Midwife-led Units Research Articles

Network promotes midwife-led units.

Midwives and academics have set up a network to promote the creation of midwifery-led units.

Women's experiences of transfer from primary maternity unit to tertiary hospital in New Zealand: part of the prospective cohort Evaluating Maternity Units study.

BackgroundThere is worldwide debate regarding the appropriateness and safety of different birthplaces for well women. The Evaluating Maternity Units (EMU) study’s primary objective was to compare clinical outcomes for well women intending to give birth in either a tertiary level maternity hospital or a freestanding primary level maternity unit. Little is known about how women experience having to change their birthplace plans during the antenatal period or before admission to a primary unit, or transfer following admission. This paper describes and explores women’s experience of these changes-a secondary aim of the EMU study.MethodsThis paper utilised the six week postpartum survey data, from the 174 women from the primary unit cohort affected by birthplace plan change or transfer (response rate 73 %). Data were analysed using descriptive statistics and thematic analysis. The study was undertaken in Christchurch, New Zealand, which has an obstetric-led tertiary maternity hospital and four freestanding midwife-led primary maternity units (2010–2012). The 702 study participants were well, pregnant women booked to give birth in one of these facilities, all of whom received continuity of midwifery care, regardless of their intended or actual birthplace.ResultsOf the women who had to change their planned place of birth or transfer the greatest proportion of women rated themselves on a Likert scale as unbothered by the move (38.6 %); 8.8 % were ‘very unhappy’ and 7.6 % ‘very happy’ (quantitative analysis). Four themes were identified, using thematic analysis, from the open ended survey responses of those who experienced transfer: ‘not to plan’, control, communication and ‘my midwife’. An interplay between the themes created a cumulatively positive or negative effect on their experience. Women’s experience of transfer in labour was generally positive, and none expressed stress or trauma with transfer.ConclusionsThe women knew of the potential for change or transfer, although it was not wanted or planned. When they maintained a sense control, experienced effective communication with caregivers, and support and information from their midwife, the transfer did not appear to be experienced negatively. The model of continuity of midwifery care in New Zealand appeared to mitigate the negative aspects of women’s experience of transfer and facilitate positive birth experiences.

Fish can't see water.

The place of birth is a subject of debate (Shah N Engl J Med 2015;372;2181–3). Recently, the National Institute for Health and Care Excellence (NICE) concluded that for healthy women with uncomplicated pregnancies giving birth at home or in a midwife-led unit is safer than an obstetrician-led hospital delivery (Intrapartum care: care of healthy women and their babies during childbirth. London: NICE; 2014). Rowe et al. (BJOG 2016;123:1123–1132) report on women planning vaginal birth after caesarean section (VBAC) at home versus in an obstetric unit. The probability of vaginal delivery increased from 70 to 88% when attempting the home delivery. Adverse perinatal outcome rates were 1.8% and 1.6% for home and hospital deliveries, but the study is underpowered on this outcome, making the author's conclusion that ‘the risk of an adverse maternal or perinatal outcome is around 2–3%’ debatable. Other studies have shown that uterine rupture occurs in 1% of women who attempt VBAC, and is difficult to predict (Grobman et al. Am J Obstet Gynecol 2008;199:30.e1–5). Consequently, most women who attempt VBAC will choose to do so in the hospital. However, as medical interventions can only be performed after informed consent, shared decision-making should give women the autonomy to make independent choices. The importance of the present study is that it shows that home delivery after a previous caesarean section is a feasible option. At all times, we should prevent scenario's such as occurred in Brazil last year, when a woman who had two previous caesarean deliveries left the hospital after she was denied an attempt for vaginal delivery by her gynaecologist, to find herself subsequently under arrest and having her baby born by caesarean delivery under force (Turner and Hill. ‘Kidnapped’ by the authorities: meet the woman forced to have a caesarean. The Telegraph, 17 April 2014 [Accessed 19 July 2015]). In my opinion, the autonomy of the woman over her own body prevails over the medical need for an intervention. Another important issue that arises from Rowe et al. is the fact that we should try to understand the difference in intervention rates between home and hospital deliveries. Whereas one explanation might be that women who opt for VBAC at home are more motivated to achieve vaginal delivery, it is beyond doubt that obstetrician-led labour care is associated with higher intervention rates than midwife-led delivery care, be it in or outside a clinical setting. Importantly, it is not the individual person or place of labour that causally influences the differences in intervention rates, but it is the obstetrician trained to use scalpels in a high-tech environment that makes the difference. We should use a scientific approach that builds on understanding the course of natural labour, prediction of poor outcome, and testing the effectiveness of interventions in clinical trials. When there would exist subtle differences in safety between midwife-led and obstetrician-led delivery, we should identify those women that actually benefit from our interventions, thus allowing the majority of women to choose a delivery as natural as they want to. In fact, we can prevent much of the dilemma studied by Rowe at al. if we normalise intervention rates in the first pregnancy. The problem is that we seem to have forgotten what normality is. Fish can't see water (Wagner Int J Gynaecol Obstet 2001;75 Suppl. 1:S25–37). Full disclosure of interests available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

