Cochrane Reviews

Home-like versus conventional institutional settings for birth ED Hodnett

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Abstract     This review should be cited as: Hodnett ED. Home-like versus conventional institutional settings for birth (Cochrane Review). In: The Cochrane Library, Issue 1, 2001. Oxford: Update Software.     A substantive amendment to this systematic review was last made on 28 September 1998. Cochrane reviews are regularly checked and updated if necessary.     Background:  Many home-like birth centres have been established near conventional labour wards for the care of pregnant women who prefer and require little or no medical intervention during labour and birth.     Objectives:  The objective of this review was to assess the effects of care in a home-like birth environment compared to care in a conventional labour ward, on labour and birth outcomes.     Search strategy:  The Cochrane Pregnancy and Childbirth Group trials register was searched. Date of last search: April 2000.     Selection criteria:  Randomised and quasi-randomised trials comparing a home-like institutional birth environment to conventional hospital care for pregnant women at low risk of obstetric complications.     Data collection and analysis:  Trial quality was assessed.     Main results:  Five trials involving almost 8000 women were included. Substantial numbers of women allocated to home-like settings were transferred to standard care before or during labour, making interpretation of results difficult. Allocation to a home-like setting was associated with lower rates of intrapartum analgesia/anaesthesia (odds ratio 0.82, 95% confidence interval 0.72 to 0.93), fetal heart rate abnormalities (0.72, 95% confidence interval 0.63 to 0.81), augmented labour, and immobility during labour, as well as greater satisfaction with care, and increased likelihood of sore nipples and mastitis. There was a non-statistically significant trend towards higher perinatal mortality in the home-like setting (odds ratio 1.49, 95% confidence interval 0.79 to 2.78).     Reviewers' conclusions:  There appear to be some benefits from home-like settings for childbirth, although increased support from caregivers may be more important. Caregivers and clients in home-like settings need to watch for signs of complications.   (The Cochrane Database of Systematic Reviews(ISBN 1 901868 05 2) 1: 00402, 2001)

Quick Access Outline Cover Sheet Background Objectives Criteria for considering studies for this review   ·  Types of studies   ·  Types of participants   ·  Types of intervention   ·  Types of outcome measures Search strategy for identification of studies Methods of the review Description of studies Methodological quality Results Table(s): Discussion Reviewers' conclusions   ·  Implications for practice   ·  Implications for research Acknowledgements Potential conflict of interest   ·  Sources of support Synopsis Keywords Reference(s)

MetaView(s), List of comparisons, Table of excluded studies , Table of included studies

Cover Sheet

Reviewer(s): Hodnett ED
Contribution of Reviewer(s): Information not supplied by reviewer
Issue protocol first published: Information not available
Issue review first published: 1996 Issue 3
Date of most recent amendment: 25 May 2000
Date of most recent substantive amendment: 28 September 1998
Most recent changes: Information not supplied by reviewer
Date new studies sought but none found: Information not supplied by reviewer
Date new studies found but not yet included/excluded: Information not supplied by reviewer
Date new studies found and included/excluded: Information not supplied by reviewer
Date reviewers' conclusions section amended: Information not supplied by reviewer
Contact address: Prof Ellen D Hodnett ; Maternal, Infant and Reproductive Health Research Unit; 790 Bay Street; Suite 715; Toronto; Ontario; CANADA; M5G 1N8; Telephone: +1 416 351 3763; Facsimile: +1 416 351 3771; E-mail: ellen.hodnett@utoronto.ca
Cochrane Library number: CD000012
Editorial group: Cochrane Pregnancy and Childbirth Group
Editorial group code: HM-PREG


Background

Countless birth rooms or birth centres have been built, adjacent to or near conventional labour wards. They are often staffed by midwives, who may or may not be part of the labour ward staff, and are intended for the care of women who are low-risk and both desire and require little or no medical intervention during labour and birth. These home-like birth settings may or may not offer antenatal and postnatal as well as intrapartum care. The two characteristics they all share concern the physical environment (furniture, wall coverings, and lighting) and the policies regarding medical interventions, both of which are intended to mimic a home rather than a hospital environment.
    

Objectives

The primary objective was to evaluate the effects, on labour and birth outcomes, of care in a home-like birth environment compared to care in a conventional labour ward. Secondary objectives were to compare conventional care with care under the following conditions:
a) care in which the home-like birth environment involved care by staff who were not part of the conventional labour ward staff;
b) care in which the home-like birth environment also included antenatal and postnatal care that was different from standard care, eg birth centre staff were involved in antenatal and postnatal care;
c) care in freestanding birth centres versus hospital-based birth centres.
    

