Ina May Gaskin Winner of the Right Livelihood Award 2011
The Jury recognises Ina May Gaskin (USA) for her whole-life s work teaching and advocating safe, woman-centred childbirth methods that best promote the physical and mental health of mother and child.
Datainsamling (studie III) Totalt 1 262 003 förlossningar i det medicinska födelseregistret 1992-2004 1602 förlossningar identifierades registrerade på de kvinnor som lämnat sitt personnummer 551 förlossningar som skett före 1992 exkluderades (syskon) 154 planerade sjukhusförlossningar exkluderades (syskon) 11 341 fullgångna singelförlossningar hämtades från MFR. Geografisk matchning gjordes. 897 planerade hemförlossningar återstod 146 sätesförlossningar exkluderades Ytterligare uteslöts tre förlossningar pga diabetes hos kvinnan, åtta tvilllingpar, 11 prematura förlossningar, 79 överburna och sex sätesförlossningar (n=107) 11 195 fullgångna singelförlossningar återstod 790 fullgångna singelförlossningar återstod 2011-11-07
Interventioner och komplikationer Bristning i ändtarmens slutmuskel mindre vanligt i hemförlossningsgruppen (RR 0.2, CI 0.0-0.7) Färre kejsarsnitt (RR 0.4, CI 0.2-0.7) Färre instrumentella förlossningar (RR 0.3, CI 0.2-0.5) 2011-11-07 2011-11-07
Multivariat analys av ogynnsamt utfall och medicinska interventioner bland planerade hemförlossningar (inklusive förlossningar som avslutats på sjukhus) och planerade sjukhusförlossningar. Hemma n=897 n (%) Sjukhus n=11341 n (%) Relativ risk (hemförloss ningar) 95 % CI Justerad relativ risk# 95 % CI för justerad risk p-värde Vaginala bristningar 161 (18) 3577 (32) 0.5 0.4-0.6 0.7 0.6-0.9 0.001 Perinealbristningar 178 (20) 2587 (23) 0.8 0.7-1.0 1.0 0.8-1.3 0.65 Sfinkter/rektal bristning 3 (0.3) 311 (3) 0.1 0.0-0.4 0.2 0.0-0.7 0.01 Episiotomi 8 (1) 820 (7) 0.1 0.0-0.2 0.1 0.0-0.2 <0.001 Kejsarsnitt 22 (2) 776 (7) 0.4 0.3-0.5 0.4 0.2-0.7 0.002 Sugklocka 20 (2) 1089 (10) 0.2 0.1-0.4 0.3 0.2-0.5 <0.001 2011-11-07
Bristningar grad III-IV Har ökat under de senaste tio åren Cirka 3000 kvinnor drabbas/år Nio procent av förstföderskorna (Prager 2008)
Riskfaktorer för bristning grad III-IV Instrumentell förlossning Episiotomi Halvliggande eller huksittande Barnets vikt >4500 g
Hemförlossningsgruppe n Fler barn med hög födelsevikt Fler överburna Knästående/stående förlossningar vanligast Känd barnmorska Andra förberedelser?
Neonatal mortalitet Barn som dött under förlossningen eller under de 28 första levnadsdagarna 2.2 per tusen i hemförlossningsgruppen, 0.6 per tusen i sjukhusgruppen (RR 3.6, CI 0.8 17.2) 2011-11-07 2011-11-07
Tidig neonatal mortalitet Barn som dött under förlossningen eller under den första levnadsveckan 1,1 per tusen i hemförlossningsgruppen, 0,53 per tusen i sjukhusgruppen (RR 1.8, CI 0.2-14.7) 2011-11-07 2011-11-07
Neonatal mortalitet Nationella data 2,2 per tusen i hemförlossningsgruppen, 2,5 per tusen bland samtliga fullgångna singelgraviditeter under studieperioden (RR 0.9, CI 0.3-4.8) 2011-11-07 2011-11-07
Dubblerad risk för neonatal mortalitet, lika stora grupper Fasta element i scenario Distribution Exact conditional Method Walters normal approximation Number of Sides 2 Group 1 Proportion Group 2 Proportion 0.0006 0.0012 Group 1 Weight 1 Group 2 Weight 1 Nominal Power 0.8 Alpha 0.05 Beräknat N Total Actual Pow er N Total 0.800 82892 2011-11-07
Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births. ABSTRACT Objective To compare perinatal mortality and severe perinatal morbidity between planned home and planned hospital births, among low-risk women who started their labour in primary care. Design A nationwide cohort study. Setting The entire Netherlands. Population A total of 529 688 low-risk women who were in primary midwife-led care at the onset of labour. Of these, 321 307 (60.7%) intended to give birth at home, 163 261 (30.8%) planned to give birth in hospital and for 45 120 (8.5%), the intended place of birth was unknown. Methods Analysis of national perinatal and neonatal registration data, over a period of 7 years. Logistic regression analysis was used to control for differences in baseline characteristics. Main outcome measures Intrapartum death, intrapartum and neonatal death within 24 hours after birth, intrapartum and neonatal death within 7 days and neonatal admission to an intensive care unit. Results No significant differences were found between planned home and planned hospital birth (adjusted relative risks and 95% confidence intervals: intrapartum death 0.97 (0.69 to 1.37), intrapartum death and neonatal death during the first 24 hours 1.02 (0.77 to 1.36), intrapartum death and neonatal death up to 7 days 1.00 (0.78 to 1.27), admission to neonatal intensive care unit 1.00 (0.86 to 1.16). Conclusions This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system.
