Severe Adverse Maternal Outcomes among Women in Midwife-Led versus Obstetrician-Led Care at the Onset of Labour in the Netherlands: A Nationwide Cohort Study

Abstract

ObjectiveTo test the hypothesis that it is possible to select a group of low risk women who can start labour in midwife-led care without having increased rates of severe adverse maternal outcomes compared to women who start labour in secondary care.Design and MethodsWe conducted a nationwide cohort study in the Netherlands, using data from 223 739 women with a singleton pregnancy between 37 and 42 weeks gestation without a previous caesarean section, with spontaneous onset of labour and a child in cephalic presentation. Information on all cases of severe acute maternal morbidity collected by the national study into ethnic determinants of maternal morbidity in the Netherlands (LEMMoN study), 1 August 2004 to 1 August 2006, was merged with data from the Netherlands Perinatal Registry of all births occurring during the same period.Our primary outcome was severe acute maternal morbidity (SAMM, i.e. admission to an intensive care unit, uterine rupture, eclampsia or severe HELLP, major obstetric haemorrhage, and other serious events). Secondary outcomes were postpartum haemorrhage and manual removal of placenta.ResultsNulliparous and parous women who started labour in midwife-led care had lower rates of SAMM, postpartum haemorrhage and manual removal of placenta compared to women who started labour in secondary care. For SAMM the adjusted odds ratio’s and 95% confidence intervals were for nulliparous women: 0.57 (0.45 to 0.71) and for parous women 0.47 (0.36 to 0.62).ConclusionsOur results suggest that it is possible to identify a group of women at low risk of obstetric complications who may benefit from midwife-led care. Women can be reassured that we found no evidence that midwife-led care at the onset of labour is unsafe for women in a maternity care system with a well developed risk selection and referral system.

The “Cocoon,” first alongside midwifery‐led unit within a Belgian hospital: Comparison of the maternal and neonatal outcomes with the standard obstetric unit over 2 years

“…9,10 Studies in several countries have shown that midwifery-led care and alternative birth places are associated with better maternal outcomes. 2,5,[11][12][13] Other studies have emphasized the importance of the proximity of a hospital in case of need. 14,15 Midwifery-led birth centers within hospitals have been created, allowing for quick emergency interventions, thanks to the immediate availability of doctors and operating theaters.…”

Effect of planned place of birth on obstetric interventions and maternal outcomes among low-risk women: a cohort study in the Netherlands

“…Midwife-led birth settings have been associated with a lower rate of severe adverse maternal morbidity [11]. Additionally, international studies showed a significantly lower risk of episiotomy [12, 13], pharmacological pain management [12–15], assisted vaginal birth [12, 13], caesarean section [12, 13], and augmentation of labour [12–15] in birth settings other than obstetric units, although in one study no difference in rate of instrumental births was found [15].…”

“…However, a recent Dutch study among 743.070 low risk women showed similar rates of perinatal morbidity and mortality among planned home and planned midwife-led hospital births [17]. Another study showed no increased rates of severe maternal morbidity among planned home births [11]. Less is known about differences in interventions and other maternal outcomes.…”

Pitfalls in the use of register‐based data for comparing adverse maternal and perinatal outcomes in different birth settings

“…However, not all indications for referral are registered in Perined. For example, in a study into severe acute maternal morbidity, 27% of women with a previous caesarean section had no record of this risk factor in Perined . Again, this can lead to problems in the definition of the numerator and denominator .…”

“…If risk levels in study groups are not equal, a comparison of outcomes provides little information on a possible difference in quality of care if confounding cannot be adequately controlled for. For example, lower rates of severe acute maternal morbidity have been found among women who start labour in midwife‐led versus in obstetrician‐led care (group a versus b) . To a large extent, this is most probably attributable to the fact that women in midwife‐led care have fewer obstetric risk factors, rather than due to the care women receive in either setting.…”