

The research aim was to explore the safety and effectiveness of the maternity services provided at two rural Community Maternity Units in Scotland, both 40 miles by main road access from a tertiary obstetric unit.

Methods

Following appropriate NHS and University ethical approval, an anonymous retrospective review of consecutive maternity records for all women who accessed care at the CMUs over a 12 month period (June 2011 to May 2012) was undertaken in 2013 -14. Data was extracted using variables chosen to provide a description of the socio-demographics of the cohort and the process and outcomes of the care provided. Data were analysed using descriptive statistics.

Results

Regarding effectiveness, the correct care pathway was allocated to 97.5% of women, early access to antenatal care achieved by 95.7% of women, 94.8% of women at one CMU received continuity of carer and 78.6% of those clinically eligible accessed care in labour. 11.9% were appropriately transferred to obstetrician-led care antenatally and 16.9% were transferred in labour. All women received one-to one care in labour and 67.1% of babies born at the CMUs were breastfed at birth.

Regarding safety, severe morbidity for women was rare, perineal trauma of 3rd degree tear occurred for 0.3% of women and 1.0% experienced an episiotomy. Severe post partum haemorrhage occurred for 0.3% of women. Babies admitted to the Neonatal unit were discharged within 48 hrs.

Conclusion

These findings support the recommendations of professional bodies and national guidelines. Maternity service provision at rural CMUs achieved a consistently high standard of safety and effectiveness when measured against national standards and international evidence.

Midwife-led maternity care in Ireland - a retrospective cohort study

Background

Midwife-led maternity care is shown to be safe for women with low-risk during pregnancy. In Ireland, two midwife-led units (MLUs) were introduced in 2004 when a randomised controlled trial (the MidU study) was performed to compare MLU care with consultant-led care (CLU). Following study completion the two MLUs have remained as a maternity care option in Ireland. The aim of this study was to evaluate maternal and neonatal outcomes and transfer rates during six years in the larger of the MLU sites.

Methods

MLU data for the six years 2008–2013 were retrospectively analysed, following ethical approval. Rates of transfer, reasons for transfer, mode of birth, and maternal and fetal outcomes were assessed. Linear-by-Linear Association trend analysis was used for categorical data to evaluate trends over the years and one-way ANOVA was used when comparing continuous variables.

Results

During the study period, 3,884 women were registered at the MLU. The antenatal transfer rate was 37.4% and 2,410 women came to labour in the MLU. Throughout labour and birth, 567 women (14.6%) transferred to the CLU, of which 23 were transferred after birth due to need for suturing or postpartum hemorrhage. The most common reasons for intrapartum transfer were meconium stained liquor/abnormal fetal heart rate (30.3%), delayed labour progress in first or second stage (24.9%) and woman’s wish for epidural analgesia (15.1%). Of the 1,903 babies born in the MLU, 1,878 (98.7%) were spontaneous vaginal births and 25 (1.3%) were instrumental (ventouse/forceps). Only 25 babies (1.3%) were admitted to neonatal intensive care unit.

All spontaneous vaginal births from the MLU registered population, occurring in the study period in both the MLU and CLU settings (n = 2,785), were compared. In the MLU more often 1–2 midwives (90.9% vs 69.7%) cared for the women during birth, more women had three vaginal examinations or fewer (93.6% vs 79.9%) and gave birth in an upright position (standing, squatting or kneeling) (52.0% vs 9.4%), fewer women had an amniotomy (5.9% vs 25.9%) or episiotomy (3.4% vs 9.7%) and more women had a physiological management of third stage of labour (50.9% vs 4.6%).

Conclusions

Midwife-led care is a safe option that could be offered to a large proportion of healthy pregnant women. With strict transfer criteria there are very few complications during labour and birth. Maternity units without the option of MLU care should consider its introduction.

