Intrapartum Transfer Research Articles

Planned Home Births in the United States Have Outcomes Comparable to Planned Birth Center Births for Low-Risk Birthing Individuals.

There are lingering concerns in the United States about home birth. We used 2 large (n = 50,043; n = 62,984), national community birth registries to compare maternal and neonatal outcomes for planned home versus planned birth center births. To compare outcomes by intended birth site, we used logistic regressions, controlling for demographic and pregnancy risk variables. Maternal outcomes included intrapartum or postpartum transfer to hospital, hospitalization, cesarean, and hemorrhage; neonatal outcomes included neonatal transfer, hospitalization, neonatal intensive care unit admission, and intrapartum or neonatal death. Analyses were conducted twice, once in each dataset. Individuals who planned home births had a lower incidence of all types of transfers, compared with those who planned birth center births, but in one dataset only, experienced more cesareans [adjusted odds ratio (95% CI): 1.32 (1.02-1.70); 0.95 (0.88-1.03)]. Planned home birth was associated with lower adjusted odds of maternal hospitalization in one dataset but not the other [0.97 (0.54-1.74); 0.85 (0.76-0.95)], and was not associated with hemorrhage. Neonatal outcomes likewise were either not associated with a planned birthplace or suggested home birth was safer: hospitalization [0.77 (0.53-1.11), 0.90 (0.82-0.98)], neonatal intensive care unit admission [0.54 (0.28-1.00), 0.97 (0.86-1.10)]. There was no observable association with intrapartum or neonatal death: 1.07 (0.68-1.67; only calculated once because of small numbers of events). Planned home births are as safe as planned birth center births for low-risk pregnancies. Current guidelines advising against planned home births are not supported by these data.

Is there a maximum transfer time for safe planned home births? Building evidence to

Abstract Evidence-based assessment of suitability for planned home birth (PHB) is a critical component of safe, effective home birth services. This study aimed to build an evidence base to inform transfer time recommendations for the Health Service Executive (HSE) Home Birth Service in Ireland. Transfer rates, time and distance were described for women who began labour at home with the HSE Home Birth Service between 2012 and 2021. Binary logistic regression was used to identify factors associated with intrapartum transfer and to examine the relationship between transfer time and outcomes. A survey on home birth policy and practice was issued to informants in countries offering comparable services to the HSE. Of 2,000 women initiating labour at home, 376 (18.9%) required intrapartum transfer, with transfer rates of 48.2% and 10.1% for primiparous and multiparous women, respectively. Primiparity (aOR: 8.95, 95% CI 6.89-11.7, p < 0.001) and maternal body mass index ≥30 (aOR: 1.93, 95% CI 1.14-3.20, p = 0.013) significantly increased the odds of intrapartum transfer. Serious adverse outcomes were rare in those requiring intrapartum transfer. No statistically significant increase in poor outcomes was detected with increasing transfer time; however, statistical power to detect small but important effects was limited. In other home birth services, transfer time is explicitly considered when assessing suitability; information provided to women includes details on transfer rates and times. While this study did not find a threshold time associated with increased risk of adverse outcomes for PHB, it has highlighted the significance of transfer time in shared decision-making on birthplace. Women considering PHB should receive parity-specific information on outcomes including transfer rates. This work highlights the pivotal role of Public Health in ensuring that evidence is combined with expert judgement and womens’ preferences to provide high quality, accessible, person-centred services. Key messages • Transfer time plays a key role in supporting shared decision-making for women considering a home birth. • This study identified opportunities to extend the comprehensiveness of assessment of suitability for planned home births using local and international evidence.

Maternal and neonatal outcomes associated with breech presentation in planned community (home and birth center) births in the United States: A prospective observational cohort study.

