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Getting the first birth right: A retrospective study of outcomes for low-risk primiparous women receiving standard care versus midwifery model of care in the same tertiary hospital
There is national and international concern for increasing obstetric intervention in childbirth and rising caesarean section rates. Repeat caesarean section is a major contributing factor, making primiparous women an important target for strategies to reduce unnecessary intervention and surgeries in childbirth.
Aim
The aim was to compare outcomes for a cohort of low risk primiparous women who accessed a midwifery continuity model of care with those who received standard public care in the same tertiary hospital.
Methods
A retrospective comparative cohort study design was implemented drawing on data from two databases held by a tertiary hospital for the period 1 January 2010 to 31 December 2011. Categorical data were analysed using the chi-squared statistic and Fisher's exact test. Continuous data were analysed using Student's t-test. Comparisons are presented using unadjusted and adjusted odds ratios, with 95% confidence intervals (CIs) and p-values with significance set at 0.05.
Results
Data for 426 women experiencing continuity of midwifery care and 1220 experiencing standard public care were compared. The study found increased rates of normal vaginal birth (57.7% vs. 48.9% p = 0.002) and spontaneous vaginal birth (38% vs. 22.4% p = <0.001) and decreased rates of instrumental birth (23.5% vs. 28.5% p = 0.050) and caesarean sections (18.8% vs. 22.5% p = 0.115) in the midwifery continuity cohort. There were also fewer interventions in this group. No differences were found in neonatal outcomes.
Conclusion
Strategies for reducing caesarean section rates and interventions in childbirth should focus on primiparous women as a priority. This study demonstrates the effectiveness of continuity midwifery models, suggesting that this is an important strategy for improving outcomes in this population.
Mode of birth, especially for primiparous women, has far-reaching implications not only for the woman and her family but also for the health care organisation as a whole. Women who have experienced a vaginal birth recover faster from the experience, are independent much sooner and enjoy a better quality of life
if they have not had an operative birth. Not only does a vaginal birth impact on the immediate experience of the woman and her family but if a woman is able to birth without intervention the first time, she will not carry the burden of a previous caesarean section into a future pregnancy and this has physical, psychological, social and financial implications for her.
The Australasian Council on Healthcare Standards (ACHS) reports a 23.0% selected primipara caesarean section rate in the Australian public system in their 2003–2010 Clinical Indicator Report. A more recent (2004–2011) report indicates a 29.2% rate in 2011, an increase of 6.2%. The ACHS definition of a selected primipara is a woman who is 20–34 years of age at the time of giving birth for the first time at greater than 20 weeks gestation. She is pregnant with a single foetus with a cephalic presentation and is 37–40.6 weeks gestation.
There is widespread national and international concern about this increase and the impact on neonatal and maternal outcomes.
This does not only include primiparous women having caesarean sections but women who plan a caesarean section for a subsequent birth. This prompted a recent study
to specifically examine why some women plan a caesarean section after birthing vaginally the first time. They concluded that there was an increased risk of planned caesarean section in the second birth for women who had obstetric interventions and adverse outcomes in the first birth. They emphasise the importance of ‘getting the first birth right’ in an effort to reduce this increasing caesarean section rate.
Midwifery led continuity of care is a strategy known to increase the chances of vaginal birth for low risk women.
Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial.
Caseload midwifery compared to standard or private obstetric care for first time mothers in a public teaching hospital in Australia: a cross sectional study of cost and birth outcomes.
Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial.
in Australia, focuses on women of mixed parity and do not offer sub-analyses for a primiparous cohort. Therefore it is unclear whether these strategies are effective for primiparous women who have experienced higher rates of operative birth and obstetric interventions than multiparous women.
Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial.
conducted a RCT comparing case-load midwifery with standard care in a group of women of mixed parity (though 70% primiparous). Unplanned sub-analyses of outcomes show that primiparous women in the case-load group were less likely to experience caesarean section and epidural analgesia and more likely to experience a spontaneous vaginal birth than their counterparts in standard care. No other analyses were offered for the primiparous cohort. Tracy et al.,
conducted a cross sectional study with a sub-analysis of outcomes for standard primiparous women experiencing caseload midwifery, standard hospital and private obstetric care. This study demonstrated that standard primiparous women in the caseload model were more likely to experience spontaneous onset and unassisted vaginal birth and had lower rates of elective caesarean section than standard primiparous women in the standard care and private obstetric models. Whilst these results are important further research is needed to examine a broader range of outcomes for a primiparous cohort of women.
