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Title: Onsite midwife-led birth units (OMBUs) for care around the time of childbirth: a systematic review
Authors: Long Q, 1 Allanson ER, 1, 2 Pontre J, 3 Tunçalp Ö, 1 Hofmeyr GJ, 4 , 5 Gülmezoglu AM 1
Affliations: 1 Department of Reproductive Health and Research, World Health Organization; 2 School of Women’s and Infants’ Health, University of Western Australia; 3 King Edward Memorial Hospital; 4 Effective Care Research Unit, University of the Witwatersrand and 5 Walter Sisulu University and Eastern Cape Department of Health, Frere Maternity Hospital
Background: Globally, facility-based childbirth has been identified as a key strategy to improve the safety of intrapartum care. Although progress has been made in many low- and middle-income countries, poorly staffed and equipped primary health facilities and non-functional referral systems have been recognised as constraints to improving maternal and newborn health outcomes in these settings. In response to potential efficiency and safety concerns of stand-alone low-risk units, in-hospital midwife-led birth units that are adjacent to higher level care obstetric units have been introduced in some countries. This arrangement may provide important benefits, particularly in settings where referral systems do not function well and access to care in a timely fashion is challenging.
Objectives: This systematic review aimed to synthesise available evidence from interventional and observational studies to assess the effects of onsite midwife-led birth units (OMBUs) around the time of childbirth on maternal and newborn health outcomes and on the provision of obstetric interventions, compared with standard obstetric units. This review also aimed to explore maternal and midwife satisfaction with OMBU care and gather data on the cost of care. For the purpose of this review, OMBU is defined as a midwife-led unit embedded within a hospital which provides comprehensive emergency obstetric and newborn care.
Methods: Outcome measures--maternal and neonatal outcomes; obstetric interventions; satisfaction of mothers and midwives; cost-effectiveness. Search strategy--Cochrane Central Register of Controlled Trials, PUBMED, EMBASE, CINAHL, Science Citation and Social Sciences Citation Index, Global Health Library and one Chinese database were searched with no language restrictions. Data analysis--Meta-analysis was conducted to synthesise data of randomised controlled trials (RCTs). Findings of observational studies were summarized by forest plots with brief narratives.
Results: Three RCTs, one controlled before- and -after study and six cohort studies were included. There were no or very few maternal and perinatal deaths in either OMBUs or standard obstetric units, with no significant differences between the two. Women giving birth in OMBUs were less likely to use epidural analgesia. The UK national cohort study and two other cohorts in China and Nepal found less oxytocin augmentation, more spontaneous vaginal deliveries, fewer caesarean sections, fewer episiotomies performed in OMBUs than in standard obstetric units. These differences were not statistically significant in RCTs and the remaining cohorts. One study investigated satisfaction with midwife-led birth care among women and midwives, with positive findings in both groups favouring OMBU. Two studies found that the total cost of birth was lower in OMBUs than in standard obstetric units. Although the cost-effectiveness of OMBU care was assessed using different approaches in the two studies, results generally suggested that an OMBU was a cost-saving model without increases in adverse perinatal outcomes compared with a standard obstetric unit.
Conclusions: OMBUs could be an alternative model for providing safe and cost-effective childbirth care, which may be particularly important in low- and middle-income countries to meet the growing demand for facility-based birth for low-risk women and improve efficiency of health systems.