Investigate maternal and neonatal outcomes associated with breech presentation in planned community births in the United States, including outcomes associated with types of breech presentation (i.e., frank, complete, footling/kneeling). Secondary analysis of prospective cohort data from a national perinatal data registry (MANA Stats). Planned community birth (homes and birth centers), United States. Individuals with a term, singleton gestation (N = 71,943) planning community birth at labor onset. Descriptive statistics to calculate associations between types of breech presentation and maternal and neonatal outcomes. Maternal: intrapartum/postpartum transfer, hospitalization, cesarean, hemorrhage, severe perineal laceration, duration of labor stages and membrane rupture Neonatal: transfer, hospitalization, NICU admission, congenital anomalies, umbilical cord prolapse, birth injury, intrapartum/neonatal death. One percent (n = 695) of individuals experienced breech birth (n = 401, 57.6% vaginally). Most fetuses presented frank breech (57%), with 19% complete, 18% footling/kneeling, and 5% unknown type of breech presentation. Among all breech labors, there were high rates of intrapartum transfer and cesarean birth compared to cephalic presentation (OR 9.0, 95% CI 7.7-10.4 and OR 18.6, 95% CI 15.9-21.7, respectively), with no substantive difference based on parity, planned site of birth, or level of care integration into the health system. For all types of breech presentations, there was increased risk for nearly all assessed neonatal outcomes including hospital transfer, NICU admission, birth injury, and umbilical cord prolapse. Breech presentation was also associated with increased risk of intrapartum/neonatal death (OR 8.5, 95% CI 4.4-16.3), even after congenital anomalies were excluded. All types of breech presentations in community birth settings are associated with increased risk of adverse neonatal outcomes. These research findings contribute to informed decision-making and reinforce the need for breech training and research and an increase in accessible, high-quality care for planned vaginal breech birth in US hospitals.

Postpartum Emergency Department Use Following Midwifery-Model vs Obstetrics-Model Care

Emergency department (ED) use postpartum is a common and often-preventable event. Unlike traditional obstetrics models, the Ontario midwifery model offers early care postpartum. To assess whether postpartum ED use differs between women who received perinatal care in midwifery-model care vs in traditional obstetrics-model care. This retrospective population-based cohort study took place in Ontario, Canada, where public health care is universally funded. Participants included women who were low risk and primiparous and gave birth to a live baby in an Ontario hospital between 2012 and 2018. Data were collected from April 2012 to March 2018 and analyzed from June 2022 to April 2023. Perinatal care clinician, namely, a midwife or obstetrician. : Any unscheduled ED visit 42 days postpartum or less. Poisson regression models compared ED use between women with midwifery-model care vs obstetrics-model care, weighting by propensity score-based overlap weights. Among 104 995 primiparous women aged 11 to 50 years, those in midwifery-model care received a median (IQR) of 7 (6-8) postpartum visits, compared with 0 (0-1) visits among those receiving obstetrics-model care. Unscheduled ED visits 42 days or less postpartum occurred for 1549 of 23 124 women (6.7%) with midwifery-model care compared with 6902 of 81 871 women (8.4%) with traditional obstetrics-model care (adjusted relative risks [aRR], 0.78; 95% CI, 0.73-0.83). Similar aRRs were seen in women with a spontaneous vaginal birth (aRR, 0.71; 95% CI, 0.65-0.78) or assisted vaginal birth (aRR, 0.70; 95% CI, 0.59-0.82) but not those with a cesarean birth (aRR, 0.94; 95% CI, 0.86-1.03) or those with intrapartum transfer of care between a midwife and obstetrician (aRR, 0.94; 95% CI, 0.87-1.04). ED use 7 days or less postpartum was also lower among women receiving midwifery model care (aRR, 0.70; 95% CI, 0.65-0.77). In this cohort study, midwifery-model care was associated with less postpartum ED use than traditional obstetrics-model care among women who had low risk and were primiparous, which may be due to early access to postpartum care provided by Ontario midwives.

Obstetric and Neonatal Outcomes Following Hospital Transfers of Home Births and Births in Midwife-led Units in Austria.

