Midwives in Ontario, Canada, provide care to low-risk women in a model of continuity or case-based care whereby a woman is attended by the same small group of midwives throughout pregnancy, birth, and the postpartum period. Women who meet selective criteria have the choice of a hospital birth or a planned home birth.Midwives are expected to attend both home and hospital births to the extent that maintenance of registration with the regulatory college depends on a record of providing care in both settings.Midwives are well integrated into the Ontario health care system; they have admission and discharge

SummaryBackground and objectives Pregnant women with chronic kidney disease (CKD) are at risk of adverse maternal and fetal outcomes. We conducted a systematic review of observational studies that described this risk.Design, setting, participants, & measurements We searched several databases from their date of inception through June 2010 for eligible articles published in any language. We included any study that reported maternal or fetal outcomes in at least five pregnant women in each group with or without CKD. We excluded pregnant women with a history of transplantation or maintenance dialysis. ResultsWe identified 13 studies. Adverse maternal events including gestational hypertension, pre-eclampsia, eclampsia, and maternal mortality were reported in 12 studies. There were 312 adverse maternal events among 2682 pregnancies in women with CKD (weighted average of 11.5%) compared with 500 events in 26,149 pregnancies in normal healthy women (weighted average of 2%). One or more adverse fetal outcomes such as premature births, intrauterine growth restriction, small for gestational age, neonatal mortality, stillbirths, and low birth weight were reported in nine of the included studies. Overall, the risk of developing an adverse fetal outcome was at least two times higher among women with CKD compared with those without.Conclusions This review summarizes current available evidence to guide physicians in their decision-making, advice, and care for pregnant women with CKD. Additional studies are needed to better characterize the risks.

BackgroundMore 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.MethodsIn 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).FindingsWe 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).InterpretationThe risk of perinatal or neonatal mortality was not different when birth was intended at home or in hospital.FundingPartial funding: Association of Ontario Midwives open peer reviewed grant.Research in ContextEvidence 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...

Background:Previous studies have shown that planned home birth is associated with a decreased likelihood of intrapartum intervention with no difference in neonatal outcomes compared with planned hospital birth. The purpose of our study was to evaluate different birth settings by comparing neonatal mortality, morbidity and rates of birth interventions between planned home and planned hospital births in Ontario, Canada. Methods:We used a provincial database of all midwifery-booked pregnancies between 2006 and 2009 to compare women who planned home birth at the onset of labour to a matched cohort of women with low-risk pregnancies who had planned hospital births attended by midwives. We conducted subgroup analyses by parity. Our primary outcome was stillbirth, neonatal death (< 28 d) or serious morbidity (Apgar score < 4 at 5 min or resuscitation with positive pressure ventilation and cardiac compressions). Results:We compared 11 493 planned home births and 11 493 planned hospital births. The risk of our primary outcome did not differ significantly by planned place of birth (relative risk [RR] 1.03, 95% confidence interval [CI] 0.68-1.55). These findings held true for both nulliparous (RR 1.04, 95% CI 0.62-1.73) and multiparous women (RR 1.00, 95% CI 0.49-2.05). All intrapartum interventions were lower among planned home births. Interpretation:Compared with planned hospital birth, planned home birth attended by midwives in a jurisdiction where home birth is well-integrated into the health care system was not associated with a difference in serious adverse neonatal outcomes but was associated with fewer intrapartum interventions.

Background Up to one-third of labouring women will experience painful 'back labour'. Sterile water injected lateral to the lumbosacral spine is a simple and well-researched approach to this pain.Objective To determine if sterile water injection for low back pain compared to placebo or alternative therapy increased or decreased the rate of Caesarean section.Search strategy We performed a literature search with no language restriction in four databases: the Cochrane library, EMBASE (1980), Ovid Medline (1950) and CINAHL (1982).Selection criteria We included all randomised controlled trials (RCTs) of sterile water injection for labour pain that included outcomes of interest and original data.Data collection and analysis We compared Caesarean section rates among women who received sterile water injection in labour with those who received either placebo treatment or another nonpharmacological treatment modality. Other outcomes included pain scores, use of regional analgesia and women's assessment of treatment. We used Revman 5 for the meta-analysis. Data were entered by one reviewer and independently cross-checked. Pooled outcomes were reported as Relative Risk (RR) or Weighted Mean Difference using Mantel-Haenszel fixed-effects model except when the I 2 value >50% indicated significant heterogeneity in which case random-effects model was used.Main results We included eight RCTs. The Caesarean section rate was 4.6% in the sterile water injection group and 9.9% in the comparison group (n = 828) (RR 0.51, 95% CI: 0.30, 0.87).Conclusion We believe that a large RCT should be mounted to validate our findings regarding the impact of sterile water injections on mode of delivery.