Maternal outcomes and birth interventions among women who begin labour intending to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analyses.

BACKGROUND: We previously concluded that risk of stillbirth, neonatal mortality or morbidity is not different whether birth is intended at home or hospital. Here, we compare the occurrence of birth interventions and maternal outcomes among low-risk women who begin labour intending to birth at home compared to women intending to birth in hospital. METHODS: We used our registered protocol (PROSPERO, http://www.crd.york.ac.uk, No.CRD42013004046) and searched five databases from 1990-2018. Using R, we obtained pooled estimates of effect (accounting for study design, study setting and parity). FINDINGS: 16 studies provided data from ~500,000 intended home births for the meta-analyses. There were no reported maternal deaths. When controlling for parity in well-integrated settings we found women intending to give birth at home compared to hospital were less likely to experience: caesarean section OR 0.58(0.44,0.77); operative vaginal birth OR 0.42(0.23,0.76); epidural analgesia OR 0.30(0.24,0.38); episiotomy OR 0.45(0.28,0.73); 3rd or 4th degree tear OR 0.57(0.43,0.75); oxytocin augmentation OR 0.37(0.26,0.51) and maternal infection OR 0.23(0.15,0.35). Pooled results for postpartum haemorrhage showed women intending home births were either less likely or did not differ from those intending hospital birth [OR 0.66(0.54,0.80) and RR 1.30(0.79,2.13) from 2 studies that could not be pooled with the others]. Similar results were found when data were stratified by parity and by degree of integration into health systems. INTERPRETATION: Among low-risk women, those intending to birth at home experienced fewer birth interventions and untoward maternal outcomes. These findings along with earlier work reporting neonatal outcomes inform families, health care providers and policy makers around the safety of intended home births. FUNDING: Partial funding: Association of Ontario Midwives open peer reviewed grant.

Perinatal or neonatal mortality among women who intend at the onset of labour to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analyses.

BACKGROUND: More women are choosing to birth at home in well-resourced countries. Concerns persist that out-of-hospital birth contributes to higher perinatal and neonatal mortality. This systematic review and meta-analyses determines if risk of fetal or neonatal loss differs among low-risk women who begin labour intending to give birth at home compared to low-risk women intending to give birth in hospital. METHODS: In April 2018 we searched five databases from 1990 onward and used R to obtain pooled estimates of effect. We stratified by study design, study settings and parity. The primary outcome is any perinatal or neonatal death after the onset of labour. The study protocol is peer-reviewed, published and registered (PROSPERO No.CRD42013004046). FINDINGS: We identified 14 studies eligible for meta-analysis including ~ 500,000 intended home births. Among nulliparous women intending a home birth in settings where midwives attending home birth are well-integrated in health services, the odds ratio (OR) of perinatal or neonatal mortality compared to those intending hospital birth was 1.07 (95% Confidence Interval [CI], 0.70 to 1.65); and in less integrated settings 3.17 (95% CI, 0.73 to 13.76). Among multiparous women intending a home birth in well-integrated settings, the estimated OR compared to those intending a hospital birth was 1.08 (95% CI, 0.84 to 1.38); and in less integrated settings was 1.58 (95% CI, 0.50 to 5.03). INTERPRETATION: The risk of perinatal or neonatal mortality was not different when birth was intended at home or in hospital. FUNDING: Partial funding: Association of Ontario Midwives open peer reviewed grant. RESEARCH IN CONTEXT: Evidence before this study Although there is increasing acceptance for intended home birth as a choice for birthing women, controversy about its safety persists. The varying responses of obstetrical societies to intended home birth provide evidence of contrasting views. A Cochrane review of randomised controlled trials addressing this topic included one small trial and noted that in the absence of adequately sized randomised controlled trials on the topic of intended home compared to intended hospital birth, a peer reviewed protocol be published to guide a systematic review and meta-analysis including observational studies. Reviews to date have been limited by design or methodological issues and none has used a protocol published a priori.Added value of this study Individual studies are underpowered to detect small but potentially important differences in rare outcomes. This study uses a published peer-reviewed protocol and is the largest and most comprehensive meta-analysis comparing outcomes of intended home and hospital birth. We take study design, parity and jurisdictional support for home birth into account. Our study provides much needed information to policy makers, care providers and women and families when planning for birth.Implications of all the available evidence Women who are low risk and who intend to give birth at home do not appear to have a different risk of fetal or neonatal loss compared to a population of similarly low risk women intending to give birth in hospital.

Experiences of the graduates of the first baccalaureate midwifery programme in Pakistan: A descriptive exploratory study.

