Alison Macfarlane

Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: The Birthplace in England national prospective cohort study

Objective To compare perinatal outcomes, maternal outcomes, and interventions in labour by planned place of birth at the start of care in labour for women with low risk pregnancies. Design Prospective cohort study. Setting England: all NHS trusts providing intrapartum care at home, all freestanding midwifery units, all alongside midwifery units (midwife led units on a hospital site with an obstetric unit), and a stratified random sample of obstetric units. Participants 64 538 eligible women with a singleton, term (≥37 weeks gestation), and “booked” pregnancy who gave birth between April 2008 and April 2010. Planned caesarean sections and caesarean sections before the onset of labour and unplanned home births were excluded. Main outcome measure A composite primary outcome of perinatal mortality and intrapartum related neonatal morbidities (stillbirth after start of care in labour, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus, or fractured clavicle) was used to compare outcomes by planned place of birth at the start of care in labour (at home, freestanding midwifery units, alongside midwifery units, and obstetric units). Results There were 250 primary outcome events and an overall weighted incidence of 4.3 per 1000 births (95% CI 3.3 to 5.5). Overall, there were no significant differences in the adjusted odds of the primary outcome for any of the non-obstetric unit settings compared with obstetric units. For nulliparous women, the odds of the primary outcome were higher for planned home births (adjusted odds ratio 1.75, 95% CI 1.07 to 2.86) but not for either midwifery unit setting. For multiparous women, there were no significant differences in the incidence of the primary outcome by planned place of birth. Interventions during labour were substantially lower in all non-obstetric unit settings. Transfers from non-obstetric unit settings were more frequent for nulliparous women (36% to 45%) than for multiparous women (9% to 13%). Conclusions The results support a policy of offering healthy women with low risk pregnancies a choice of birth setting. Women planning birth in a midwifery unit and multiparous women planning birth at home experience fewer interventions than those planning birth in an obstetric unit with no impact on perinatal outcomes. For nulliparous women, planned home births also have fewer interventions but have poorer perinatal outcomes.

Has the medicalisation of childbirth gone too far

Over the past few centuries childbirth has become increasingly influenced by medical technology, and now medical intervention is the norm in most Western countries. Richard Johanson and colleagues argue here that perhaps normal birth has become too “medicalised” and that higher rates of normal birth are in fact associated with beliefs about birth, implementation of evidence based practice, and team working Until the 17th century, birth in most parts of the world was firmly in the exclusively female domestic arena, and hospital birth was uncommon before the 20th century, except in a few major cities. 1 2 Before the invention of forceps, men had been involved only in difficult deliveries, using destructive instruments with the result that babies were invariably not born alive and the mother too would often die. Instrumental delivery with forceps became the hallmark of the obstetric era. In the 19th and 20th centuries, medical influence was extended further by the development of new forms of analgesia, anaesthesia, caesarean section, and safe blood transfusion. The introduction first of antiseptic and aseptic techniques and later of sulphonamides, coupled with changes in the severity of puerperal sepsis, lowered the maternal mortality that had made hospitals dangerous places in which to give birth.3 #### Summary points Obstetricians play an important role in preserving lives when there are complications of pregnancy or labour In developed countries, however, obstetrician involvement and medical interventions have become routine in normal childbirth, without evidence of effectiveness Factors associated with increased obstetric intervention seem to include private practice, medicolegal pressures, and not involving women fully in decision making Emerging evidence suggests that higher rates of normal births are linked to beliefs about birth, implementation of evidence based practice, and team working Maternal mortality in the West fell substantially during the 20th century. The World Health Organization and Unicef …

The Impact of the Increasing Number of Multiple Births on the Rates of Preterm Birth and Low Birthweight: An International Study

OBJECTIVES We studied the effects of twins and triplets on perinatal health indicators in the overall population in the 1980s and 1990s in Canada, England and Wales, France, and the United States. METHODS Data were derived mostly from live birth registration. We used rates, relative risks, and population attributable risks for twins and triplets separately. RESULTS In each country, the increase in multiple births, and the increase in preterm delivery among multiple births, contributed almost equally to the rise in or stabilization of the overall rates of preterm delivery. Twins contributed a much larger proportion of the preterm deliveries and low-birthweight newborns than did triplets. CONCLUSIONS Twins have a major population-based impact on the trends of perinatal health indicators.

