Vanora Hundley

Midwife managed delivery unit: a randomised controlled comparison with consultant led care.

Abstract Objective: To examine whether intrapartum care and delivery of low risk women in a midwife managed delivery unit differs from that in a consultant led labour ward. Design: Pragmatic randomised controlled trial. Subjects were randomised in a 2:1 ratio between the midwives unit and the labour ward. Setting: Aberdeen Maternity Hospital, Grampian. Subjects—2844 low risk women, as defined by existing booking criteria for general practitioner units in Grampian. 1900 women were randomised to the midwives unit and 944 to the labour ward. Main outcome measures: Maternal and perinatal morbidity. Results: Of the women randomised to the midwives unit, 647 (34%) were transferred to the labour ward antepartum, 303 (16%) were transferred intrapartum, and 80 (4%) were lost to follow up. 870 women (46%) were delivered in the midwives unit. Primigravid women (255/596, 43%) were significantly more likely to be transferred intrapartum than multigravid women (48/577, 8%). Significant differences between the midwives unit and labour ward were found in monitoring, fetal distress, analgesia, mobility, and use of episiotomy. There were no significant differences in mode of delivery or fetal outcome. Conclusions: Midwife managed intrapartum care for low risk women results in more mobility and less intervention with no increase in neonatal morbidity. However, the high rate of transfer shows that antenatal criteria are unable to determine who will remain at low risk throughout pregnancy and labour.

An investigation of women's involvement in the decision to deliver by caesarean section.

Objective To assess the degree and nature of womens involvement in the decision to deliver by caesarean section, and womens satisfaction with this involvement.

Decision making about mode of delivery among pregnant women who have previously had a caesarean section: a qualitative study

Objective  To explore prospectively women’s decision making regarding mode of delivery after a previous caesarean section.

Are women's expectations and preferences for intrapartum care affected by the model of care on offer?

Objective  To investigate the effect of service provision on consumer preferences, in particular, whether women who have access to systems of care which offer particular attributes (such as continuity of carer) value these attributes more highly than women for whom the attributes are not a realistic option.

Satisfaction and the three C's: continuity, choice and control. Women's views from a randomised controlled trial of midwife-led care

Objective 1. To explore whether there are differences in womens satisfaction with care in a midwife‐managed delivery unit compared with that in a consultant‐led labour ward. 2. To compare factors relating to continuity, choice and control between the two randomised groups.

Effects of algorithm for diagnosis of active labour: cluster randomised trial.

Objective To compare the effectiveness of an algorithm for diagnosis of active labour in primiparous women with standard care in terms of maternal and neonatal outcomes. Design Cluster randomised trial. Setting Maternity units in Scotland with at least 800 annual births. Participants 4503 women giving birth for the first time, in 14 maternity units. Seven experimental clusters collected data from a baseline sample of 1029 women and a post-implementation sample of 896 women. The seven control clusters had a baseline sample of 1291 women and a post-implementation sample of 1287 women. Intervention Use of an algorithm by midwives to assist their diagnosis of active labour, compared with standard care. Main outcomes Primary outcome: use of oxytocin for augmentation of labour. Secondary outcomes: medical interventions in labour, admission management, and birth outcome. Results No significant difference was found between groups in percentage use of oxytocin for augmentation of labour (experimental minus control, difference=0.3, 95% confidence interval −9.2 to 9.8; P=0.9) or in the use of medical interventions in labour. Women in the algorithm group were more likely to be discharged from the labour suite after their first labour assessment (difference=−19.2, −29.9 to −8.6; P=0.002) and to have more pre-labour admissions (0.29, 0.04 to 0.55; P=0.03). Conclusions Use of an algorithm to assist midwives with the diagnosis of active labour in primiparous women did not result in a reduction in oxytocin use or in medical intervention in spontaneous labour. Significantly more women in the experimental group were discharged home after their first labour ward assessment. Trial registration Current Controlled Trials ISRCTN00522952.