Home births and births in midwife-led units and the associated potential risks are still being debated. An analysis of the quality of results of planned home births and births in midwife-led units which require intrapartum transfer of the mother to hospital provides important information on the quality of processes during births which occur outside hospital settings. The aim of this study was to analyze neonatal and maternal outcomes after the initial plan to deliver at home or in a midwife-led unit had to be abandoned and the mother transferred to hospital. The method used was an analysis of data obtained from the Austrian Birth Registry. The dataset consisted of singleton term pregnancies delivered in the period from 1 January 2017 to 31 December 2021 (n=286056). For the analysis, two groups were created for comparison (planned hospital births and hospital births recorded in the Registry as births originally planned as home births or births in midwife-led units but which required a transfer to hospital) and assessed with regard to previously defined variables. Data were analyzed using frequency description, bivariate analysis and regression models. In Austria, an average of 19% of planned home births have to be discontinued and the mother transferred to hospital. Home births and births in midwife-led units which require transfer of the mother to hospital are associated with higher intervention rates intrapartum, high rates of vacuum delivery, and higher emergency c-section rates compared to planned hospital births. Multifactorial regression analysis showed significantly higher risks of poorer scores for all neonatal outcome parameters (Apgar score, pH value, transfer rate). If a birth which was planned as a home delivery or as a delivery in a midwife-led unit fails to progress because of (possible) anomalies, the midwife must respond and transfer the mother to hospital. This leads to a higher percentage of clinical interventions occurring in hospital. From the perspective of clinical obstetrics, it is understandable, based on the existing data, that giving birth outside a clinical setting cannot be recommended.

Exploring home births in Catalonia (Spain): A cross-sectional study of women's experiences and influencing factors.

The study explores the experiences of women with low-risk pregnancies and no complications who planned a home birth. A cross-sectional study was conducted using an online questionnaire. The questionnaire included socio-demographic, obstetric and perinatal variables. Birth satisfaction was evaluated via the Spanish version of the childbirth experience questionnaire. The study group comprised home-birthing women in Catalonia, Spain. Data were collected from 1 January 2019 to 31 December 2021. Statistical analysis was performed using SPSS. A total of 236 women responded. They reported generally positive experiences, with professional support and involvement being the most highly rated dimensions. Better childbirth experiences were associated with labour lasting less than 12 h, no perineal injuries, no intrapartum transfers to hospital, euthocic delivery and the presence of a midwife. Women's positive home birth experiences were linked to active participation and midwife support. Multiparous women felt safer. Medical interventions, especially transfers to hospitals, reduced satisfaction, highlighting the need for improved care during home births. Home births should be included among the birthplace options offered by public health services, given the extremely positive feedback reported by women who gave birth at home. Home birth is not an option offered under Catalonia's public health system only as a private service. The experience of home-birthing women is unknown. This study shows a very positive birth experience due to greater participation and midwife support. The results help stakeholders assess home birth's public health inclusion and understand valued factors, supporting home-birthing women. The study followed the STROBE checklist guidelines for cross-sectional studies. Women who planned a home birth participated in the pilot test to validate the instrument, and their contributions were collected by the lead researcher. The questionnaire gathered the participants' email addresses, and a commitment was made to disseminate the study's results through this means.

Race, ethnicity, and indications for primary cesarean birth: Associations within a national birth center registry.

Racial and ethnic disparities in cesarean rates in the United States are well documented. This study investigated whether cesarean inequities persist in midwife-led birth center care, including for individuals with the lowest medical risk. National registry records of 174,230 childbearing people enrolled in care in 115 midwifery-led birth center practices between 2007 and 2022 were analyzed for primary cesarean rates and indications by race and ethnicity. The lowest medical risk subsample (n = 70,521) was analyzed for independent drivers of cesarean birth. Primary cesarean rates among nulliparas (15.5%) and multiparas (5.7%) were low for all enrollees. Among nulliparas in the lowest-risk subsample, non-Latinx Black (aOR = 1.37; 95% CI, 1.15-1.63), Latinx (aOR = 1.51; 95% CI, 1.32-1.73), and Asian participants (aOR = 1.48; 95% CI, 1.19-1.85) remained at higher risk for primary cesarean than White participants. Among multiparas, only Black participants experienced a higher primary cesarean risk (aOR = 1.49; 95% CI, 1.02-2.18). Intrapartum transfers from birth centers were equivalent or lower for Black (14.0%, p = 0.345) and Latinx (12.7%, p < 0.001) enrollees. Black participants experienced a higher proportion of primary cesareans attributed to non-reassuring fetal status, regardless of risk factors. Place of admission was a stronger predictor of primary cesarean than race or ethnicity. Place of first admission in labor was the strongest predictor of cesarean. Racism as a chronic stressor and a determinant of clinical decision-making reduces choice in birth settings and may increase cesarean rates. Research on components of birth settings that drive inequitable outcomes is warranted.