BACKGROUND: in 2012 the Aga Khan University in Karachi, Pakistan opened the country's first bachelor's degree program in midwifery for women who held diplomas in nursing and midwifery. The principal aims were to prepare midwives who would be competent to provide full-scope practice. For quality assurance, the programme was continuously monitored and assessed. As part of this ongoing evaluation process we sought in-depth feedback from the first graduates about their student experiences. OBJECTIVE: this study aimed to explore the experiences of the first graduates of a Bachelor of Science in Midwifery (BScM) program to deepen our understanding of their views of the program's strengths and difficulties and to obtain their suggestions for change. DESIGN AND METHODS: This qualitative descriptive exploratory study used universal sampling to collect data from all 21 of the first graduates of the BScM Program. Data collection involved focus group discussions using a semi structured interview guide and content analysis. The study was approved by Institutional Ethics Review Committee. FINDINGS: three main themes emerged from the data: (1) Competence acquisition, (2) Attitude transformation, and (3) Strengths and limitations of the program. CONCLUSIONS: the study findings highlighted that the degree program in midwifery had a positive impact on graduates' perceptions of their knowledge, skills, attitudes and ability to implement evidence-based midwifery practice. The graduates regarded the university's environment, teaching-learning strategies, preceptorship model, self-directed learning and exposure to diverse clinical settings as major facilitators in achieving competence.

The first competency-based higher education programme for midwives in the South Asian region--Pakistan.

Midwives in Pakistan and the South Asian region who complete a diploma program face many challenges for career growth and development. The absence of higher education in professional midwifery in the region has contributed to general non-acceptance and invisibility of midwifery. In response to the interest, Aga Khan University (AKU) developed bachelors program in midwifery based on the Global Standards for Midwifery Education developed by the International Confederation of Midwives (ICM) with the vision to equip midwives to provide full-scope practice, develop confidence to practice midwifery independently, become clinical leaders and contribute to the future of midwifery. The final curriculum had a balance of theory and clinical practice in order to develop a high level of clinical competence that would meet the ICM standards and guidelines. The two year bachelors program is currently in progress. The first cohort of 21 midwives graduated in 2014 and a second cohort was enrolled in 2015. There is a planning for a future graduate program in midwifery to prepare individuals for leadership roles in practice, teaching, maternal-child health provision and policy making through a master's degree in midwifery.

Protocol: systematic review and meta-analyses of birth outcomes for women who intend at the onset of labour to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital.

BACKGROUND: There has been a renewed interest in the place of birth, including intended home birth, for low risk women. In the absence of adequately-sized randomised controlled trials, a recent Cochrane review recommended that a systematic review and meta-analysis, including observational studies, be undertaken to inform this topic. The objective of this review is to determine if women intending at the onset of labour to give birth at home are more or less likely to experience a foetal or neonatal loss compared to a cohort of women who are comparable to the home birth cohort on the absence of risk factors but who intend to give birth in a hospital setting. METHODS: We will search using Embase, MEDLINE, CINAHL, AMED and the Cochrane Library to find studies published since 1990 that compare foetal, neonatal and maternal outcomes for women who intended at the onset of labour to give birth at home to a comparison cohort of low risk women who intended at the onset of labour to give birth in hospital. We will obtain pooled estimates of effect using Review Manager. Because of the likelihood of differences in outcomes in settings where home birth is integrated into the health care system, we will stratify our results according to jurisdictions that have a health care system that integrates home birth and those where home birth is provided outside the usual health care system. Since parity is known to be associated with birth outcomes, only studies that take parity into account will be included in the meta-analyses. We will provide results by parity to the extent possible. SYSTEMATIC REVIEW REGISTRATION: This protocol was registered with PROSPERO at http://www.crd.york.ac.uk/Prospero/ (Registration number: CRD42013004046).

Models of organization of maternity care by midwives in Canada: a descriptive review.

Most provinces in Canada now offer regulated midwifery, but the way services are delivered across the country varies. The Canadian Midwifery Regulators Consortium has identified a need to examine the different ways in which care is being organized; this is to determine what elements are essential to maintain and where flexibility is desirable, in order to promote growth of the profession and maximize the contribution of midwifery to the provision of services. In April 2012 a planning meeting (funded by Canadian Institutes of Health Research) brought together midwifery leaders, researchers, regulators, and lead clinicians of several maternity service programs across Canada. The various approaches to organizing care were discussed and three of the programs presented were selected for this descriptive review because of their unique approaches and ability to respond to the needs of communities and of care providers within those communities who strive to deliver sustainable maternity care. The programs include an interprofessional group-care approach in British Columbia, an expanded scope of practice in an underserved community in the Northwest Territories, and an interprofessional collaboration of primary maternity caregivers in Nova Scotia. Each is discussed in terms of the population served, the program itself, and the fit of that microsystem within the larger health care system. The organization of maternity care must address the needs of communities and providers alike to make the greatest contribution. Through collaborative and creative organizational approaches, midwives have an opportunity to contribute in a meaningful way and increase their impact on the provision of services.

Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: a retrospective cohort study.

