Midwifery-led Unit Research Articles

Normal birth rates before and after the merging of mixed-risk and low-risk maternity wards in Iceland: A retrospective cohort study on the impact of inter-professional preventative measures.

In 2014, the National University Hospital of Iceland (NUHI) merged a mixed-risk birth unit and a midwifery-led low-risk unit into one mixed-risk unit. Interprofessional preventative and mitigating measures were implemented since there was a known threat of cultural contamination between mixed-risk and low-risk birth environments. The aim of the study was to assess whether the NUHI's goal of protecting the rates of birth without intervention had been achieved and to support further development of labor services. A retrospective cohort study of all women who had singleton births at NUHI birth units in two 2-year periods, 2012-2013 and 2015-2016. The primary outcome variables, birth without intervention, with or without artificial rupture of membranes (AROM), were adjusted for confounding variables using logistic regression analysis. Secondary outcome variables (individual interventions and maternal and neonatal complications) were analyzed using descriptive statistics, t test, and Chi-square test. The rate of births without interventions, both with and without AROM, increased significantly after the unit merger and accompanying preventative measures. The rates of AROM, oxytocin augmentation, episiotomies, and epidural analgesia decreased significantly. The rate of induction increased significantly. There were no significant differences in maternal or neonatal complication rates. Interprofessional preventative measures, implemented alongside a mixed-risk and low-risk birth unit merger, can increase rates of births without interventions in a mixed-risk hospital setting. However, it is necessary to maintain awareness of the possible effects of a mixed-risk birth environment on the use of childbirth interventions and examine the long-term effects of preventative measures.

Births in freestanding midwifery-led units in Norway: What women view as important aspects of care

ObjectiveTo describe what women view as important aspects of care when giving birth in freestanding midwifery-led units in Norway. MethodsData from four open-ended questions in the Babies Born Better survey, Version 1, 2 and 3 was used. We performed inductive content analysis to explore and describe women’s experiences with the care they received. ResultsIn all, 190 women who had given birth in midwifery-led units in Norway between 2010 and 2020 responded to the B3 survey. The final sample comprised 182 respondents. The analysis yielded three main categories: 1) The immediate birth surroundings, 2) Personal and safe support, and 3) Organisational conditions. ConclusionThis study adds valuable knowledge regarding what women describe as important aspects of care in free-standing midwifery-led units. Women experience maternity services in these units as peaceful, flexible and family-friendly. However, some women perceive the freestanding midwifery-led unit as a vulnerable service, mainly due to lack of midwives on call and uncertainty around temporary closure of the freestanding midwifery-led units. This finding points to the importance of staffing of birth facilities to ensure that all women giving birth have available midwifery care at all times, which is recommended in the National guidelines for care during labour and birth. Predictability around place of birth for the upcoming birth is crucial for every woman and her family. These goals might be achieved by a stable, continuous maternity service in all geographical areas of the country.

Designing maternity care spaces: a research design process involving staff and users’ requirements to improve a Midwifery-Led Unit layout

Designing maternity care spaces: a research design process involving staff and users’ requirements to improve a Midwifery-Led Unit layout

Women’s Length of Stay in a Danish Specialized Unit for Perinatally Bereaved Parents