Intrapartum time intervals and transfer of nulliparae from community births to maternity care units in Germany.

Over one-third of nulliparae planning births either at home or in freestanding midwife-led birthing centers (community births) in high-income countries are transferred during labor. Perinatal data are reported each year in Germany for women planning community birth. So far, data sets have not been linked to describe time-related factors associated with nulliparous transfer to hospital. To describe the prevalence of referral for nulliparae and assess maternal and labor characteristics associated with intrapartum transfer. Perinatal data from 2010 to 2015 were linked (n = 26,115). Women were reviewed with respect to international eligibility criteria for community birth; 1997 women were excluded (7.6%). Descriptive statistics were reported; unadjusted and adjusted odds ratios with 95% confidence intervals (CI) tested the predictive effect of demographic and labor factors on rates of intrapartum transfer. One in three nulliparous women (30.6%) were transferred to hospital. Compared with community births, transferred women were significantly more likely to experience longer time intervals during labor: from rupture of membranes (ROM) until birth lasting 5 to 18 h (OR 6.05, CI 5.53-6.61) and 19 to 24 h (OR 10.83, CI 9.45-12.41) compared to one to 4 h; and from onset of labor until birth 11 to 24 h (OR 6.72, CI 6.24-7.23) and 25 to 29 h (OR 26.62, CI 22.77-31.11) compared to one to 10 h. When entering all factors into the model, we found the strongest predictors of transfer to be fetal distress, longer time intervals between ROM until birth and onset of labor until birth. Nulliparous transfer rates were similar to rates in other high-income countries; 94% of referrals were non-urgent. Time was found to be an independent risk factor for the transfer of nulliparae planning community birth.

Women and maternity care providers experiences of planned home birth in Northern Ireland: A descriptive survey

BackgroundWhere a woman gives birth impacts both her postnatal outcomes and experiences. However, for women who plan home birth in Northern Ireland, their experiences and that of their maternity care providers are rarely sought. AimThis study examined women’s and maternity care providers’ experiences and perceptions of home birth service provision in Northern Ireland. MethodsOnline surveys were used to investigate the experiences of women (n = 62) who had experienced a home birth or had a view on planned home birth and maternity care providers (n = 77) who offered home birth services in Northern Ireland between November 2018 and November 2020. The surveys were analysed using descriptive statistics. FindingsThe women were all multigravida, with 39 experiencing a planned home birth and three having an intrapartum transfer. Most of the women (61.3 %; n = 38/62) knew about home birth services through social media or friends and 91% (n = 57/62) discussed their plans for home birth with their maternity care providers antenatally. Maternity care providers were mostly supportive (64.9 %; n = 50/77) of women having a choice about place of birth. Midwives were mostly confident (52 %; n = 13/25) or very confident (28 %; n = 7) about caring for women having a planned home birth but did not always feel supported by colleagues. DiscussionMost women rated their care as excellent or very good. Midwives reported limited support from colleagues for home birth provision. ConclusionThere is a need to support women in their birthplace choice and empower maternity care providers to facilitate this through a fully resourced home birth service infrastructure and collegial support.

Smooth Transitions: Enhancing Interprofessional Collaboration when Planned Community Births Transfer to Hospital Care.

In Washington state, planned community births are attended by direct entry licensed midwives (LMs) and certified nurse-midwives (CNMs). The most recently published vital statistics data from 2018 reported that 3.6% of the 84,648 births in Washington occurred at home or in freestanding birthing centers. Approximately 16.2% of planned home birth and birth center clients experience intrapartum or early postpartum transfer to the hospital, while 1.8% of their newborns do. The safety of and satisfaction with these types of referrals depends on multisystem processes performed by a variety of health care professionals. Smooth Transitions is a quality improvement (QI) initiative in Washington state that was developed to enhance interprofessional collaboration between community-based midwives, emergency medical services (EMS), and hospital personnel to improve the quality of hospital transfers from planned community settings. Key interventions to date have included (1) information sharing to dispel misconceptions and provide context regarding community births and midwives; (2) co-creation of transfer guidelines; (3) regularly held interprofessional meetings to review transfers and build relationships; and (4) ongoing review of qualitative feedback that captures the perspectives of all involved. Responses on questionnaires and audits indicate that Smooth Transitions has had a positive impact on provider, staff, and patient experiences with hospital transfers. Future endeavors will include strengthening quantitative data collection processes to measure safety indicators, expanding relationships with EMS, and building a case review process that is legally protected. By engaging representatives of all stakeholder groups and addressing community-to-hospital transfers as a multisystems issue, replication of the Smooth Transitions QI Program nationally could promote increased community midwifery integration by enhancing the referral experience for both patients and caregivers.

