The PhD Abstracts below were published in MSo Volumes 6, 7 & 8.

Care closer to home

What does it offer?
Dr Charlotte Overgaard, Aalborg University/King’s College, London

This thesis represents an empirical study of safety and quality of maternity care in freestanding midwifery units in Denmark. It is publication-based and consists of a thesis overview and three peer-reviewed publications. A multidisciplinary and mixed-methods approach is applied and the work is informed by sociological theories of childbirth, medicine, midwifery and health.

At the same time as it is both a biological and a cultural phenomenon, childbirth is a significant personal life event shaped by the historical, social and political context in which it takes place. In most high- and middle-income countries, obstetric units (OU) have become the primary setting for birth, also for low risk women. 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-technological, individualised, and patient-centred care.

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 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 and birth complications and interventions correlates with women’s level of social disadvantage
• To investigate the influence of social disadvantage on women’s birth experience and care perceptions

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 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 and their 218 matched controls were invited to participate in a questionnaire survey one month after birth.

No significant differences in perinatal morbidity were observed between groups. Significantly fewer birth complications and birth interventions, including caesarean section, instrumental delivery, and epidural analgesia occurred among women in the FMU group.

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 patient-centred care elements such as support, participation in decision-making, information, and women’s feeling of being listened to.

The FMUs’ location in community hospitals in 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 on clinical birth outcomes. In all cases, socially disadvantaged women in the FMU group had comparable and, in some respects, favourable clinical outcomes when compared to OU women with the same level of disadvantage.

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. 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. Policy makers may consider increasing the availability of FMU care and information about different care models in order to support women in making an informed decision about their preferred place of birth.

Overgaard C, Møller AM, Fenger-Grøn M, Knudsen LB, Sandall J. Freestanding midwifery unit versus obstetric unit: a matched cohort study of outcomes in low-risk women. BMJ Open 2011;2:e000262.doi:10.1136/bmjopen-2011-000262
Overgaard C, Fenger-Grøn M, Sandall J. Freestanding midwifery units versus obstetric units: does the effect of place of birth differ with level of social disadvantage?  BMC Public Health 2012, 12:478 doi:10.1186/1471-2458-12-478
Overgaard C, Fenger-Grøn M, Sandall J. The impact of birthplace on women’s birth experiences and perceptions of care. Social Science & Medicine 2012; 74: 973

Dr Charlotte Overgaard, Aalborg University, DK / King’s College, London UK

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Abstracts are published here as provided by the author and in the order in which we receive them.