- Birth centers are a durable model of high-quality, high-value maternity care
- Home Birth: An Annotated Guide to the Literature
- Cochrane Database Review: Planned hospital birth versus planned home birth Sep 2012
- Cochrane Database Review: Midwife-led versus other models of care for childbearing women, 2009
- Outcomes Associated With Planned Home and Planned Hospital Births in Low-Risk Women Attended by Midwives in Ontario, Canada
- Outcomes of Planned Home Birth With Registered Midwife Versus Planned Hospital Birth With Midwife or Physician
- Perinatal Mortality and Morbidity in a Nationwide Cohort of 529,688 Low-Risk Planned Home and Hospital Births
- The Millbank Report - Evidence-Based Maternity Care: What It Is and What It Can Achieve
- Midwifery Licensure and Discipline Program in Washington State: Economic Costs and Benefits
- Outcomes of Planned Home Births With Certified Professional Midwives: Large Prospective Study in North America
- Transforming Maternity Care Landmark Reports
- The Evidence Basis for the Ten Steps of Mother Friendly Care
- Supporting Access to Midwifery Services in the United States
- Cochrane Review:Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour
- NACPM Response to poorly designed Wax et al Meta-analysis
- BMJ Letter Regarding Misleading Wax Meta-analysis
Outcomes of Care in Birth Centers: Demonstration of a Durable Model
Introduction: The safety and effectiveness of birth center care have been demonstrated in previous studies, including the National Birth Center Study and the San Diego Birth Center Study. This study examines outcomes of birth center care in the present maternity care environment.
Methods: This was a prospective cohort study of women receiving care in 79 midwifery-led birth centers in 33 US states from 2007 to 2010. Data were entered into the American Association of Birth Centers Uniform Data Set after obtaining informed consent. Analysis was by intention to treat, with descriptive statistics calculated for maternal and neonatal outcomes for all women presenting to birth centers in labor including those requiring transfer to hospital care.
Results: Of 15,574 women who planned and were eligible for birth center birth at the onset of labor, 84% gave birth at the birth center. Four percent were transferred to a hospital prior to birth center admission, and 12% were transferred in labor after admission. Regardless of where they gave birth, 93% of women had a spontaneous vaginal birth, 1% an assisted vaginal birth, and 6% a cesarean birth. Of women giving birth in the birth center, 2.4% required transfer postpartum, whereas 2.6% of newborns were transferred after birth. Most transfers were nonemergent, with 1.9% of mothers or newborns requiring emergent transfer during labor or after birth. There were no maternal deaths. The intrapartum fetal mortality rate for women admitted to the birth center in labor was 0.47/1000. The neonatal mortality rate was 0.40/1000 excluding anomalies.
Discussion: This study demonstrates the safety of the midwifery-led birth center model of collaborative care as well as continued low obstetric intervention rates, similar to previous studies of birth center care. These findings are particularly remarkable in an era characterized by increases in obstetric intervention and cesarean birth nationwide.
Home Birth: An Annotated Guide to the Literature.
Aug 2011. Vedam S, Schummers L, Fulton C. Vancouver, British Columbia, Canada: University of British Columbia;
This annotated bibliography provides citations and critical appraisal of original studies on home birth.
Planned hospital birth versus planned home birth: Cochrane Database Systematic Review 2012
Olsen O, Clausen JA. Planned hospital birth versus planned home birth. Cochrane Database of Systematic Reviews 2012, Issue 9.
Observational studies of increasingly better quality and in different settings suggest that planned home birth in many places can be as safe as planned hospital birth and with less intervention and fewer complications. This is an update of a Cochrane review first published in 1998.
To assess the effects of planned hospital birth compared with planned home birth in selected low-risk women, assisted by an experienced midwife with collaborative medical back up in case transfer should be necessary.
There is no strong evidence from randomised trials to favour either planned hospital birth or planned home birth for low-risk pregnant women. However, the trials show that women living in areas where they are not well informed about home birth may welcome ethically well-designed trials that would ensure an informed choice. As the quality of evidence in favour of home birth from observational studies seems to be steadily increasing, it might be as important to prepare a regularly updated systematic review including observational studies as described in the Cochrane Handbook for Systematic Reviews of Interventions as to attempt to set up new randomised controlled trials.
