Intrapartum and neonatal mortality in low-risk term women in midwife-led care and obstetrician-led care at the onset of labor: A national matched cohort study.

INTRODUCTION: Midwife-led models of care have been the subject of debate for many years. We conducted a study to compare intrapartum and neonatal mortality rates in midwife-led (primary) vs obstetrician-led (secondary) care at the onset of labor in low-risk term women. MATERIAL AND METHODS: We performed an unmatched and a propensity score matched cohort study using data from the national perinatal audit registry (PAN) and from the national perinatal registry (PERINED) of the Netherlands. We included women with singleton pregnancies (without congenital anomalies or antepartum fetal death) who gave birth at term between 2010 and 2012. We excluded the following major risk factors: non-vertex position of the fetus, previous cesarean birth, hypertension, diabetes mellitus, prolonged rupture of membranes (≥24 hours), vaginal bleeding in the second half of pregnancy, nonspontaneous start of labor and post-term pregnancy (≥42 weeks). The primary outcome was intrapartum or neonatal mortality up to 28 days after birth. Secondary outcome measures were mode of delivery and a 5-minute Apgar score <7. RESULTS: We included 259 211 women. There were 100/206 642 (0.48‰) intrapartum and neonatal deaths in the midwife group and 23/52 569 (0.44‰) in the obstetrician group (odds ratio [OR] 1.11, 95% CI 0.70-1.74). Propensity score matched analysis showed mortality rates of 0.49‰ (26/52 569) among women in midwife-led care and 0.44‰ (23/52 569) for women in obstetrician-led care (OR 1.13, 95% CI 0.65-1.98). In the midwife group there were significantly lower rates of vaginal instrumental deliveries (8.4% vs 13.0%; matched OR 0.65, 95% CI 0.62-0.67) and intrapartum cesarean sections (2.6% vs 8.2%; matched OR 0.32, 95% CI 0.30-0.34), and fewer neonates with low Apgar scores (<7 after 5 minutes) (0.69% vs 1.11%; matched OR 0.61, 95% CI 0.53-0.69). CONCLUSIONS: Among low-risk term women, there were comparable intrapartum and neonatal mortality rates for women starting labor in midwife-led vs obstetrician-led care, with lower intervention rates and fewer low Apgar scores in the midwife group.

Intrapartum and neonatal mortality among low-risk women in midwife-led versus obstetrician-led care in the Amsterdam region of the Netherlands: a propensity score matched study.

OBJECTIVE: To compare intrapartum and neonatal mortality in low-risk term women starting labour in midwife-led versus obstetrician-led care. STUDY DESIGN: We performed a propensity score matched study using data from our national perinatal register, completed with data from medical files. We studied women without major risk factors with singleton pregnancies who gave birth at term between 2005 and 2008 in the Amsterdam region of the Netherlands. Major risk factors comprised non-vertex position of the fetus, previous Caesarean birth, hypertension, (gestational) diabetes mellitus, post-term pregnancy (≥42 weeks), prolonged rupture of membranes (>24 hours), vaginal bleeding in the second half of pregnancy or induced labour. Groups were devided by midwife-led versus obstetrician-led care at the onset of labour. The primary outcome was intrapartum and neonatal (<28 days) mortality. Secondary outcomes included obstetric interventions, 5 min Apgar scores<7 and neonatal intensive care admittance for >24 hours. RESULTS: We studied 57 396 women. Perinatal mortality occurred in 30 of 46 764 (0.64‰) women in midwife-led care and in 2 of 10 632 (0.19‰) women in obstetrician-led care (OR 3.4, 95% CI 0.82 to 14.3). A propensity score matched analysis in a 1:1 ratio with 10 632 women per group revealed an OR for perinatal mortality of 4.0 (95% CI 0.85 to 18.9). CONCLUSION: Among low-risk women, midwife-led care at the onset of labour was associated with a statistically non-significant higher mortality rate.

The validity of the variable "NICU admission" as an outcome measure for neonatal morbidity: a retrospective study.

