Midwife-led maternity care in Ireland – a retrospective cohort study

Abstract Background Midwife-led maternity care is shown to be safe for women with low-risk during pregnancy. In Ireland, two midwife-led units (MLUs) were introduced in 2004 when a randomised controlled trial (the MidU study) was performed to compare MLU care with consultant-led care (CLU). Following study completion the two MLUs have remained as a maternity care option in Ireland. The aim of this study was to evaluate maternal and neonatal outcomes and transfer rates during six years in the larger of the MLU sites. Methods MLU data for the six years 2008–2013 were retrospectively analysed, following ethical approval. Rates of transfer, reasons for transfer, mode of birth, and maternal and fetal outcomes were assessed. Linear-by-Linear Association trend analysis was used for categorical data to evaluate trends over the years and one-way ANOVA was used when comparing continuous variables. Results During the study period, 3,884 women were registered at the MLU. The antenatal transfer rate was 37.4% and 2,410 women came to labour in the MLU. Throughout labour and birth, 567 women (14.6%) transferred to the CLU, of which 23 were transferred after birth due to need for suturing or postpartum hemorrhage. The most common reasons for intrapartum transfer were meconium stained liquor/abnormal fetal heart rate (30.3%), delayed labour progress in first or second stage (24.9%) and woman’s wish for epidural analgesia (15.1%). Of the 1,903 babies born in the MLU, 1,878 (98.7%) were spontaneous vaginal births and 25 (1.3%) were instrumental (ventouse/forceps). Only 25 babies (1.3%) were admitted to neonatal intensive care unit. All spontaneous vaginal births from the MLU registered population, occurring in the study period in both the MLU and CLU settings (n = 2,785), were compared. In the MLU more often 1–2 midwives (90.9% vs 69.7%) cared for the women during birth, more women had three vaginal examinations or fewer (93.6% vs 79.9%) and gave birth in an upright position (standing, squatting or kneeling) (52.0% vs 9.4%), fewer women had an amniotomy (5.9% vs 25.9%) or episiotomy (3.4% vs 9.7%) and more women had a physiological management of third stage of labour (50.9% vs 4.6%). Conclusions Midwife-led care is a safe option that could be offered to a large proportion of healthy pregnant women. With strict transfer criteria there are very few complications during labour and birth. Maternity units without the option of MLU care should consider its introduction

Irish and New Zealand Midwives\u27 expertise at preserving the perineum intact (the MEPPI study): perspectives on preparations for birth

Objectives: perineal trauma during birth can result in short or long term morbidity for women. Internationally, rates of episiotomy and severe perineal tears vary considerably. In New Zealand, in 2011, and in a trial of midwife-led care in Ireland, episiotomy rates were found to be considerably lower than those in many other countries. A qualitative exploratory study was undertaken to ascertain how midwives achieve these low rates, in these countries and settings. Design and participants: a qualitative exploratory study was conducted. Midwives expert in preserving the perineum intact (PPI) from two maternity units in the Republic of Ireland and from varied birth settings in New Zealand, were eligible to participate. Twenty-one consenting midwives took part, seven from Ireland and 14 from New Zealand. Methods: university ethical approval was granted. Face-to-face, semi-structured interviews were used to collect the data. Interviews were recorded and transcribed verbatim. The data were analysed using Ethnograph software and were organised into prominent themes. Findings: four themes were identified; ?Sources of knowledge for PPI?, ?Associated factors?, ?Decision-making on episiotomy?, and ?Preparations for PPI?. Participants drew heavily on multiple sources of knowledge in building their own expertise for PPI. Physical characteristics of the perineum featured prominently as factors leading to PPI. Episiotomy was, in the main, only performed when there were signs of fetal distress. Antenatal perineal massage was supported. Conclusion: this study provides valuable insight into the views and skills of midwives, with expertise in PPI at birth, adding to the body of evidence on this topic

Comparison of midwife-led and consultant-led care of healthy women at low risk of childbirth complications in the republic of ireland: a randomised trial

