Effect of a collaborative interdisciplinary maternity care program on perinatal outcomes.

BACKGROUND: The number of physicians providing maternity care in Canada is decreasing, and the rate of cesarean delivery is increasing. We evaluated the effect on perinatal outcomes of an interdisciplinary program designed to promote physiologic birth and encourage active involvement of women and their families in maternity care. METHODS: We conducted a retrospective cohort study involving 1238 women who attended the South Community Birth Program in Vancouver, Canada, from April 2004 to October 2010. The program offers comprehensive, collaborative, interdisciplinary care from family physicians, midwives, community health nurses and doulas to a multiethnic, low-income population. A comparison group, matched for neighbourhood of residence, maternal age, parity and gestational age at delivery, comprised 1238 women receiving standard care in community-based family physician, obstetrician and midwife practices. The primary outcome was the proportion of women who underwent cesarean delivery. RESULTS: Compared with women receiving standard care, those in the birth program were more likely to be delivered by a midwife (41.9% v. 7.4%, p < 0.001) instead of an obstetrician (35.5% v. 69.6%, p < 0.001). The program participants were less likely than the matched controls to undergo cesarean delivery (relative risk [RR] 0.76, 95% confidence interval [CI] 0.68-0.84) and, among those with a previous cesarean delivery, more likely to plan a vaginal birth (RR 3.22, 95% CI 2.25-4.62). Length of stay in hospital was shorter in the program group for both the mothers (mean ± standard deviation 50.6 ± 47.1 v. 72.7 ± 66.7 h, p < 0.001) and the newborns (47.5 ± 92.6 v. 70.6 ± 126.7 h, p < 0.001). Women in the birth program were more likely than the matched controls to be breastfeeding exclusively at discharge (RR 2.10, 95% CI 1.85-2.39). INTERPRETATION: Women attending a collaborative program of interdisciplinary maternity care were less likely to have a cesarean delivery, had shorter hospital stays on average and were more likely to breastfeed exclusively than women receiving standard care.

Early labor assessment and support at home versus telephone triage: a randomized controlled trial.

OBJECTIVE: To compare rates of cesarean delivery among women who were triaged by obstetric nurses, either by telephone or by means of home visits. METHODS: Healthy, nulliparous women in labor at term with uncomplicated pregnancies residing in the City of Vancouver, British Columbia, and suburbs between November 2001 and October 2004 were randomized when they sought advice about when to come to hospital. Women randomized to telephone triage (n=731) were provided with advice by telephone. Women randomized to a home visit (n=728) were triaged after a "hands-on" assessment in their homes. RESULTS: The relative risk (RR) for cesarean delivery among home-triaged women compared with those receiving only telephone support was 1.12 (95% confidence interval [CI] 0.94-1.32). The study was designed to have 80% power to detect a RR less than 0.78 or greater than 1.27 for cesarean delivery. Significantly fewer women in the home visit group were admitted to hospital with cervical dilatation at 3 cm or less (RR 0.85, 95% CI 0.76-0.94). Significantly more women in the home visit group managed their labor without a visit to hospital for assessment (RR 1.54, 95% CI 1.23-1.92). There were no statistically significant differences in use of narcotic analgesia, epidural analgesia, and augmentation of labor. Adverse neonatal outcomes were rare and did not differ between study groups. CONCLUSION: Early labor assessment and support at home versus support by telephone reduces the number of visits to hospital in latent phase labor but does not impact cesarean delivery rates among healthy nulliparous women. CLINICAL TRIAL REGISTRATION: ISRCTN, www.controlled-trials.com/isrctn, MCT-44153 LEVEL OF EVIDENCE: I.

Satisfaction with planned place of birth among midwifery clients in British Columbia.

The purpose of this study was to compare satisfaction with the birth experience among a population of women planning birth at home versus in hospital. In British Columbia, Canada, all midwives offer women meeting eligibility requirements for homebirth the choice to give birth in hospital or at home. Therefore, satisfaction can be attributed to planned place of birth, as the caregivers were the same in both settings. The mean overall score on the Labour Agentry Scale among women who had planned a homebirth (n = 550), 188.49 +/- 16.85, was significantly higher than those who planned birth in hospital (n = 108), 176.60 +/- 23.79; P < .001. Overall satisfaction with the birth experience was higher among women planning birth at home, 4.87 +/- 0.42 versus 4.80 +/- 0.49 on a scale of 1 to 5, although this difference was not statistically significant; P = .06. Among women whose actual place of birth was congruent with where they had planned, overall satisfaction was higher in the homebirth group, 4.95 +/- 0.20 versus 4.75 +/- 0.53; P < .001. Although satisfaction with the birth experience was high in both the home and hospital settings, women planning birth at home were somewhat more satisfied with their experience, particularly if they were able to complete the birth at home.

Early labour assessment and support at home: a randomized controlled trial.

OBJECTIVE: To compare childbirth outcomes of women prospectively randomized to receive early labour assessment and support either through a home visit or by telephone triage. METHODS: Women in early labour, upon seeking prior telephone advice on whether or not they were ready to be admitted to BC Women's Hospital (as was standard hospital practice), were voluntarily randomized to receive either a home visit by an obstetrical nurse or telephone triage. RESULTS: One hundred seventeen women were randomized to receive home care and 120 to receive telephone triage. Significantly fewer women in the home care group arrived at hospital in the latent stage of labour, compared to women in the telephone triage group (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.19-0.72). Significantly fewer women in the home care group received narcotics (OR, 0.55; 95% CI, 0.32-0.96). Differences observed in use of epidural analgesia (OR, 0.64; 95% CI, 0.36-1.16) were not statistically significant. Newborns in the home care group were significantly less likely to be admitted to a level II observation nursery (OR, 0.13; 95% CI, 0.03-0.60). More women in the home care group would recommend this type of care to a friend (P = 0.001). CONCLUSION: Our findings suggest an association of early labour assessment at home with both admission to hospital in the active phase of labour and reduction in use of analgesia during labour. Early labour support at home was associated with reduced rates of admission of neonates to a level II observation nursery, possibly secondary to reduced exposure to analgesics. Early labour care at home by hospital-based obstetrical nurses is safe and acceptable to women, and may offer advantages in terms of reduced interventions and more vigorous neonates.