Do we have enough evidence to judge midwife led units safe Lesley Page KCL

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Do we have enough evidence to judge midwife led
units safe?Lesley Page KCL
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The shift to hospital based birth

• The largest uncontrolled social medical
• experiment of the 20th Century
• From 1954 to the 1980s rate fell from 35 to 1
• No evaluation-increase in safety and reduction of
  inequalities never proved

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Inequalities in outcomes continue

• Babies of mothers living in the most
• deprived areas twice more likely to be
• stillborn and 2.2 more times likely to die in the
  first month of life.
• CEMACH 2007

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Inequalities in outcomes continue

• Mothers where both partners
• unemployed 20 times more likely to die
• Women living in most deprived areas 45 more
  likely to die
• Minority ethnic groups 3 times more likely to die
• Black African women mortality rate 7 times higher
  than white.
• Why Mothers Die 2000-2002

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Shift to institutionalisation of birth

• Rise in caesarean section rate
• In developed world average 21.1
• Range from 6.2 to 36

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Why rise in caesarean rate is of concern

• Risk of morbidity and mortality to mother
• Risk to future pregnancies

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The view that out of hospital birth is less safe
prevails

• Despite evidence to the contrary

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• Can we judge safety on a single indicator,
  perinatal mortality?

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Rethinking

• Risk of unnecessary intervention for mother, baby
  and future generations is ignored
• Wider view of safety necessary

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Steady and continuing rise in the rate of
caesarean sections

• Developed world 21.2
• Range 6.2 to 36

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Caesarean section does not confer additional
health gain
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Midwifery led care, particularly out of hospital
care, may reduce the risk of intervention
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Midwifery led care

• At home
• In Community hospitals
• In birth centres-attached and non attached
• In hospital

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Home birth

• No less safe than hospital birth for women and
  babies without complications
• Associated with lower intervention rate
• Provides more positive experience for many women

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Best Evidence. Home Birth-perinatal outcomes

• Lower rate of use of analgesia and epidural
• Less induced labour
• Less augmented labour
• Lower rate of caesarean section
• Less use of episiotomy
• Less instrumental delivery

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Home Birth-Babies outcomes

• Apgar scores-lower frequency of low Apgar scores
  to no significant differences
• Perinatal Mortality-Most studies report no
  difference except NCC-WCH analysis and Bastian.

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Home Birth-Babies outcomes

• NCC-WCH-lower rate of IPPM for births completed
  at home but higher rate of IPPM for transferred
  group
• Northern Region no difference
• Woodcock no difference
• Bastian PMR higher for babies born at home
  (included high risk women)

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Birth centres

• Provide environments where midwives can fully use
  their skills
• Women wish for access to midwife led birth
  centres
• Provide support for normal birth
• No reliable evidence on benefit or
  harm-unreliable studies and difficulty with
  definition
• Lower intervention rate in midwifery led out of
  hospital birth centres

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Large study of birth place

• In process at the NPEU Oxford
• Mary Logan
• Project Manager
• National Perinatal Epidemiology Unit
  (NPEU)University of Oxford Old Road
  CampusOxfordOX3 7LF
• Email birthplace_at_npeu.ox.ax.uk
• Tel [phone]
• Fax [phone]

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Midwifery

• Based on the need to respect, recognize and
  support physiological processes
• Support positive transition to parenthood and
  family formation
• More likely to provide a positive experience of
  care and to reduce intervention rate with
  continuity of care

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Safer maternity services

• Those that recognize and respond to effects of
  ethnicity and inequalities
• Recognize the risk of unnecessary interventions