Clinical outcomes of the first midwife-led normal birth unit in China: a retrospective cohort study
Introduction
This paper reports the clinical outcomes of the first six months of operation of an innovative midwife-led normal birth unit (MNBU) in 2008, known locally as ‘ (homely birthplace)’. It was developed in response to the high rate of caesarean sections in China and a prevailing view that midwives were ‘unnecessary’ to normal birth (et al., 2003, Cheung et al., 2005a, Cheung et al., 2005b, Cheung et al., 2006a, Cheung et al., 2006b, Mander and Cheung, 2006). The study was the result of a major action research project. There is no evidence to support the claim that hospital is the safest place for healthy women to give birth (Zander and Chamberlain, 1999, Sinclair, 2002), and the increase in caesarean section rates cannot be fully explained by increases in hospital births in China (Guo et al., 2007). MNBUs in the developed world have been reported to facilitate vaginal birth, promote the role of midwives and empower women (Law and Lam, 1999, Janssen et al., 2002, Sinclair, 2002, Walsh, 2007). In light of this, the MNBU was developed after a survey of Chinese midwives in Hangzhou (population 7.5 million) to promote women’s participation in decision-making (Cheung et al., 2009a).
At the onset of the study, 56 midwives were employed by the hospital. The first Chinese MNBU became operational on 1 March 2008. The annual birth rate in the hospital was 3949 in 2007 and 4071 in 2008, and the total number of births over the study period was 2307. The vaginal birth rate in the MNBU was 87.6%, compared with 58.8% for standard care. The MNBU is sensitive to the local context and has proved to work in everyday practice for local healthy women and the hospital maternity services. The following report will explain how the MNBU works in order to build an accumulative understanding of its mechanism.
Section snippets
Background
The MNBU is part of the maternity department in Hangzhou First People’s Hospital. It was developed in three stages: (1) investigation of Chinese midwives’ views about such a unit, their own abilities and the feasibility of practising there (Cheung et al., 2009a); (2) development of appropriate philosophies, policies, strategies and procedures (Cheung et al., 2009b); and (3) a preliminary study of the implementation and evaluation of the MNBU (Mander et al., 2010).
The newly developed MNBU is
Aims
This paper reports the evaluation of the first six months of operation of the MNBU. The primary objective of the unit was to increase the normal birth rate, thereby decreasing the rate of caesarean sections. Secondary objectives included:
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increasing women’s support in labour;
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decreasing the use of routine practices that are not supported by evidence (such as pubic shaving, augmentation of labour and routine episiotomy);
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increasing women’s satisfaction with care; and
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increasing midwives’
Methods
The clinical outcomes were part of a major action research project that led to implementation of the MNBU. This part of the project used a retrospective cohort and a questionnaire survey to capture hard outcomes, such as mode of birth, augmentation, pain relief and episiotomy (Parahoo, 2006, Polit and Beck, 2006, Medical Research Council, 2008). The hospital researchers were involved at all stages of the design, development, process and outcome analysis of this study to increase the likelihood
Findings
The outcomes of the retrospective cohort suggest that the mothers in the MNBU were less likely to have a caesarean section than the mothers in the standard care unit (Table 2).
Two hundred and ten of 226 women (92.9%) accessing the MNBU attended antenatal classes with their birth companions, and all were accompanied during their labour and birth. None of the women labouring in the standard care unit had a birth companion. Women, their support persons, midwives and obstetricians were all positive
Discussion
Four related issues are discussed below which may have wider relevance in other parts of China and elsewhere.
Conclusion
This study demonstrates that working in the MNBU enables midwives to practice to the full extent of their role. It is associated with reduced obstetric intervention, increased spontaneous births and increased rates of job satisfaction for Chinese midwives, with the potential to empower them to regain their lost profession.
The two-to-one model of care is associated with a higher level of satisfaction among both the service users and the health workers. The rekindling of these fundamentally
Implications
The study has provided the international community with a successful case study of a Chinese experience of an MNBU. This innovative MNBU now acts as an exemplar for midwifery and maternity services elsewhere in China. The success of the MNBU in the Chinese context and the accompanying high vaginal birth rate and low caesarean section rate add weight to the growing body of international evidence that midwives are the best placed professionals to care for healthy childbearing women. The MNBU
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