Midwives & Home birth vs. an OB & hospital ?

On Tue, 09 Sep 2003 21:30:40 -0700, aps wrote:

In article , Larry McMahan
wrote:

LSU Grad of '89 writes:

: I just can't identify with it. I LIKE knowing I've done tests and
: ultrasounds and stuff to make sure - with modern technology - that my baby
: is progressing fine. I just don't believe that a midwife can catch
: everything - right ?

1. Did you know that there is no benefit to be shown from routine
ultrasound. Ultrasound has only proven beneficial when looking for
specific indications. It is grossly overused.

No argument with that, but for those of us who haven't cultivated a
distrust in medical science, it can be reassuring. And it's not clear
what you mean by "specific indications." Our ultrasound involved a
bunch of specific measurements, which we enthusiastically asked a lot
of questions about.

I don't mistrust medical science - I am an ex-nurse, I respect medics,
I respect what medicine, and surgery, can do for people. However,
pregnancy in the main is not a medical or surgical problem. Why would
I need a doctor when I'm not ill? I have had consultant care during
this pregnancy because of previous problems, but it is the midwives I
rely on, and it is midwives who will, DV, be there when I have my
baby, not a doctor.

out of the studies VERY STRONGLY is that the rate of complicaitons for
planned hospital births is much higher than for planned home births.

Mainly because pregnancies with identified risks for complications are
planned for hospital birth.

Not necessarily. Women with no risks go to hospital to have a baby
and, if they don't conform to the expected timetable, find themselves
in the "cascade of interventions". And think about hospital-acquired
infections - those are a complication.

[snip]

Unfortunately you have a view of midwives that is straight out of the middle
ages. What you do not know is how modern and professional they are, and
how much the obstetric process has actually increased risks by the
inappropriate
overuse of technology. I suggest that you do some objective reading on the
subject before becoming subject to such unfounded fears.

I agree that many fears about home natural midwife birth are unfounded
and irrational, but there's plenty of axe grinding on both side of the
issue. And I doubt that a woman who has faith mainly in one side would
do very well in the opposite. Knowing a lot about both approaches is
probably the best strategy

The trouble is, the original poster didn't appear to know a lot about
both approaches.
--
EDD 1/11/03
32 weeks

LSU Grad of '89 wrote:
OK, this really bothered me so I will share it in hopes that I am just too
used to the "modern" way. A woman at work is having hr first child, she's
~5months and has had no visits to an OB or Doctor. She is completely relying
on a midwife. She will have a natural birth at home with the midwife and
husband in attendance.


Sounds fine to me. I didn't have mine at home, but when my 2nd was
born I had a midwife rather than an OB, and it was *so* much better -
like night and day. If I were to have a 3rd I'd strongly consider a
home birth.

I just can't identify with it. I LIKE knowing I've done tests and
ultrasounds and stuff to make sure - with modern technology - that my baby
is progressing fine. I just don't believe that a midwife can catch
everything - right ?



What does this have to do with whether you use a midwife or not?
Midwives can order tests.


Hope this isn't a flame starter, I just cannot identify with the natural at
home no doctors thing. Give me an epidural, no problem...Mother hood is
demanding enough without being a hero when you don't need to. Vicki is
right - no one hands you a medal after labor and says "you get a gold medal
for having the most pain !"


In all likelihood, your epidural will be no problem. But you might be
one of the unlucky ones.


However, I completely understand that each person has a right to their own
method, and just because I cannot identify with this, it doesn't mean it's
wrong. I just have this nagging feeling that if it were me, I'd be concerned
that I wasn't doing the best I could do for my baby. I can't help worrying
for her but I don't know why...I guess I can't imagine going through an
entire pregnancy without ever seeing a doctor when one has insurance and
access (can mid wives write prescriptions for prenatal tablets ?) My friend
works where I do and has excellent insurance...



But when I hear of somebody *planning ahead of time* for an epidural,
I'm concerned that she isn't doing the best she could for her baby or
herself. I didn't have an epidural with either of my hospital births,
and I've never regretted it.

Also - I don't know where you're located, but midwives here in GA can
prescribe a lot more than prenatal vitamins (not that you'd need a
prescription - just go to the grocery store or health food store and
buy some.)

