A retrospective cohort study to evaluate the effect of ‘Place Presenting in Labour’ and ‘Model of Midwifery Care’ on maternal and neonatal outcomes for the low risk women birthing in Counties Manukau District Health Board facilities 2011-2012

摘要

The Place of Birth has been debated for decades by health professionals, consumer groups, the media and the general public, both in New Zealand and internationally. This research uses a retrospective cohort methodology to examine the effect of Place of Birth on five perinatal outcomes; birth method, maternal admission to theatre and high dependency unit, maternal blood loss, neonatal admission to neonatal unit, and finally Apgar scores at 5 minutes. Method: the study took advantage of data that had been collected and stored as part of routine maternity care. After exclusions, the final cohort consisted of 4207 well women with a singleton, cephalic pregnancy who went into spontaneous labour. An accuracy assessment was undertaken to ascertain the accuracy of the database. Binary regression analysis was used to examine an association between Place Presenting in Labour and the five outcomes, controlling for potential confounding variables (age; parity; ethnicity; smoking status; body mass index (BMI); and deprivation). Results: Low risk women presenting in labour to the primary unit are four times less likely to experience an emergency caesarean section (OR 0.25, 95% C.I: 0.157-0.339) almost one and a half times less likely to experience a PPH (OR 0.692, 95% C.I: 0.534 – 0.898) five times less likely to be admitted to high dependency unit/intensive care/theatre (OR 0.201, 95% C.I: 0.102- 0.398) than women presenting in labour to the tertiary hospital. Babies of low risk women presenting in labour to the primary units are three times less likely to have an Apgar below 7 at 5 minutes (OR 0.313, 95% C.I: 0.124 -0.791) and, correspondingly, two times less likely to be admitted to the neonatal intensive care (OR 0.492, 95% C.I: 0.324-0.747) than babies of women presenting in labour to the tertiary hospital. Conclusions: Primary units; Papakura Maternity Unit, Botany Downs Maternity Unit and Pukekohe Maternity Unit offer low risk women a level of protection from operative birth, postpartum haemorrhage, admission to theatre or other tertiary services when compared to the tertiary unit Middlemore Hospital. The primary units offer a level of protection to the babies of low risk women from admission to neonatal intensive care and an Apgar below 7 at 5 minutes. There is a pressing need for a health promotion campaign that will re-educate women about their birth choices and reinvigorate the midwifery profession to promote birth outside of large tertiary institutions. Contemporary, high quality, contextual information promoting the safety of alternative birth settings should be made readily available to women and their families as a matter of priority. The Place of Birth has been debated for decades by health professionals, consumer groups, the media and the general public, both in New Zealand and internationally. This research uses a retrospective cohort methodology to examine the effect of Place of Birth on five perinatal outcomes; birth method, maternal admission to theatre and high dependency unit, maternal blood loss, neonatal admission to neonatal unit, and finally Apgar scores at 5 minutes. Method: the study took advantage of data that had been collected and stored as part of routine maternity care. After exclusions, the final cohort consisted of 4207 well women with a singleton, cephalic pregnancy who went into spontaneous labour. An accuracy assessment was undertaken to ascertain the accuracy of the database. Binary regression analysis was used to examine an association between Place Presenting in Labour and the five outcomes, controlling for potential confounding variables (age, parity, ethnicity, smoking status, body mass index and deprivation). Results: Low risk women presenting in labour to the primary unit are four times less likely to experience an emergency caesarean section (OR 0.25, 95% C.I: 0.157-0.339) almost one and a half times less likely to experience a PPH (OR 0.692, 95% C.I: 0.534 – 0.898) five times less likely to be admitted to high dependency unit/intensive care/theatre (OR 0.201, 95% C.I: 0.102- 0.398) than women presenting in labour to the tertiary hospital. Babies of low risk women presenting in labour to the primary units are three times less likely to have an Apgar below 7 at 5 minutes (OR 0.313, 95% C.I: 0.124 -0.791) and, correspondingly, two times less likely to be admitted to the neonatal intensive care (OR 0.492, 95% C.I: 0.324-0.747) than babies of women presenting in labour to the tertiary hospital. Conclusions: Primary units; Papakura Maternity Unit, Botany Downs Maternity Unit and Pukekohe Maternity Unit offer low risk women a level of protection from operative birth, postpartum haemorrhage, admission to theatre or other tertiary services when compared to the tertiary unit Middlemore Hospital. The primary units offer a level of protection to the babies of low risk women from admission to neonatal intensive care and an Apgar below 7 at 5 minutes. There is a pressing need for a health promotion campaign that will re-educate women about their birth choices and reinvigorate the midwifery profession to promote birth outside of large tertiary institutions. Contemporary, high quality, contextual information promoting the safety of alternative birth settings should be made readily available to women and their families as a matter of priority.