*Cochrane Reviews are systematic reviews of primary research in human health care and health policy, and are internationally recognised as the highest standard in evidence-based health care.
Midwife-led versus other models of care for childbearing women: Cochrane Database Systematic Review 2008
Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2008, Issue 4.
Midwife-led care confers benefits for pregnant women and their babies and is recommended.
In many parts of the world, midwives are the primary providers of care for childbearing women. Elsewhere it may be medical doctors or family physicians who have the main responsibility for care, or the responsibility may be shared. The underpinning philosophy of midwife-led care is normality, continuity of care and being cared for by a known and trusted midwife during labour. There is an emphasis on the natural ability of women to experience birth with minimum intervention. Some models of midwife-led care provide a service through a team of midwives sharing a caseload, often called 'team' midwifery. Another model is 'caseload midwifery', where the aim is to offer greater continuity of caregiver throughout the episode of care. Caseload midwifery aims to ensure that the woman receives all her care from one midwife or her/his practice partner. All models of midwife-led care are provided in a multi-disciplinary network of consultation and referral with other care providers. By contrast, medical-led models of care are where an obstetrician or family physician is primarily responsible for care. In shared-care models, responsibility is shared between different healthcare professionals.
The review of midwife-led care covered midwives providing care antenatally, during labour and postnatally. This was compared with models of medical-led care and shared care, and identified 11 trials, involving 12,276 women. Midwife-led care was associated with several benefits for mothers and babies, and had no identified adverse effects.
The main benefits were a reduction in the use of regional analgesia, with fewer episiotomies or instrumental births. Midwife-led care also increased the woman's chance of being cared for in labour by a midwife she had got to know, and the chance of feeling in control during labour, having a spontaneous vaginal birth and initiating breastfeeding. However, there was no difference in caesarean birth rates.
Women who were randomised to receive midwife-led care were less likely to lose their baby before 24 weeks' gestation, although there were no differences in the risk of losing the baby after 24 weeks, or overall. In addition, babies of women who were randomised to receive midwife-led care were more likely to have a shorter length of hospital stay.
The review concluded that most women should be offered midwife-led models of care, although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.
*Cochrane Reviews are systematic reviews of primary research in human health care and health policy, and are internationally recognised as the highest standard in evidence-based health care.
Outcomes Associated With Planned Home and Planned Hospital Births in Low-Risk Women Attended by Midwives in Ontario, Canada, 2003-2006: a Retrospective Cohort Study.
Sept 2009. Birth. 36(3):180-9. EK Hutton et al. McMaster University, Ontario, Canada.
"The study found serious complications - death, the need for medical care immediately after birth, neonatal resuscitation, admission to a pediatric intensive care unit and low birth weight - were lower in the home birth group (2.3 per cent) compared to the hospital group (2.8 per cent), as were rates for all interventions (5.2 per cent home birth vs. 8.1 per cent hospital), including cesarean section."
“METHODS: The database provided outcomes for all women planning a home birth at the onset of labor (n = 6,692) and for a cohort, stratified by parity, of similar low-risk women planning a hospital birth.”
Outcomes of Planned Home Birth With Registered Midwife Versus Planned Hospital Birth With Midwife or Physician
September 15, 2009. Canadian Medical Association Journal. vol. 181 no. 6-7. Patricia A. Janssen, PhD, et al. British Columbia, Canada.
“Interpretation: Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.”
“Methods: We included all planned home births attended by registered midwives from Jan. 1, 2000, to Dec. 31, 2004, in British Columbia, Canada (n = 2889), and all planned hospital births meeting the eligibility requirements for home birth that were attended by the same cohort of midwives (n = 4752). We also included a matched sample of physician-attended planned hospital births (n = 5331).”