Clisby

aps wrote:

No argument with that, but for those of us who haven't cultivated a
distrust in medical science, it can be reassuring. And it's not clear
what you mean by "specific indications." Our ultrasound involved a
bunch of specific measurements, which we enthusiastically asked a lot
of questions about.

Specific indications: presence or absence or partial development of
brain, four chambered heart, organs functional and present, abdominal
contents enclosed in the abdomen, spinal cord development internally,
identifying number of fetuses present, placental function, cord
integrity. Measurements of the fetus and fluid can be subjective and
not entirely helpful. Sure, it's neat to the look at your growing baby.
I had home births AND ultrasounds and they were not perfect,
especially the last one that was light by 2lbs, short on size, and the
gender.

Kris

LSU Grad of '89 wrote:
OK, this really bothered me so I will share it in hopes that I am just too
used to the "modern" way. A woman at work is having hr first child, she's
~5months and has had no visits to an OB or Doctor. She is completely relying
on a midwife. She will have a natural birth at home with the midwife and
husband in attendance.

This is common practice in the Netherlands and there is still
no study that shows a higher risk for pre- or post-natal
mortality or birth defects. If the woman is going through a
normal pregancy, measuring the heartbeat of the foetus and
it's growth by fundal height is more than enough to assure a
healthy baby. A midwife is perfectly capable of monitoring the
baby's and the mother's health. (S)He can take bloodpressure
and measure a heartbeat as well as any OB.

Yes, you can find defects with u/s and tests. But what do we
gain from that? The risk of being mis-diagnozed and going
through a very stressful time. Or vice versa. You start to
hear numbers like 'the risk is only 1 in 1000'. But what if
you are the 1000-th? There is NEVER a warranty that all is
well, no matter how much you test.

The current medical technology is both a blessing and a curse.
Especially when it is used to ward the medical professional
from any possible mistakes, as is common in the US, instead
of using it as a preventive measure.

--
-- I
mommy to DS (14m)
guardian of DH
EDD 05-17-2004
War doesn't decide who's right - only who's left

aps writes:

: 1. Did you know that there is no benefit to be shown from routine
: ultrasound. Ultrasound has only proven beneficial when looking for
: specific indications. It is grossly overused.

: No argument with that, but for those of us who haven't cultivated a
: distrust in medical science, it can be reassuring. And it's not clear
: what you mean by "specific indications."

I'll spell it out in detail. When an ultrasound is used to determine
whether a specific suspected conditions exists (for example, ectopic
pregnancy, or to see if the fetus is still viable) then it provides
a positive benefit. However, if an ultrasound is done just because it
has been so many weeks and we want to look at the baby and see if all
is well, then no benefit is realized.

: out of the studies VERY STRONGLY is that the rate of complicaitons for
: planned hospital births is much higher than for planned home births.

: Mainly because pregnancies with identified risks for complications are
: planned for hospital birth.

This is absolutely wrong, and show a total misunderstanding for the way
that medical research is conducted. When comparing home versus hospital
(or any two situations) subjects are chosen from both populations *with
exactly the same risk profile*! This is a process called controlling for
confounding variables, and is done to prevent just the kind of bias you
note above.

: I don't think lsugo89 said that nobody should do natural birth.

luugo89 made a number of statements that she worried about her friend
who chose midwifery over obstetrics, and made other explicit and implicit
statements in her post that she thought midwife assisted homebirth was
less safe than OB assisted hospital birth, when, in fact, the research
shows just the opposite.

: I think either of these routes would give you the objective information to
: be able to speak soundly on this subject.

: See, it just sounds like she'd have to voice your opinion on order to
: "speak soundly."

I think what she would have to do to "speak soundly" is study the medical
research literature on the subject, both pro and con, and not just spout
off her uninformed opinion while ignoring the objective evidence.

: 1. This issue has been discussed on this newsgroup many times. If you take
: a women who has experience both a medicated birth with an epidural, and an
: unmedicated birth, which do you think that woman will say that she preferred.
: At least 95% of the mothers on mkp who have done both say they would go
: natural in an instant. I am sure you will get not a few replies to this

: Actually, our labor nurse said exactly the opposite--she had 2
: unmedicated and 1 with an epidural, and she said the epidural was the
: better experience.

