A. de Jonge

Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births

Objective  To compare perinatal mortality and severe perinatal morbidity between planned home and planned hospital births, among low‐risk women who started their labour in primary care.

Supine position compared to other positions during the second stage of labor: A meta-analytic review

The routine use of the supine position during the second stage of labor can be considered to be an intervention in the natural course of labor. This study aimed to establish whether the continuation of this intervention is justified. Nine randomized controlled trials and one cohort study were included. A meta-analysis indicated a higher rate of instrumental deliveries and episiotomies in the supine position. A lower estimated blood loss and lower rate of postpartum hemorrhage were found in the supine position, however it is not clear whether this is a real or only an observed difference. Heterogenous, non-pooled data showed that women experienced more severe pain in the supine position and had a preference for other birthing positions.Many methodological problems were identified in the studies and the appropriateness of a randomized controlled trial to study this subject is called into question. A cohort study is recommended as a more appropriate methodology, supplemented by a qualitative method to study womens experiences. Objective laboratory measurements are advised to examine the difference in blood loss.In conclusion, the results do not justify the continuation of the routine use of the supine position during the second stage of labor.

Birthing positions. A qualitative study into the views of women about various birthing positions

The aim of this study was to gain insight into the influences on womens use of birthing positions, and into the labor experiences of women in relation to the birthing positions they used.Quantitative studies have shown some medical advantages of non-supine birthing positions. They also suggested some psychological benefits but these are difficult to interpret. In this study in-depth interviews were conducted to gain a deeper understanding of the relationship between birthing positions and the labor experience.We found that the advice given by midwives was the most important factor influencing the choice of birthing positions. If medically possible, women benefited from having the autonomy to find the positions that were most useful to them. Their choices varied greatly, as did their experience of pain in relation to the type of position. Women, regardless of ethnicity, were most familiar with the supine position but valued practical information on other options.In conclusion, because the supine position is dominant in westernized societies, midwives have an important role to play in widening the range of womens choices. Midwives should empower women to find the positions that are most suitable for them, by giving practical advice during pregnancy and labor.

Persisting rise in referrals during labor in primary midwife-led care in the Netherlands

BACKGROUND There are concerns about the Dutch maternity care system, characterized by a strict role division between primary and secondary care. The objective of this study was to describe trends in referrals and in perinatal outcomes among labors that started in primary midwife-led care. METHODS We performed a descriptive study of all 789,795 labors that started in primary midwife-led care during 2000 to 2008 in The Netherlands. Referrals to obstetrician-led care or pediatrician were classified as urgent or nonurgent. Perinatal safety was described by perinatal mortality (intrapartum or neonatal 0-7 days), admission to neonatal intensive care unit 0-7 days, and Apgar score < 7 at 5 minutes. RESULTS The proportion of referrals during labor or after birth declined from 52.6 to 42.6 percent for nulliparous women and from 83.2 to 76.7 percent for multiparous women. Especially nonurgent referrals during the first stage increased, for nulliparous women from 28.7 to 40.7 percent and for multiparous women from 10.5 to 16.5 percent. Referrals were less frequent in planned home births. Perinatal mortality was 0.9 per thousand births for nulliparous women, and 0.6 per thousand for multiparous women. A low Apgar score was registered in 8.6 per thousand births for nulliparous women, and 4.1 per thousand for multiparous women. CONCLUSIONS There was a considerable rise in nonurgent referrals to obstetrician-led care in primary midwife-led care during labor. Perinatal safety did not improve significantly over time. The persisting rise in referrals challenges the sustainability of the current strict role division between primary and secondary maternity care in The Netherlands.

Increased blood loss in upright birthing positions originates from perineal damage

Objective  To assess whether the risk of severe blood loss is increased in semi‐sitting and sitting position, and if so, to which extent blood loss from perineal damage is responsible for this finding.

Risk of perineal damage is not a reason to discourage a sitting birthing position: a secondary analysis

Aim:  To examine the association between semi‐sitting and sitting position at the time of birth and perineal damage amongst low‐risk women in primary care.

Limited midwifery care for undocumented women in the Netherlands.

