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

BACKGROUND: 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. OBJECTIVES: To describe the prevalence of referral for nulliparae and assess maternal and labor characteristics associated with intrapartum transfer. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Midwives' attitudes towards supporting normal labour and birth - A cross-sectional study in South Germany.

OBJECTIVE: supporting healthy and normal physiological birth is part of the global maternity care agenda. Rising rates of interventions have been attributed to several factors, including characteristics, attitudes and preferences of childbearing women and their care providers. In this paper, the application of a scale that measures midwives' attitudes towards supporting normal labour and birth is described as well as factors that are associated with favourable attitudes, such as general self-efficacy, years in midwifery practice, and primary practice setting. DESIGN: in this cross-sectional study an online questionnaire was sent out via e-mail to midwives in two regions of South Germany. The questionnaire contained a validated general self-efficacy scale, a 38-item instrument that measures attitudes towards supporting normal birth among German midwives and questions about midwives' practice experiences and educational preparation. FINDINGS: on average, participants (n=188) were 39 years old (SD=10.3), and had 12 years of experience caring for women during labour and birth (SD=9.6). Multivariate modelling revealed that higher general self-efficacy, working primarily in out-of-hospital settings and having provided intrapartum care for fewer years were significantly associated with midwives' favourable attitudes towards supporting physiological birth (variance explained R(2)=29.0%, n=184). General self-efficacy (1.4%) and years of work experience (3.3%) contributed less of the variance in the outcome than work setting (24.5%). Sources of knowledge about normal birth were not significantly associated with the outcome and reduced the overall variance explained by 0.2%. CONCLUSIONS: the study has shown that, compared to work setting, the general self-efficacy of German midwives, years providing intrapartum care and sources of knowledge about normal birth had comparatively little impact on their attitude towards supporting normal physiologic birth. Increasing exposure to out-of-hospital birth among German midwives throughout education and practice and fostering the skills and confidence necessary to support normal birth in hospital settings are important strategies to decrease unnecessary obstetric interventions.