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

Early labor assessment has the potential to reduce the number of women receiving oxytocin for augmentation, the rate of epidural analgesia for pain relief, and the duration of the active and second stages of labor, and to improve women's evaluations of their labor and birth experiences.

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...

Asking diff erent questions: research priorities to improve the quality of care for every woman, every child Unacceptably high rates of adverse outcomes persist for childbearing women and infants, including maternal and newborn mortality, stillbirth, and short-term and long-term morbidity. 1 In light of the challenges to achieve the UN Sustainable Development Goals, it is timely to reconsider priorities for research in maternal and newborn health. Are we asking the right questions? 2 Recent evidence indicates the importance of seeking knowledge beyond the treatment of complications, to inform better ways of providing sustainable, high quality care, including preventing problems before they occur. 3 The 2014 publication of The Lancet's Series on Midwifery presented a unique opportunity to generate future areas of inquiry by drawing on the most extensive examination to date of evidence on the care that all women and newborn infants need across the continuum from pre-pregnancy, birth, post partum, and the early weeks of life. [4][5][6] The Series summarised the evidence base for quality maternal and newborn care in a new framework that focuses on the needs of women, infants, and families and diff erentiates between what care is provided, how it is provided, and Research prioritiesResearch priority score

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 1990À2018. 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.