Pregnancy related anxiety and general anxious or depressed mood and the choice for birth setting: a secondary data-analysis of the DELIVER study

Background

In several developed countries women with a low risk of complications during pregnancy and childbirth can make choices regarding place of birth. In the Netherlands, these women receive midwife-led care and can choose between a home or hospital birth. The declining rate of midwife-led home births alongside the recent debate on safety of home births in the Netherlands, however, suggest an association of choice of birth place with psychological factors related to safety and risk perception. In this study associations of pregnancy related anxiety and general anxious or depressed mood with (changes in) planned place of birth were explored in low risk women in midwife-led care until the start of labour.

Methods

Data (n = 2854 low risk women in midwife-led care at the onset of labour) were selected from the prospective multicenter DELIVER study. Women completed the Pregnancy Related Anxiety Questionnaire-Revised (PRAQ-R) to assess pregnancy related anxiety and the EuroQol-6D (EQ-6D) for an anxious and/or depressed mood.

Results

A high PRAQ-R score was associated with planned hospital birth in nulliparous (aOR 1.92; 95% CI 1.32–2.81) and parous women (aOR 2.08; 95% CI 1.55–2.80). An anxious or depressed mood was associated with planned hospital birth (aOR 1.58; 95% CI 1.20–2.08) and with being undecided (aOR 1.99; 95% CI 1.23–2.99) in parous women only. The majority of women did not change their planned place of birth. Changing from an initially planned home birth to a hospital birth later in pregnancy was, however, associated with becoming anxious or depressed after 35 weeks gestation in nulliparous women (aOR 4.17; 95% CI 1.35–12.89) and with pregnancy related anxiety at 20 weeks gestation in parous women (aOR 3.91; 95% CI 1.32–11.61).

Conclusion

Low risk women who planned hospital birth (or who were undecided) more often reported pregnancy related anxiety or an anxious or depressed mood. Women who changed from home to hospital birth during pregnancy more often reported pregnancy related anxiety or an anxious or depressed mood in late pregnancy. Anxiety should be adequately addressed in the process of informed decision-making regarding planned place of birth in low risk women.

Different settings of place of midwife-led birth: evaluation of a midwife-led birth centre

Objectives

The claimed advantages of home deliveries, including fewer medical interventions, are potentially counter balanced by the small additional risk on perinatal adverse outcome compared to hospital deliveries in low risk women. Homelike birth centres have been proposed a new setting for low risk women combining the advantages of home and hospital, resulting in lower intervention rates with equal safety. This paper addresses whether the introduction of a midwife-led birth centre adjacent to the hospital combines the advantages of home and hospital deliveries. Additionally, we investigate whether the introduction of a midwife-led birth centre leads to a different risk selection of women planning their delivery either at home, at the hospital or at the birth centre.

Methods

Anonymized data, between January 2007 and June 2012, was collected from the four participating midwife practices. Women (n = 5558) were categorized according to intended place of birth. Women’s characteristics and pregnancy outcomes were compared between the period before and after its introduction using Chi square and Fisher’s Exact tests. Direct and indirect standardized rates were calculated for different outcomes [(1) intrapartum and neonatal mortality (<24 h), (2) composite outcome of neonatal morbidities, (3) composite outcome of maternal morbidities, and (4) medical intervention], taking the period before introduction as reference.

Results

After the introduction of the birth centre a different risk selection was observed. Women’s characteristics were most unfavourable for intended birth centre births. Additionally, an higher neonatal risk load was seen within these women. After its introduction neonatal morbidities decreased (5.0 vs. 3.8 %) and maternal morbidities decreased (8.3 vs. 7.3 %). Interventions were about equal. Direct and indirect standardization provided similar results.

Conclusion

Neonatal morbidity and maternal morbidity tended to decrease, while overall intervention rates were unaffected. The introduction of the midwife-led birth centre seems to benefit the outcome of midwife-led deliveries. We interpret this change by the redistribution of the higher risk women among the low risk population intending birth at the birth centre instead of home.

The effect of gestational weight gain on likelihood of referral to obstetric care for women eligible for primary, midwife-led care after antenatal booking

OBJECTIVE

to examine the effect of gestational weight gain (GWG) on likelihood of referral from midwife-led to obstetrician-led care during pregnancy and childbirth for women in primary care at the outset of their pregnancy.