Background: Ethnic minority women in Western countries have poorer pregnancy outcomes compared to majority populations, and undocumented women are particularly vulnerable. We intended to assess whether midwives adjust their care if women are undocumented and have no health insurance. Methods: A retrospective matched cohort study in primary midwifery care practices in Amsterdam and Rotterdam, the Netherlands. Undocumented, uninsured women (N = 141) were matched with documented, insured ethnic minority women (N = 141). Information was extracted from patient records. Results: Undocumented women attended their first prenatal visit 5 weeks later in their pregnancy and received care elsewhere or disappeared from care more frequently (59.6 versus 34.3%). They frequently have an excess of 110% of the number of expected antenatal visits (32.4% versus 16.9%) and had a preterm birth more frequently (OR 4.59, 95% CI 1.43 to 14.72). Midwives were equally likely to follow referral guidelines in both groups. Undocumented women were more likely to give birth at home (OR 2.14, 95% CI 1.07–4.28) and less likely to receive maternity home care assistance (56.0 versus 79.7%). Conclusion: Although referral guidelines are generally followed by midwives, undocumented women are more at risk of adverse perinatal outcomes and inadequate care than documented ethnic minority women.

Intrapartum and neonatal mortality in primary midwife-led and secondary obstetrician-led care in the Amsterdam region of the Netherlands: A retrospective cohort study

OBJECTIVE To compare intrapartum- and neonatal mortality and intervention rates in term women starting labour in primary midwife-led versus secondary obstetrician-led care. DESIGN Retrospective cohort study. SETTING Amsterdam region of the Netherlands. PARTICIPANTS Women with singleton pregnancies who gave birth beyond 37+0 weeks gestation in the years 2005 up to 2008 and lived in the catchment area of the neonatal intensive care units of both academic hospitals in Amsterdam. Women with a primary caesarean section or a pregnancy complicated by antepartum death or major congenital anomalies were excluded. For women in the midwife-led care group, a home or hospital birth could be planned. MEASUREMENTS Analysis of linked data from the national perinatal register, and hospital- and midwifery record data. We assessed (unadjusted) relative risks with confidence intervals. Main outcome measures were incidences of intrapartum and neonatal (<28 days) mortality. Secondary outcomes included incidences of caesarean section and vaginal instrumental delivery. FINDINGS 53,123 women started labour in primary care and 30,166 women in secondary care. Intrapartum and neonatal mortality rates were 37/53,123 (0.70‰) in the primary care group and 24/30,166 (0.80‰) in the secondary care group (relative risk 0.88; 95% CI 0.52-1.46). Women in the primary care group were less likely to deliver by secondary caesarean section (5% versus 16%; RR 0.31; 95% CI 0.30-0.32) or by instrumental delivery (10% versus 13%; RR 0.76; 95% CI 0.73-0.79). KEY CONCLUSIONS We found a low absolute risk of intrapartum and neonatal mortality, with a comparable risk for women who started labour in primary versus secondary care. The intervention rate was significantly lower in women who started labour in primary care. IMPLICATIONS FOR PRACTICE These findings suggest that it is possible to identify a group of women at low risk of complications that can start labour in primary care and have low rates of medical interventions whereas perinatal mortality is low.

Pitfalls in the use of register‐based data for comparing adverse maternal and perinatal outcomes in different birth settings

Routinely collected registration data are an efficient source for conducting research. In particular, they are useful for studies with rare outcomes, as these require large sample sizes, which are difficult to obtain through targeted data collection. Registration data are often used to compare severe, adverse maternal and perinatal outcomes in different birth settings. However, registration data are primarily recorded for purposes other than research, such as supporting care processes. Subsequently, if these data are used for scientific studies, the analyses are, by definition, ‘secondary’ and therefore are likely to have more limitations compared to prospectively and purposely collected research data. We want to show how some of these limitations can lead to erroneous conclusions, using the Dutch perinatal register as an example. This may help researchers to avoid some of the pitfalls of using register based data and help service users, professionals and policy makers to recognise these limitations when interpreting study findings. This article is protected by copyright. All rights reserved.

A qualitative interview study into experiences of management of labor pain among women in midwife-led care in the Netherlands

INTRODUCTION Many pregnant women are concerned about the pain they will experience in labor and how to deal with this. This studys objective was to explore womens postpartum perception and view of how they dealt with labor pain. METHODS Semistructured postpartum interviews were analyzed using the constant comparison method. Using purposive sampling, we selected 17 women from five midwifery practices across the Netherlands, from August 2009 to September 2010. RESULTS Women reported that control over decision making during labor (about dealing with pain) helped them to deal with labor pain, as did continuous midwife support at home and in hospital, and effective childbirth preparation. Some of these women implicitly or explicitly indicated that midwives should know which method of pain management they need during labor and arrange this in good time. DISCUSSION It may be difficult for midwives to discriminate between women who need continuous support through labor without pain medication and those who genuinely desire pain medication at a certain point in labor, and who will be dissatisfied postpartum if this need is unrecognized and unfulfilled.