Women who have experienced a vaginal birth are more autonomous in the postnatal period because they are not inhibited by a level of pain experienced by women who have had an assisted vaginal or caesarean birth. Although these interventions are sometimes required, the resulting discomfort may impact negatively on the woman's ability to initiate breastfeeding
Any baby born by caesarean section (elective or in labour), has an increased risk of respiratory difficulties and admission to a neonatal intensive care unit (NICU).
World Health Organization 2005 Global Survey on Maternal and Perinatal Health Research Group. Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study.
This has organisational funding implications because of the significant cost of caring for a baby in NICU. The introduction of a first obstetric intervention that may lead to others during labour for low risk women is very costly to the health system.
A more recent review of studies examining midwife-led care compared to doctor-led care suggested that further research was needed to establish the cost-effectiveness of midwife-led care.
This study found that a woman receiving ‘one on one’ care by a case-loading midwife saves the organisation over $500 per birth when compared to the costs for a woman receiving standard care. Women who experience a spontaneous vaginal birth (i.e. unassisted with no obstetric intervention) are also able to ambulate earlier, which encourages early transfer home with her baby, because of the reduced risk of respiratory difficulties. This has cost saving implications for the organisation.
The following methods were used in this study to determine if continuity of midwifery care at this site impacted on intervention and caesarean section rates.
3. Methods
A retrospective comparative cohort study design was implemented drawing on data from two databases held in an Australian tertiary hospital:
•
Birth outcomes system (BOS) is a clinical information management system designed to capture obstetric information and medical and obstetric history.
•
Clinical records information system (CRIS) is a computerised patient record where paper records are converted to digital format.
In this study every data entry in BOS was cross-checked with those in CRIS. Hard copy clinical notes were accessed for any missing data or for electronic data that appeared implausible.
Outcomes for low risk primiparous women giving birth between 1st January 2010 and 31st December 2011 who accessed two different models of care were compared. The models of care were:
•
Continuity midwifery model: A model of care that provides a woman with a designated midwife who provides all care in pregnancy, is ‘on call’ for and cares for her in labour and provides postnatal support for two weeks. Women accessing this model plan to give birth in the Birth Centre which (during the period of the study), was an ‘alongside’ birth centre on the ground floor with Delivery Suite situated on level three of the same building. In this model, women who develop complications in pregnancy and in labour will remain in the care of the midwives providing continuity of care with the birth taking place in Delivery Suite, as the Birth Centre is an environment for low risk women only. Women usually transfer home within 24 h with their continuity midwife providing postnatal support for a further two weeks.
•
Standard public care: Midwives, obstetric registrars, obstetricians and general practitioners share a woman's care, with the woman having no expectation that she will see the same midwife more than once and will not know her midwife in labour or the postnatal period. Women within this model of care plan to give birth in the Delivery Suite which is a traditional labour ward and are encouraged to transfer home 2–3 days later, with postnatal support from midwives unknown to them previously.
3.1 Sample
The sample comprised low-risk primiparous women who: gave birth for the first time, had a singleton pregnancy, had a foetus with a cephalic presentation, had a gestation of >37 weeks, were not planning an elective caesarean section, had no pre-existing or emerging medical conditions, had no emerging obstetric complications, had a BMI <40 and did not enter either model of care >30 weeks gestation. There were no maternal age or end-gestation limitations included in these criteria. The continuity of midwifery care model did not (in the study period) place age restrictions on women accepted into the programme and all women in both models of care were covered by a policy that recommended induction of labour by 41 + 3 weeks gestation.
3.2 Outcomes
The primary outcome of interest in this study was spontaneous vaginal birth (SVB). The definition of SVB employs more robust criteria than that applied to normal vaginal birth (NVB). NVB is any unassisted vaginal birth but may include induction or augmentation of labour, epidural anaesthesia and episiotomy whereas SVB precludes a vaginal birth where there has been any such intervention (Source: NSW Health – Towards Normal Birth policy). The secondary outcomes of interest were: mode of birth, onset of labour, augmentation of labour, analgesia and epidural use, postpartum haemorrhage (PPH), perineal status and neonatal outcomes including: Apgar score <7 at 5 min, stillbirth/neonatal death, admission to neonatal unit, breastfeeding within an hour of birth and length of postnatal hospital stay.
3.3 Data analysis
All analyses were performed using Statistical Programme for the Social Sciences (SPSS version number 21). Analyses were performed on an ‘intention to treat’ basis (i.e. by planned model/place of birth rather than actual). Categorical data were analysed using the chi-squared statistic and Fisher's exact test. Continuous data were analysed using Student's t-test. All tests were two-tailed and significance was set at p < 0.05. Comparisons are presented using unadjusted and adjusted odds ratios, with 95% confidence intervals (CIs) and p-values with significance set at 0.05. Outcomes were compared using logistic regression analysis adjusting for Body Mass Index, smoking and maternal age.