DESIGN

secondary analysis of data from a prospective cohort study.

SETTING

Dutch midwife-led practices.

PARTICIPANTS

a cohort of 1288 women of Northern European descent, with uncomplicated, singleton pregnancy at antenatal booking who consequently were eligible for primary, midwife-led care.

MEASUREMENTS

because of the absence of an established GWG guideline in the Netherlands, we compared the effect of inadequate and excessive GWG according to two GWG guidelines: the criterion traditionally used, which is based on knowledge of the physiological components of GWG, advising 10-15kg as a normal GWG irrespective of a woman׳s BMI category, and the 2009 Institute of Medicine recommendations (IOMr) on GWG, which provide BMI related advice. Outcome measures were: number of women referred from midwife-led to obstetrician-led care during pregnancy and during childbirth; indications of referral and birth outcomes.

FINDINGS

GWG above traditional criteria (Tc; >15kg between 12 and 36 weeks) was associated with increased odds for referral during childbirth (adjusted odds ratio (aOR) 1.88; 95% confidence interval (CI) 1.22-2.90), but had no effect on referral during pregnancy (aOR .86; 95% CI .57-1.30). No associations were established between GWG below Tc (<10kg) and referral during pregnancy (aOR 1.08; 95% CI .78-1.50) or childbirth (aOR 1.08; 95% CI .74-1.56). No associations were found between GWG below and above the IOMr and referral during pregnancy (below IOMr: aOR 1.01; 95% CI .71-1.45; above IOMr: aOR .89; 95% CI .61-1.28) or childbirth (below IOMr: aOR .85; 95% CI .57-1.25; above IOMr: aOR 1.09; 95% CI .73-1.63). With regard to the effect of GWG according to both recommendations on indications for referral and birth outcomes, GWG above Tc was associated with higher rates of referral for hypertensive disorders (aOR 1.91; 95% CI 1.04-3.50) and for meconium stained liquor (aOR 2.22; CI 1.33-3.71) after adjusting for BMI and parity.

CONCLUSIONS

GWG above Tc - irrespective of BMI category - was associated with doubled odds of referral to specialist care during childbirth. GWG below or above IOMR and GWG below TC were not associated with adverse obstetric outcomes in women who were eligible for primary care at the outset of their pregnancy.

IMPLICATIONS FOR PRACTICE

weight gain <15kg between 12 and 36 weeks is advised for women in all BMI categories in this population. It is important to validate GWG guidelines in a target population before implementing them.

A cost-comparison of midwife-led compared with consultant-led maternity care in Ireland (the MidU study)

OBJECTIVE

to compare the cost of maternity care between two midwife-led units, and their linked consultant-led units, following a large randomised trial in Ireland.

DESIGN

ethical approval was received for this unblinded, pragmatic randomised trial (MidU) funded by the Health Service Executive (Dublin North-East, Ireland), conducted 2004-2009. A comparison of costs analysis was conducted on the outcomes from the trial.

SETTING

two maternity units in Ireland, with 'alongside' midwife-led units.

PARTICIPANTS

all women without risk factors for labour and birth who booked at the two maternity units before 24 weeks׳ gestation were assessed for inclusion. Consenting women (n=1653) were centrally randomised on a 2:1 ratio (1101:552) to midwife-led or consultant-led care.

INTERVENTIONS

women randomised to consultant-led care received standard care. Women randomised to the midwife-led arm received midwife-led care provided by a small group of midwives in two units, situated ׳alongside׳ the consultant-led units, throughout pregnancy, birth and postnatal.

MEASUREMENTS

mean difference in clinician salaries, cost of care based on managers׳ data, known costs of postnatal bed days and costs of key interventions were measured.

FINDINGS

the average cost of caring for a woman allocated to the midwife-led units was €2598, compared to €2780 in the consultant-led units (average difference €182 per woman, analysed by 'intention to treat').

