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Current Research
- 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
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.”
Article Citing the Study
Pub Med Citation and Full Text Link
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."
Full Text pdf
Correction Abstract
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.
Pub Med Citation and Full Text Link
Summary by Wendy Gordon, LM, CPM (PDF)
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.
Milbank Report PDF
More about the Report
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.
Summary of the DOH report
Complete Report PDF
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.
Cochrane Review Abstract and Plain Language Summary and link to Full Text
RELATED LINKS
Pub Med
PubMed comprises more than 21 million citations for biomedical literature from MEDLINE, life science journals, and online books.
Heal-WA
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.