Shall we take a poll? :-) See one reply in this thread already from a nurse
who has voted for unmedicated. :-)

: 2. Numerous studies have shown that the epidural anesthesia passes from the
: mother to the babies bloodstream, and that babies who are born to moms with
: epidurals have lower apgar scores, are more morbid, have more difficulty
: breastfeeding, and in general do not respond as quickly or well.

: My wife had an early epidural and the did a couple bolus' during labor.
: Our daughter scored 9.9 apgar and breastfed like a champ. I don't
: disagree that statistically epidurals are more likely to produce those
: problems, but that's not the same as what you're stating.

Excuse me? How are they different?

: Unfortunately you have a view of midwives that is straight out of the middle
: ages. What you do not know is how modern and professional they are, and
: how much the obstetric process has actually increased risks by the
: inappropriate
: overuse of technology. I suggest that you do some objective reading on the
: subject before becoming subject to such unfounded fears.

: I agree that many fears about home natural midwife birth are unfounded
: and irrational, but there's plenty of axe grinding on both side of the
: issue. And I doubt that a woman who has faith mainly in one side would
: do very well in the opposite. Knowing a lot about both approaches is
: probably the best strategy

Hmm. I think this is exactly what I was arguing. See also the other
responses in this thread.

Larry
Rice Grad 69, 73, 75. BA, MS, PhD :-)

aps wrote:

In article , Larry McMahan
wrote:

1. Did you know that there is no benefit to be shown from routine
ultrasound. Ultrasound has only proven beneficial when looking for
specific indications. It is grossly overused.


No argument with that, but for those of us who haven't cultivated a
distrust in medical science, it can be reassuring. And it's not clear
what you mean by "specific indications." Our ultrasound involved a
bunch of specific measurements, which we enthusiastically asked a lot
of questions about.

Meaning, I think, "We have reason to believe this baby has that problem.
Let's use ultrasound to confirm or deny that the problem exists." All
of the very specific measurements they take at an ultrasound can be very
interesting and seeing the babe can be reasuring, but this kind of
information and assurance doesn't change the outcome of the pregnancy.

FWIW, I've had 4 ultrasounds (I'm currently 29 weeks), at 8 weeks
(dating), 20 weeks (routine, but couldn't see the heart), 24 weeks (saw
the heart, but diagnosed a two-vessel umbillical cord, and 28 weeks (to
confirm the cord thing and check baby's growth rate because of same;
baby is fine, even somewhat bigger than expected).

From that, you could argue that it was a darn good thing we had those
ultrasounds, because use deep, heavy, voice here] now we know about a
potential problem with the baby, [end deep, heavy voice] since the
two-vessel cord is associated with some birth defects.

However, the association between the two-vessel cord and birth defects
for babies who have no other risk factors is very low. Most babies with
this kind of cord have no problems whatsoever. From what I can find, if
there are problems and the problems are major, the fetus would have been
non-viable. If the problems are minor, they are the kind of things that
would be caught in routine post-natal well-baby checks.

So, what have we gotten for all those ultrasounds? something to worry
about, more doctor visits, and more visits to come since this moves my
pregnancy closer to "high risk" just out of medical paranoia, more
insurance paperwork and overall increased medical costs [for us, for our
insurance carrier, and for society in general]. Frankly, I've
appreciated the assurance, but I'm not sure it's worth it. As DH
pointed out, had we not had the first ultrasound at all, we'd still be
in pretty much the same position knowledge-wise, with less hassle.
Pretty ironic.

JMO,
Valerie

LSU Grad of '89 wrote:

OK, this really bothered me so I will share it in hopes that I am just too
used to the "modern" way. A woman at work is having hr first child, she's
~5months and has had no visits to an OB or Doctor. She is completely relying
on a midwife. She will have a natural birth at home with the midwife and
husband in attendance.

I just can't identify with it. I LIKE knowing I've done tests and
ultrasounds and stuff to make sure - with modern technology - that my baby
is progressing fine. I just don't believe that a midwife can catch
everything - right ?


Why not? Midwives are well trained and perfectly
capable of providing care for a normal pregnancy and birth--
and of identifying any conditions that require a specialist
and referring out for them. And the proof of that is in the
pudding. Homebirth midwives in general have as good or
*better* safety stats than OBs (and *much* lower rates of
malpractice suits). Your friend's baby is absolutely no
more likely to suffer as a result of your friend's choice
to birth at home than your baby was as a result of your
choice to birth in hospital (which does increase certain
kinds of risks).