A cost-comparison of midwife-led compared with consultant-led maternity care in Ireland (the MidU study)

Objectiveto compare the cost of maternity care between two midwife-led units, and their linked consultant-led units, following a large randomised trial in Ireland. Designethical approval was received for this unblinded, pragmatic randomised trial (MidU) funded by the Health Service Executive (Dublin North-East, Ireland), conducted 2004–2009. A comparison of costs analysis was conducted on the outcomes from the trial. Settingtwo maternity units in Ireland, with ‘alongside’ midwife-led units. Participantsall women without risk factors for labour and birth who booked at the two maternity units before 24 weeks׳ gestation were assessed for inclusion. Consenting women (n=1653) were centrally randomised on a 2:1 ratio (1101:552) to midwife-led or consultant-led care. Interventionswomen randomised to consultant-led care received standard care. Women randomised to the midwife-led arm received midwife-led care provided by a small group of midwives in two units, situated ׳alongside׳ the consultant-led units, throughout pregnancy, birth and postnatal. Measurementsmean difference in clinician salaries, cost of care based on managers׳ data, known costs of postnatal bed days and costs of key interventions were measured. Findingsthe average cost of caring for a woman allocated to the midwife-led units was €2598, compared to €2780 in the consultant-led units (average difference €182 per woman, analysed by ‘intention to treat’). Key conclusions and implications for practicecare in these two midwife-led units costs less than care provided by the consultant-led units. Given the clinical findings, which showed that care provided in the midwife-led units is as safe as that in the consultant-led units and results in less intervention, more midwife-led units should be incorporated into maternity care in Ireland so that scarce resources can be used more effectively.

Women and healthcare providers' perceptions of a midwife-led unit in a Swiss university hospital: a qualitative study.

BackgroundThe development of medical-led care in obstetrics over the past decades has contributed to improving outcomes for both mother and child. Although efficiency has improved in complex situations, unnecessary interventions are still practiced in low-risk pregnancies, contrary to international recommendations. A shift to a less interventionist model of care has encouraged many countries to review their policies on maternal health care and develop models such as the “midwife-led unit” (MLU) where the midwife plays a predominant role with a minimum of routine intervention. Existing research has provided convincing evidence that MLUs lead to better maternal and neonatal outcomes when compared to traditional models. They not only improve the level of satisfaction amongst women, but are also associated with reduced healthcare costs. This study aimed to explore the perceptions of women and healthcare providers regarding the creation of an MLU in a Swiss university hospital.MethodsA descriptive research study using qualitative methods was conducted among pregnant women and new mothers in a Swiss maternity unit, including also midwives and medical staff. Data collection was carried out through one-to-one interviews, focus groups, and telephone interviews (n = 63). After transcription, thematic analysis was performed.ResultsThe triangulation of perceptions of women and healthcare providers indicated support for the implementation of an MLU to promote physiological delivery. Most women welcomed the idea of an MLU, in particular how it could help in offering continuity of care. Healthcare providers were optimistic about the implementation of an MLU and recognised the need for some women to have access to a less interventionist approach. From the women’s perspective, barriers concerned the lack of awareness of midwives’ full scope of practice, while barriers for midwives and obstetricians were related to the challenge to develop a good interprofessional collaboration.ConclusionAlternative models to provide maternity care for low-risk women have been developed and evaluated widely in several countries outside Switzerland. This study showed that women and healthcare providers were favourable towards the development of a new care model, while taking into account the specific expectations and barriers raised by participants.

