In-hospital Birth Center Research Articles

A Midwifery-Led In-Hospital Birth Center Within an Academic Medical Center

The University of California San Diego Community Women's Health Program (CWHP) has emerged as a successful and sustainable coexistence model of women's healthcare. The cornerstone of this midwifery practice is California's only in-hospital birth center. Located within the medical center, this unique and physically separate birth center has been the site for more than 4000 births. With 10% cesarean delivery and 98% breast-feeding rates, it is an exceptional example of low-intervention care. Integrating this previously freestanding birth center into an academic center has brought trials of mistrust and ineffectual communication. Education, consistent leadership, and development of multidisciplinary guidelines aided in overcoming these challenges. This collaborative model provides a structure in which residents learn to be respectful consultants and appreciate differences in medical practice. The CWHP and its Birth Center illustrates that through persistence and flexibility a collaborative model of maternity services can flourish and not only positively influence new families but also future generations of providers.

Satisfaction with a Modified Form of In‐Hospital Birth Center Care Compared with Standard Maternity Care

For safety reasons an in-hospital birth center was replaced by a modified form of birth center care with the same medical guidelines and equipment as in standard care. The aim of this study was to investigate women's and men's satisfaction with modified care compared with standard care. Women in both groups gave birth from July 2007 to July 2008. The same medical low-risk criteria during pregnancy applied to both groups. Of those invited to the study, 547 (82.7%) women in modified birth center care and 445 (66.7%) men returned a questionnaire posted 2 months after the birth, and 786 (71.6%) women and 639 (58.2%) men in standard care. Odds ratios (ORs) for being satisfied were calculated with 95 percent confidence intervals (CIs) and adjusted for possible confounders. We also explored the effects of different components of care on overall satisfaction. Adjusted ORs for being satisfied overall were approximately doubled in the modified birth center group compared with the standard care group: antenatal care-OR: 2.1 (95% CI: 1.6-2.7) in women and OR: 2.2 (95% CI: 1.5-2.8) in men; intrapartum care-OR: 2.2 (95% CI: 1.7-2.9) in women and OR: 1.7 (95% CI: 1.3-2.4) in men; and postpartum care-OR: 1.7 in women (95% CI: 1.4-2.2) and OR: 2.1 (95% CI: 1.6-2.8) in men. Important explanations of these differences included perception of the midwife as being more supportive, the presence of a calmer environment and atmosphere (intrapartum), and the option for fathers to stay overnight (postpartum). In-hospital birth center with medical equipment on site increased overall satisfaction with all episodes of care compared with standard care. (BIRTH 39:2 June 2012).

Use of Hyaluronidase to Prevent Perineal Trauma During Spontaneous Births: A Randomized, Placebo‐Controlled, Double‐blind, Clinical Trial

The purpose of this study was to compare the frequency and severity of perineal trauma during spontaneous birth with or without perineal injections of hyaluronidase (HAase). A randomized, placebo-controlled, double-blind clinical trial was conducted in a midwife-led, in-hospital birth center in São Paulo, Brazil. Primiparous women (N = 160) were randomly assigned to an experimental (n = 80) or control (n = 80) group. During the second stage of labor, women in the experimental group received an injection of 20.000 turbidity-reducing units of HAase in the posterior region of the perineum, and those in the control group received a placebo injection. The assessment of perineal outcome was performed by 2 independent nurse-midwives. A 1-tailed Fisher exact test was performed, and a P value < .025 was considered statistically significant. Perineal integrity occurred in 34.2% of the experimental group and in 32.5% of the control group, which was not a statistically significant difference (P= .477). First-degree laceration was the most common trauma in the posterior region of the perineum in women in both groups (experimental = 56%, control = 42.6%). Severe perineal trauma occurred in 28.9% of the experimental group and 38.8% of the control group, which also was not a statistically significant difference (P= .131). The depth of second-degree perineal lacerations in the experimental and control groups, measured by the Peri-Rule, was 1.9 cm and 2.3 cm, respectively. An episiotomy was performed in 11 women (experimental group = 3, control group = 8), and 4 (all in control group) had third-degree lacerations. The use of injectable HAase did not increase the proportion of intact perineum and did not reduce the proportion of severe perineal trauma in our sample.