BACKGROUND: Midwives in Ontario, Canada, provide care in the home and hospital and are required to submit data for all births to the Ontario Ministry of Health database. The purpose of this study was to compare maternal and perinatal/neonatal mortality and morbidity and intrapartum intervention rates for women attended by Ontario midwives who planned a home birth compared with similar low-risk women who planned a hospital birth between 2003 and 2006. METHODS: The database provided outcomes for all women planning a home birth at the onset of labor (n = 6,692) and for a cohort, stratified by parity, of similar low-risk women planning a hospital birth. RESULTS: The rate of perinatal and neonatal mortality was very low (1/1,000) for both groups, and no difference was shown between groups in perinatal and neonatal mortality or serious morbidity (2.4% vs 2.8%; relative risk [RR], 95% confidence intervals [CI]: 0.84 [0.68-1.03]). No maternal deaths were reported. All measures of serious maternal morbidity were lower in the planned home birth group as were rates for all interventions including cesarean section (5.2% vs 8.1%; RR [95% CI]: 0.64 [0.56, 0.73]). Nulliparas were less likely to deliver at home, and had higher rates of ambulance transport from home to hospital than multiparas planning home birth and had rates of intervention and outcomes similar to, or lower than, nulliparas planning hospital births. CONCLUSIONS: Midwives who were integrated into the health care system with good access to emergency services, consultation, and transfer of care provided care resulting in favorable outcomes for women planning both home or hospital births.

Using a sampling strategy to address psychometric challenges in tutorial-based assessments.

INTRODUCTION: Tutorial-based assessment, despite providing a good match with the philosophy adopted by educational programmes that emphasize small group learning, remains one of the greatest challenges for educators working in this context. The current study was performed in an attempt to assess the psychometric characteristics of tutorial-based evaluation upon adopting a multiple sampling approach that requires minimal recording of observations. METHOD: After reviewing the literature, a simple 3-item evaluation form was created. The items were "Professional Behaviour," "Contribution to Group Process," and "Contribution to Group Content." Explicit definition of these items was provided on an evaluation form. Twenty five tutors in five different programmes were asked to use the form to evaluate their students (N=169) after every tutorial over the course of an academic unit. Each item was rated using a 10-point scale. RESULTS: Cronbach's alpha revealed an appropriate internal consistency in all five programmes. Test-retest reliability of any single rating was low, but the reliability of the average rating was at least 0.75 in all cases. The construct validity of the tool was supported by the observation of increasing ratings over the course of the academic unit and by the finding that more senior students received higher ratings than more junior students. CONCLUSION: Consistent with the context specificity phenomenon, the adoption of a "minimal observations often" approach to tutorial-based assessment appears to maintain better psychometric characteristics than do attempts to assess tutorial performance using more comprehensive measurement tools.

External cephalic version beginning at 34 weeks' gestation versus 37 weeks' gestation: a randomized multicenter trial.

OBJECTIVE: In about 3% to 4% of all pregnancies at term, the fetal presentation will be noncephalic. External cephalic version (ECV) at term has been shown to decrease the rate of noncephalic presentation at birth and to decrease the rate of cesarean section associated with breech presentation. However, success rates for ECV are low. We did a randomized trial to compare a policy of beginning ECV early, at between 34 and 36 weeks' gestation, and beginning ECV at 37 to 38 weeks' gestation. STUDY DESIGN: At 25 centers in seven countries, 233 women with a singleton breech fetus were randomly assigned to having an ECV procedure done early (at between 34 weeks 0 days and 36 weeks 0 days), or delayed (at between 37 weeks 0 days and 38 weeks 0 days). An experienced practitioner undertook the ECV procedure, and repeat ECV procedures were allowed. Tocolytics and use of epidural analgesia were included as part of the protocol. The primary outcome was the rate of noncephalic presentation at birth. An intention-to-treat analysis was used. RESULTS: Data were received for 232 women, with 116 women in each of the early and delayed ECV groups. Of these, 86.2% in the early ECV group and 67.2% in the delayed ECV group had at least one ECV performed. The rate of noncephalic presentation at birth in the early ECV group was 66 of 116 (56.9%) and 77 of 116 (66.4%) in the delayed ECV group (relative risk [RR] [95% CI] 0.86 [0.70-1.05], P =.09). The rate of serious fetal complications and the rate of preterm birth at <37 weeks were not significantly increased in the early ECV group compared with the delayed ECV group (6.9% vs 7.8%, RR [95% CI] 0.89 [0.36-2.22], P =.69 and 8.6% vs 6.1%, RR [95% CI] 1.42 [0.56-3.59], P =.31, respectively). The rate of cesarean section in the early ECV group was 75 of 116 (64.7%) and 83 of 116 (71.6%) in the delayed ECV group (RR [95% CI] 0.90 [0.76-1.08], P =.32). Neonatal outcomes were comparable in the two groups. The rate of reversion to noncephalic was low in both groups. The majority of women in both groups indicated that they would consider having an ECV in another pregnancy. CONCLUSION: Early ECV performed at 34 to 36 weeks compared with 37 to 38 weeks may reduce the risk of noncephalic presentation at delivery. A large pragmatic trial of early ECV is now required to assess this approach further in terms of cesarean section rates and neonatal outcomes before changes in clinical practice.