Women׳s birthplace decision-making, the role of confidence: Part of the Evaluating Maternity Units study, New Zealand

Objectiveto explore women׳s birthplace decision-making and identify the factors which enable women to plan to give birth in a freestanding midwifery-led primary level maternity unit rather than in an obstetric-led tertiary level maternity hospital in New Zealand. Designa mixed methods prospective cohort design. Methodsdata from eight focus groups (37 women) and a six week postpartum survey (571 women, 82%) were analysed using thematic analysis and descriptive statistics. The qualitative data from the focus groups and survey were the primary data sources and were integrated at the analysis stage; and the secondary qualitative and quantitative data were integrated at the interpretation stage. SettingChristchurch, New Zealand, with one tertiary maternity hospital and four primary level maternity units (2010–2012). Participantswell (at ‘low risk’ of developing complications), pregnant women booked to give birth in one of the primary units or the tertiary hospital. All women received midwifery continuity of care, regardless of their intended or actual birthplace. Findingsfive core themes were identified: the birth process, women׳s self-belief in their ability to give birth, midwives, the health system and birth place. ‘Confidence’ was identified as the overarching concept influencing the themes. Women who chose to give birth in a primary maternity unit appeared to differ markedly in their beliefs regarding their optimal birthplace compared to women who chose to give birth in a tertiary maternity hospital. The women who planned a primary maternity unit birth expressed confidence in the birth process, their ability to give birth, their midwife, the maternity system and/or the primary unit itself. The women planning to give birth in a tertiary hospital did not express confidence in the birth process, their ability to give birth, the system for transfers and/or the primary unit as a birthplace, although they did express confidence in their midwife. Key conclusions and implications for practicebirthplace is a profoundly important aspect of women׳s experience of childbirth. Birthplace decision-making is complex, in common with many other aspects of childbirth. A multiplicity of factors needs converge in order for all those involved to gain the confidence required to plan what, in this context, might be considered a ‘countercultural’ decision to give birth at a midwife-led primary maternity unit.

Audit of a new model of birth care for women with low risk pregnancies in South Africa: the primary care onsite midwife-led birth unit (OMBU).

BackgroundSouth Africa’s health system is based on the primary care model in which low-risk maternity care is provided at community health centres and clinics, and ‘high-risk’ care is provided at secondary/tertiary hospitals. This model has the disadvantage of delays in the management of unexpected intrapartum complications in otherwise low-risk pregnancies, therefore, there is a need to re-evaluate the models of birth care in South Africa. To date, two primary care onsite midwife-led birth units (OMBUs) have been established in the Eastern Cape. OMBUs are similar to alongside midwifery units but have been adapted to the South African health system in that they are staffed, administered and funded by the primary care service. They allow women considered to be at ‘low risk’ to choose between birth in a community health centre and birth in the OMBU.MethodsThe purpose of this audit was to evaluate the impact of establishing an OMBU at Frere Maternity Hospital in East London, South Africa, on maternity services. We conducted an audit of routinely collected data from Frere Maternity Hospital over two 12 month periods, before and after the OMBU opened. Retrospectively retrieved data included the number of births, maternal and perinatal deaths, and mode of delivery.ResultsAfter the OMBU opened at Frere Maternity Hospital, the total number of births on the hospital premises increased by 16%. The total number of births in the hospital obstetric unit (OU) dropped by 9.3%, with 1611 births out of 7375 (22%) occurring in the new OMBU. The number of maternal and perinatal deaths was lower in the post-OMBU period compared with the pre-OMBU period. These improvements cannot be assumed to be the result of the intervention as observational studies are prone to bias.ConclusionsThe mortality data should be interpreted with caution as other factors such as change in risk profile may have contributed to the death reductions. There are many additional advantages for women, hospital staff and primary care staff with this model, which may also be more cost-effective than the standard (freestanding) primary care model.