In-Hospital Birth Center with the Same Medical Guidelines as Standard Care: A Comparative Study of Obstetric Interventions and Outcomes

A challenge of obstetric care is to optimize maternal and infant health outcomes and the mother's experience of childbirth with the least possible intervention in the normal process. The aim of this study was to investigate the effects of modified birth center care on obstetric procedures during delivery and on maternal and neonatal outcomes. In a cohort study 2,555 women who signed in for birth center care during pregnancy were compared with all 9,382 low-risk women who gave birth in the standard delivery ward in the same hospital from March 2004 to July 2008. Odds ratios (OR) were calculated with 95% confidence interval (CI) and adjusted for maternal background characteristics, elective cesarean section, and gestational age. The modified birth center group included fewer emergency cesarean sections (primiparas: OR: 0.69, 95% CI: 0.58-0.83; multiparas: OR: 0.34, 95% CI: 0.23-0.51), and in multiparas the vacuum extraction rate was reduced (OR: 0.42, 95% CI: 0.26-0.67). In addition, epidural analgesia was used less frequently (primiparas: OR: 0.47, 95% CI: 0.41-0.53; multiparas: OR: 0.25, 95% CI: 0.20-0.32). Fetal distress was less frequently diagnosed in the modified birth center group (primiparas: OR: 0.72, 95% CI: 0.59-0.87; multiparas: OR: 0.45, 95% CI: 0.29-0.69), but no statistically significant differences were found in neonatal hypoxia, low Apgar score less than 7 at 5 minutes, or proportion of perinatal deaths (OR: 0.40, 95% CI: 0.14-1.13). Anal sphincter tears were reduced (primiparas: OR: 0.73, 95% CI: 0.55-0.98; multiparas: OR: 0.41, 95% CI: 0.20-0.83). Midwife-led comprehensive care with the same medical guidelines as in standard care reduced medical interventions without jeopardizing maternal and infant health.

A Descriptive Study of “Being with Woman” During Labor and Birth

The objective of this study was to learn more about women's perceptions of the nurse-midwifery practice of "being with woman" during childbirth. The descriptive, correlational design used a convenience sample of 238 low-risk postpartum women in a hospital nurse-midwifery practice, with two childbirth settings: a standard labor and delivery unit and an in-hospital birth center. The main outcome measure was a 29-item seven-response Likert scale questionnaire, the Positive Presence Index (PPI), administered to women cared for during labor and birth by nurse-midwives to measure the concept of being with woman. Statistical analysis demonstrated women who gave birth in the in-hospital birth center or who began labor in the in-hospital birth center prior to an indicated transfer to the standard labor and delivery unit gave higher PPI scores than women who were admitted to and gave birth on the standard labor and delivery unit. Parity, ethnicity, number of midwives attending, presence of personal support persons, length of labor, and pain relief medications were unrelated to PPI scores. Two coping/comfort techniques, music therapy and breathing, were found to be correlated with reported higher PPI scores than those of women who did not use the techniques. These results can be used to encourage continued use of midwifery care and for low client to midwife caseloads during childbirth, and to modify hospital settings to include more in-hospital birth centers.

Birth centre care over a 10‐year period: Infant morbidity during the first month after birth

To study morbidity during the first month of life affecting infants of mothers booked for birth centre care during pregnancy. 3238 live single-born infants whose mothers were admitted to an in-hospital birth centre, located at South Hospital in Stockholm, between 1989 and 2000 were compared with 179,502 infants whose mothers received standard maternity care in the Stockholm region during the same period, and who fulfilled the same medical inclusion criteria as those of the birth centre group. Information on other exposures and outcomes was collected from the Swedish Medical Birth and Hospital Discharge Registers. Logistic regression analyses were performed to calculate the odds ratio (OR), using 95% confidence intervals (95% CI). Compared with infants born in standard care, infants in the birth centre group had a higher risk of respiratory problems (OR 1.39; 95% CI 1.14-1.69), a difference correlated to less serious respiratory diagnoses. However, the difference was not statistically significant if the birth centre group was compared only with infants born in standard care at South Hospital (OR 1.18; 95% CI 0.94-1.47). Birth centre care was associated with a lower risk of fractures (OR 0.40; 95% CI 0.25-0.63). Birth centre care was not associated with severe infant morbidity and even appeared to reduce the risk of birth trauma, such as clavicle and other fractures.

