Essential reading

AIMS Journal 2006, Vol 18, no 3

AIMS asks Denis Walsh what papers he considers are essential reading for people who want to be informed about free-standing birth centres.He suggests the following:

• Outcomes of Free-Standing, Midwifery-Led Birth Centres.
• Report of a structured review of birth centre outcomes.
• Maternity Services at Wyre Forest Birth Centre: Report of an independent inquiry under Section 2 of the NHS Act of 1977.
• Marginalised women's comparisons of their hospital and freestanding birth centre experience: a contract of inner city birthing centres.
• Subverting assembly-line birth: Childbirth in a free-standing birth centre.

Outcomes of Free-Standing, Midwifery-Led Birth Centres.

"First systematic review of quantitative outcomes for free-standing birth centres spanning last 30 years."

Abstract: Background: Over the last two decades, childbirth worldwide has been increasingly concentrated in large centralized hospitals, with a parallel trend toward more birth interventions. At the same time in several countries, interest in midwife-led care and free-standing birth centers has steadily increased. The objective of this review is to establish the current evidence base for freestanding, midwife-led birth centers.

Methods: A structured review, based on Cochrane guidelines, was conducted that included nonrandomized studies. The comparative outcomes measured were rates of normal vaginal birth; cesarean section; intact perineum; episiotomy; transfers; and babies remaining with their mothers.

Results: Of the 5 controlled studies that met the review criteria, all except one was a single site study. Since no study was randomized, meta-analysis was not performed. The included studies all raised quality concerns, and significant heterogeneity was observed among them. For the outcomes measured, every study reported a benefit for women intending to give birth in the free-standing, midwife-led unit.

Conclusions: The benefits shown for women recruited into the included studies who intended to give birth in a free-standing, midwife-led unit suggest a question about the efficacy of consultant unit care for low-risk women. However, the findings cannot be generalized beyond the individual studies. Good quality controlled studies are needed to investigate these issues in the future.

Reference

• Walsh, D. & Downe, S. (2004), Birth, 31(3), pp. 222-229.

Report of a structured review of birth centre outcomes.

"Review commissioned by the Department of Health of free-standing birth centres. Makes more tentative conclusions than Walsh & Downe's review and calls for randomised controlled trials."

No abstract is available, but review recommendations included developing and implementing:

• A standard baseline definition of the term 'birth centre'
• Evaluation of factors which influence women to make personally appropriate decisions about location of care for birth
• A large scale pragmatic randomised controlled trial
• Standardised evidence-based criteria in terms of likely benefits and harms
• An international data-sharing network
• Valid and reliable methods for evaluating data on psychosocial outcomes
• Research to estimate the cost and resource use attributable to birth centre care
• A standardised system of data collection.

Reference

• Stewart, M., McCandlish, R. & Henderson, J. (2004) National Perinatal Epidemiology Unit (Available at: www.npeu.ox.ac.uk/birthcentrereview/

Maternity Services at Wyre Forest Birth Centre: Report of an independent inquiry under Section 2 of the NHS Act of 1977.

"Important report following neonatal deaths in a free-standing birth centre in the UK, not because of negative publicity but because a number of good practice principles are laid out that would serve birth centres well, particularly around clinical governance."

This report explored why six full-term, newly born babies died unexpectedly in less than 3 years in a free-standing birth centre. (Only one had a significant congenital problem.) No abstract is available, but the enquiry found:

• The structures and processes to ensure the quality and safety of clinical care were largely in place but not functioning effectively.
• A lack of data with which to make meaningful statistical comparisons with other units
• Limited evidence of positive engagement and real involvement with women
• While the staff were experienced, caring and committed, and the unit was adequately staffed, there were problems with training, relationships with the rest of the Trust and attitude to change
• The birth centre was isolated managerially and lacked leadership from the Trust
• The Primary Care Trust made little use of its role as commissioner for maternity services.

Reference

• Garland, P., Cunningham, S., Mander,A., Sweeney, J. (2004) West Midlands South Strategic Health Authority.
  (Available at: www.wmssha.nhs.uk/Corporate/Papers_and_Publications/Maternity_Report.pdf. Accessed: 30 November, 2006)

Marginalised women's comparisons of their hospital and freestanding birth centre experience: a contract of inner city birthing centres.

"One of two ethnographies of birth centres in the USA, and an important contribution regarding marginalised groups' experience of birth centre care."

Abstract: The process of birth provides a structure around which social and cultural forces guide its expression. These social and cultural forces reflect the organization of power in a society while creating the potential for diversity in birth beliefs, practices, and experiences. In this article, marginalized women contrast their experiences in the cultures of two divergent birth systems: the technocratic hospital system and a freestanding midwifery managed birth center system. The women in this study come from many different cultures, yet they share a common desire to (a) control the birth environment, (b) establish supportive interpersonal connections with providers, (c) have a safe birth, and (d) be treated with dignity and respect. However, the descriptions in this article illustrate the gender, race, and class power inequities experienced when technocratic cultural forces conflicted with oppressed women's basic needs for respect and control.

Reference

• Esposito, N. W. (1999), Health Care for Women International, 20 (2), pp. 111-26.

Subverting assembly-line birth: Childbirth in a free-standing birth centre.

"First published paper of first UK ethnography of a free-standing birth centre, and gives important insights into the organisational processes."

Abstract: Across the world, concern is being expressed about the rising rates of birth interventions. As a result, there is growing interest in alternative organisational models of maternity care. Most of the research to date on these models has examined clinical outcomes. This paper, discussing key findings from an ethnographic study of a free-standing birth centre in the UK, explores organisational dimensions to care. It suggests that the advantages of scale have been under recognised by policy makers to date. The birth centre displays organisational characteristics that contrast with the dominant Fordist/Taylorist model of large maternity units. These characteristics allow for greater temporal flexibility in labour care and tend to privilege relational, 'being' care over task-orientated, 'doing' care. In addition, features of a bureaucracy are much less in evidence, enabling entrepreneurial activity to flourish. There may be lessons here for other heath services as well as maternity services in optimising the advantages of small-scale provision.

Reference

• Walsh, D. (2006) , Social Science & Medicine, 62(6), pp.1330-1340.

'Nesting' and 'Matrescence': Distinctive Features of a Free-Standing Birth Centre'

"Second published paper of first UK ethnography of a free-standing birth centre. Insights into ethos and philosophy of care."

Abstract: Objective: to explore the culture, beliefs, values, customs and practices around the birth process within a free-standing birth centre. Design: ethnography.

Setting: a birth centre situated in the English midlands. Participants: women attending the centre, midwives and maternity-care assistants working at the centre. Findings: women in the study seemed to invoke intuitive nesting-related behaviours in their assessment of the suitability of the birth centre. In addition, the birth centre staff's focus on creating the right ambience for birth may also emanate from nesting concerns. Birth centre staff assisted women through the 'becoming mother' transition, which is conceptualised as 'matrescent' care.

Key conclusions: the birth centre environment elicited nesting-like behaviours from both women and staff. This formed part of a nurturing orientation that was conceptualised as 'matrescent' (becoming mother) care. 'Matrescence' does not seem to be grounded in clinical skills but is relationally mediated.

Implications for practice: nesting-like behaviours and 'matrescent' care in this context challenge maternity services to review traditional conceptualisations of safety and traditional expressions of clinical intrapartum care. Denis Walsh is an independent midwifery consultant and senior lecturer in research at the University of Central Lancashire.

Reference

• Walsh, D. (2006) , Midwifery 22, pp. 228-239. (Freely available online at www.quellenaissancedemain.info/images/stories/mdn/uk.pdf)