Is induction of labour by Propess® safe? A comparison of midwife-led versus obstetrician-led labour management

This retrospective study compared maternal and fetal outcomes after labour induction, using a dinoprostone vaginal pessary (Propess®) in midwife-led and obstetrician-led labour management. Labour induction outcomes, delivery mode and rates of admission to the neonatal intensive care unit were compared. A total of 405 women, 40.5% (n = 164) from midwife-led units and 59.5% (n = 241) from an obstetrician-led unit, participated. There was no statistically significant difference between the two groups in caesarean section rate or neonatal intensive care unit admission rates (p = 0.789 and 0.769, respectively). Non-reassuring fetal non-stress test and uterine hyperstimulation risks were higher in the obstetrician-led unit (p = 0.003 and 0.001, respectively, and odds ratio (OR) 0.165, 95% CI: 0.117–0.232 and OR 0.218, 95% CI: 0.078–0.611, respectively). Postpartum blood transfusion rate was higher in the midwife-led units (p = 0.002, OR 8.082, 95% CI: 1.879–39.292). Labour induction with Propess® is safe during both midwife-led and obstetrician-led labour management.

PA.32 Stabilisation and Transfer of Sick New-Borns Delivered in Stand-Alone Midwifery Led Units

BackgroundWomen should be offered the choice of delivering at home, in midwife-led units (MLU) or obstetric units.1 20% of Shropshire mothers choose delivery in an MLU which refer into Shrewsbury...

PLD.18 Recurrence rate of Manual Removal of Placenta and associated Postpartum Haemorrhage

IntroductionRecurrence rate of retained placenta requiring manual removal of placenta (MROP) varies in the reported literature. NICE guidance suggests birth at an obstetric unit for women who have previously had...

New mothers say they like ‘homely environment’ at midwife-led unit

New mothers say they like ‘homely environment’ at midwife-led unit

Unique and proforma birth plans: A qualitative exploration of midwives׳ experiences

Backgroundbirth plans detailing a woman׳s preferences for intrapartum care are a common feature in British maternity units, and are a means of encouraging the implementation of choice. Proforma versions may be incorporated routinely in antenatal case notes, or the woman may devise her own unique birth plan. Although women׳s views of birth plans have been explored, the views of midwives have not to date been evaluated. The growth of midwife-led units in the UK has highlighted different philosophies of care, some of which can be reflected in the different types of birth plan. Given the increasingly diverse nature of UK midwifery workplaces we set out to explore and compare the experience of midwives working in midwife-led and obstetric-led settings in relation to unique and proforma birth plans. Methodqualitative study using focus groups of midwives in a midwife-led unit (MLU; n=5) and obstetric-led unit (OLU; n=4) in the East of England. We used an interpretative phenomenological analytical approach. Findingsthree main themes arose from the data. Firstly, the term ‘birth plan’ can be misleading, and was criticised for encouraging the belief that birth can be ‘planned’. In addition, midwives claimed that ‘unique’ birth plans, especially those influenced by some consumer advocacy groups, are becoming standardised in their rejection of policies and procedures and requests for intervention-free birth. Secondly, birth plans were a source of irritation for midwives in both groups, although the cause of the irritation differed between groups. Finally, it was found that midwives in both groups felt that birth plans put pressure on them, although again, the source of the pressure, and therefore the way in which midwives reacted to this pressure, differed between groups. Conclusionsthe term ‘birth plan’ can be misleading and create false expectations. If ‘unique’ birth plans are becoming ‘standardised’ in the sense that they routinely request the same things, they are little different to proforma birth plans. Some midwives perceive pressure both from women and the wider multidisciplinary team as a result of birth plans, a perception that causes some irritation.

Achieving a positive balance

British Journal of MidwiferyVol. 21, No. 11 BirthwriteAchieving a positive balanceCathy WarwickCathy WarwickSearch for more papers by this authorCathy WarwickPublished Online:18 Nov 2013https://doi.org/10.12968/bjom.2013.21.11.766AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References National Perinatal Epidemiology Unit (2012) The Birthplace cohort study: Key findings. www.npeu.ox.ac.uk/birthplace/results (accessed 22 October 2013) Google ScholarNational Federation of Women's Institutes and NCT (2013) Support Overdue: Women's experiences of maternity services. NCT, London Google ScholarRoyal College of Midwives (2013) Evidence to the NHS Pay Review Body for 2014. RCM, London Google ScholarRoyal College of Midwives, Birthchoice UK (2013) Trends in Freestanding Midwife-led Units in England and Wales 2001-2013. RCM, London Google ScholarSandall J, Soltani H, Gates S, Shennan A, Devane D (2013) Midwife-led continuity models versus other models of care for childbearing women. The Cochrane Library 3: CD004667 Google ScholarTracy SK, Hartz DL, Tracy MB, Allen J, Forti A, Hall B, White J, Lainchbury A, Stapleton H, Beckmann M, Bisits A, Homer C, Foureur M, Welsh A, Kildea S (2013) Caseload midwifery care versus standard maternity care for women of any risk: [email protected], a randomised controlled trial. The Lancet 382: DOI: 10.1016/s0140-6736(13)61406-3 Crossref, Google Scholar FiguresReferencesRelatedDetailsCited byPriority issues from 0–199 March 2015 | British Journal of Midwifery, Vol. 23, No. 3Joint call for addressing issues in the 0–19 health-care service16 March 2015 | British Journal of School Nursing, Vol. 10, No. 2Priority issues from 0–1920 March 2015 | Journal of Health Visiting, Vol. 3, No. 3 1 November 2013Volume 21Issue 11ISSN (print): 0969-4900ISSN (online): 2052-4307 Metrics History Published online 18 November 2013 Published in print 1 November 2013 Information© MA Healthcare LimitedPDF download