Sustainable maternity services in remote and rural Scotland? A qualitative survey of staff views on required skills, competencies and training

Objectives: To explore staff views on their roles, skills and training to deliver high quality and local intrapartum services in remote and rural settings against national recommendations. Design: Interview and postal survey. Setting: A stratified representative sample of remote and rural maternity units in Scotland (December 2002 to May 2003). Participants: Staff proportionally representative of professional groups involved in maternity care. Results: Staff interviews took place at 11 units (response rate 93%). A subsequent postal survey included the interview sample and staff in a further 11 units (response rate 78%). Medical specialisation, workforce issues, and proposed regulatory evaluation of competencies linked to throughput raised concerns about the sustainability and safety of services, particularly for “generalists” in rural maternity care teams and for medical cover in small district general hospitals with large rural catchments. Risk assessment and decision making to transfer were seen as central for effective rural practice and these were influenced by rural context. Staff self-reported competence and confidence varied according to procedure, but noted service change appeared to be underway ahead of their preparedness. Self-reported competence in managing obstetric emergencies was surprisingly high, with the caveat that they were not independently assessed in this study. Staff with access to video conference technology reported low actual use although there was enthusiasm about its potential use. Conclusions: Considerable uncertainties remain around staffing models and training to maintain maternity care team skills and competencies. Further research is required to test how this will impact on safety, appropriateness, and access and acceptability to rural communities.

A national survey of obstetric early warning systems in the United Kingdom: five years on

The Confidential Enquiries into Maternal Deaths in the UK have recommended obstetric early warning systems for early identification of clinical deterioration to reduce maternal morbidity and mortality. This survey explored early warning systems currently used by maternity units in the UK. An electronic questionnaire was sent to all 205 lead obstetric anaesthetists under the auspices of the Obstetric Anaesthetists’ Association, generating 130 (63%) responses. All respondents reported use of an obstetric early warning system, compared with 19% in a similar survey in 2007. Respondents agreed that the six most important physiological parameters to record were respiratory rate, heart rate, temperature, systolic and diastolic blood pressure and oxygen saturation. One hundred and eighteen (91%) lead anaesthetists agreed that early warning systems helped to prevent obstetric morbidity. Staffing pressures were perceived as the greatest barrier to their use, and improved audit, education and training for healthcare professionals were identified as priority areas.

Are birth kits a good idea? A systematic review of the evidence.

OBJECTIVE to identify the current state of knowledge regarding the effects of births kits on clean birth practices and on newborn and maternal outcomes. DESIGN the scoping review was informed through a systematic literature review; a call for information distributed to experts in maternal and child health, relevant research centres and specialist libraries; and a search of the web sites of groups working in the area of maternal and child health. Data were synthesised to produce a summary of the state of knowledge regarding birth kits. Meta-analysis was not attempted because of the varied study designs and the heterogeneous nature of the interventions. PARTICIPANTS births kit use was identified in 51 low resource countries, but evaluations were scarce, with only nine studies reporting effects of intervention packages including births kits. FINDINGS the quality of evidence for inferring causality was weak, with only one randomised controlled trial. In two studies, births kit use along with co-interventions resulted in a statistically significant increase in the likelihood of the attendant having clean hands. The impact on other aspects of cleanliness was less clear. Intervention packages which include births kits were associated with reduced newborn mortality (three studies), omphalitis (four studies), and puerperal sepsis (three studies). The one study that considered maternal mortality was not large enough to estimate relative reduction with much precision. None of the studies reported any adverse effects; however, none explicitly described looking for negative consequences. CONCLUSION providing birth kits to facilitate clean practices seems commonsense, but there is no evidence to indicate effects, positive or negative, separate from those achieved by a broader intervention package. More robust methods and knowledge systems are needed to understand the contextual factors and share relevant implementation lessons.

Using economics alongside clinical trials: why we cannot choose the evaluation technique in advance

When drafting protocols for the use of economic evaluation alongside clinical trials, it is common to have to specify which type of economic evaluation is going to be carried out. Will it be a cost-benefit analysis (CBA), cost-effectiveness analysis (CEA) or a cost-utility analysis (CUA)? It is our contention that prior specification of the appropriate economic technique is not possible, in the majority of cases, until data on effectiveness and cost are actually available. In this letter, we aim to demonstrate the thinking behind our contention and to illustrate this with two case studies; one of a recent randomised trial, the other of a trial currently in progress.