ObjectiveTo describe the clinical characteristics of women admitted to a specialized unit for bereaved parents and to identify the characteristics of women who stayed more than 2 days. DesignA population-based descriptive study. SettingA midwifery-led specialized unit for bereaved parents at Aarhus University Hospital, Denmark. ParticipantsWomen with miscarriage (>14 weeks), missed abortion (>14 weeks), termination of pregnancy (>14 weeks), stillbirth, or death of their neonate during the first 48 hours after birth. MethodsWe collected information from the electronic health care records for women admitted to the unit from January 2012 through December 2018, including parity, type of loss, gestational age, mode and duration of birth, pain relief, and duration of stay. ResultsFrom January 1, 2012. to December 31, 2018, 579 women were admitted to the unit. Hospitalization varied from 1 day to 1 week. More women with a loss after 22 gestational weeks stayed for more than 2 days. In multivariate analyses, the hazard ratio (HR) of staying longer than 2 days was 1.3 times greater for primiparous women than for multiparous women (HR = 1.3, 95% confidence interval [1.0, 1.7]) and 2.4 times greater for women with near-term loss compared to women with perinatal loss before gestational week 22 (HR = 2.4, 95% confidence interval [1.7, 3.6]). ConclusionProviding unlimited stay at a specialized unit for perinatal loss resulted in variation in length of stay. Primiparous women and women who lost neonates or fetuses closer to term gestation were more likely to stay in the unit for up to 8 days. This may indicate a need for individual support not available in standard care.

Introduction of standardized, cumulative quantitative measurement of blood loss into routine maternity care

Introduction Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity in the UK. Visual estimation of blood loss is unreliable yet remains common practice. As part of a national quality improvement project to improve care during PPH, standardized, quantitative measurement of blood loss (QBL) for all deliveries was introduced into a tertiary obstetric unit in Cardiff, Wales. Methods Retrospective analysis of 875 consecutive maternities between December 2017 and February 2018 was undertaken. Of these, 372 mothers had both pre- and post-partum hemoglobin (Hb) were recorded. Regression analyses were performed to investigate the relationship between change in Hb adjusted for red cell transfusion and QBL. Results The correlation coefficient between QBL and adjusted change in Hb for all deliveries (n = 372) was 0.57. This corresponded to an estimated fall of adjusted change in Hb of 15.3 g/L (95% CI: 13.1, 17.6) per 1000 mL blood loss. Discussion QBL has been shown to be reliable across all maternity settings, with reproducible results in theater and delivery rooms (on the obstetric unit and alongside midwifery-led unit). QBL is moderately correlated with adjusted change in Hb for all volumes of bleeding and gives clinicians more accurate knowledge of blood loss than visual estimation. This low-cost, low-fidelity intervention can influence the timely escalation of clinical care and therefore patient outcome.

Are women attending a midwifery-led birthing center at increased risk of anal sphincter injury?

In recent years there has been renewed interest in midwifery-led care for women, with studies reporting similar neonatal outcomes despite lower rates of intervention in midwifery-led birthing centers. Research into obstetric anal sphincter injuries (OASI) in these birthing centers is scarce. The objective of this study was to compare the rate of OASI after spontaneous vaginal delivery in nulliparous women in consultant or midwifery-led units over a ten-year period. All spontaneous vaginal deliveries in nulliparous women from 2008 to 2017 were analyzed in a single-center retrospective study. Women who had neuraxial analgesia were excluded. The primary endpoint was OASI. Labor characteristics in both groups were compared, and a multiple regression model was created. During the study period, there were 3260 spontaneous vaginal deliveries in nulliparous women; 75.7% (2467/3260) delivered in the consultant-led unit and 24.3% (793/3260) in the midwifery-led unit (MLU). Women delivering in the MLU had a greater risk of anal sphincter injury than those delivering in the CLU (4.9% [39/793] vs 2.5% [62/2467], OR 2.01, 95% CI 1.32 - 3.01). Significant risk factors that increased the risk of OASI on regression analysis were birthweight and delivery in the midwifery-led unit. Women delivering in the midwifery-led unit appear to be at double the risk of OASI when compared to those delivering in the consultant-led unit. These results are in contrast to previous studies in midwifery-led centers. This difference may be site-specific and further research is required before these results form part of patient counseling.

Latent Phase of Labour in a Freestanding Midwifery Unit

This descriptive service evaluation aimed to explore the latent phase of labour, as experienced by two women who birthed at one freestanding midwifery-led unit. Literature exploring women’s experiences of the latent phase has focused on women who birth in hospital environments. When to seek care was the overarching theme that linked the themes of uncertainty, support and pain, and although findings are insightful, they are limited. Findings do suggest that home assessments during the latent phase may enhance woman-centred care and encourage women to remain at home during this phase. A larger-scale phenomenological study exploring women’s experiences of the latent phase of labour, may enable guidelines and practice to be revised to provide personalised care and a positive experience of the latent phase.