Hope this isn't a flame starter, I just cannot identify with the natural at
home no doctors thing. Give me an epidural, no problem...Mother hood is
demanding enough without being a hero when you don't need to. Vicki is
right - no one hands you a medal after labor and says "you get a gold medal
for having the most pain !"


I'm afraid that is a bit of a flame starter. Do
you really think that women choose to forego drugs in
labor just so they can crow about it?! Give them
a little credit for being somewhat brighter than the
average tree stump. Women who choose that route
generally do so because they believe it is better,
healthier, and lower risk to do so--and while I am
firmly behind the right of women to choose pharmacological
pain relief in labor if they so desire, there is ample
evidence that making that choice *DOES* increase some
risks, if only slightly. I know you don't mean to
suggest it, but your comment above really is quite
insulting in that it implies that women who choose
midwifery care and homebirth don't care about their
babies as much as you care about yours. If one were
to go around slinging those sorts of accusations, they
might just as easily condemn your choices as increasing
the risks for your baby just so that you wouldn't have
to go through a little pain--which would be equally
unfair and erroneous.


However, I completely understand that each person has a right to their own
method, and just because I cannot identify with this, it doesn't mean it's
wrong. I just have this nagging feeling that if it were me, I'd be concerned
that I wasn't doing the best I could do for my baby. I can't help worrying
for her but I don't know why...I guess I can't imagine going through an
entire pregnancy without ever seeing a doctor when one has insurance and
access (can mid wives write prescriptions for prenatal tablets ?) My friend
works where I do and has excellent insurance...


Some midwives can write prescriptions and some can't
(depends on the kind of midwife), but why would that even
matter? You can get perfectly good non-prescription prenatal
vitamins that have everything the prescription ones do.
And if a midwife can't write prescriptions for something
that is actually needed, then she refers the woman to a
specialist who can do so.
As for whether she's doing the best for her baby,
if you were to look at the medical evidence, you would
likely find that your friend's midwife was practicing
MORE in line with the best medical evidence available
than your doctor was (speaking in broad generalities).
Current obstetrical practice in the US has several areas
that run contrary to the best evidence based medicine as
reported by leading institutions like the Cochrane Group.
The midwifery model of care tends to more closely parallel
the recommendations of evidence based medicine.
Furthermore, while one can debate the merits of
some of the testing (e.g., routine ultrasound has been
shown to provide NO better outcomes than no routine
ultrasound--it simply provides an opportunity for
mid-trimester termination for obvious anomalies, and
it misses many anomalies at that), if a woman who is
seeing a midwife wants any of the usual tests (ultrasound,
AFP/triple screen, amnio, etc.) the midwife can either
order them or will refer the woman to someone who can
order them.

I can certainly understand why you feel the way
you do. We are very much socially conditioned to feel
that way in the US, and there are a great many people
who have a vested interest in us continuing to operate
under that understanding. But if you really look at
the evidence, your friend's choices are perfectly safe
and sensible as long as she's having a normal pregnancy.
And if her midwives are worth their salt, if she
shows any evidence of NOT having a normal, healthy
pregnancy she will consult with an OB and will change
plans as necessary to accommodate the situation.

Best wishes,
Ericka

aps wrote:

In article , Larry McMahan
wrote:

1. Did you know that there is no benefit to be shown from routine
ultrasound. Ultrasound has only proven beneficial when looking for
specific indications. It is grossly overused.

No argument with that, but for those of us who haven't cultivated a
distrust in medical science, it can be reassuring. And it's not clear
what you mean by "specific indications." Our ultrasound involved a
bunch of specific measurements, which we enthusiastically asked a lot
of questions about.