Criteria for considering studies for this review

Types of studies

All studies which involved random or quasi-random allocation of women and compared the effects of a home-like institutional birth environment to conventional hospital care.
    

Types of participants

Pregnant women at low risk of obstetric complications.
    

Types of intervention

Trials were included if they involved care during labour and birth in a 'home-like' birth setting. Antenatal and postnatal care may also have occurred in the home-like setting. Care may have been provided by the same group of caregivers, or by separate groups of caregivers in the home-like versus conventional settings.
    

Types of outcome measures

Outcomes of interest included rates of intrapartum medical interventions, intra- and post-partum complications, method of delivery, perinatal mortality at term, mothers' evaluations of their care, method of infant feeding and difficulties with feeding, measures of neonatal health, and adjustment to mothering.
    

Search strategy for identification of studies

This review has drawn on the search strategy developed for the Pregnancy and Childbirth Group as a whole.
    Relevant trials were identified in the Group's Specialised Register of Controlled Trials. See Review Group's details for more information. In addition, the Cochrane Controlled Trials Register was searched for relevant trials, using the following search terms: 'birth centre/center', 'birth room', 'birth environment', and 'home-like'. Date of last search: April 2000.
        

Methods of the review

Trials under consideration were evaluated for methodological quality and appropriateness for inclusion, without consideration of their results. Included trial data were processed as described in Clarke 1999. Wherever necessary unpublished data were requested from the trial authors. For all data analyses in this review, data were entered based on the principle of intention to treat. A fixed-effects model was used.
    

Description of studies

See table of 'Characteristics of included studies'.
    Five trials involving almost 8000 women were included in this Review. All trials involved comparisons of care in home-like versus standard hospital settings; however there were differences in the scope of the interventions. The Stockholm trial (Waldenstrom 1997) evaluated care during pregnancy, childbirth, and the postpartum period by a team of 10 midwives at a hospital birth centre, compared to standard care by different midwives during the antenatal, intrapartum and postnatal periods, with labour and birth in a standard labour ward. The Aberdeen trial (Hundley 1994) evaluated care in a home-like, midwife-managed delivery unit with care in a consultant-led labour ward; the midwives also worked in the conventional ward. The London (Chapman 1986) and Montreal (Klein 1984) trials compared care in home-like birth rooms within standard labour wards; the same staff cared for women in both groups. The Leicester trial (MacVicar 1993) compared intrapartum care in a home-like, midwife-managed unit with care in a standard labour ward; women allocated to the former group had up to 3 antenatal visits (at 26, 36 and 41 weeks) in a clinic run by the midwives in the birth centre, with the remainder of their antenatal care by their general practitioner or community midwife.
    No randomised trials were found which compared care in a freestanding birth centre with hospital-based birth centres or conventional hospital care.
    

Methodological quality

See: Table of included studies
With the exception of the quasi-random method (strict, centrally-controlled alternation) used in the smallest trial (Klein 1984), all trials used sealed, opaque envelopes to randomise participants. However, the largest trial (MacVicar 1993) had the weakest method of allocation to study groups. Sealed envelopes containing randomly-generated group assignments were attached to the records of 7906 pregnant women at booking. Of these, only 3510 (44%) were considered eligible for the study, and the envelopes were opened. A further 8% of those randomised to the experimental group refused to participate in the trial. Analyses were by intent-to-treat of the 3510 women who met eligibility criteria.
    Substantial numbers of women allocated to home-like settings were transferred to standard care because they no longer met eligibility criteria for the home-like setting. In two trials (Hundley 1994; MacVicar 1993), slightly less than 50% of women randomized to the birth centres actually gave birth in them. Thirty per cent of women in the Waldenstrom trial were transferred to standard care antenatally or intrapartum for medical reasons, and an additional 3% withdrew from birth centre care at their own request. In the Klein (Klein 1984) trial, 63% of nulliparous women and 19% of multiparous women were transferred intrapartum to standard care. In the smallest trial (Chapman 1986), 29% of 76 women were transferred from birth room to standard care.
        