Disconnection: Exploring transfer from midwifery-led to consultant-led care a phenomenological study of women’s views

BackgroundUnderstanding women’s feelings during the transfer process can illuminate women’s perspectives thus minimising the risk for postnatal psychological and emotional morbidity, and inform midwifery practice. AimTo explore the meaning women ascribe to their feelings when transferred from an environment emphasising a social model of pregnancy and birth in a Midwifery Led Unit, to a contrasting, more ‘medicalised’ setting of a Consultant Led Unit. MethodsThe study adopted an idiographic focus, by conducting semi-structured interviews with new mothers. A purposive sample of eleven women was recruited via participating midwifery led units and their ‘Facebook’ page. An interpretative phenomenological approach was selected to explore mothers’ individual perceptions of experiences. FindingsParticipants described feeling a strong sense of community in the midwifery led unit, where they enjoyed a sense of belonging, safety, and support. The overarching theme of ‘disconnection’ signified feelings of muted agency when transferred to a different environment. Women used adaptive processes to reconcile themselves to a medicalised ideology. The impact of the transfer also resulted in a sense of alienation and ‘not belonging’. ConclusionAdjustment to a different model of care meant women needed to rapidly amend their notions of normality and agency, at the same time as entering motherhood. Raising awareness about the possible psychological adjustments women have to make during at this time could provide reassurance to other women. It also highlights the need for support during and after transfer. Strengthening continuity of care could help facilitate the adjustment process.

Developing and evaluating an online learning tool to improve midwives’ accuracy of visual estimation of blood loss during waterbirth: An experimental study

ObjectiveThe principal objective was to test the effectiveness of an online learning tool to improve midwives’ accuracy of blood loss estimations in a birthing pool environment. The secondary objective was to assess the acceptability of the online learning tool to the midwives using it. DesignA one group pre-test, post-test experiment with immediate and six weeks follow-up to test ability together with an online questionnaire to assess perceived usefulness of an online learning tool. SettingA large NHS maternity hospital comprising an acute care obstetric unit, a small district unit labour ward, one alongside midwifery-led unit and three freestanding midwifery-led units. ParticipantsVolunteer NHS employed midwives who had experience in caring for women labouring and giving birth in water (n = 24). InterventionAn online learning tool comprising six randomly ordered short video simulations of blood loss in a birthing pool in real time, and a tutorial giving verbal and pictorial guidance on making accurate blood loss estimations in water was developed then piloted. Midwives’ accuracy scores for estimating blood loss in each of the videos were calculated at three timepoints; pre and immediately post the learning component, and six weeks later. The estimated blood loss volume was subtracted from the actual blood loss volume, to give the difference between estimated and real blood loss in millilitres (ml) which was then converted to percentage difference to standardise comparison across the six volumes. The differences between pre- and post-learning for each of the six blood volumes was analysed using a repeated measures ANOVA. Statistical significance was set at p < 0.05. An online questionnaire incorporated questions using Likert scales to gauge confidence and competence and free text. Free text responses were analysed using a modified form of inductive content analysis. FindingsTwenty-two midwives completed the online learning and immediate post-test, 14 completed a post-test after six weeks, and 15 responded to the online questionnaire. Pre-test results showed under-estimation of all blood loss volumes and particularly for the two largest volumes (1000 and 1100 ml). Across all volumes, accuracy of estimation was significantly improved at post-test 1. Accuracy diminished slightly, but overall improvement remained, at post-test 2. Participants rated the online tool positively and made suggestions for refining it. Key conclusions and implications for practiceThis is the first study measuring the accuracy of midwives’ blood loss estimations in a birthing pool using real-time simulations and testing the effectiveness of an online learning tool to improve this important skill. Our findings indicate a need to develop interventions to improve midwives’ accuracy at visually estimating blood loss in water, and the potential of an online approach. Most women who labour and/or give birth in water do so in midwifery-led settings without immediate access to medical support. Accuracy in blood loss estimations is an essential core skill