3.4 Ethical considerations
Ethical approval was gained from the relevant ACT Health Human Research Ethics (HREC) committees (ETHLR.11.097). No further approval was necessary as all requirements stated by this Committee, are paralleled by the University of Canberra HREC.
4. Results
There were 5542 births in the two calendar years 2010 and 2011. Almost 45% of those were to primiparous women (n = 2479) with 1983 receiving standard care and birthing in Delivery Suite and 496 being cared for by continuity model midwives and planning to birth in the Birth Centre. The previously described exclusion criteria were employed which resulted in a total final sample of 1646, comprising 1220 women receiving standard care who planned to birth in Delivery Suite and 426 women who planned to birth in the Birth Centre in the care of continuity midwives. Please see Fig. 1 for a flow diagram illustrating this process.
Table 1 presents the baseline characteristics of the women in each group. It was not possible to determine socioeconomic status, educational level, marital status or ethnicity of the women included in this study. The mean age of women in the midwifery continuity model is statistically (though not clinically) significantly higher than that of the women receiving standard care. It is also interesting to note that the smoking rate is significantly higher in the standard care group.
Table 1Baseline maternal characteristics by model of care.
A significantly greater proportion of women in the midwifery continuity model experienced normal vaginal, spontaneous vaginal and water births, with fewer experiencing assisted vaginal birth compared to the standard care group. Table 2 illustrates the primary outcome variable: mode of birth by planned model of care.
Table 3 presents the results of regression analysis with crude and adjusted odds ratios for these outcomes. Women in the care of continuity midwives and planning to give birth in the Birth Centre had a statistically significant increased chance of NVB, SVB and water birth and less risk of an assisted vaginal birth and caesarean section than their counterparts receiving standard care and planning to birth in the delivery suite.
Table 4 shows analysis of obstetric interventions providing the crude odds ratios and odds ratios after adjusting for smoking, maternal age and BMI. These include augmentation and induction of labour, episiotomy and epidural anaesthesia. There was little difference in rates of augmentation of labour and whilst there were fewer episiotomies for the women in the continuity model, it did not reach statistical significance. However these women did have statistically significant reduced odds of induction of labour and epidural anaesthesia than their counterparts receiving standard care.
Table 4Regression analysis of obstetric interventions.
Table 5 shows the results for secondary outcomes. The standard care group showed a significantly higher chance of ‘intact perineum’ whilst the continuity of care group showed reduced odds of ‘narcotic administration’ and consequently, a greater chance of no analgesia being administered. No differences were found in neonatal outcomes or transfers to neonatal units but there were increased rates of breastfeeding initiation within an hour of birth and early transfer home (within 24 h of birth) within the continuity cohort.
In this study, low risk primiparous women receiving continuity of midwifery care who planned to give birth in the Birth Centre had significantly improved outcomes compared to their standard care counterparts, with the exception of perineal status. Whilst these improved outcomes have been demonstrated previously in cohorts of mixed risk
Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial.
this is the first study of its kind to focus primarily on outcomes for primiparous women, capturing outcomes for this group that have not been presented elsewhere and presenting a more finely tuned analysis with adjustments made for relevant potential confounders.
The literature regarding primiparous caesarean section rates is contentious. A number of studies
have found no statistically significant difference in caesarean section rates when comparing midwifery-led models of care to other models. However, these studies included women of all parity, with no subgroup analysis of primiparous women. Sub-group analysis of primiparous women was conducted in two recent Australian studies
Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial.
Caseload midwifery compared to standard or private obstetric care for first time mothers in a public teaching hospital in Australia: a cross sectional study of cost and birth outcomes.
Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial.
Caseload midwifery compared to standard or private obstetric care for first time mothers in a public teaching hospital in Australia: a cross sectional study of cost and birth outcomes.
15.4% vs 19.5%. Our study results for this outcome fall between these results at 18.8% vs 22.5%. The variation in these results may be explained in part by the research design with the McLachlan et al. study being an RCT and Tracy et al. and our study, observational and thus vulnerable to selection bias.
In our study women experiencing continuity of midwifery care were also less likely to experience epidural anaesthesia and assisted vaginal birth and this was consistent with findings from other recent Australian studies.
Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial.