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

care in these two midwife-led units costs less than care provided by the consultant-led units. Given the clinical findings, which showed that care provided in the midwife-led units is as safe as that in the consultant-led units and results in less intervention, more midwife-led units should be incorporated into maternity care in Ireland so that scarce resources can be used more effectively.

Exploration of preterm birth rates associated with different models of antenatal midwifery care in Scotland: Unmatched retrospective cohort analysis

OBJECTIVES

preterm birth represents a significant personal, clinical, organisational and financial burden. Strategies to reduce the preterm birth rate have had limited success. Limited evidence indicates that certain antenatal care models may offer some protection, although the causal mechanism is not understood. We sought to compare preterm birth rates for mixed-risk pregnant women accessing antenatal care organised at a freestanding midwifery unit (FMU) and mixed-risk pregnant women attending an obstetric unit (OU) with related community-based antenatal care.

METHODS

unmatched retrospective 4-year Scottish cohort analysis (2008-2011) of mixed-risk pregnant women accessing (i) FMU antenatal care (n=1107); (ii) combined community-based and OU antenatal care (n=7567). Data were accessed via the Information and Statistics Division of the NHS in Scotland. Aggregates analysis and binary logistic regression were used to compare the cohorts׳ rates of preterm birth; and of spontaneous labour onset, use of pharmacological analgesia, unassisted vertex birth, and low birth weight. Odds ratios were adjusted for age, parity, deprivation score and smoking status in pregnancy.

FINDINGS

after adjustment the 'mixed risk' FMU cohort had a statistically significantly reduced risk of preterm birth (5.1% [n=57] versus 7.7% [n=583]; AOR 0.73 [95% CI 0.55-0.98]; p=0.034). Differences in these secondary outcome measures were also statistically significant: spontaneous labour onset (FMU 83.9% versus OU 74.6%; AOR 1.74 [95% CI 1.46-2.08]; p<0.001); minimal intrapartum analgesia (FMU 53.7% versus OU 34.4%; AOR 2.17 [95% CI 1.90-2.49]; p<0.001); spontaneous vertex delivery (FMU 71.9% versus OU 63.5%; AOR 1.46 [95% CI 1.32-1.78]; p<0.001). Incidence of low birth weight was not statistically significant after adjustment for other variables. There was no significant difference in the rate of perinatal or neonatal death.

CONCLUSIONS

given this study׳s methodological limitations, we can only claim associations between the care model and or chosen outcomes. Although both cohorts were mixed risk, differences in risk levels could have contributed to these findings. Nevertheless, the significant difference in preterm birth rates in this study resonates with other research, including the recent Cochrane review of midwife-led continuity models. Because of the multiplicity of risk factors for preterm birth we need to explore the salient features of the FMU model which may be contributing to this apparent protective effect. Because a randomised controlled trial would necessarily restrict choice to pregnant women, we feel that this option is problematic in exploring this further. We therefore plan to conduct a prospective matched cohort analysis together with a survey of unit practices and experiences.

Trend analysis of primary midwife-led delivery care at a Japanese perinatal center

OBJECTIVE

To perform trend analysis of primary midwife-led delivery care for 'low risk' pregnant women at our hospital.

METHODS

A retrospective cohort study was performed to examine trends and outcomes of labor under primary midwife-led delivery care at the Japanese Red Cross Katsushika Maternity Hospital between 2008 and 2012.

RESULTS

During the study period, the rate of deliveries initially considered 'low risk' decreased from 25 to 22% (p < 0.01). This change was associated with increased cases of previous Cesarean deliveries and preterm delivery. There were no significant changes in the neonatal outcomes; however, the rate of Cesarean delivery and incidence of severe perineal laceration in primary midwife-led delivery care were decreased from 2.1 and 3.3% to 0.3 (p = 0.02) and 1.1% (p = 0.04), respectively due to the close cooperation between midwives and obstetricians.