Confidence: Fundamental to midwives providing labour care in freestanding midwifery-led units

The aim of this study was to reveal what enables, safeguards and sustains midwives to provide labour care in freestanding midwifery-led units. DesignA hermeneutic phenomenological study was undertaken in the Auckland region of New Zealand. In-depth interviews were conducted with 14 participants: 11 midwives who provide care in freestanding midwifery-led units and three obstetricians who provide antenatal consultations on site in midwifery-led units. Main findingsConfidence is necessary to provide intrapartum care in freestanding midwifery units. This confidence is cultivated by working in the community or freestanding unit and believing this unit is an appropriate space for healthy women to labour and birth. Normal labour and birth are commonplace in this space which in turn reinforces midwives’ confidence. Maintaining confidence for midwives to work in these units requires trusting relationships in the midwifery team. Further, there needs to be mutually respectful relationships with obstetric colleagues. Midwives who have lesser experience, or experience in obstetric unit only, may need support to step into the role of providing labour care in freestanding midwifery units. When the midwife feels supported, when s/he witnesses women and families experiencing their normal birth, one's resolve to practising in this manner is strengthened. The midwife holds confidence. Key conclusions and implications for practiceConfidence required to provide labour care in a midwifery-led unit is cultivated through immersion in these units.

Falling caesarean section rate and improving intra-partum outcomes: a prospective cohort study

Objective: To evaluate caesarean section (CS) rates and moderate to severe hypoxaemic ischaemic encephalopathy (HIE) rates with other core intra-partum outcomes following reconfiguration of maternity services in Cardiff, South Wales, UK.Design: Cohort study of births from 2006 to 2015.Settings: A University tertiary referral centre for foetal and maternal medicine with 6000 births/year, University Hospital of Wales, United Kingdom.Method: Data relating to births from 1 January 2006 to 31 December 2015 were extracted from the computerized maternity database on a yearly basis. Case notes of all mothers and babies for the same duration were hand searched for documentation of HIE. HIE data was also collected prospectively by neonatologist (SC) and obstetrician (PA).Main outcome measures: Incidence of caesarean section births, babies with moderate to severe HIE, instrumental vaginal births, obstetric anal sphincter injuries (OASIS) associated with instrumental delivery, and major post-partum haemorrhage (MPPH) of 2500 mL or more.Results: During this 10-year period, a downward trend in emergency CS rate was seen from 15.6% in 2006 to 10.5% in 2015, reducing total CS rate from 25.5% in 2006 to 21.2% in 2015. A downward trend in the incidence of moderate and severe HIE was seen over the same period. There was an increase in operative vaginal births (OVB) from 12.8% to 15%. The rate of spontaneous vaginal births (SVB) remained stable. The incidence of OASIS remained constant and MPPH rate has fallen.Conclusions: Following amalgamation of two medium sized obstetric units and the opening of a Midwifery Led Unit (MLU), core intrapartum outcomes have improved. Contributing factors are the introduction of regular multidisciplinary training with enhanced team working, compulsory education for obstetricians and midwives on cardiotocograph (CTG) interpretation, increased consultant presence on delivery suite, robust risk management systems and broad multidisciplinary agreement on clinical guidelines promoting vaginal birth.

Being Alongside - with #MatExp!

The theme for this month’s The Practising Midwife journal is Alongside. When I thought about what this meant to me many ideas sprung to mind – collaboration with the multi-disciplinary team, our new alongside midwifery-led unit at South Warwickshire Foundation Trust, @JennytheM’s latest blog on her skin-to-skin campaign for premature babies born in theatre. So many issues and topics to discuss which should I choose? The Whose Shoes event that I attended and participated in last month incorporated all of these things in an exciting and multi-dimensional way, so I would like to share that wonderful day with you (that’s me below in the pic!)

