1A. Consider all birthplace options, recognizing that birth experiences are enhanced in home, birth center, or hospital settings that support parent's informed choices for the labor, birthing, and postpartum process.
Premise: The practice of licensed midwives during out-of-hospital births may be shown to be as safe as that of physicians and certified-nurse midwives during in- and out-of-hospital births.
Research Question: Can births attended by licensed midwives be as safe as those attended by physicians and certified nurse-midwives?
Background: In 1983, the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics together released a statement that promoted only the hospital as a safe environment for labor, delivery, and the postpartum period. In 1991, the ACOG also released a statement disapproving of homebirth. Few studies have been conducted in the United States examining the safety of out-of-hospital births attended by midwives licensed according to international standards; however, much evidence from other countries where homebirth with midwives is practiced illustrates that this method is safe.
Subjects: The study included 6,944 licensed midwife-attended out-of-hospital births; 23,596 physician-attended, in-hospital births; 14,777 certified nurse midwife-attended, in-hospital births; and 4,054 out-of-hospital births attended by a certified nurse midwife.
Study Design: Birth certificates linked to infant death certificates for births between 1981 and 1990 in the State of Washington were used for this study. Also, all licensed midwives practicing between 1981and 1990 in the State of Washington were identified. Three other comparison groups were established in order to compare information gathered from licensed midwife-attended births: physician-attended, in-hospital births; certified nurse midwife-attended, in-hospital births; and certified nurse midwife-attended, out-of-hospital births. Variables chosen for analysis included low birth weight, low 5-minute Apgar scores, neonatal mortality, and postneonatal mortality. Other variables that could possibly affect outcomes of the birth were also collected, including age, race, ethnicity, marital status, occupation, number of prior pregnancies, history of fetal deaths after 20 weeks, trimester of first prenatal visit, residence type, smoking status, preeclampsia, and diabetes.
Findings: In this study, the majority of women giving birth were white. Women with a history of prior fetal death after 20 weeks gestation were more likely to be cared for by physicians or licensed midwife groups than by nurse midwives. Smoking, preeclampsia, and diabetes during pregnancy were highest among those in the physician-care group, followed by the nurse midwife in-hospital group. Low birth weight risk was decreased in the out-of-hospital licensed midwife group when compared with the in-hospital nurse midwife group. No significant differences were noted between groups in low 5-minute Apgar scores and in neonatal or post neonatal deaths.
Research reviewed by Laura Sims, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.
Premise: Midwifery care is associated with lower intervention rates than standard hospital care.
Research Question: Does midwifery care, when compared with standard maternity services, have any significance on interventions during labor and on maternal and infant outcomes?
Variables: Rates of cesarean sections, instrumental vaginal deliveries on the total number of deliveries, augmentation of labor, electronic fetal monitoring, and use of analgesia on all deliveries except cesarean. Variables also included the number of episiotomies on vaginal deliveries and infant outcomes on the total number of babies, including twins.
Subjects: Seven trials investigated 9,148 women.
Findings: In a meta-analysis review, midwives were shown to use fewer obstetric interventions (e.g., forceps, augmentation, analgesia, and electronic monitoring) during labor. The cesarean section rate, however, did not significantly differ (odds ratio 0.91; 95% confidence interval 0.78 to 1.05). A decrease in the episiotomy rate during midwife care (odds ratio .069; 95%; confidence interval 0.61 to 0.77) was also associated with an increase in perineal tears in the pooled alternative groups (odds ratio 1.11; 95% confidence interval 1.00 to 1.24). No significant change was evident in the amount of maternal complications. No maternal deaths occurred. Apgar scores were also statistically similar. Thus, fewer interventions used by midwives did not compromise the health of mothers or infants.
Research reviewed by Rochelle Gower, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.
Premise: Continued controversy remains concerning what constitutes optimal prenatal, antenatal, and postpartal care for pregnant women who are obstetrically at low risk.
Research Objective: To compare the process and outcomes of care for women who intended to deliver in the Quebec pilot project birth centers with those of women delivering under medical supervision in a hospital setting.
Background: Recent clinical trials have found that women receiving midwifery care had a lower risk of episiotomy, a similar proportion of infants with abnormal 5-minute Apgar scores, and no increase in perinatal mortality.
Subjects: The study included 961 recipients of midwifery care and 961 recipients of physician care whose expected delivery date was between January 26, 1995, and July 3, 1996, and whose pregnancy lasted at least 20 weeks.
Study Design: A cohort study with matched controls.
Findings: Women receiving physician services experienced more technological interventions than those receiving midwifery care: ultrasound examinations (98.4% vs. 81.1%), genetic amniocentesis (11%vs. 6%), nonstress tests (34% vs. 23.8%), and 50-g. glucose screen (55.1% vs. 23.4%). More women in the physicians group were hospitalized than were women in the midwifery group (10.3% vs. 3.3%). The length of time from admission to delivery was shorter for the recipients of midwifery care (median 5.1 vs. 6.9 hours). Women who were recipients of midwifery care had a lower rate of cesarean sections than the physician group (nulliparas, 10.8% vs. 19.8%; multiparas, 1.4% vs. 6.8%). Episiotomies were performed less frequently in the midwifery group than in the physician group (6.9% vs. 36.5%). There was a slight increased need for assisted ventilation of babies in the midwifery group and an increase in abnormal fetal tone (11 vs. 5), but this was not considered statistically significant. Women receiving care from midwives were less likely to be delivered by forceps or vacuum extraction.
Research reviewed by Karla Batten, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.