CONCLUSION

The rate of deliveries initially considered 'low risk' decreased over the last 5-year period. Closer cooperation between midwives and obstetricians is important in primary midwife-led delivery care.

Empowering change: realist evaluation of a Scottish Government programme to support normal birth

BACKGROUND

midwife-led care has consistently been found to be safe and effective in reducing routine childbirth interventions and improving women's experience of care. Despite consistent UK policy support for maximising the role of the midwife as the lead care provider for women with healthy pregnancies, implementation has been inconsistent and the persistent use of routine interventions in labour has given rise to concern. In response the Scottish Government initiated Keeping Childbirth Natural and Dynamic (KCND), a maternity care programme that aimed to support normal birth by implementing multiprofessional care pathways and making midwife-led care for healthy pregnant women the national norm.

AIM

the evaluation was informed by realist evaluation. It aimed to explore and explain the ways in which the KCND programme worked or did not work in different maternity care contexts.

METHODS

the evaluation was conducted in three phases. In phase one semi-structured interviews and focus groups were conducted with key informants to elicit the programme theory. At phase two, this theory was tested using a multiple case study approach. Semi-structured interviews and focus groups were conducted and a case record audit was undertaken. In the final phase the programme theory was refined through analyses and interpretation of the data.

SETTING AND PARTICIPANTS

the setting for the evaluation was NHS Scotland. In phase one, 12 national programme stakeholders and 13 consultant midwives participated. In phase two case studies were undertaken in three health boards; overall 73 participants took part in interviews or focus groups. A case record audit was undertaken of all births in Scotland during one week in two consecutive years before and after pathway implementation.

FINDINGS

government and health board level commitment to, and support of, the programme signalled its importance and facilitated change. Consultant midwives tailored change strategies, using different approaches in response to the culture of care and inter-professional relationships within contexts. In contexts where practice was already changing KCND was seen as validating and facilitating. In areas where a more medical culture existed there was strong resistance to change from midwives and medical staff and robust implementation strategies were required. Overall the pathways appeared to enable midwives to achieve change.

KEY CONCLUSIONS

our study highlighted the importance of those involved in a change programme working across levels of hierarchy within an organisation and from the macro-context of national policy and institutions to the meso-context of regional health service delivery and the micro-context of practitioner's experiences of providing care. The assumptions and propositions that inform programmes of change, which are often left at a tacit level and unexamined by those charged with implementing them, were made explicit. This examination illuminated the roles of the three key change mechanisms adopted in the KCND programme - appointment of consultant midwives as programme champions, multidisciplinary care pathways, and midwife-led care. It revealed the role of the commitment mechanism, which built on the appointment of the local change champions. The analysis indicated that the process of change, despite these clear mechanisms, needed to be adapted to local contexts and responses to the implementation of KCND.

IMPLICATIONS FOR PRACTICE

initial formative evaluation should be conducted prior to development of complex healthcare programmes to ensure that (1) the interventions will address the changes required, (2) key stakeholders who may support or resist change are identified, and (3) appropriate facilitation strategies are developed tailored to context.

What do midwives need to know about approaches of women towards labour pain management? A qualitative interview study into expectations of management of labour pain for pregnant women receiving midwife-led care in the Netherlands

OBJECTIVE

to investigate factors important to women receiving midwife-led care with regard to their expectations for management of labour pain.

DESIGN

semi-structured ante partum interviews and analyses using constant comparison method.

PARTICIPANTS

fifteen pregnant women between 36 and 40 weeks gestation receiving midwife-led care.

SETTING

five midwifery practices across the Netherlands between June 2009 and July 2010.

MAIN OUTCOME

women's expectations regarding management of labour pain.

RESULTS

we found three major themes to be important in women's expectations for management of labour pain: preparation, support and control and decision-making. In regards to all these themes, three distinct approaches towards women's planning for pain management in labour were identified: the 'pragmatic natural', the 'deliberately uninformed' and the 'planned pain relief' approach.

CONCLUSION

midwives need to recognise that women take different approaches to pain management in labour in order to adapt care to the individual woman.