Improving the quality and content of midwives’ discussions with low-risk women about their options for place of birth: Co-production and evaluation of an intervention package

ObjectiveWomen's planned place of birth is gaining increasing importance in the UK, however evidence suggests that there is variation in the content of community midwives’ discussions with low risk women about their place of birth options. The objective of this study was to develop an intervention to improve the quality and content of place of birth discussions between midwives and low-risk women and to evaluate this intervention in practice. DesignThe study design comprised of three stages: (1) The first stage included focus groups with midwives to explore the barriers to carrying out place of birth discussions with women. (2) In the second stage, COM-B theory provided a structure for co-produced intervention development with midwives and women representatives; priority areas for change were agreed and the components of an intervention package to standardise the quality of these discussions were decided. (3) The third stage of the study adopted a mixed methods approach including questionnaires, focus groups and interviews with midwives to evaluate the implementation of the co-produced package in practice. SettingA maternity NHS Trust in the West Midlands, UK. ParticipantsA total of 38 midwives took part in the first stage of the study. Intervention design (stage 2) included 58 midwives, and the evaluation (stage 3) involved 66 midwives. Four women were involved in the intervention design stage of the study in a Patient and Public Involvement role (not formally consented as participants). FindingsIn the first study stage participants agreed that pragmatic, standardised information on the safety, intervention and transfer rates for each birth setting (obstetric unit, midwifery-led unit, home) was required. In the second stage of the study, co-production between researchers, women and midwives resulted in an intervention package designed to support the implementation of these changes and included an update session for midwives, a script, a leaflet, and ongoing support through a named lead midwife and regular team meetings. Evaluation of this package in practice revealed that midwives’ knowledge and confidence regarding place of birth substantially improved after the initial update session and was sustained three months post-implementation. Midwives viewed the resources as useful in prompting discussions and aiding communication about place of birth options. Key conclusions and implications for practiceCo-production enabled development of a pragmatic intervention to improve the quality of midwives’ place of birth discussions with low-risk women, supported by COM-B theory. These findings highlight the importance of co-production in intervention development and suggest that the place of birth package could be used to improve place of birth discussions to facilitate informed choice at other Trusts across the UK.

A qualitative exploration of how midwives' and obstetricians' perception of risk affects care practices for low-risk women and normal birth.

Maternity care is facing increasing intervention and iatrogenic morbidity rates. This can be attributed, in part, to higher-risk maternity populations, but also to a risk culture in which birth is increasingly seen as abnormal. Technology and intervention are used to prevent perceived implication in adverse outcomes and litigation. Does midwives' and obstetricians' perception of risk affect care practices for normal birth and low-risk women in labour, taking into account different settings? The research methods are developed within a qualitative framework. Data were collected using semi-structured interviews and analysed thematically. A purposive sample of 25 midwives and obstetricians were recruited from three maternity settings in Ireland. This included obstetric-led hospitals, an alongside midwifery-led unit and the community. Midwifery is assuming a peripheral position with regard to normal birth as a progressive culture of risk and medicalisation affects the provision of maternity care. This is revealed in four themes; (1) professional autonomy and hierarchy in maternity care; (2) midwifery-led care as an undervalued and unsupported aspiration; (3) a shift in focus from striving for normality to risk management; and (4) viewing pregnancy through a 'risk-lens'. Factors connected to the increased medicalisation of birth contribute to the lack of midwifery responsibility for low-risk women and normal birth. Midwives are resigned to the current situation and as a profession are reluctant to take action. Improved models of care, distinct from medical jurisdiction, are required. Midwives must take responsibility for leading change as their professional identity is in jeopardy.