Incidence of severe pre-eclampsia, postpartum haemorrhage and sepsis as a surrogate marker for severe maternal morbidity in a European population-based study: the MOMS-B survey

Objective  To describe the incidence of three conditions of acute severe maternal morbidity in selected regions in nine European countries.

Variations in policies for management of the third stage of labour and the immediate management of postpartum haemorrhage in Europe

Background  The EUropean Project on obstetric Haemorrhage Reduction: Attitudes, Trial, and Early warning System (EUPHRATES) is a set of five linked projects, the first component of which was a survey of policies for management of the third stage of labour and immediate management of postpartum haemorrhage following vaginal birth in Europe.

International migration and adverse birth outcomes: role of ethnicity, region of origin and destination

Background The literature on international migration and birth outcomes shows mixed results. This study examined whether low birth weight (LBW) and preterm birth differed between non-migrants and migrant subgroups, defined by race/ethnicity and world region of origin and destination. Methods A systematic review and meta-regression analyses were conducted using three-level logistic models to account for the heterogeneity between studies and between subgroups within studies. Results Twenty-four studies, involving more than 30 million singleton births, met the inclusion criteria. Compared with US-born black women, black migrant women were at lower odds of delivering LBW and preterm birth babies. Hispanic migrants also exhibited lower odds for these outcomes, but Asian and white migrants did not. Sub-Saharan African and Latin-American and Caribbean women were at higher odds of delivering LBW babies in Europe but not in the USA and south-central Asians were at higher odds in both continents, compared with the native-born populations. Conclusions The association between migration and adverse birth outcomes varies by migrant subgroup and it is sensitive to the definition of the migrant and reference groups.

Stillbirths and infant deaths among migrants in industrialized countries

Introduction. The relation of migration to infant outcomes is unclear. There are studies which show that some migrant groups have similar or even better outcomes than those from the receiving country. Equally, raised risk of adverse outcomes for other migrant groups has been reported. Objective. We sought to determine (1) if migrants in western industrialized countries have consistently higher risks of stillbirth, neonatal mortality, or infant mortality, (2) if there are migrant sub‐groups at potentially higher risk, and (3) what might be the explanations for any risk differences found. Design and Setting. Systematic review of the literature on perinatal health outcomes among migrants in western industrialized countries. Methods and Main outcome measures. Drawing on a larger systematic review of perinatal outcomes and migration, we reviewed studies including mortality outcomes (stillbirths and infant deaths). Results. Eligible studies gave conflicting results. Half (53%) reported worse mortality outcomes, one third (35%) reported no differences and a few (13%) reported better outcomes for births to migrants compared to the receiving country population. Refugees were the most vulnerable group. For non‐refugees, non‐European migrants in Europe and foreign‐born blacks in the United States had the highest excess mortality. In general, adjustment of background factors did not explain the increased mortality rate among migrants. Regarding causes of death, higher preterm birth rates explained the increased mortality figures among some migrant groups. The increased mortality from congenital anomalies may be related to restricted access to screening, but also to differing attitudes to screening and termination of pregnancy. Conclusions. Mortality risk among babies born to migrants is not consistently higher, but appears to be greatest among refugees, non‐European migrants to Europe, and foreign‐born blacks in the US. To understand this variation better, more information is needed about migrant background, such as length of time in receiving country and receiving country language fluency. Additional data on demographic, health care, biological, medical, and socioeconomic risk factors should be gathered and analyzed in greater detail.

General obstetrics: Preterm birth and multiple pregnancy in European countries participating in the PERISTAT project

Objective  To compare rates of preterm birth among multiple births in European countries, to estimate their contribution to overall preterm birth rates and to explore factors which could explain differences between preterm birth rates.

Comparability of published perinatal mortality rates in Western Europe: the quantitative impact of differences in gestational age and birthweight criteria

Objective To quantify the impact of publication criteria on differences in published national perinatal mortality rates among Western European countries.

Wide differences in mode of delivery within Europe: risk-stratified analyses of aggregated routine data from the Euro-Peristat study

To use data from routine sources to compare rates of obstetric intervention in Europe both overall and for subgroups at higher risk of intervention.