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

Intrapartum and neonatal mortality in low‐risk term women in midwife‐led care and obstetrician‐led care at the onset of labor: A national matched cohort study

“…Interventions during labor were substantially lower in all non‐obstetric unit settings, with intrapartum cesarean section rates of 11.1% in obstetric units and 2.8% in intended home births (OR 0.31, 95% CI 0.23‐0.41) . This was partly in line with our study, which showed lower intrapartum cesarean section rates for women starting labor in midwife‐led care (2.6% vs 8.2% in obstetrician‐led care) and other studies comparing intervention rates in midwife‐led vs obstetrician‐led care …”

“…In the Utrecht region of the Netherlands (from 2007 to 2008), Evers et al found an increased risk of perinatal mortality in the midwife‐led care group (1.39‰ vs 0.60‰; unadjusted relative risk 2.3, 95% CI 1.1‐4.8), despite the fact that women starting labor in obstetrician‐led care were predominantly high risk . We repeated this study in the Amsterdam region (from 2005 to 2008) and found no significant difference in intrapartum and neonatal mortality rates between groups (0.70‰ in midwife‐led group vs 0.80‰ in obstetrician‐led group; unadjusted relative risk 0.88, 95% CI 0.52‐1.46) . However, evaluating these groups by start of labor is challenging, mostly because of the differences in patient characteristics in midwife‐led and obstetrician‐led care, lack of power (due to low mortality rates among term pregnancies in a regional cohort) and the data quality of the registry data to define, for example, line of care at the start of labor and low‐risk status …”

“…Midwife‐led care therefore includes home births and midwife‐led hospital births (using intermittent auscultation), whereas obstetrician‐led care is always set in a hospital (using fetal trace monitoring with cardiotocography). Previous studies in the Utrecht and Amsterdam regions of the Netherlands showed conflicting results when comparing perinatal mortality in women who started labor in midwife‐led vs obstetrician‐led care …”

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

“…When the analysis was repeated in the Amsterdam area, this problem was addressed by selecting births in the numerator as well as the denominator from the Amsterdam NICU region. 5 In this analysis among 83 909 births, no significant difference in intrapartum and neonatal death rates was found among births that started in midwife-led versus obstetrician-led care.…”

“…Therefore, births in groups a and b came from a different geographical area in the numerator and denominator; births outside the Utrecht NICU region that met the inclusion criteria were included in the numerator but not in the denominator. When the analysis was repeated in the Amsterdam area, this problem was addressed by selecting births in the numerator as well as the denominator from the Amsterdam NICU region . In this analysis among 83 909 births, no significant difference in intrapartum and neonatal death rates was found among births that started in midwife‐led versus obstetrician‐led care.…”