What he means is that if you just do an ultrasound
because one is 20 weeks along and you do an ultrasound on
every woman at 20 weeks (i.e., you do routine 20 week u/s),
you do not improve outcomes. Doing those routine u/s doesn't
make for healthier babies. Sometimes it provides some
information, but that information is not generally actionable
in a way that changes outcomes for mom and baby. Of the
things that are important to discover, there are generally
symptoms that will cause a NON-routine u/s to be done.
For instance, a placenta previa is obviously important to
diagose, but it will generally show up as bleeding in the
third trimester. This bleeding will cause them to do an
u/s and they will find the previa and schedule a c-section
as needed. On the other hand, with a 20 week routine u/s,
they see lots of low-lying placentas and worry women sick
about it when the majority of them will not be any issue
at term.
The routine u/s *does* give an opportunity to
terminate the pregnancy if obvious anomalies are found,
but if anomalies are found there's generally little to
do about it. This is certainly a benefit, but let's
call a spade a spade--it isn't about making the baby
or the birth healthier or safer. It's about providing
an opportunity for decision making.
In addition, as you point out, it can make women
feel reassured. However, there are two issues involved
with that which merit some thought. First, are we so
sure that u/s poses no possible long term health risks
that we're willing to do them en masse to provide
reassurance but not actionable information? The ACOG
isn't that sure, which is why it continues to not
recommend routine u/s as the standard of care even
though many doctors do it anyway. Second, when we
rely on external things like u/s to provide reassurance
during pregnancy, we can cause *more* anxiety! There's
the anxiety that comes from spurious results (like
the early "dianosis" of placenta previa). There's also
the fact that the u/s only gives limited reassurance
that what could be seen was okay at a particular moment
in time. There's a tendency for this sort of information
to simply crank up the level of reassurance needed so
that one wants more and more and more information in order
to feel okay about the progress of the pregnancy. Some
researchers in other countries which haven't become so
technologically oriented during pregnancy have found that
the introduction of things like routine ultrasound results
in *increased* anxiety overall during pregnancy compared
with anxiety prior to the introduction of that technology.
To some extent we can't put that genie back in the bottle,
but it's a dynamic worth thinking about.


out of the studies VERY STRONGLY is that the rate of complicaitons for
planned hospital births is much higher than for planned home births.

Mainly because pregnancies with identified risks for complications are
planned for hospital birth.


No, most of these studies compare births resulting only
from normal pregnancies. Thus, the fact that hospitals *also*
serve a high risk population is not a factor in that comparison.


1. This issue has been discussed on this newsgroup many times. If you take
a women who has experience both a medicated birth with an epidural, and an
unmedicated birth, which do you think that woman will say that she preferred.
At least 95% of the mothers on mkp who have done both say they would go
natural in an instant. I am sure you will get not a few replies to this

Actually, our labor nurse said exactly the opposite--she had 2
unmedicated and 1 with an epidural, and she said the epidural was the
better experience.


But he is not inaccurate in reporting what women on
this forum have said previously.

Best wishes,
Ericka

LSU Grad of '89 wrote:

I LIKE knowing I've done tests and
ultrasounds and stuff to make sure - with modern technology - that my baby
is progressing fine.

That's fine for you. First, not everyone wants those
things. "Tests" and ultrasounds don't ensure you a healthy
baby (and can miss a frighteningly high proportion of
unhealthy babies), nor do they make complications less
likely. Second, many midwives (including mine, who was a
DEM as opposed to a CNM) can order whatever tests and
ultrasounds the mother desires.

I just don't believe that a midwife can catch
everything - right ?

Doctors can't catch everything, either. There are no
guarantees when it comes to kids, regardless of how you
choose to give birth.


I just cannot identify with the natural at
home no doctors thing.

No need for you to. I can't identify with the medicated at
the hospital with whatever doc happens to be in rotation
coming in at the last minute thing.

Give me an epidural, no problem...Mother hood is
demanding enough without being a hero when you don't need to.

For me, not having an epidural wasn't about being a hero. I
wouldn't have minded one when I was at 2cm (because I was
*tired*), but you don't get an epidural at 2cm. (Well, you
can at the hospital closest to me, but then you wind up with
a pitocin drip and continuous monitoring and all sorts of
other stuff that has nothing to do with heroism, either.)
When I was at 4cm (the time you'd normally get an epidural,
I didn't need one. Allyson asked me at one point during
transition and again while i was pushing if it hurt a lot.
And I said it didn't hurt at all, and that I definitely
wanted to do this again.


I just have this nagging feeling that if it were me, I'd be concerned
that I wasn't doing the best I could do for my baby.

Then you probably shouldn't have a homebirth. I felt I was
doing the very best thing I could do for my baby.


I guess I can't imagine going through an
entire pregnancy without ever seeing a doctor when one has insurance

I paid out of pocket for my midwifery care, and would do so
again, even if a hospital birth were completely free.