Strengthening Interprofessional Collaboration to Improve Transfers Between a Freestanding Birth Center and an Academic Medical Center.

The number of individuals choosing to give birth in a freestanding birth center has doubled since 2004. As many as half of all pregnant persons planning for a birth center birth ultimately develop medical complications and are unable to give birth outside of the hospital. Integrating birth centers into their regional perinatal health care system optimizes outcomes by establishing predetermined pathways for antepartum and intrapartum transfers of care and facilitates ongoing communication and cooperation among clinicians. The Vanderbilt Birth Center is a freestanding birth center that is operated by an academic medical center and partners with a hospital-based midwifery practice that cares for patients transferring from the birth center. Since the inception of the birth center in 2015, the entire perinatal team has worked to improve the process and experience of patient transfer from birth center to hospital care. This article will present strategies implemented through the ongoing collaboration between birth center and hospital health care providers. These include adopting a shared electronic health record, clinical practice guidelines that align across birth sites, preparing birth center patients prenatally for the possibility hospital transfer, the presentation of a united team across birth sites, clear and widely disseminated communication pathways for hospital admission and patient handoff, and ongoing opportunities for interteam communication, collaboration, and education. These strategies may benefit similar midwifery practice models as they seek to partner with larger health care systems and improve the transfer experience for their patients.

Adoption of Consensus Guidelines for Safe Prevention of the Primary Cesarean Delivery by Freestanding Birth Centers.

Slow or arrested progress in labor is the most frequent (64%) indication for nonemergent transfer of laboring people from freestanding birth centers to the hospital. After the 2014 publication of the Consensus Statement on Safe Prevention of Primary Cesarean Delivery (Consensus Statement), many freestanding birth centers changed their clinical practice guidelines to allow more time for active labor in the birth center prior to hospital transfer. The result of these changes has not been evaluated in birth centers. Evaluation of adoption of guidelines based on the Consensus Statement in hospitals has shown inconsistent results. Birth centers were contacted to determine whether they changed clinical practice guidelines in response to the Consensus Statement. A before-after analysis compared outcomes for the 2 calendar years before and the 2 calendar years after adoption of new guidelines with a retrospective analysis of deidentified client-level data collected in the American Association of Birth Centers Perinatal Data Registry. A third of responding birth centers (11 of 33) changed their clinical practice guidelines, mostly redefining the onset of active labor as beginning at 6 cm cervical dilatation and allowing 4 hours of arrest of dilatation in active labor before transfer to the hospital. These changes were associated with fewer diagnoses of prolonged first stage of labor (13.8% vs 8.0%, P &lt; .01) but not with fewer intrapartum transfers (14.0% vs 14.7%, P = .55) or cesarean births (5.0 vs 4.1%, P = .26.) DISCUSSION: We found no evidence that making these practice changes was associated with better outcomes. Two hours of a lack of documented cervical change in active labor is likely long enough to diagnose arrested progress in labor. Research on proportion of morbidity and mortality associated with prolonged labor could inform practice guidelines for transfers.