Results

Table(s):

MetaView(s), List of comparisons, Table of excluded studies , Table of included studies
Given the possibility of selection bias in most studies, particularly in the largest trial (MacVicar 1993), all results should be interpreted with caution. However, the results were generally consistent across trials.
    Women who were allocated to care in home-like settings were less likely to use pharmacologic pain relief measures during labour, less likely to have labour augmented with oxytocin, less likely to be immobile during labour, less likely to have fetal heart rate abnormalities, and were happier with their care, than women who received standard care. There was a trend toward greater perinatal mortality in the home-like settings (OR= 1.83, 95% CI 0.96, 3.48); the excess perinatal mortality occurred in the three trials in which the experimental intervention included antenatal care that differed from the conventional care. Although women allocated to home-like settings were less likely to have an episiotomy, they were more likely to have vaginal/perineal tears, and there was no difference in the likelihood of having a non-intact perineum. One trial (Waldenstrom 1997) found a greater incidence of sore nipples and mastitis in the birth centre group.
    There were too few trials to permit subgroup analyses.
        

Discussion

Over 8,000 women have participated in randomized trials of home-like birth settings. Despite variations in methodological quality and in the scope of the experimental intervention, the results of the trials are quite consistent. The trend toward higher rates of perinatal mortality in the home-like settings raises questions about whether a focus on normalcy has a negative impact on the ability of caregivers and their clients to detect, act upon, and/or receive assistance with complications. A similar trend is found in the Review, 'Continuity of caregivers during childbirth'.
    The lower rates of intrapartum analgesia may be a result of two factors: increased support during labour (see the Review, 'Support during childbirth') and the lack of availability of some pharmacologic pain relief measures in many birth centres (and thus women must agree to transfer to the standard labour ward to receive it). Also, the lower rates of augmentation of labour may reflect the restrictions on intrapartum oxytocic use in birth centres, and the increased mobility during labour may be a function of the lack of availability of both electronic fetal monitoring and epidural analgesia. Detection bias (due to the use of electronic fetal heart rate monitoring in the conventional settings and auscultation in the home-like settings) may account for the difference in rates of fetal heart rate abnormalities.
    The higher rates of sore nipples and milk stasis in the only trial to report these outcomes (Waldenstrom 1997) may have been due to either a reporting bias (the close contact with birth centre staff may have led to more reporting of problems by women) and/or to birth centre midwives' lack of expertise in breastfeeding support.
    

Reviewers' conclusions

Implications for practice

Countless hospitals have allocated scarce resources towards renovation of labour wards, endeavouring to provide more attractive, home-like settings. Undoubtedly such settings are more pleasant work environments for caregivers, and the environments may favourably influence caregivers' attitudes towards the care of labouring women. However, hospitals which are considering renovations of their labour wards should be made aware that there is much stronger evidence to support the need for changes in caregivers' behaviour than there is to support the need for structural changes to labour wards. If renovations are desired they should be accompanied by efforts to change caregivers' behaviour, such that the latter provide support to labouring women (see Review, 'Support during childbirth').
    Just as an over-enthusiastic focus on risk and intervention can lead to unnecessary interventions and avoidable complications for healthy childbearing women and their fetuses, an over-emphasis on normalcy may lead to delayed recognition of or action regarding complications. Caregivers and their clients should be alert to need for detection and prompt action in the event of unforeseen complications.
    

Implications for research

Future trials of alternative birth settings should 1) seek participants' consent prior to randomization, 2) use bias-free methods of random allocation, and 3) ensure that the interval between random allocation and application of the experimental or control intervention is as short as possible.
    

Acknowledgements

None.
    

Potential conflict of interest

None known.
        

Sources of support

Extramural sources of support to the review
    No sources of support supplied
Intramural sources of support to the review
    University of Toronto CANADA

Synopsis

Home-like settings bring some benefits for childbirth but increased support for caregivers may be more important.
    A home-like birth centre is an option for some women who are considered to be at a low risk of developing complications during labour and birth, and who desire little or no medical intervention. These centres are established near a conventional labour ward and are intended to mimic a home rather than a hospital environment. The review of trials found some benefits for mothers from home-like settings for childbirth, but also found that increased support for caregivers may be more important.
    

Keywords

*Birthing Centers; *Delivery Rooms; Female; Human; Pregnancy;

Reference(s)

References to studies included [ 1-11 ] published data only
Chapman 1986[ 1 ]    Hundley 1994[ 2 ]    Hundley 1994[ 3 ]    Hundley 1994[ 4 ]    Klein 1984[ 5 ]    MacVicar 1993[ 6 ]    Waldenstrom 1997[ 7 ]    Waldenstrom 1997[ 8 ]    Waldenstrom 1997[ 9 ]    Waldenstrom 1997[ 10 ]    Waldenstrom 1997[ 11 ]
References to studies excluded [ 1 ]
Westreich[ 1 ]
Additional references [ 1 ]
Clarke 1999[ 1 ]

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