(can mid wives write prescriptions for prenatal tablets ?)

CNMs can. But the only advantage to prescription prenatals
is that you can get a 30 or 90 day supply for $5 or $10 if
your insurance has prescription coverage. I bought mine
over the counter - $15 for 270 tablets, identical to a
common prescription prenatal.

Phoebe

"Ericka Kammerer" wrote in message
...
aps wrote:
In article , Larry McMahan
wrote:
1. This issue has been discussed on this newsgroup many times. If you
take
a women who has experience both a medicated birth with an epidural, and
an
unmedicated birth, which do you think that woman will say that she
preferred.
At least 95% of the mothers on mkp who have done both say they would go
natural in an instant. I am sure you will get not a few replies to this

Actually, our labor nurse said exactly the opposite--she had 2
unmedicated and 1 with an epidural, and she said the epidural was the
better experience.

But he is not inaccurate in reporting what women on
this forum have said previously.

In addition, a few studies have shown higher rates of maternal satisfaction
with unmedicated vs. medicated births, particularly when the mother receives
good, continuous support during labor and/or uses midwifery care. Here are
four abstracts:

Midwifery. 2002 Dec;18(4):260-7. Related Articles, Links


Evaluation of satisfaction with midwifery care.

Harvey S, Rach D, Stainton MC, Jarrell J, Brant R.

Arbour Birth Center, Calgary, Alberta, Canada.

OBJECTIVE: to determine if there were differences in women's satisfaction
with maternity care given by doctors and midwives. In addition a simple,
six-question, satisfaction questionnaire was to be tested. DESIGN: a
randomised controlled trial comparing two models of maternity care. SETTING:
a tertiary referral centre in Alberta, Canada. PARTICIPANTS: one hundred and
ninety four women with a low-risk pregnancy were randomly assigned to either
the midwife care, experimental group (n = 101), or the doctor care, control
group (n = 93). INTERVENTIONS: a pilot midwifery programme was introduced
into a maternity services delivery system that did not have established
midwifery. MEASUREMENTS: women's satisfaction was measured, at two weeks
postpartum, with the Labour and Delivery Satisfaction Index (LADSI), general
attitudes toward the birth experience, also at two weeks postpartum; with
the Attitudes about Labour and Delivery Experience (ADLE) questionnaire.
Fluctuations in satisfaction were measured with a Six Simple Questions (SSQ)
questionnaire at 36 weeks gestation and 48 hours, two and six weeks
postpartum. FINDINGS: women in the midwife group reported significantly
greater satisfaction and a more positive attitude toward their childbirth
experience than women in the doctor group (p 0.001). The SSQ demonstrated
scores similar to the LADSI. Satisfaction in both groups was lowest at 36
weeks gestation and highest immediately postpartum. KEY CONCLUSIONS: women
experiencing low-risk pregnancies were more satisfied with care by midwives
than with care provided by doctors. Satisfaction scores were high for both
groups and may have been lower for women in the doctor group as a result of
disappointment with caregiver assignment as all women had sought midwifery
care. The SSQ measures similar dimensions to the LADSI but the agreement is
not strong enough to recommend its use as a substitute at this time.
IMPLICATIONS FOR PRACTICE: the significantly higher satisfaction of the
women with the care provided by the midwives together with better clinical
outcomes reported elsewhere suggest that the option of midwifery care should
be accessible as an option for all women in Canada. Further research is
suggested to determine the usefulness of the SSQ. Copyright 2002 Elsevier
Science Ltd.

Cochrane Database Syst Rev. 2001;(4):CD000012. Related Articles, Links


Comment in:
ACP J Club. 2002 Jul-Aug;137(1):29.

Update of:
Cochrane Database Syst Rev. 2000;(2):CD000012.

Home-like versus conventional institutional settings for birth.

Hodnett ED.

Maternal-Child Nursing Research, University of Toronto, 790 Bay Street,
Suite 950, Toronto, Ontario, Canada, M5G 1N8.

