Mary Newburn

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 …

Estimating intrapartum‐related perinatal mortality rates for booked home births: when the ‘best’ available data are not good enough

Objective  To critically appraise a recent study on the safety of home birth (Mori R, Dougherty M, Whittle M. BJOG 2008;115:554) and assess its contribution to the debate about risks and benefits of planned home birth for women at low risk of complications.

Meeting needs of childbearing women and newborn infants through strengthened midwifery

Wherever women and babies are, whatever their circumstances or the health system in place, their survival, health, and wellbeing can be improved by midwifery care, as clearly shown in the Lancet Midwifery Series. Together with The State of the World’s Midwifery 2014 and Every Newborn Series, this Series honours progress achieved, delineates needed next steps, and identifi es tremendous potential for further health gain. The key messages warrant international attention and action to ensure that all women give birth with dignity and safely, and that everyone receives quality care at the beginning of life. What do women want from their maternity care? The meta-syntheses reviewed for this Series found that women desire respectful, clinically competent care. They value good communication, high-quality information, having a sense of control, and the ability to participate in their care and make choices. They want trusting relationships with care providers who are sensitive to their personal and cultural needs. These qualities map closely to the International Confederation of Midwives (ICM) Key Midwifery Concepts and to the Series defi nition of midwifery practice. In national surveys, childbearing women overwhelmingly trust that their maternity-care providers and systems reliably deliver quality care. Maternity care systems worldwide must meet their fi duciary responsibilities to address widespread issues identifi ed in the Series, including failure to provide quality midwifery care consistently; the risk, and waste, of using medical procedures too liberally; use of practices without proven benefi t; disrespectful, distressing treatment; and associated preventable morbidity and mortality. A primary care model is appropriate for most childbearing women and newborn infants who are healthy and at low risk of complications. However, the global trend is for increased use of specialised maternity care, regardless of need. ICM’s Essential Competencies for Basic Midwifery Practice align the scope of midwifery practice with a primary care model, including “preventative measures, the promotion of normal physiologic labour and birth, the detection of complications, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures”—all closely related to the Series defi nition of midwifery. Similarly, the ICM scope of practice states that “a midwife may practise in any setting including the home, community, hospitals, clinics or health units”, enabling matching of women to their level of need, their preferred setting, or available care options. This Series emphasises that optimising normal biopsychosocial processes is a core element of midwifery care. Pharmacological and surgical interventions, use of breast-milk substitutes, and other deviations from normality should be reserved for indications with a strong evidence base and not used liberally or routinely with healthy women and babies. Growing bodies of evidence clarify that such care is prudent, if not critical. Care that promotes, supports, and protects innate, hormonally driven, physiological processes optimises labour, birth, breastfeeding, and attachment, assisting women and newborn infants during these immense perinatal life transitions, whereas medical interventions often disrupt these processes. Various scientifi c frameworks fi nd heightened sensitivity during this period of rapid Published Online June 23, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60856-4

Promoting normality in childbirth.

See also Papers p 1155 Researchers have shown much interest in possible explanations for rising caesarean section rates.1 Consumer choice is seen as being very influential. An often cited survey of London obstetricians found that 31% would choose caesarean section as their preferred mode of delivering babies. 2 3 However, there appear to be paradoxes within this decision making process.4 Professionals choose abdominal delivery, on the basis that it appears to be “easier, less painful and more convenient,” even though they consider it to be more expensive and dangerous than a vaginal delivery.4 A subsequent study, with a wider national base, found a more balanced attitude to normal birth, but this has yet to be commented on in the national press.5 National data in this area have been collected and the results of the national sentinel audit of caesarean section were presented at the Royal College of Obstetricians and Gynaecologists on 26 October 2001. Accurate comparative figures on rates, indications, standards which can be audited, womens views …

Perinatal and maternal outcomes in planned home and obstetric unit births in women at ‘higher risk’ of complications: secondary analysis of the Birthplace national prospective cohort study

To explore and compare perinatal and maternal outcomes in women at ‘higher risk’ of complications planning home versus obstetric unit (OU) birth.

The INFANT trial

Birmingham Clinical Trials Unit (PB) and Institute of Applied Health Research (SK), College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK; Department of Health Sciences, University of Leicester, Leicester, UK (DJF); National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK (EJ, LL, MQ); CLAHRC South London, Kings College London, London, UK (MN); National Childbirth Trust, London, UK (RP); Centre for Health Economy, Australian Hearing Hub, Macquire University, Sydney, NSW, Australia (LS); and Imperial College London, London, UK (PS).