Swedish women's interest in home birth and in-hospital birth center care.

In Sweden, few alternatives to a hospital birth are available, and little is known about consumer interest in alternative birth care. The aim of this study was to determine women's interest in home birth and in-hospital birth center care in Sweden, and to describe the characteristics of these women. All Swedish-speaking women booked for antenatal care during 3 weeks during 1 year were invited to participate in the study. Three questionnaires, completed after the first booking visit in early pregnancy, at 2 months, and 1 year after the birth, asked about the women's interest in two alternative birth options and a wide range of possible explanatory variables. Consent to participate in the study was given by 3283 women (71% of all women eligible). The rates of response to the three questionnaires were 94, 88, and 88 percent, respectively. One percent of participants consistently expressed an interest in home birth on all three occasions, and 8 percent expressed an interest in birth center care. A regression analysis showed five factors that were associated with an interest in home birth: a wish to have the baby's siblings (OR 20.2; 95% CI 6.2-66.5) and a female friend (OR 15.2; 95% CI 6.2-37.4) present at the birth, not wanting pharmacological pain relief during labor and birth (OR 4.7; 95% CI 1.4-15.3), low level of education (OR 4.5; 95% CI 1.8-11.4), and dissatisfaction with medical aspects of intrapartum care (OR 3.6; 95% CI 1.4-9.2). An interest in birth center care was associated with experience of being in control during labor and birth (OR 8.3; 95% CI 3.2-21.6), not wanting pharmacological pain relief (OR 2.3; 95% CI 1.3-4.1), and a preference to have a known midwife at the birth (OR 2.2; 95% CI 1.6-2.9). If Swedish women were offered free choice of place of birth, the home birth rate would be 10 times higher, and the 20 largest hospitals would need to have a birth center. Women interested in alternative models of care view childbirth as a social and natural event, and their needs should be considered.

Effects of birth centre care on fathers' satisfaction with care, experience of the birth and adaptation to fatherhood

As part of an evaluation of an in-hospital birth centre, 576 expectant fathers were randomly allocated to birth centre care and 567 to standard maternity care in the earlier part of their partner's pregnancy. A questionnaire mailed 2 months after the birth asked about satisfaction with care, experience of labour and birth and adaptation to fatherhood. The response rates were 99% and 94% in the birth centre group and standard care group, respectively. The birth centre group had more positive experiences of intrapartum and postpartum care than the standard care group. Attitudes by staff were assessed as more positive, the fathers felt they were treated with greater respect, and during labour the midwife was more supportive of their needs as partners. However, birth centre care did not seem to have any major effect on the fathers' experience of labour and birth, or any long-term effect on adaptation during the first 2 months. Measures of physical and mental well-being, experience of fatherhood, involvement in infant care and utilization of paternal leave did not differ statistically between the trial groups.

Continuity of carer and satisfaction

Objective: to study the association between continuity of carer and satisfaction with antenatal, intrapartum and postpartum domiciliary care. Design: a descriptive study comparing satisfaction measures between women cared for by a known or unknown midwife. Data on satisfaction were extracted from the intervention group of a birth centre trial, and the names of the individual carers from two clinical databases kept at the birth centre. Setting: an in-hospital birth centre in Stockholm. Subjects: 410 women who had been randomly allocated to birth centre care during pregnancy, and who had a normal vaginal delivery at the centre. Complete data, including the names of the caregivers and the women's satisfaction scores, were available in 175 cases (43%) during the antenatal episode, 404 cases (98%) during the intrapartum episode and in 254 cases (62%) during the episode of postpartum domiciliary care. Main outcome measures: overall satisfaction with antenatal care, intrapartum care, labour and birth, and postpartum domiciliary care. Findings: no statistical differences were observed in satisfaction with antenatal care between women who had seen only one, two, or more than two midwives at their checkups during pregnancy; in satisfaction with intrapartum care or the birth itself when comparing women who were delivered by a known or unknown midwife; or in satisfaction with domiciliary care when the midwife was known or unknown. Conclusion: the findings suggest that continuity of carer is less important in a birth centre. The high levels of satisfaction in women having birth centre care were probably more affected by the attitudes of the carers, the philosophy of care, and the nice and calm environment than by knowing the individual midwife well.