Water VBAC: Exploring a new frontier for women's autonomy

Backgroundalthough Vaginal Birth After Caesarean section (VBAC) has been promoted successfully as one means of reducing the caesarean section rate, the practice of VBAC using water immersion (Water VBAC) is restricted. Very little valid, reliable research evidence is available on this birth method, although initial small-scale audits indicate that Water VBAC has no adverse effect on maternal and neonatal outcomes. Methodin-depth semi-structured interviews were carried out with a purposive sample of eight women who had undergone Water VBAC in one midwife-led unit. The interviews aimed to explore their reasons for requesting this birthing method, and their experience of the process. An interpretative phenomenological analytical approach was adopted. Findingsthe women pursued Water VBAC for two main reasons: in order to prevent a repeat of the obstetric events that previously led to a caesarean section, and to counteract their previous negative birth experiences. The women reported improved physical and psychological outcomes from their Water VBAC experience when compared with their previous experience of caesarean section. Three main themes emerged: ‘minimising’, ‘maximising’ and ‘managing’. Water VBAC entailed an attempt to minimise the medicalisation of the women's childbirth experience. This was achieved by limiting medical staff input in favour of midwife-led care, which was believed to minimise negative physical and psychological experiences. Correspondingly, Water VBAC was perceived as maximising physical and psychological benefits, and as a means of allowing women to obtain choice and assert control over their labour and birth. The women planning a Water VBAC believed they had to manage the potential risks associated with Water VBAC, as well as manage the expectations and behaviour of friends, family and the health care professionals involved in their care. Conclusionsfor the women participating in this research, actively pursuing Water VBAC constituted a means of asserting their autonomy over the childbirth process. The value accorded to being able to exercise choice and control over their childbearing experience was high. These women's accounts indicated that information-giving and shared decision-making require improvement, and that inconsistencies in the attitudes of health care professionals need to be addressed.

Does transitional care improve neonatal and maternal health outcomes? A systematic review

Current evidence has shown that transitional care benefits the health outcomes of moderately compromised infants and mothers in terms of de-medicalisation of care, improving mother and infant attachments, parenting skills for dependant infants and the potential for shorter length of hospitalisation. Transitional care units exist in a variety of forms in neonatal services, ranging from nurse-led to midwife-led units. This review establishes whether transitional care units improve maternal and neonatal health outcomes. Objective: To review and synthesise published research on ‘Does transitional care improve neonatal and maternal health outcomes?’ Methods: Systematic reviews of published literature from nine electronic databases were undertaken and a total of ten studies were reviewed that met the reviews inclusion criteria. Findings: Five studies were rated as moderate strength, four studies were rated as very high quality and one study was rated as poor quality. Three overarching primary outcomes were identified. Within each outcome, a series of seven secondary outcome measures were reported. These included very positive benefits on one end of the scale and no benefits at the other end. The outcome measures report inconsistently across studies of the values of transitional care units for infants, ‘shorter length of stay’, ‘transitional model of care’ and the ‘reduced risks of infection’. Family centred care, mother as main carer, and increased bonding and attachments featured strongly across studies and thus supported the benefits of transitional care units in improving neonatal and maternal health outcomes. Conclusion: This review highlighted the values of transitional care in increasing the ‘mother–infant’ model of care. More studies are required for the evidence base for strategies to reduce the length of hospitalisation for moderately vulnerable infants. It was discovered that there are substantial variables in transitional care unit practices in the UK, as well as a need for well-conducted studies.