Experience of childbirth Empowering Scaring Meaningful (Larkin, 2009, Lavender 1999, Cheyney 2009)
Experiences of homebirth Extended meaning Family centered Empowering (Sjöblom 2008, Lindgren 2006, Viisainen 2001)
Prevalence 0.38 per thousand according to code in the Medical Birth Register 0.95 per thousand according to data collection 53 percent not coded (Lindgren 2008)
Study population 1997-2008 I. All women in Sweden with experience of a planned homebirth between N=671 II. Women who had a CS on maternal request N=126
Data analysis Characteristics Birth experience (Likert scale) How du you feel when you think about the birth? Did you at any time during birth feel threat to the baby s life?
Results Higher education (OR 2.3, 95% CI 1.5-3.6) Lower BMI (OR 0.1; 95% CI 0.01-0.6) Less smokers (OR 0.2; 0.1-0.4)
Less anxiety for the baby (OR 0.1; 0.03-0.4) Participated in decision making (OR 6.0; 95% CI 3.3-10.7) Support from midwife (OR 3.9; 2.2-7.0) Control (OR 3.3; 1.6-6.6) Positive birth experience (OR 2.9; 1.7-5.0) Satisfied with intrapartum care (OR 2.3; 1.3-4.1)
Conclusion Women who planned a home birth and women who have a caesarean section on maternal request are, from a characteristic point of view, two entirely different groups of mothers. Although women who had their wishes about mode of delivery fulfilled, in a birth context that neither promotes home birth nor caesarean section without medical reasons, most studied variables favoured home birth with more involvement in decision making and a more positive birth experience.
Pregnancy in the Netherlands Healthy from start Primary level of care Complications from start Secondary level of care Healthy through pregnancy Home or hospital, primary level of care Complications at birth From primary to secondary level of care Complications during pregnancy Hospital, secondary level of care 22 % of all births occur at home (2010)
Prospective study 1 January 2007 31 December 2008 Utrecht 21000 deliveries/year Full term pregnancies Stillbirths, neonatal deaths and NICU Audit all cases, eight expert panel Parity and level of care
Data collection Total cohort 37735 children Missing 91 (0,2) Primary care 18686 (49,5) Secondary care 18958 (50,2) Primary care 13194 (35,0) Referral during labor 5492 (14,6/29,4) Secondary care 24450 (64,8)
Results 60 antepartum deaths 22 intrapartum deaths Overall perinatal death 2,62/1000 37 cases in primary care 23 in secondary care Delivery related deaths n=36
Delivery related deaths Variables Total no Deaths RR (95% CI) Start in 1 care 18686 26 2.33 (1.12-1.44) Nulliparous 7719 13 2.27 (0.87-5.98) Multiparous 10967 13 2.56 (0.84-7.85 Start in 2 care 16739 10 Ref Nulliparous 8104 6 Multiparous 8635 4 Referral during labor 5492 12 3.66 (1.58-8.46) Nulliparous 3815 7 2.48 (0.83-7.37) Multiparous 1677 5 6.44 (1.73-23.9)
Admission to NICU Altogether 210 children (5.58/1000) 107 (51%) started in primary care 75 (70%) referrals during labor 179 (85%) gave birth in secondary care 2.43/1000 in primary care (n.s.) 13.7 /1000 referrals RR 1.4 (1.0-1.9) 5.45/1000 secondary care (ref)
Reasons for admission % 60 50 40 30 20 10 0
Data not adjusted for Parity Age Socioeconomic class Ethnicity Multiple pregnancy All factors more prevalent among women at high risk
What does this say? The first study to show adverse outcome in primary care What about referrals? (43 %/13 % resp of all women in primary care) Midwife not present at first stage of labor Delay due to transport, obstetric availability, attitudes Risk selection not effective
Critique on the study Ank de Jonge, senior midwife researcher Prospective? Neighbor regions only included when the baby was a case The population not representative (doubled neonatal mortality) Previous audits did not find the same relation Undocumented women are more likely to give birth at home (OR 2.14, 95% CI 1.07 4.28) and less likely to receive maternity home care assistance (56.0 versus 79.7%) de Jonge 2011.
More critique Victor J Pop, professor of primary care Misclassifications regarding referrals 8% of the high risk pregnancies were low risk
Birthplace study www.npeu.ox.ac.uk/birthplace The results of this major research programme will be published on the NIHR Service Delivery and Organisation (SDO) Programme website in autumn 2011. The first set of reports will cover the first five studies in the Birthplace programme: Study 1: Birthplace terms and definitions consensus process Study 2: Mapping maternity care: the configuration of maternity care in England Study 3: The Birthplace national prospective cohort study: perinatal and maternal outcomes by planned place of birth Study 4: Birthplace cost-effectiveness analysis of planned place of birth: individual level analysis Study 5: Birthplace qualitative organisational case studies
Thank you!