Model of care and chance of spontaneous vaginal birth: a prospective, multicenter matched-pair analysis from North Rhine-Westphalia

Abstract

Background Advantages of midwife-led models of care have been reported; these include a higher vaginal birth rate and less interventions. In Germany, 98.4% of women are giving birth in obstetrician-led units. We compared the outcome of birth planned in alongside midwifery units (AMU) with a matched group of low-risk women who gave birth in obstetrician-led units. Methods A prospective, controlled, multicenter study was conducted. Six of seven AMUs in North Rhine-Westphalia participated. Healthy women with a singleton term cephalic pregnancy booking for birth in AMU were eligible. For each woman in the study group a control was chosen who would have been eligible for birth in AMU but was booking for obstetrician-led care; matching for parity was performed. Mode of birth was chosen as primary outcome parameter. Secondary endpoints included a composite outcome of adverse outcome in the third stage and / or postpartum hemorrhage; higher-order obstetric lacerations; and for the neonate, a composite outcome (5-min Apgar < 7 and / or umbilical cord arterial pH < 7.10 and / or transfer to specialist neonatal care). Statistical analysis was by intention to treat. A non-inferiority analysis was performed. Results Five hundred eighty-nine case-control pairs were recruited, final analysis was performed with 391 case-control pairs. Nulliparous women constituted 56.0% of cases. For the primary endpoint vaginal birth superiority was established for the study group (5.66%, 95%-CI 0.42% – 10.88%). For the composite newborn outcome (1.28%, 95%-CI -1.86% - -4.47%) and for higher-order obstetric lacerations (2.33%, 95%-CI -0.45% - 5.37%) non-inferiority was established. Non-inferiority was not present for the composite maternal outcome (-1.56%, 95%-CI -6.69% - 3.57%). The epidural anesthesia rate was lower (22.9% vs. 41.1%), and the length of hospital stay was shorter in the study group (p < 0.001 for both). Transfer to obstetrician-led care occurred in 51.2% of cases, with a strong association to parity (p < 0.001). Request for regional anesthesia was the most common cause for transfer (47.1%). Conclusion Our comparison between care in AMU and obstetrician-led care with respect to mode of birth and other outcomes confirmed the superiority of this model of care for low-risk women. This pertains to AMU where admission and transfer criteria are in place and adhered to.

Ja zur Geburtshilfe – aber nicht unter ärztlicher Leitung: Ein Discrete Choice Experiment zur Analyse der Jobpräferenzen von Hebammen in Deutschland

“…Da Hebammen dieses Modell stark bevorzugen, könnten Krankenhäuser ihre freien Stellen auf einer hebammengeleiteten Entbindungsstation schneller besetzen. Doch obwohl hebammengeleitete Kreißsäle nicht kostenintensiver als die üblichen Kreißsäle sind und sogar als optimales Modell für risikoarme Geburten bewertet werden, existieren in Deutschland bislang nur wenige davon [22][23][24]. Im Jahr 2020 boten nur 23 Kliniken insgesamt hebammengeleitete Kreißsäle an, und gerade einmal 1 % aller Geburten fanden in solchen Abteilungen statt [25].…”

Midwifery continuity of care: A scoping review of where, how, by whom and for whom?

“…The continuity of care services were located as part of the usual hospital [37,43], in an alongside birth centre [44][45][46] or in a free-standing birth centre [47]. Some midwife-led continuity of care services were offered through homebirth practices, either as part of the hospital system [48,49] or as a private service [50].…”