What women want: Exploring pregnant women’s preferences for alternative models of maternity care

Depending on obstetric risk, maternity care may be provided in one of two locations at hospital level: a consultant-led unit (CLU) or a midwifery-led unit (MLU). Care in a MLU is sparsely provided in Ireland, comprising as few as two units out of a total 21 maternity units. Given its potential for greater efficiencies of care and cost-savings for the state, there has been an increased interest to expand MLUs in Ireland. Yet, very little is known about women’s preferences for midwifery-led care, and whether they would utilise this service when presented with the choice of delivering in a CLU or MLU. This study seeks to involve women in the future planning of maternity care by investigating their preferences for care and subsequent motivations when choosing place of birth. Qualitative research is undertaken to explore maternal preferences for these different models of care. Women only revealed a preference for the MLU when co-located with a CLU due to its close proximity to medical services. However, the results suggest women do not have a clear preference for either model of care, but rather a hybrid model of care which encompasses features of both consultant- and midwifery-led care.

A systematic review to examine the evidence regarding discussions by midwives, with women, around their options for where to give birth.

BackgroundDiscussion of place of birth is important for women and maternity services, yet the detail, content and delivery of these discussions are unclear. The Birthplace Study found that for low risk, multiparous women, there was no significant difference in neonatal safety outcomes between women giving birth in obstetric units, midwifery-led units, or home. For low risk, nulliparous women giving birth in a midwifery-led unit was as safe as in hospital, whilst birth at home was associated with a small, increased risk of adverse perinatal outcomes. Intervention rates were reduced in all settings outside hospital. NICE guidelines recommend all women are supported in their choice of birth setting.Midwives have the opportunity to provide information to women about where they choose to give birth. However, research suggests women are sometimes unaware of all the options available.This systematic review will establish what is known about midwives’ perspectives of discussions with women about their options for where to give birth and whether any interventions have been implemented to support these discussions.MethodsThe systematic review was PROSPERO registered (registration number: CRD42015017334). The PRISMA statement was followed. Medline, Cochrane, CINAHL, PsycINFO, Popline and EMBASE databases were searched between 2000-March 2015 and grey literature was searched. All identified studies were screened for inclusion. Qualitative data was thematically analysed, whilst quantitative data was summarised.ResultsThe themes identified relating to influences on midwives’ place of birth discussions with women were organisational pressures and professional norms, inadequate knowledge and confidence of midwives, variation in what midwives told women and the influence of colleagues. None of the interventions identified provided sufficient evidence of effectiveness and were of poor quality.ConclusionsThe review has suggested the need for a pragmatic, understandable place of birth dialogue containing standard content to ensure midwives provide low risk women with adequate information about their place of birth options and the need to improve midwives knowledge about place of birth. A more robust, systematic evaluation of any interventions designed is required to improve the quality of place of birth discussions. By engaging with co-produced research, more effective interventions can be designed, implemented and sustained.

Outcomes of care at ‘Føderiket Midwifery Unit’ 2007–2011, a freestanding midwifery-led unit in Oslo, Norway: A prospective cohort study

The aim of this study was to provide a description and evaluation of birth outcomes for women who started care at Føderiket Midwifery Unit (FMU), a freestanding midwifery unit in Oslo. FMU opened in 2007 as a five-year project. It was closed in 2011 for economic reasons, and the planned evaluations were never performed. Data from 495 women who started care at FMU were prospectively collected. Socio-demographic characteristics, transfers to hospital, maternal and neonatal outcomes were described. The findings showed that 115 (23%) of the women were primiparous and 380 (77%) multiparous. A total of 408 women (82%) had no complications and no need for additional medical treatment during labour and birth. There were 73 (15%) transfers before birth, and 14 (3%) after birth. Nine women (2%) were delivered by caesarean section and 19 (4%) by vacuum extraction. Thirty women (6%) had postpartum haemorrhage &gt;500 ml and five (1%) received blood transfusions. Five babies (1%) were transferred to the Neonatal Intensive Care Unit, all were discharged to their homes within a week. There were no cases of deaths, or serious morbidity. Our conclusions are that the results after four years management were comparable to other freestanding midwifery-led units in Western countries.