Travel Time to Delivery, Antenatal Care, and Birth Outcomes: A Population-Based Cohort of Uncomplicated Pregnancies in British Columbia, 2012–2019

ObjectiveHealth policy and system leaders need to know whether long travel time to a delivery facility adversely affects birth outcomes. In this study, we estimated associations between travel time to delivery and outcomes in low-risk pregnancies. MethodsThis population-based cohort included all singleton births without obstetric comorbidities or intrapartum facility transfers in British Columbia, Canada, from 2012 to 2019. Travel time was measured from maternal residential postal code to delivery facility using road network analysis. We estimated associations between travel time and severe maternal morbidity, stillbirth, pre-term birth, and small-for-gestational age (SGA) and large-for-gestational age (LGA) status using logistic regression, adjusted for confounders (adjusted odds ratios [aORs]). To examine variations in associations between travel time and outcomes by antenatal care utilization, we stratified models by antenatal care categories. ResultsOf 232 698 births, 3.8% occurred at a facility ≥60 minutes from the maternal residence. Obesity, adolescent age, substance use, inadequate prenatal care, and low socioeconomic status were more frequent among those traveling farther for delivery. Travel time ≥120 minutes was associated with increased risk of stillbirth (aOR 1.8; 95% CI 1.2–2.8), pre-term birth (aOR 2.3; 95% CI 2.1–2.5), LGA (aOR 1.5; 95% CI 1.4–1.6), and severe maternal morbidity (aOR 1.5; 95% CI 1.2–1.8), but not SGA (aOR 1.0; 95% CI 0.8–1.1), when compared with a travel time of 1–29 minutes. Risk of stillbirth was greatest with inadequate and intensive (adequate plus) antenatal care but persisted for severe maternal morbidity, pre-term birth, and LGA across categories. ConclusionLonger travel time to delivery was associated with increased risk of adverse outcomes in low-risk pregnancies after adjusting for confounding factors. Associations were stronger among those with inadequate antenatal care.

Birth Outcomes of Women with Obesity Enrolled for Care at Freestanding Birth Centers in the United States

IntroductionCurrent US guidelines for the care of women with obesity generalize obesity‐related risks to all women regardless of overall health status and assume that birth will occur in hospitals. Perinatal outcomes for women with obesity in US freestanding birth centers need documentation.MethodsPregnancies recorded in the American Association of Birth Centers Perinatal Data Registry were analyzed (n = 4,455) to form 2 groups of primiparous women (n = 964; 1:1 matching of women with normal body mass indices [BMIs] and women with obese BMIs [>30]), using propensity score matching to address the imbalance of potential confounders. Groups were compared on a range of outcomes. Differences between groups were evaluated using χ2 test for categorical variables and Student's t test for continuous variables. Paired t test and McNemar's test evaluated the differences among the matched pairs.ResultsThe majority of women with obese BMIs experienced uncomplicated perinatal courses and vaginal births. There were no significant differences in antenatal complications, proportion of prolonged pregnancy, prolonged first and second stage labor, rupture of membranes longer than 24 hours, postpartum hemorrhage, or newborn outcomes between women with obese BMIs and normal BMIs. Among all women with intrapartum referrals or transfers (25.3%), the primary indications were prolonged first stage or second stage (55.4%), inadequate pain relief (14.8%), client choice or psychological issue (7.0%), and meconium (5.3%). Primiparous women with obesity who started labor at a birth center had a 30.7% transfer rate and an 11.1% cesarean birth rate.DiscussionWomen with obese BMIs without medical comorbidity can receive safe and effective midwifery care at freestanding birth centers while anticipating a low risk for cesarean birth. The risks of potential, obesity‐related perinatal complications should be discussed with women when choosing place of birth; however, pregnancy complicated by obesity must be viewed holistically, not simply through the lens of obesity.

Transfers of Care between Healthcare Professionals in Obstetric Units of Different Sizes across Spain and in a Hospital in Ireland: The MidconBirth Study.

