Care closer to home - what does it offer? A study of safety and quality of maternity care in freestanding midwifery units

ABSTRACT
Background
Childbirth and maternity care services are important issues to society because the clinical and psycho-social outcomes of birth have immediate as well as long-term consequences for the health and well-being of infants, women and families. Our understandings of what is good and right in childbirth and maternity care services are however based on cultural beliefs and they bear the
imprint of wider social structures and debates.

The last few decades have seen maternity care services become more centralised and specialised. In most high- and middle-income countries, obstetric units (OU) have become the primary setting for birth, regardless of the woman’s risk of obstetric complications. This model of care is dominated by a medical and technological perspective that has led some to question the ability of OUs to meet the needs of all birthing women. While OUs have given increased attention to women’s autonomy and the “humanisation” of care, midwifery units have emerged as an alternative to OU care for low risk women, offering low-technology, individualised, and patient-centred care, typically closer to home
for many women.

Aims
The aims of this study were:
 To compare perinatal and maternal morbidity, birth complications, interventions, use of pain relief as well as women’s birth experiences, care satisfaction and perceptions of care in two freestanding midwifery units (FMU) and two obstetric units (OU) in northern Denmark, all pursuing an ideal of high-quality, humanistic and patient-centred care
 To investigate whether the effect of birthplace on perinatal and maternal morbidity, birth complication, birth intervention, and the relief of pain varies correlates with women’s level of social disadvantage
 To investigate the influence of social disadvantage on women’s birth experience and care perceptions

Design
Overall, the study was designed as a cohort study with a matched control group. A postal questionnaire survey was undertaken as part of this study.

The study included 839 low-risk women intending FMU birth in the period between March 2004 and October 2008. The women were prospectively and individually matched on nine selected obstetric/socio-economic factors to 839 low-risk women intending OU birth. A sub-group of 218 FMU women, admitted between January and October 2006, and their 218 matched controls, were invited
to participate in a questionnaire survey.

Educational level was chosen as the primary proxy for social position. Analysis was by intention-to-treat.

Results
No significant differences in perinatal morbidity were observed between groups (Apgar scores <7/5,<9/5 and <7/1, admittance to neonatal unit, asphyxia, and readmission). Although rare, adverse outcomes occurred in both groups. FMU births were significantly less likely to involve abnormal fetal heart rate, fetal-pelvic complications, shoulder dystocia, occipital-posterior presentation, and
postpartum haemorrhage >500ml compared to OU births. Significantly fewer FMU women had caesarean section, instrumental delivery, oxytocin augmentation and epidural analgesia. Transfer during birth or <2 hours after birth occurred in 14.8 % of all FMU births, more frequently in primiparas
than in multiparas (36.7 % versus 7.2 %).
Of the 436 women invited to participate in the survey, 375 women (86 %) responded. Birth experience and satisfaction with care were rated significantly more positively by FMU than by OU women.
Significantly better results for FMU care were also found for specific patient-centred care elements (support, participation in decision-making, attentiveness to psychological needs and to wishes for birth, information, and for women’s feeling of being listened to).
The FMUs’ location in community hospitals in the centre towns of predominantly rural areas offered women a choice of low-technology patient-centred care relatively close to home, an offer which was accepted by women from a far wider range of social backgrounds than seen in most studies of out-of-OU birth.

Subgroup analysis revealed a significant, negative effect of low education and employment levels on birth experience. This effect was found only for the OU group; showing the potential of FMU care to mitigate the effects of social disadvantage on women’s birth experience.

A similar effect of FMU care was not found where clinical birth outcomes were concerned. In all cases, FMU women without post-secondary education had comparable and, in some respects,favourable outcomes when compared to OU women with the same level of education while advantaged and disadvantaged women were found to benefit equally well from FMU care. In this restricted sample of low-risk women receiving one of two different models of midwifery-led care in a public health care system, the effect of birthplace on birth outcomes did not vary with women’s level of education.

Conclusion
Overall, this study provides strong support for FMU care, even in settings where all frontline care in OUs is provided by midwives and where the humanistic paradigm of childbirth and patient-centred care is prevalent, as was the case in the North Denmark Region. FMU care appears to offer important benefits for birthing women in terms of improved birth experience and reduced maternal morbidity with no additional risk to the infant; elements of FMU care are thus deemed useful in the development of OU care for low-risk women.
In a public health perspective, FMU care holds great potential for the improvement of maternal health and well-being in populations of low-risk women. It is therefore suggested that FMU care is made available to low-risk women regardless of their social position and parity, and that all women
are provided adequate information about different care models, including their benefits and harms, in order to support them in making an informed decision about their preferred place of birth.