Geburtshäuser: Versorgungsalternative zur Klinikentbindung?

After midwife-led birth centres had been included into the Social Security Statute Book (§134a SGB V) and thus become covered by German Public Health Insurance since April 1st, 2007 contract negotiations on flat rate costs have followed. Meanwhile the 2nd edition of this -agreement has come into effect. The present contribution describes how this non-hospital obstetric care has developed in the last 3 years. The medical care situation is explained based on legal conditions. Special attention is paid to regulations concerning quality management as well as the certification or auditing required to remain listed in the national register of midwife-led units at the Social Health Insurance. Results are shown from data collected by the Associa-tion for Quality Assurance on Out-of-hospital births (QUAG) and from a pilot project which also contains comparisons with clinical findings. The discussion refers to data taken from German as well as international publications. The conclusion points out some aspects in need of further development.

Mastering your profession

British Journal of Midwifery • February 2013 • Vol 21, No 2 As you are all more than aware, the UK is undergoing another baby boom. In a report issued to Parliament last month, the Royal College of Midwives (RCM) highlighted that although there has been a 7% rise in the number of full-time midwives in the UK, there are still too few (about 5000) in relation to the number of births (RCM, 2012). In 2011, there were 688 120 babies born to women in England, the highest number for 40 years (RCM, 2012), and in the UK, of the 808 000 births, 196 000 were to non-UK born women (Office for National Statistics, 2012). Each culture has its own beliefs and challenges and as Britain’s population diversifies, it is more important than ever to understand these differences to help provide high quality, individualised care to women and to promote the normality of birth. One of our remits in BJM, is to encourage the expansion of knowledge and we have always placed emphasis on the importance of continual professional development. Our portfolio of study days throughout the UK provide you with the opportunity to deepen your knowledge of female genital mutilation, stillbirths and complex needs while our study tours to China, run by our partner company Master Travel, give you a unique insight into midwifery practices in a challenging and rapidly expanding nation. The exploration of midwifery in different cultures provides the opportunity to discover a different philosophy of clinical practice, and allows you to broaden your professional and personal horizons. In countries such as China, where almost 50 000 babies are born each day, the rate of caesarean sections performed are well above the World Health Organization’s recommended 10–15% (Feng et al, 2012). Sufang et al (2007) found that the huge demand for the procedure across urban and rural areas of China was linked to the ‘one-child norm’ and women’s demand for the procedure. Furthermore, the cost of a caesarean section is higher than a vaginal birth, so many hospitals encourage the surgery to make more money. However, the Beijing Health Bureau has been promoting normal vaginal birth in order to lower the high caesarean section rate. Stricter supervision will be exerted and hospitals will be punished if they are found to perform unnecessary caesareans. The recent anouncement that 100 hospitals in the UK will share a £25 million fund to improve and upgrade their maternity units is indeed a welcome one and will go far to help promote normal birth in this country. However, would this money be better spent on employing more midwives to cope with the increasing population? I am afraid I am yet another statistic who has added to this baby boom. Set to go off on maternity leave at the end the week, I believe my antenatal care in the last 8 months has given me a great insight into the fantastic work midwives do from the perspective of a service user. My care has been second to none despite the stretched nature of maternity services and I fully intend to make the most of my midwife-led birth unit. BJM

Midwife-Led Units: A Place to Work, A Place to Give Birth

BACKGROUND:With an estimated 120 midwife-led units (MLUs) and 15 years’ experience, the United Kingdom displays expertise in what ways women and professionals might benefit from MLUs. This study explored midwives’ satisfaction and skills for working in an MLU and a consultant unit (CU) and how these compared.METHODS:In this exploratory study, both quantitative and qualitative data were collected by anonymous questionnaire from 45 midwives in 2 Scottish maternity units (July 2007).RESULTS:Midwives working in the MLUs reported a higher level of job satisfaction than midwives working in the CU. Demographic characteristics of the 2 groups differed: MLU midwives were older, had been in practice longer, and had higher grade posts. Qualitative findings revealed some reasons midwives preferred working in the MLU with the emotional support they could give to women, and highlighted some negative predictors of midwives’ satisfaction. The questionnaire also explored the midwives’ practice: most agreed that the ability to avert and manage problems, work in a low-technology setting, and let labor be are necessary to work in these units.CONCLUSION:Our findings revealed midwives’ greater satisfaction from working in MLU compared to CU. We identified midwives’ opinions of specific skills to work in MLU, highlighting areas of importance for midwifery.

