Service configuration, unit characteristics and variation in intervention rates in a national sample of obstetric units in England: an exploratory analysis

Objectives: To explore whether service configuration and obstetric unit (OU) characteristics explain variation in OU intervention rates in "low-risk" women. Design: Ecological study using funnel plots to explore unit-level variations in adjusted intervention rates and simple linear regression, stratified by parity, to investigate possible associations between unit characteristics/configuration and adjusted intervention rates in planned OU births. Characteristics considered: OU size, presence of an alongside midwifery unit (AMU), proportion of births in the National Health Service (NHS) trust planned in midwifery units or at home and midwifery "under" staffing. Setting: 36 OUs in England. Participants: "Low-risk" women with a "term" pregnancy planning vaginal birth in a stratified, random sample of 36 OUs. Main outcome measures: Adjusted rates of intrapartum caesarean section, instrumental delivery and two composite measures capturing birth without intervention ("straightforward"and "normal" birth). Results: Funnel plots showed unexplained variation in adjusted intervention rates. In NHS trusts where proportionately more non-OU births were planned, adjusted intrapartum caesarean section rates in the planned OU births were significantly higher (nulliparous: R2=31.8%, coefficient=0.31, p=0.02; multiparous: R2=43.2%, coefficient=0.23, p=0.01), and for multiparous women, rates of "straightforward" (R2=26.3%, coefficient=-0.22, p=0.01) and "normal" birth (R2=17.5%, coefficient=0.24, p=0.01) were lower. The size of the OU (number of births), midwifery "under" staffing levels (the proportion of shifts where there were more women than midwives) and the presence of an AMU were associated with significant variation in some interventions. Conclusions: Trusts with greater provision of non-OU intrapartum care may have higher intervention rates in planned "low-risk" OU births, but at a trust level this is likely to be more than offset by lower intervention rates in planned non-OU births. Further research using high quality data on unit characteristics and outcomes in a larger sample of OUs and trusts is required

Obstetric interventions in two groups of hospitals in Catalonia: A cross-sectional study

Background: Childbirth assistance in highly technological settings and existing variability in the interventions performed are cause for concern. In recent years, numerous recommendations have been made concerning the importance of the physiological process during birth. In Spain and Catalonia, work has been carried out to implement evidence-based practices for childbirth and to reduce unnecessary interventions. To identify obstetric intervention rates among all births, determine whether there are differences in interventions among full-term single births taking place in different hospitals according to type of funding and volume of births attended to, and to ascertain whether there is an association between caesarean section or instrumental birth rates and type of funding, the volume of births attended to and women's age. Methods: Cross-sectional study, taking the hospital as the unit of analysis, obstetric interventions as dependent variables, and type of funding, volume of births attended to and maternal age as explanatory variables. The analysis was performed in three phases considering all births reported in the MBDS Catalonia 2011 (7,8570 births), full-term single births and births coded as normal. Results: The overall caesarean section rate in Catalonia is 27.55% (CI 27.23 to 27.86). There is a significant difference in caesarean section rates between public and private hospitals in all strata. Both public and private hospitals with a lower volume of births have higher obstetric intervention rates than other hospitals (49.43%, CI 48.04 to 50.81). Conclusions: In hospitals in Catalonia, both the type of funding and volume of births attended to have a significant effect on the incidence of caesarean section, and type of funding is associated with the use of instruments during delivery. © 2014 Escuriet et al.; licensee BioMed Central Ltd

The birthplace study : Turning the tide of childbirth

Copyright 2012 Elsevier B.V., All rights reserved.The publication of the Birthplace Study should herald a major shift in the provision and organization of maternity services, in particular the expansion of births outside obstetric units or at home. The media portrayal of the findings were disappointing as the focus was very much on the homebirth findings in relation to first-time mothers and did not promote the unequivocal evidence that delivery in a midwifery-led unit is safe. The adverse outcomes for low-risk women who choose to give birth in an obstetric unit were glossed over as if of limited significance. Based on the findings of the study, maternity service commissioners and providers need to develop a strategy to ensure low-risk women are given informed choice with respect to place of birth and that recourses are available to support this. This study provides us with a really good opportunity to turn the tide of childbirth.Peer reviewe

Implementing a National Policy Initiative to Support Normal Birth: Lessons From the All Wales Clinical Pathway for Normal Labour

Introduction This article discusses findings from an ethnographic study of a national policy initiative in Wales, United Kingdom. The policy aimed to decrease the caesarean section rate and increase the number of normal births by implementing a clinical pathway for normal labour. The aim of this study was to explore the real life experiences of those involved in the development and use of the policy. Methods A range of qualitative methods was used, including observation, semistructured interviews, focus groups, and documentary analysis. Data were collected from midwives, doctors, midwifery managers, and mothers. Field notes and transcripts were thematically analysed. Results The article discusses aspects of the findings related to the early stages of policy formation and development, including the initial phase of national implementation. It considers the challenges presented by creating national policies, discussing positive and negative aspects of the process. Discussion The key themes discussed are effective consultation and involvement, group processes, “ownership,” reaching consensus, and the need for ongoing support. Issues of relevance to maternity care providers in other cultural locations are discussed and recommendations are made