OBJECTIVE: To determine whether "neonatal intensive care unit (NICU) admission" is a valid surrogate outcome measure to assess neonatal condition in clinical studies. DESIGN: Retrospective study. SETTING: Tertiary hospital in the Netherlands. POPULATION: Neonates admitted to NICU during a 10-year period. Inclusion was restricted to singletons born beyond 37 weeks of gestation, and admitted to NICU in the first 24 h for delivery-related morbidity. METHODS: Patient characteristics and admission data were compared for four groups based on the line of care during delivery, i.e. home birth (Ia), midwife-led hospital delivery (Ib), secondary care (II), tertiary care (III). MAIN OUTCOME MEASURES: Percentage of neonates/infants that died during NICU admission, diagnosis on admission, treatment received and a Neonatal Therapeutic Intervention Score System (NTISS). RESULTS: We studied 776 newborns (Ia 52, Ib 25, II 160, III 512, 27 unknown). The mortality rate differed significantly (Ia 15%, Ib 12%, II 22%, III 1%, p < 0.01), as did the NTISS morbidity scores at admission [Ia 12.0 (6.0-23.0), Ib 8.5 (6.3-10.0), II 21.0 (15.0-30.0), III 6.0 (4.0-9.0); p < 0.01], diagnosis at admission, received treatment and the duration of admission. CONCLUSIONS: The severity of neonatal illness after 37 weeks of gestation differed depending on the line of care in which they were born, with neonates born in secondary care consistently having the highest morbidity, and those born in tertiary care having the lowest. NICU admission should not be used as an outcome measure for neonatal morbidity, specifically not when comparing different birth settings.

[Insufficient evidence supporting iron supplementation in anaemia during pregnancy]. / Onvoldoende bewijs voor ijzersuppletie bij anemische zwangeren.

The Royal Dutch Organization of Midwives (KNOV) recently presented their practice guideline 'Anaemia in midwifery practice'. The guideline identified available evidence on diagnosis, prognosis and treatment of anaemia in pregnancy. Anaemia based on iron deficiency and subsequent treatment with iron supplementation are probably the most frequent aspects of care for pregnant women. However, there is surprisingly enough no evidence of the efficacy of iron supplementation treatment on relevant clinical outcomes in pregnant women with anaemia. We plead to make the next guideline a multidisciplinary one. Such a guideline may lead to a large pragmatic trial evaluating the efficacy of iron supplementation treatment for patients with anaemia.

[Practice guideline 'Perinatal management of extremely preterm delivery']. / Richtlijn 'Perinataal beleid bij extreme vroeggeboorte'.

At the request of the State Secretary of the Dutch Ministry of Health, Welfare and Sport a national multidisciplinary workgroup developed an evidence-based practice guideline for the management of pregnant women with an imminent preterm delivery after a pregnancy of less than 26 weeks duration and for extremely preterm neonates. Active care measures are advised for neonates from a gestational age of 24 0/7 weeks onwards, unless there are serious arguments that justify a conservative management. In cases of imminent preterm delivery, intrauterine transport to a perinatological care centre is advised from a gestational age of 23 4/7 weeks onwards. In cases of imminent preterm delivery, glucocorticoids to enhance fetal lung maturity should be administered from a gestational age of 23 5/7 weeks onwards. From a gestational age of 24 0/7 weeks onwards a caesarean section may be considered if the fetal condition during spontaneous labour justifies this.

Medical abortion practices: a survey of National Abortion Federation members in the United States.

BACKGROUND: Little is known about clinical implementation of medical abortion in the United States following approval of mifepristone as an abortifacient by the Food and Drug Administration (FDA) in 2000. We collected information regarding medical abortion practices of National Abortion Federation (NAF) members for the year 2001. METHODS: Questionnaires were mailed to 337 active US NAF member facilities. RESULTS: A total of 258 facilities responded (77%); 252 nonhospital facilities were included in the analysis. Most of these facilities (87%) offered medical abortion in 2001, providing an estimated 28,400 medical abortions, approximately 52% of medical abortions in the US that year. Over 75% began offering mifepristone/misoprostol abortions within 5 months of the start of mifepristone distribution. Almost all (99%) reported using mifepristone/misoprostol regimens, with most offering one or more evidence-based alternative regimens (83%); a few (4%) used the FDA-approved regimen. CONCLUSION: After FDA approval of mifepristone, NAF member facilities rapidly adopted evidence-based mifepristone/misoprostol regimens.