Alternative versus conventional institutional settings for birth

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Authors


Abstract

Background

Alternative institutional settings have been established for the care of pregnant women who prefer and require little or no medical intervention. The settings may offer care throughout pregnancy and birth, or only during labour; they may be part of hospitals or freestanding entities. Specially designed labour rooms include bedroom-like rooms, ambient rooms, and Snoezelen rooms.

Objectives

Primary: to assess the effects of care in an alternative institutional birth environment compared to care in a conventional institutional setting. Secondary: to determine if the effects of birth settings are influenced by staffing, architectural features, organizational models or geographical location.

Search methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2010).

Selection criteria

All randomized or quasi-randomized controlled trials which compared the effects of an alternative institutional maternity care setting to conventional hospital care.

Data collection and analysis

We used standard methods of the Cochrane Collaboration Pregnancy and Childbirth Group. Two review authors evaluated methodological quality. We performed double data entry and have presented results using risk ratios (RR) and 95% confidence intervals (CI).

Main results

Nine trials involving 10684 women met the inclusion criteria. We found no trials of freestanding birth centres or Snoezelen rooms. Allocation to an alternative setting increased the likelihood of: no intrapartum analgesia/anaesthesia (five trials, n = 7842; RR 1.17, 95% CI 1.01 to 1.35); spontaneous vaginal birth (eight trials; n = 10,218; RR 1.04, 95% CI 1.02 to 1.06); breastfeeding at six to eight weeks (one trial, n = 1147; RR 1.04, 95% CI 1.02 to 1.06); and very positive views of care (two trials, n = 1207; RR 1.96, 95% CI 1.78 to 2.15). Allocation to an alternative setting decreased the likelihood of epidural analgesia (seven trials, n = 9820; RR 0.82, 95% CI 0.75 to 0.89); oxytocin augmentation of labour (seven trials, n = 10,020; RR 0.78, 95% CI 0.66 to 0.91); and episiotomy (seven trials, n = 9944; RR 0.83, 95% CI 0.77 to 0.90). There was no apparent effect on serious perinatal or maternal morbidity/mortality, other adverse neonatal outcomes, or postpartum hemorrhage. No firm conclusions could be drawn regarding the effects of variations in staffing, organizational models, or architectural characteristics of the alternative settings.

Authors' conclusions

When compared to conventional settings, hospital-based alternative birth settings are associated with increased likelihood of spontaneous vaginal birth, reduced medical interventions and increased maternal satisfaction.

Resumen

Antecedentes

Centros de atención del parto convencionales versus alternativos

Los centros de atención del parto alternativos se han establecido para la atención de las mujeres embarazadas que prefieren y necesitan poca o ninguna intervención médica. Los centros pueden ofrecer atención durante todo el embarazo y el parto, o sólo durante el trabajo de parto; pueden ser parte de hospitales o de instituciones independientes. Las habitaciones de parto especialmente diseñadas incluyen habitaciones similares a dormitorios, habitaciones ambientales y habitaciones Snoezelen.

Objetivos

Primarios: evaluar los efectos de la atención en un ambiente institucional de atención del parto alternativo en comparación con la atención en un centro institucional convencional. Secundarios: determinar si los efectos de los centros de atención del parto están influenciados por el personal, las características arquitectónicas, los modelos de organización o la ubicación geográfica.

Estrategia de búsqueda

Se hicieron búsquedas en el Registro de Ensayos del Grupo Cochrane de Embarazo y Parto (Cochrane Pregnancy and Childbirth Group) (31 mayo 2010).

Criterios de selección

Todos los ensayos controlados aleatorios o cuasialeatorios que compararon los efectos de un centro materno de atención alternativa con la atención hospitalaria convencional.

Obtención y análisis de los datos

Se utilizaron los métodos estándar del Grupo Cochrane de Embarazo y Parto (Pregnancy and Childbirth Group). Dos autores de la revisión evaluaron la calidad metodológica. La introducción de los datos se realizó por duplicado y los resultados se presentaron mediante los cocientes de riesgos (CR) y los intervalos de confianza (IC) del 95%.

Resultados principales

Nueve ensayos con 10 684 mujeres cumplieron los criterios de inclusión. No se encontraron ensayos de centros de atención del parto independientes ni de habitaciones Snoezelen. La asignación a un centro de atención alternativo aumentó la probabilidad de: ninguna analgesia/anestesia intraparto (cinco ensayos, n = 7842; CR 1,17; IC del 95%: 1,01 a 1,35); parto vaginal espontáneo (ocho ensayos; n = 10,218; CR 1,04; IC del 95%: 1,02 a 1,06); lactancia a las seis a ochos semanas (un ensayo, n = 1147); CR 1,04; IC del 95%: 1,02 a 1,06) y criterios muy positivos de la atención (dos ensayos, n = 1207; CR 1,96; IC del 95%: 1,78 a 2,15). La asignación a un centro de atención alternativo disminuyó la probabilidad de analgesia epidural (siete ensayos, n = 9820; CR 0,82; IC del 95%: 0,75 a 0,89); estimulación del trabajo de parto con oxitocina (siete ensayos, n = 10 020; CR 0,78; IC del 95%: 0,66 a 0,91) y episiotomía (siete ensayos, n = 9944; CR 0,83; IC del 95%: 0,77 a 0,90). No hubo efectos evidentes sobre la morbilidad perinatal o materna graves ni sobre la mortalidad, otros resultados neonatales adversos ni sobre la hemorragia posparto. No fue posible establecer conclusiones firmes con respecto a los efectos de las variaciones en el personal, los modelos de organización ni en las características arquitectónicas de los centros de atención alternativos.

Conclusiones de los autores

Comparados con los centros convencionales, los centros de atención del parto alternativos en el hospital se asocian con una mayor probabilidad de parto vaginal espontáneo y con una reducción de las intervenciones médicas y de la satisfacción materna.

Traducción

Traducción realizada por el Centro Cochrane Iberoamericano

Plain language summary

Alternative versus conventional institutional settings for birth

In high- and moderate-income countries, labour wards have become the settings for childbirth for the majority of childbearing women. Routine medical interventions have also increased steadily over time, leading to many questions about benefits, safety, and risk for healthy childbearing women. The design of conventional hospital labour rooms is similar to the design of other hospital sick rooms, i.e. the hospital bed is a central feature of the room, and medical equipment is in plain view. In an effort to support normal labour and birth for healthy childbearing women, a variety of institutional maternity care settings have been constructed. Some are 'home-like' bedrooms within hospital labour wards. Others are 'home-like' birthing units adjacent to the labour wards. Others are freestanding birth centres. More recently, 'ambient' and Snoezelen rooms have been constructed within labour wards; these rooms are not home-like but contain a variety of sensory stimuli and furnishings designed to promote feelings of calmness, control, and freedom of movement.

The primary aim of this review is to evaluate the effects, on labour and birth outcomes, of care in an alternative institutional birth setting compared to care in a conventional hospital labour ward. We included nine trials involving 10,684 women. We found no trials of freestanding birth centres. When compared to conventional institutional settings, alternative settings were associated with reduced likelihood of medical interventions, increased likelihood of spontaneous vaginal birth, increased maternal satisfaction, and greater likelihood of continued breastfeeding at one to two months postpartum, with no apparent risks to mother or baby. Unfortunately in several trials, the design features of the alternative setting were confounded by differences in the organizational models of care (including separate staff and more continuity of caregiver in the alternative setting), and thus it is not possible to draw conclusions about the independent effects of the design of the birth environment. We conclude that women and policy makers should be informed about the benefits of institutional settings which focus on supporting normal labour and birth.

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