The strength of this data is that it includes all Registered Midwife-attended births in the province as data collection is mandatory. And, as one midwife there said about the conclusions: it shows that, when comparing the same midwives' outcomes in home vs hospital, "we're better than ourselves when women choose home birth."
Perinatal Mortality and Morbidity in a Nationwide Cohort of 529,688 Low-Risk Planned Home and Hospital Births.
August 2009. British Journal of Obstetrics and Gynecology. 116(9):1177-84. de Jonge A, et al. The Netherlands.
No significant differences were found between planned home and planned hospital birth for the outcomes analyzed including intrapartum death and neonatal death during the first 24 hours, intrapartum death and neonatal death up to 7 days, and admission to a neonatal intensive care unit. N=529,688 low-risk women who were in primary midwife-led care at the onset of labour. Of these, 321,307 (60.7%) intended to give birth at home, 163,261 (30.8%) planned to give birth in hospital and for 45,120 (8.5%), the intended place of birth was unknown.
The Millbank Report - Evidence-Based Maternity Care: What It Is and What It Can Achieve
Childbirth Connection, the Reforming States Group and the Milbank Memorial Fund collaborated in planning, developing and issuing the report, including formulating policy recommendations.
The Milbank Report on evidence-based maternity care identifies midwifery care as an underused intervention “suitable for routine use.”
What are top implications of this report for childbearing women, maternity professionals and policy makers?
Childbearing women need to understand that maternity care that is routinely available often is not in the best interest of themselves and their babies. Pregnant women have the right and responsibility to become informed and make wise choices — for example, their choice of caregiver, birth setting and specific procedures, drugs and tests. Becoming informed and taking responsibility can be a big task — and can have very big pay-offs.
Health professionals need to recognize that usual ways of practicing frequently do not reflect the best evidence about safe, effective maternity care. The field of pregnancy and childbirth care ushered in the era of evidence-based practice: many hundreds of currently underutilized systematic reviews point the way to improved maternity practice and outcomes. The Evidence-Based Maternity Care report (PDF) identifies dozens of reviews that are relevant to care of a large segment of the maternal-newborn population. Engaging with the unparalleled move for health care quality and patient safety can improve professional performance and satisfaction and reduce risk of liability.
Policymakers can play an important role in improving quality, health outcomes and resource use by addressing barriers to evidence-based maternity care. Recommendations for addressing barriers in the new report (PDF) fall in four areas: measuring performance and leveraging results, fixing perverse financial incentives, educating the key groups, and filling priority research gaps.
Midwifery Licensure and Discipline Program in Washington State: Economic Costs and Benefits
January 2008. Commissioned by the legislature and directed by the Washington State Department of Health.
The study found that low-risk, out-of-hospital births of Medicaid patients cost the state at least $473,000 less than comparable low-risk hospital births during the two-year state budget cycle (or $236,000 per year), and over $2.7 million in costs are avoided per two-year budget cycle when both public and private insurers are included.
The study also noted, but did not quantify, many other prospective costs that are avoided, due to the intensive level of prenatal and postnatal care provided by licensed midwives. These include: higher breast-feeding rates, fewer low-birth weight babies, a greatly reduced c-section rate, and a significantly lower risk of other costly medical interventions during labor and birth.
Outcomes of Planned Home Births With Certified Professional Midwives: Large Prospective Study in North America
June 18, 2005. British Medical Journal. 330(7505):1416. Johnson KC, and Daviss BA.
“Conclusions: Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.” n=5418. The strength of the study results from its prospective cohort design and mandatory participation by all CPMs. All women who planned (when labour began) to deliver at home with a Certified Professional Midwife (CPM) across the United States (98% of cohort) and Canada in the year 2000 had to be registered prospectively and their outcomes were compared with low risk US hospital births.
Transforming Maternity Care Landmark Reports
The Transforming Maternity Care Blueprint for Action calls for increased use of midwives and family practice physicians.
Childbirth Connection brought together more than 100 health care leaders – from delivery systems, providers, and consumers to health plans and purchasers, liability insurers and quality experts – to develop two direction-setting reports, “2020 Vision for a High-Quality, High-Value Maternity Care System” and “Blueprint for Action.” These reports were the culmination of over two years’ collaborative multi-stakeholder work aimed at reversing troubling trends and achieving high-quality, high-value maternity care.