Economic evaluation of birth care in low-risk women. A comparison between a midwife-led birth unit and a standard obstetric unit within the same hospital in Norway. A randomised controlled trial

Objectiveto investigate the cost-effectiveness in birth care for low-risk women, in an alongside midwife-led unit (MU) compared to a standard obstetric unit (SCU) within the same hospital. Designeconomic evaluation based on the findings of a randomised trial, randomising participants either into the MU or SCU. The hospital's activity-based costing system CPP was used to estimate costs, as no data on complete resource use exists. Settingthe Department of Obstetrics and Gynaecology, Østfold Hospital Trust, Norway. Participantsthe study population consists of 1,110 consenting healthy women, assessed to be at low-risk at spontaneous onset of labour. Measurementseffect measures; avoided caesarean sections, instrumental vaginal deliveries, complications requiring treatment in the operating room, epidural analgesia and oxytocin augmentation. Costs (€) were calculated by costs per day multiplied with length of stay, added costs for procedures performed outside the units. The results are expressed in incremental cost-effectiveness ratios (ICER) with SCU as comparator. Findingstotal costs per stay were significantly lower for women at the MU (€1,672) compared to the SCU (€1,950, p<0.001). The ICER showed that MU was a dominant strategy (lower costs and reduction in clinical procedures) for all effect measures. Based on the sensitivity analysis, allocating low-risk women to MU significantly reduced costs, but was not a dominant strategy for all outcomes. Key conclusionsthe MU is more cost-effective than the SCU for low-risk women without prelabour preference for level of birth care provided equal capacity at the units. Implications for practiceit is cost-effective to organise birth care for low-risk women in a separate midwife-led unit.

Informed decision making

British Journal of Midwifery • May 2012 • Vol 20, No 5 The Birthplace Study is in the news again. Following a more recent study published in last month’s British Medical Journal (Schroeder et al, 2012), regarding the cost-effectiveness of alternative places of birth for women with a low risk of complications, many of the popular newspapers have been commenting on the cost-efficiency of homebirths. In essence, Schroeder et al’s study found that planned homebirths were the most cost-effective option for multiparous women at low risk for complications. Homebirths were also the most cost-effective option for nulliparous women; however, it should be noted in the case of nulliparous women, homebirths were found to be associated with poorer outcomes for the baby (9.3 per 1000 births compared with 5.3 per 1000 births in obstetric units) (Birthplace in England Collaborative Group (BECG), 2011). In general, the results of this more recent study, together with last November’s Birthplace Study (BECG, 2011), show that homebirths are not only safe but also costeffective. This evidence adds further weight to the argument in favour of midwife-led units and homebirths. At a time when the NHS is aiming to improve the quality and delivery of care while reducing costs to make £20 billion efficiency savings by 2014/15 (Department of Health (DH), 2011), this may come as music to the ears of budget controllers. Louise Silverton, Deputy General Secretary of the Royal College of Midwives, has said: ‘The potential for cost savings could make offering women more choice an attractive option for the NHS’ (Dabrowski, 2012). However, while births may be planned for home, complications do happen and not just for first-time mothers. Along with all the various costs of birth complications, there is also the cost of transport, as mothers who expericence complications have to be transferred from their planned place of birth to hospital. Transfer rates can be very high—considering planned homebirths for firsttime mothers, the Birthplace Study (BECG, 2011) found a peri-partum transfer rate of 45%. There are obvious costs here, and not just monetary—outcomes and quality of life for mother and baby will also be affected, and these costs need to be considered. The question now is whether low-risk women will be actively encouraged to give birth at home, just to make cost-efficiency savings. I hope not. There are many other benefits to homebirths, including one-on-one care with a midwife and a decreased risk of infection for both the mother and the baby (Wax et al, 2010). The emphasis ought to be on choice: women have a choice, and it is only right that their choice is informed and balanced. As the government said: ‘no decisions about me without me’ (DH, 2010). Midwives of course have a vital role to play and have the knowledge and experience to help women make the most informed decisions possible. BJM