Volume 185 - Issue 7
Birth centre trials are unreliable
Author: Andrew F Pesce
Med J Aust 2006; 185 (7): 407. || doi: 10.5694/j.1326-5377.2006.tb00628.x
Published online: 2 October 2006
Published online: 2 October 2006
In reply: Fahy and Tracy highlight the lack of high-level evidence about the relative safety of different models of maternity care. But in criticising the Cochrane review, it is important not to “shoot the messenger”.
There is no doubt that the Cochrane review is not ideal but, like it or not, it remains the best evidence we have. The review of 8677 women in six randomised trials found a relative risk (RR) of perinatal death of 1.83 (95% CI, 0.99–3.38) in birth centres versus conventional institutional settings. In the 3332 pregnancies assigned to continuity of care by midwives who did not also work in conventional delivery suites, the RR was 2.38 (95% CI, 1.05–5.41).1
It would be fair to say that such findings should lead to real concerns about lack of safety rather than reassure the unbiased observer.
Other published evidence has raised similar concerns. A retrospective review of over 183 000 low-risk births in Stockholm, Sweden, found a statistically significant fourfold increase in intrapartum fetal mortality in women planning birth centre care compared with those planning standard care (three intrapartum deaths in 3256 babies of women planning birth centre care versus 36 deaths in 180 380 babies of those planning standard care).2 The increase in intrapartum mortality was almost sevenfold for primigravidae. These findings led to evidence-based changes in the organisation of the birth centre involved to minimise the identified risks.
To paraphrase Fahy and Tracy, rather than criticising the best available evidence reviewing birth centre outcomes, it would be more constructive to engage in rigorously designed research to assess how risk might be minimised in all forms of maternity care.
References
- Hodnett ED, Downe S, Edwards N, Walsh D. Home-like versus conventional institutional settings for birth. Cochrane Database Syst Rev 2005; (1): CD000012. DOI: 10.1002/14651858.CD000012.pub2.
- Gottvall K, Grunewald C, 2Waldenstrom U. Safety of birth centre care: perinatal mortality over a 10-year period. BJOG 2004; 111: 71-78. 0_i1091777