Background: In Europe, the majority of healthy women give birth at conventional obstetric units with the assistance of registered midwives. This study examines the relationships between the intrapartum transfer of care (TOC) from midwife to obstetrician-led maternity care, obstetric unit size (OUS) with different degrees of midwifery autonomy, intrapartum interventions and birth outcomes. Methods: A prospective, multicentre, cross-sectional study promoted by the COST Action IS1405 was carried out at eight public hospitals in Spain and Ireland between 2016–2019. The primary outcome was TOC. The secondary outcomes included type of onset of labour, oxytocin stimulation, epidural analgesia, type of birth, episiotomy/perineal injury, postpartum haemorrhage, early initiation of breastfeeding and early skin-to-skin contact. A logistic regression was performed to ascertain the effects of studied co-variables on the likelihood that participants had a TOC; Results: Out of a total of 2,126 low-risk women, those whose intrapartum care was initiated by a midwife (1772) were selected. There were statistically significant differences between TOC and OUS (S1 = 29.0%, S2 = 44.0%, S3 = 52.9%, S4 = 30.2%, p < 0.001). Statistically differences between OUS and onset of labour, oxytocin stimulation, type of birth and episiotomy or perineal injury were observed (p = 0.009, p < 0.001, p < 0.001, p < 0.001 respectively); Conclusions: Findings suggest that the model of care and OUS have a significant effect on the prevalence of intrapartum TOC and the birth outcomes. Future research should examine how models of care differ as a function of the OUS in a hospital, as well as the cost-effectiveness for the health care system.

Journey of vulnerability: a mixed-methods study to understand intrapartum transfers in Tanzania and Zambia

BackgroundTimely intrapartum referral between facilities is pivotal in reducing maternal/neonatal mortality and morbidity but is distressing to women, resource-intensive and likely to cause delays in care provision. We explored the complexities around referrals to gain understanding of the characteristics, experiences and outcomes of those being transferred.MethodsWe used a mixed-method parallel convergent design, in Tanzania and Zambia. Quantitative data were collected from a consecutive, retrospective case-note review (target, n = 2000); intrapartum transfers and stillbirths were the outcomes of interest. A grounded theory approach was adopted for the qualitative element; data were collected from semi-structured interviews (n = 85) with women, partners and health providers. Observations (n = 33) of transfer were also conducted. Quantitative data were analysed descriptively, followed by binary logistic regression models, with multiple imputation for missing data. Qualitative data were analysed using Strauss’s constant comparative approach.ResultsIntrapartum transfer rates were 11% (111/998; 2 unknown) in Tanzania and 37% (373/996; 1 unknown) in Zambia. Main reasons for transfer were prolonged/obstructed labour and pre-eclampsia/eclampsia. Women most likely to be transferred were from Zambia (as opposed to Tanzania), HIV positive, attended antenatal clinic < 4 times and living > 30 min away from the referral hospital. Differences were observed between countries. Of those transferred, delays in care were common and an increase in poor outcomes was observed. Qualitative findings identified three categories: social threats to successful transfer, barriers to timely intrapartum care and reparative interventions which were linked to a core category: journey of vulnerability.ConclusionAlthough intrapartum transfers are inevitable, modifiable factors exist with the potential to improve the experience and outcomes for women. Effective transfers rely on adequate resources, effective transport infrastructures, social support and appropriate decision-making. However, women’s (and families) vulnerability can be reduced by empathic communication, timely assessment and a positive birth outcome; this can improve women’s resilience and influence positive decision-making, for the index and future pregnancy.

Over 50% of Nulliparous Women ≥40 Years of Age Will Have a Cesarean Delivery [31Q

INTRODUCTION: Women ≥40 years old at delivery are increasing and older women are at higher risk for adverse pregnancy outcomes. We sought to evaluate delivery outcomes in these women. METHODS: We conducted an IRB exempt, retrospective cohort study using data from a multi-center quality initiative. Nulliparous singleton births between 1/2012-12/2017 at participating hospitals were included. Patients with intrapartum transfers, missing birth data, or missing/implausible data for maternal age were excluded. Age was stratified into 4 groups: 12-19 years, 20-29 years, 30-39 years, and 40-55 years. Rates of delivery outcomes were compared between women aged 20-29 years and 40-55 years using a χ2 test. Adjusted relative risks were calculated after controlling for obesity (body mass index ≥30), race-ethnicity, and chronic hypertension. RESULTS: There were 48,093 nulliparous singleton births at 20+0 to 42+6 weeks' gestation. After exclusions (n=1891) were removed, the cohort included 46,202 births: 36,146 (78.2%) in 20-29 years and 1155 (2.5%) in 40-55 years groups. Only 33% of older women achieved a spontaneous vaginal birth, compared to 62% of women age 20-29 (p&lt;0.001). This difference is primarily due to high cesarean delivery (CD) rate (57.7%) in older women, with 25.8% of older women never attempting vaginal birth. Older women are at significantly higher risk of having a CD for all major indications with only a minority (2.8%) of older women having a non-medically indicated CD. CONCLUSION: Older women have an over 50% risk of CD with lower rate of attempting and achieving vaginal birth. This can be useful in counseling about delivery expectations.