Background: No midwifery-led units existed in Ireland before 2004. The aim of this study was to compare midwife-led (MLU) versus consultant-led (CLU) care for healthy, pregnant women without risk factors for labour and delivery. Methods: An unblinded, pragmatic randomised trial was designed, funded by the Health Service Executive (Dublin North-East). Following ethical approval, all women booking prior to 24 weeks of pregnancy at two maternity hospitals with 1,300-3,200 births annually in Ireland were assessed for trial eligibility. 1,653 consenting women were centrally randomised on a 2: 1 ratio to MLU or CLU care, (1101: 552). 'Intention-to-treat' analysis was used to compare 9 key neonatal and maternal outcomes. Results: No statistically significant difference was found between MLU and CLU in the seven key outcomes: caesarean birth (163 [14.8%] vs 84 [15.2%]; relative risk (RR) 0.97 [95% CI 0.76 to 1.24]), induction (248 [22.5%] vs 138 [25.0%]; RR 0.90 [0.75 to 1.08]), episiotomy (126 [11.4%] vs 68 [12.3%]; RR 0.93 [0.70 to 1.23]), instrumental birth (139 [12.6%] vs 79 [14.3%]; RR 0.88 [0.68 to 1.14]), Apgar scores < 8 (10 [0.9%] vs 9 [1.6%]; RR 0.56 [0.23 to 1.36]), postpartum haemorrhage (144 [13.1%] vs 75 [13.6%]; RR 0.96 [0.74 to 1.25]); breastfeeding initiation (616 [55.9%] vs 317 [57.4%]; RR 0.97 [0.89 to 1.06]). MLU women were significantly less likely to have continuous electronic fetal monitoring (397 [36.1%] vs 313 [56.7%]; RR 0.64 [0.57 to 0.71]), or augmentation of labour (436 [39.6%] vs 314 [56.9%]; RR 0.50 [0.40 to 0.61]). Conclusions: Midwife-led care, as practised in this study, is as safe as consultant-led care and is associated with less intervention during labour and delivery

A general meta‐ecosystem model to predict ecosystem functions at landscape extents

The integration of ecosystem processes over large spatial extents is critical to predicting whether and how local and global changes may impact biodiversity and ecosystem functions. Yet, there remains an important gap in meta‐ecosystem models to predict multiple functions (e.g. carbon sequestration, elemental cycling, trophic efficiency) across ecosystem types (e.g. terrestrial‐aquatic, benthic‐pelagic). We derive a flexible meta‐ecosystem model to predict ecosystem functions at landscape extents by integrating the spatial dimension of natural systems as spatial networks of different habitat types connected by cross‐ecosystem flows of materials and organisms. We partition the physical connectedness of ecosystems from the spatial flow rates of materials and organisms, allowing the representation of all types of connectivity across ecosystem boundaries. Through simulating a forest‐lake‐stream meta‐ecosystem, our model illustrates that even if spatial flows induced significant local losses of nutrients, differences in local ecosystem efficiencies could lead to increased secondary production at regional scale. This emergent result, which we dub the ‘cross‐ecosystem efficiency hypothesis', emphasizes the importance of integrating ecosystem diversity and complementarity in meta‐ecosystem models to generate empirically testable hypotheses for ecosystem functions

A general meta-ecosystem model to predict ecosystem function at landscape extents

The integration of meta-ecosystem processes over large spatial extent is critical to predicting whether and how global changes might impact biodiversity and ecosystem functions. Yet, there remains an important gap in meta-ecosystem models to predict multiple ecosystem functions (e.g., carbon sequestration, elemental cycling, trophic efficiency) across different ecosystem types (e.g., terrestrial-aquatic, benthic-pelagic). We derive a generic meta-ecosystem model to predict ecosystem function at landscape extents by integrating the spatial dimension of natural systems as spatial networks of different habitat types connected by cross-ecosystem flows of materials and organisms. This model partitions the physical connectedness of ecosystems from the spatial flow rates of materials and organisms, allowing the representation of all types of connectivity across ecosystem boundaries as well as the interaction(s) between them. The model predicts that cross-ecosystem flows maximize the realization of multiple functions at landscape extent. Spatial flows, even the ones that significantly reduce the overall amount of nutrients in the meta-ecosystem, can reallocate nutrients to more efficient ecosystems, leading to greater levels of productivity at both local and regional scales. This ‘cross-ecosystem efficiency hypothesis’ is a general and testable hypothesis emphasizing the complementarity and interconnectedness among ecosystems and the importance of addressing ecosystem diversity for meta-ecosystem function