Freestanding midwifery unit versus obstetric unit: a matched cohort study of outcomes in low-risk women

Abstract

ObjectiveTo compare perinatal and maternal morbidity and birth interventions in low-risk women giving birth in two freestanding midwifery units (FMUs) and two obstetric units (OUs).DesignA cohort study with a matched control group.SettingThe region of North Jutland, Denmark.Participants839 low-risk women intending FMU birth and a matched control group of 839 low-risk women intending OU birth were included at the start of care in labour. OU women were individually chosen to match selected obstetric/socio-economic characteristics of FMU women. Analysis was by intention to treat.Main outcome measuresPerinatal and maternal morbidity and interventions.ResultsNo significant differences in perinatal morbidity were observed between groups (Apgar scores <7/5, <9/5 or <7/1, admittance to neonatal unit, asphyxia or readmission). Adverse outcomes were rare and occurred in both groups. FMU women were significantly less likely to experience an abnormal fetal heart rate (RR: 0.3, 95% CI 0.2 to 0.5), fetal–pelvic complications (0.2, 0.05 to 0.6), shoulder dystocia (0.3, 0.1 to 0.9), occipital–posterior presentation (0.5, 0.3 to 0.9) and postpartum haemorrhage >500 ml (0.4, 0.3 to 0.6) compared with OU women. Significant reductions were found for the FMU group's use of caesarean section (0.6, 0.3 to 0.9), instrumental delivery (0.4, 0.3 to 0.6), and oxytocin augmentation (0.5, 0.3 to 0.6) and epidural analgesia (0.4, 0.3 to 0.6). Transfer during or <2 h after birth occurred in 14.8% of all FMU births but more frequently in primiparas than in multiparas (36.7% vs 7.2%).ConclusionComparing FMU and OU groups, there was no increase in perinatal morbidity, but there were significantly reduced incidences of maternal morbidity, birth interventions including caesarean section, and increased likelihood of spontaneous vaginal birth. FMU care may be considered as an adequate alternative to OU care for low-risk women. Pregnant prospective mothers should be given an informed choice of place of birth, including information on transfer.

Factors associated with maternal intrapartum transfers from a freestanding birth centre in São Paulo, Brazil: A case control study

“…A prospective cohort study from Denmark compared results of two FBCs and two hospital obstetric units. The intrapartum transfer rate from the birth centres was 11.5%, but primiparous women were transferred in greater numbers (36.7%) compared to multiparous women (7.2%) (Overgaard et al, 2011). An American study which included 84 BCs reported an intrapartum transfer rate four times higher among nulliparous compared with multiparous women (Rooks et al, 1992).…”

“…Evidence from systematic reviews and recently published cohort studies demonstrates that women who give birth in a non-obstetric setting are more likely to have spontaneous vaginal birth and lower rates of intervention, including instrumental birth, episiotomy, oxytocin augmentation and epidural analgesia (Walsh and Downe, 2004;Hodnett et al, 2010; Contents lists available at SciVerse ScienceDirect Overgaard et al, 2011;Birthplace in England Collaborative Group, 2011;Cheung et al, 2011).…”

“…Adverse events can occur in the intrapartum or postpartum period, despite careful evaluation of a woman during pregnancy and at the commencement of her labour to ensure she meets criteria to give birth in a birth centre. The time required for transfer or the distance to the referral centre could delay urgent interventions, such as emergency caesarean sections and newborn resuscitation (Overgaard et al, 2011). Furthermore, the situation may be complicated by a lack of cooperation or poor communication between the hospital and staff in the non-obstetric setting (David et al, 2006).…”

Exploration of preterm birth rates associated with different models of antenatal midwifery care in Scotland: Unmatched retrospective cohort analysis

“…Transfer rates vary by type of unit ("freestanding" or "alongside") and parity (NICE 2007), but in most if not all such cases the woman will have received the antenatal care package originating in the FMU. While reviews of FMUs focus largely on intrapartum care (Newburn and Singh 2003;Overgaard et al 2011), it is the antenatal care package with which we are interested here because our principal focus is on the risk of preterm birth. We emphasise that this study was concerned with the locus of antenatal care, not with planned or actual place of birth.…”

Evaluating midwifery units (EMU): Lessons from the pilot study

“…On the other hand, there is a widely held perception that in the interest of safety, as many women as possible should birth in higher-level maternity units such as tertiary maternity units (TMUs) where specialist obstetric, anaesthetic and neonatal intervention is available on site (NSW Health Department, 2002b; The Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 2005). One of the major concerns about FMUs is the potential delay in treatment in the event of transfer to tertiary care via car or ambulance, which could lead to serious adverse outcomes (Overgaard et al, 2011). The question is: Are there significant differences in outcomes of labour and birth for women who plan to give birth at FMUs compared to women of similar risk status who plan to give birth at TMUs?…”