Caseload midwifery compared to standard or private obstetric care for first time mothers in a public teaching hospital in Australia: a cross sectional study of cost and birth outcomes.
Caseload midwifery compared to standard or private obstetric care for first time mothers in a public teaching hospital in Australia: a cross sectional study of cost and birth outcomes.
we also found that women experiencing continuity of midwifery care were less likely to have induction of labour, episiotomy and no differences in the neonatal outcomes measured. Other findings that are noteworthy in this study are that women experiencing continuity of midwifery care were more likely to have no analgesia in labour (including narcotics) and their babies were more likely to be breastfed within an hour of birth compared to women in standard care. The evidence is clear that an un-medicated labour, spontaneous vaginal birth and skin to skin contact following birth provide women with the best chance of successful breastfeeding initiation
and this has important and lifelong implications for the baby.
Experiencing a vaginal birth with as little intervention as possible is an important outcome for primiparous women not only because it avoids the risks associated with assisted and surgical birth and obstetric intervention but because it has a significant impact on their childbearing future. The mechanism by which continuity of midwifery and birth centre care achieves these outcomes for women is not yet well understood. The mechanisms may include the special partnership women have formed in the antenatal period with their ‘known’ midwife
concluded that continuous support in labour should be accepted as the norm.
At this site, it is unusual for a midwife working in the continuity model to be caring for more than one woman in labour at any given time whereas midwives working with the standard care group may be caring for at least two and they are usually women unknown to them before admission in labour. There is no data available to indicate if the women in the standard care group knew their support midwife but more than 80% of women in the midwifery continuity model had a ‘known midwife’ supporting them in labour and birth with their primary midwife being present for more than half their labours and births (58.45%). Whilst this may have influenced some outcomes, it did not appear to have had a protective effect on perineal trauma, with the standard care cohort having a statistically significant higher ‘intact perineum’ rate. This may be related to the levels of experience of midwives working in the two different settings but we do not have any data to support this hypothesis.
6. Limitations
Whilst there are advantages to this study design there are also some limitations: A cohort study is weaker than a randomised controlled trial (RCT) or a prospective study
due to the potential for bias. However, considering most outcomes were worse in the standard care group it may be unethical to conduct an RCT on models of care with such knowledge to hand. Observational studies are valuable because they reflect outcomes of a model of care in a ‘real world’ context rather than an experimental one. Every effort has been made in this study to ensure the homogeneity of the cohorts by adhering to the strict inclusion/exclusion criteria. We acknowledge that the philosophy of women accessing continuity of care may impact on these results including attitudes towards analgesic use and induction of labour, though this is difficult to substantiate.
The use of existing databases also brings its own limitations. The researcher was limited to the data available and in this case, data was not reliably collected on key demographics including socioeconomic status, educational level, marital status and ethnicity of the women. These are important variables that may impact on the dependent variable under consideration. It is reasonable to assume that the cohort of women accessing the continuity model were probably different to those attending standard care on some key demographic factors and the differences in proportions of women who smoked in each cohort was suggestive of this. It would be useful for future studies to analyse demographic and socioeconomic data or for these items to be added in standard clinical/patient systems to support future analysis.
7. Conclusion
This study shows that the midwifery continuity of care/carer model of care reduces obstetric intervention rates and assisted/operative birth rates in this low risk primiparous population and increases normal vaginal birth rates at this site. The study contributes to the existing body of knowledge that urges the health care system to use midwifery continuity models both for improved health outcomes for women and babies and to save valuable health dollars. The global and local importance of midwifery continuity models cannot be over-emphasised. When resources are limited we need to be strategic in ensuring every primiparous woman has access to this model of care to ensure we ‘get the first birth right’.
Acknowledgements and disclosures
During the period of the study, the first author was employed as a Registered Midwife at the tertiary hospital where the study was undertaken A Scholarship was granted by the ACT Health Nursing & Midwifery Office in 2010. A Practice development Scholarship (PDS2011-2012) was also granted to the midwifery unit by the ACT Research Centre for Nursing & Midwifery Practice (RCNMP) in 2011. We are grateful for this support and also grateful to Liz Sharpe (Director of Nursing and Midwifery during the period of the study) for supporting the study and facilitating access to two on-site databases. The first author also acknowledges the support of the other authors.
References
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Quality of life after cesarean and vaginal delivery.
Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial.
Caseload midwifery compared to standard or private obstetric care for first time mothers in a public teaching hospital in Australia: a cross sectional study of cost and birth outcomes.
World Health Organization 2005 Global Survey on Maternal and Perinatal Health Research Group. Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study.
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