Twelve years and more than 30,000 nurse-midwife-attended births: The Los Angeles County + University of Southern California Women's Hospital birth center experience

This article describes the setting, policies, practices, and outcomes of the nurse-managed in-hospital birth center at Los Angeles County + University of Southern California Women's Hospital, where women are selected upon admission for birth center care. A retrospective review of available data was made; when compared with hospital records, the primary data source was found to be 96% accurate. Results of the review indicated that from 1981 to 1992, there were 36,410 birth center admissions and 30,311 births, all attended by nurse-midwives; no intrapartum maternal or fetal deaths occurred among all admissions. The intrapartum transfer rate averaged 17%, and declined steadily from a high of 28% in 1982 to a low of 7% in 1990. More in-depth review showed an overall primary cesarean birthrate of 1.8% and an operative birthrate of 4% among the 25,890 admissions and 22,490 births from 1985 to 1992. Detailed postpartum and newborn outcomes from 1982 to 1986 showed a neonatal intensive care unit admission rate of 1.5% and a one-week newborn readmission rate of 1.3% among newborns discharged within 12 to 24 hours; 85% of all newborns returned for follow-up care. This large longitudinal experience demonstrates excellent outcomes that can be achieved when nurse-midwives, working cooperatively with a multidisciplinary health care team, provide in-hospital birth center care to a predominately low-income Hispanic population using a variety of less-traditional intrapartum management techniques. Broader implications for making alternative maternity care services available for low-income women with nurse-midwives and nurses playing a central role are discussed.

No effect of birth centre care on either duration or experience of breast feeding, but more complications: findings from a randomised controlled trial

Objective: to study the effect of birth centre care on the duration of breast feeding, breast feeding complications, and women's experiences of breast feeding. Design: randomised controlled trial. Setting: in-hospital birth centre at South Hospital, Stockholm, and standard obstetric care in the Greater Stockholm area. Subjects: 1230 women with expected date of birth between October 1989 and February 1992, interested in participating in a birth centre trial, and meeting medical low-risk criteria. 617 women were allocated to the experimental group offered birth centre care (EG), and 613 to the control group offered standard obstetric care (CG). Main outcome measures: duration of breast feeding, breast feeding complications such as sore nipples, engorgement, milk stasis, and mastitis, and women's experiences of breast feeding. Findings: no difference was found between EG and CG in the duration of breast feeding. Ninety-three per cent in both groups were breast feeding exclusively two months post partum. The average number of months of breast feeding, exclusively or partly, when investigated one year after the birth was 8.6 in EG and 8.5 in CG. No difference was observed in women's experiences of breast feeding, but rather more women in EG than in CG reported sore nipples, 36% and 30% respectively (p = 0.03), and milk stasis, 26% and 19% respectively (p = 0.002). Conclusions: birth centre care had no effect on the duration of breast feeding, or on women's experiences of breast feeding. Prenatal attitudes were probably more significant predictors of these outcomes than differences in the two modes of maternity care in this population of highly breast feeding-motivated women. The larger proportion of sore nipples and milk stasis in the EG might have been due to earlier discharge, or to midwives less skilled in assisting with breast feeding at the birth centre than in the postpartum wards.

Early Discharge of Mothers and Infants following Vaginal Childbirth at the United States Air Force Academy: A Three-Year Study

Since opening the Air Force's first in-hospital birth center, the United States Air Force Academy Hospital has followed a policy of 24-hour discharge of mothers and babies--a major paradigm shift in traditional military treatment facility practice. This study was conducted to evaluate this change. Records were reviewed of all vaginal births in the first 3 years of operation. Factors considered included demographic data, parity, gestational age, and complicating factors, both mother and infant. Postpartum bed days were reduced by 48%, the maternal readmission rate was 0.59%, and the infant readmission rate was 0.29%. It is the opinion of this author that 24-hour discharge is safe, cost effective, promotes access to care, and is desirable for patient satisfaction. With 1,340 subjects evaluated, the results of this study are provided to encourage and support a change in traditional practice patterns in military treatment facilities.