Intrapartum transfers from the Birth Centre to the Obstetric Unit in 2017 – analysis of reasons

Abstract Introduction. The standard of perinatal care gives the woman the right to consciously choose the place of birth. Birth Centres (BC) run by midwives implement a vision of a non-medicalized birth in intimate homelike conditions. Aim. The aim of the study is to determine the causes of transfers from the Birth Centre to the Obstetric Unit and to indicate the social and demographic characteristics of the women giving birth that may predispose to transfer. Material and methods. The study was based on the analysis of the medical records of women who were transferred from the BC to the St. Sophia Obstetric Unit in Warsaw. 88 women who were transferred constituted the study group. Results. The most numerous group were women giving birth aged 30-34. The majority were giving birth for the first time and had higher education. Intrapartum transfers were related to the mother’s obstetric condition, fetal condition or disruption of the childbirth. Conclusions. Failure to progress of labour is the main cause of transfers. The women giving birth for the first time aged 30 and over, admitted for to the BC after 40 weeks of pregnancy and dilation below 4 cm were the most often transferred group of women.

Inside the head of the partner when intrapartum transfer takes place from a birth centre to an obstetric unit

Use of a Surpass flow diverter (FD) device in the treatment of acutely ruptured aneurysm has not been well studied and reported in the literature.We retrospectively reviewed patients with subarachnoid hemorrhage who were treated by Surpass FD placement at our hospital between June 2016 and March 2018. Detailed analysis of medical records was performed to obtain patient age, gender, clinical history, Hunt and Hess grade, Fisher grade, results of radiographic and procedural details including technical success and complication, clinical outcome, and follow-up angiographic results.Our search identified 16 patients with 16 aneurysms who were treated with Surpass FD, of which 13 aneurysms (81%) were in the anterior circulation and 3 (19%) were in the posterior circulation. Aneurysm size ranged from 1.1 to 16 mm, with a mean of 4 mm. The mean delay between subarachnoid hemorrhage and endovascular treatment was 5 days (range, 3–20 days). Only 1 Surpass FD was used in each patient, ranging in size from 3 × 25 mm to 4 × 50 mm. Fifteen patients (94%) achieved favorable clinical outcome (modified Rankin Scale score 0–1) at 3 months. One patient died of invasive fungal infection. Angiographic follow-up results were assessed by O'Kelly-Marotta grading scale in 15 surviving patients and showed a grade D result (no filling) in 13/15 aneurysms (87%) at 3 and 6 months.A Surpass FD device is a feasible option for the treatment of ruptured intracranial aneurysms that are difficult to treat by conventional clipping and coiling; however, larger and comparative studies with long-term follow-up are needed to confirm its safety and efficacy.

Birthplace in Australia: Antenatal preparation for the possibility of transfer from planned home birth

ObjectiveThe aim of the study was to explore how women and midwives prepare, during the antenatal period, for the possibility of intrapartum transfer from planned home birth. DesignA Constructivist Grounded Theory approach was taken in order to focus upon the social interactions and processes that emerged. SettingUrban and regional areas in four states of south eastern Australia. ParticipantsThirty-one semi-structured interviews were conducted with women and midwives. FindingsThere were three sub-categories relating to preparation for the possibility of transfer. These were 'Building the midwife–woman partnership', 'Fostering professional connections' and 'Reducing uncertainty'. The reciprocal trust inherent in the midwife–woman partnership helped women feel safe in relation to the possibility of intrapartum transfer to hospital. Midwives who had positive transfer experiences spoke about their commitment to fostering professional connections with hospitals and health professionals as a part of building the capacity for collaboration if, and when, a transfer occurred. Reducing uncertainty involved preparation that included not only providing information and emotional support to the woman around the possibility of transfer, but also arranging for her to book in to a back-up hospital.