BACKGROUND: Many home-like birth centres have been established near
conventional labour wards for the care of pregnant women who prefer and
require little or no medical intervention during labour and birth.
OBJECTIVES: The objective of this review was to assess the effects of care
in a home-like birth environment compared to care in a conventional labour
ward, on labour and birth outcomes. SEARCH STRATEGY: The Cochrane Pregnancy
and Childbirth Group trials register was searched. Date of last search: July
2001. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing a
home-like institutional birth environment to conventional hospital care for
pregnant women at low risk of obstetric complications. DATA COLLECTION AND
ANALYSIS: Trial quality was assessed. MAIN RESULTS: Six trials involving
almost 9000 women were included. Substantial numbers of women allocated to
home-like settings were transferred to standard care before or during
labour. Allocation to a home-like setting was associated with lower rates of
intrapartum analgesia/anaesthesia (odds ratio 0.82, 95% confidence interval
0.72 to 0.93), augmented labour (odds ratio 0.72, 95% confidence interval
0.64, 0.81), and operative delivery (odds ratio 0.85, 95% confidence
interval 0.70, 0.96), as well as greater satisfaction with care. There was a
non-statistically significant trend towards higher perinatal mortality in
the home-like setting (odds ratio 1.49, 95% confidence interval 0.79 to
2.78). REVIEWER'S CONCLUSIONS: There appear to be some benefits from
home-like settings for childbirth, although increased support from
caregivers may be more important. Caregivers and clients in home-like
settings need to watch for signs of complications.

Lancet. 1982 Oct 9;2(8302):808-10. Related Articles, Links


Analgesia and satisfaction in childbirth (the Queen Charlotte's 1000 Mother
Survey).

Morgan BM, Bulpitt CJ, Clifton P, Lewis PJ.

Maternal satisfaction with the experience of childbirth was investigated in
1000 women having a vaginal delivery of a live child. Effective pain relief
did not ensure a satisfactory birth experience. Epidural block produced the
most effective analgesia but there were more dissatisfied women among the
epidural patients than among those who did not receive this analgesia (p
less than 0.05). Bad experience scores were evaluated one year later and
were clearly related to a forceps delivery and long labour, both of which
were more common in the epidural group. The desirability of an "epidural on
demand" service should be tested against an "epidural when necessary"
service.

Cochrane Database Syst Rev. 2003;(3):CD003766. Related Articles, Links


Continuous support for women during childbirth.

Hodnett ED, Gates S, Hofmeyr GJ, Sakala C.

Faculty of Nursing, 50 St George Street, Toronto, Ontario, Canada, M5S 3H4.

BACKGROUND: Historically, women have been attended and supported by other
women during labour. However, in recent decades in hospitals worldwide,
continuous support during labour has become the exception rather than the
routine. Concerns about the consequent dehumanization of women's birth
experiences have led to calls for a return to continuous support by women
for women during labour. OBJECTIVES: Primary: to assess the effects, on
mothers and their babies, of continuous, one-to-one intrapartum support
compared with usual care. Secondary: to determine whether the effects of
continuous support are influenced by: (1) routine practices and policies in
the birth environment that may affect a woman's autonomy, freedom of
movement, and ability to cope with labour; (2) whether the caregiver is a
member of the staff of the institution; and (3) whether the continuous
support begins early or later in labour. SEARCH STRATEGY: We searched the
Cochrane Pregnancy and Childbirth Group trials register (30 January 2003)
and the Cochrane Central Register of Controlled Trials (The Cochrane
Library, Issue 1, 2003). SELECTION CRITERIA: All published and unpublished
randomized controlled trials comparing continuous support during labour with
usual care. DATA COLLECTION AND ANALYSIS: Standard methods of the Cochrane
Collaboration Pregnancy and Childbirth Group were used. All authors
participated in evaluation of methodological quality. Data extraction was
undertaken independently by one author and a research assistant. Additional
information was sought from the trial authors. Results are presented using
relative risk for categorical data and weighted mean difference for
continuous data. MAIN RESULTS: Fifteen trials involving 12,791 women are
included. Primary comparison: Women who had continuous intrapartum support
were less likely to have intrapartum analgesia, operative birth, or to
report dissatisfaction with their childbirth experiences. Subgroup analyses:
In general, continuous intrapartum support was associated with greater
benefits when the provider was not a member of the hospital staff, when it
began early in labour, and in settings in which epidural analgesia was not
routinely available. REVIEWER'S CONCLUSIONS: All women should have support
throughout labour and birth.
--
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(Julian [6], Aurora [4], and Vernon's [18mo] mom)
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