Service configuration, unit characteristics and variation in intervention rates in a national sample of obstetric units in England: an exploratory analysis

Objectives To explore whether service configuration and obstetric unit (OU) characteristics explain variation in OU intervention rates in ‘low-risk’ women. Design Ecological study using funnel plots to explore unit-level variations in adjusted intervention rates and simple linear regression, stratified by parity, to investigate possible associations between unit characteristics/configuration and adjusted intervention rates in planned OU births. Characteristics considered: OU size, presence of an alongside midwifery unit (AMU), proportion of births in the National Health Service (NHS) trust planned in midwifery units or at home and midwifery ‘under’ staffing. Setting 36 OUs in England. Participants ‘Low-risk’ women with a ‘term’ pregnancy planning vaginal birth in a stratified, random sample of 36 OUs. Main outcome measures Adjusted rates of intrapartum caesarean section, instrumental delivery and two composite measures capturing birth without intervention (‘straightforward’ and ‘normal’ birth). Results Funnel plots showed unexplained variation in adjusted intervention rates. In NHS trusts where proportionately more non-OU births were planned, adjusted intrapartum caesarean section rates in the planned OU births were significantly higher (nulliparous: R2=31.8%, coefficient=0.31, p=0.02; multiparous: R2=43.2%, coefficient=0.23, p=0.01), and for multiparous women, rates of ‘straightforward’ (R2=26.3%, coefficient=−0.22, p=0.01) and ‘normal’ birth (R2=17.5%, coefficient=0.24, p=0.01) were lower. The size of the OU (number of births), midwifery ‘under’ staffing levels (the proportion of shifts where there were more women than midwives) and the presence of an AMU were associated with significant variation in some interventions. Conclusions Trusts with greater provision of non-OU intrapartum care may have higher intervention rates in planned ‘low-risk’ OU births, but at a trust level this is likely to be more than offset by lower intervention rates in planned non-OU births. Further research using high quality data on unit characteristics and outcomes in a larger sample of OUs and trusts is required.

Findings of meta-analysis cannot be relied on

Mayor reports that a meta-analysis has linked planned home births with a twofold higher rate of neonatal mortality compared with hospital births.1 2 Closer inspection calls this finding into question. The quality of studies in any meta-analysis is critical, but no assessment was reported. Studies were observational with many not matched adequately for confounders. Neonatal …

An estimation of intrapartum-related perinatal mortality rates for booked home births in England and Wales between 1994 and 2003

Sir, Mori et al.1 in their study of intrapartum-related perinatal mortality (IPPM) attempted to use the ‘best available data’ to ascertain the safety of planned home birth. The validity of this study hinges on being able to determine accurately the numbers of planned home births. The authors took the number of actual home births and adjusted these using estimates for the numbers of both unintended home births and transfers. However, they have used inappropriate assumptions and have compounded these mistakes by making errors in their calculations. The authors use two ways to determine the numbers of unintended/unplanned home births, Calculation A and Calculation B, producing widely differing answers of 66 265 and 20 206. ‘Calculation A’ estimates unintended home births as a percentage of all home births (50.7%) and ‘Calculation B’ as a percentage of overall births (0.32%). There is no reason to suppose that the number of unplanned home births are affected by a rise or fall in planned home births. However, it is likely that a small consistent proportion of pregnant women concealed their pregnancy or had a precipitate birth at home. Indeed, Murphy et al.2 reported from 1970 to 1979 that unintended home births formed a relatively constant percentage of all births, around 0.35% (range 0.27–0.46%). In contrast, unintended home births increased from 17 to 57% when expressed as a percentage of all home births. This demonstrates that Calculation B is more reliable, yet Mori’s conclusions are based on Calculation A. In addition, calculations of the numbers of births and IPPM rates using Calculation A are subjected to a number of errors and are therefore invalid. The Murphy study2 data applicable to Calculation A are included in table 1 (34.1%) but omitted from the calculation of both the weighted mean and the sensitivity ranges used to create table 2. Using a revised weighted mean and lower range reduces the IPPM in table 2 for booked home birth, whether completed or not, and increases the range in which the true rates could lie. Furthermore, the study by Redshaw et al.3 is included in Calculation B, but not Calculation A, adding to the inaccuracy of table 2. There is also an error in table 2 in the completed home birth group, where 31 intrapartum-related deaths for 83 343–111 126 gives a range of 0.28–0.37, not 0.28–1.15 as reported. The authors inappropriately make a direct comparison between women who ‘planned home birth but transferred to hospital’, with ‘all women giving birth’. However, if such a comparison is made, it should be with a matched group of women who booked hospital birth and developed complications. The key finding that ‘there was no evidence of difference in the IPPM rate for the booked home birth group compared to the overall rate’ was not reported in the abstract as it should have been. DOI: 10.1111/j.1471-0528.2008.01835.x www.blackwellpublishing.com/bjog Correspondence