Neonatal outcomes and delivery of care for infants born late preterm or moderately preterm: a prospective population-based study

ObjectiveTo describe neonatal outcomes and explore variation in delivery of care for infants born late (34–36 weeks) and moderately (32–33 weeks) preterm (LMPT).Design/settingProspective population-based study comprising births in four major...

An exploration of influences on women’s birthplace decision-making in New Zealand: a mixed methods prospective cohort within the Evaluating Maternity Units study

BackgroundThere is worldwide debate surrounding the safety and appropriateness of different birthplaces for well women. One of the primary objectives of the Evaluating Maternity Units prospective cohort study was to compare the clinical outcomes for well women, intending to give birth in either an obstetric-led tertiary hospital or a free-standing midwifery-led primary maternity unit. This paper addresses a secondary aim of the study – to describe and explore the influences on women’s birthplace decision-making in New Zealand, which has a publicly funded, midwifery-led continuity of care maternity system.MethodsThis mixed method study utilised data from the six week postpartum survey and focus groups undertaken in the Christchurch area in New Zealand (2010–2012). Christchurch has a tertiary hospital and four primary maternity units. The survey was completed by 82% of the 702 study participants, who were well, pregnant women booked to give birth in one of these places. All women received midwifery-led continuity of care, regardless of their intended or actual birthplace.ResultsAlmost all the respondents perceived themselves as the main birthplace decision-makers. Accessing a ‘specialist facility’ was the most important factor for the tertiary hospital group. The primary unit group identified several factors, including ‘closeness to home’, ‘ease of access’, the ‘atmosphere’ of the unit and avoidance of ‘unnecessary intervention’ as important. Both groups believed their chosen birthplace was the right and ‘safe’ place for them. The concept of ‘safety’ was integral and based on the participants’ differing perception of safety in childbirth.ConclusionsBirthplace is a profoundly important aspect of women’s experience of childbirth. This is the first published study reporting New Zealand women’s perspectives on their birthplace decision-making. The groups’ responses expressed different ideologies about childbirth. The tertiary hospital group identified with the ‘medical model’ of birth, and the primary unit group identified with the ‘midwifery model’ of birth. Research evidence affirming the ‘clinical safety’ of primary units addresses only one aspect of the beliefs influencing women’s birthplace decision-making. In order for more women to give birth at a primary unit other aspects of women’s beliefs need addressing, and much wider socio-political change is required.

The relationship between frequency of obstetric ultrasound scans and birthplace preference – A case control study

Objectiveto investigate the relationship between frequency of ultrasounds and birthplace preference. Study designretrospective case-control study with the number of ultrasounds as the exposure and the pregnant woman׳s preference to give birth in a low-technology setting (midwifery-led unit or home) or a high-technology setting (obstetric unit) as the primary outcome. Sample and Settinglow-risk primigravid women receiving antenatal care at a central London academic medical centre. Measurementsantenatal ultrasound frequency; birthplace preference at the initial pregnancy appointment (T1) and at the commencement of labour (T2); demographic data including ethnicity, index of multiple deprivation, age, and body mass index. Findings1100 cases were reviewed. Women received an average of 4.03 ultrasounds during their pregnancy (SD=1.96, range 2–14). The frequency of ultrasounds for women who had a low-technology T2 birthplace preference was significantly lower than for those who had a high-technology T2 birthplace preference (t=2.98, df=1098, p=0.003, r=0.1), and women who had a constant low-technology birthrate preference had significantly less ultrasounds than other women (F (3,644)=3.475, p=.02). However, within a logistic regression the frequency of ultrasound was not associated with T2 birthplace preference, after controlling for T1 birthplace preference. Key conclusionsthe findings of this investigation suggest that a preference made early in pregnancy is a greater predictor of birthplace preference than exposure to antenatal ultrasounds. Implications for practicefurther research is required to inform interventions that would encourage low-risk pregnant women to select a low-technology place of birth.