The Evidence Basis for the Ten Steps of Mother Friendly Care
Winter 2007. Journal of Perinatal Education, Vol. 16, Supplement 1.
"STEP 1: Offers all birthing mothers unrestricted access to birth companions, labor support, professional midwifery care. ACCESS TO MIDWIFERY CARE – Use of midwives was associated with:
- Increased length of prenatal visits, more education and counseling during prenatal care, and fewer hospital admissions.
- Less need for analgesia and/or epidural anesthesia and increased use of alternative pain relief methods, as well as more freedom of movement in labor and intake of food and drink.
- Decreased use of amniotomy (membrane rupture), IVs, electronic fetal monitoring; fewer inductions and augmentations of labor; and fewer injuries of the perineum (tissue between vagina and anus) as shown by fewer episiotomies, fewer rectal tears, and more intact perineums.
- Fewer cesareans overall, including fewer emergency cesareans for fetal distress or for inadequate progress in labor, and more vaginal births after cesareans (VBACs).
- Fewer infants born preterm, low birthweight or with complications such as birth injury or requiring resuscitation after birth, and more infants exclusively breastfeeding at 2-4 months after birth."
Supporting Access to Midwifery Services in the United States (Position Paper)
March 2001. American Journal of Public Health. 91(3):482-5.
This Policy Statement # 20004 was adopted by the Governing Council of the American Public Health Association, November 15, 2000. “The American Public Health Association (APHA) takes a position in support of the expansion of midwifery as a key strategy to improving access to care for childbearing families for the purpose of increasing their health care options and thereby to the subsequent improvement of birth outcomes.”
Comparing continuous electronic monitoring of the baby's heartbeat in labour using cardiotocography (CTG, sometimes known as EFM) with intermittent monitoring (intermittent auscultation, IA)
Alfirevic Z, Devane D, Gyte GML. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews 2006, Issue 3.
Monitoring the baby's heartbeat is one way of checking babies' well-being in labour. By listening to, or recording the baby's heartbeat, it is hoped to identify babies who are becoming short of oxygen (hypoxic) and who may benefit from caesarean section or instrumental vaginal birth. A baby's heartbeat can be monitored intermittently by using a fetal stethoscope, Pinard (special trumpet shaped device), or by a handheld Doppler device. The heartbeat can also be checked continuously by using a CTG machine. This method is sometimes known as electronic fetal monitoring (EFM) and produces a paper recording of the baby's heart rate and their mother's labour contractions. Whilst a continuous CTG gives a written record, it prevents women from moving during labour. This means that women may be unable to change positions or use a bath to help with comfort and control during labour. It also means that some resources tend to be focused on the needs of the CTG rather than the woman in labour. This review compared continuous CTG monitoring with intermittent auscultation (listening). It found 12 trials involving over 37,000 women. Most studies were not of high quality and the review is dominated by one large, well-conducted trial of almost 13,000 women who received care from one person throughout labour in a hospital where the membranes have either ruptured spontaneously or were artificial ruptured as early as possible and oxytocin stimulation of contractions was used in about a quarter of the women. There was no difference in the number of babies who died during or shortly after labour (about 1 in 300). Fits (neonatal seizures) in babies were rare (about 1 in 500 births), but they occurred significantly less often when continuous CTG was used to monitor fetal heart rate. There was no difference in the incidence of cerebral palsy, although other possible long-term effects have not been fully assessed and need further study. Continuous monitoring was associated with a significant increase in caesarean section and instrumental vaginal births. Both procedures are known to carry the risks associated with a surgical procedure although the specific adverse outcomes have not been assessed in the included studies.
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Authoritative, current, evidence-based information for health care providers in Washington State.
Cochrane Reviews related to Pregnancy and Childbirth
Cochrane Reviews are systematic reviews of primary research in human health care and health policy, and are internationally recognised as the highest standard in evidence-based health care.