Selina Wallis (was Nylander)~ May 2009 The Incidence of Women giving birth in Liverpool in 2005-07 having a ‘Physiological Birth’ as compared to ‘Normal Births’ and ‘Cephalic Vertex Births’: Are there differences in health outcomes for mothers and babies by type of birth? Selina Wallis (was Nylander)~ May 2009

Introduction Intervention in the birth process, whilst intended to reduce mortality and morbidity, may lead to negative health outcomes for mothers and babies. Normal birth rates currently published by the DoH in the Maternity Statistics bulletin include births that have been augmented and/or used systemic analgesics for pain relief. In 2007 the Maternity Care Working Party published a consensus statement about the need to audit levels of Normal birth. Some members of the party felt the definition should exclude augmentation and systemic analgesics. Few studies have looked at post birth condition of mothers and babies after vaginal births with and without common interventions

Aims This study aimed to: Calculate the incidence of vaginal, non assisted births in the Liverpool Women’s Hospital (LWH) between 2005-2007 that were : 1 ‘Physiological births’ (PB) excluding augmentation and systemic analgesics; 2 ‘Normal births’ (NB); excluding induction, epidural and episiotomy 3 ‘Cephalic vertex births’ (CVB). Determine if there were significant differences in maternal and neonatal health outcomes by type of vaginal birth Outcomes included Breastfeeding after birth and on discharge to community Perineal tearing Maternal blood loss Neonatal condition at birth (Apgar score, cord pH, base excess and resuscitation)

Methods This was a quantitative hospital-based cross-sectional study using delivery records’ data available at Liverpool Women’s Hospital (LWH). All birth records with a gestation of 37-42 weeks from 01.01.2005 to 31.12.2007 were obtained for mothers who gave birth to live singleton infants and whose delivery records had been entered on the hospital database (Meditech). Birth records excluded from the analysis were multiple births, still births and inductions for high risk maternal or foetal conditions. Data was exported into a database and divided into three vaginal birth groups. Demographic and health outcomes were summarised using percentages and Chi-square tests with p value to compare differences between categories. Confounding factors identified from the literature, were adjusted for using a multivariate logistic regression model Health outcomes between groups were compared for each outcome using Odds ratios (OR) and 95% confidence intervals (CI).

Results Demographics

Average Birth weight (g) 3521.7 3421.7 3382.2 <40 Weeks 30.6 39.1 Variable CVB % NB % PB % Chi P All Vaginal Births n=13963 37.5 19.4 43.3 Primaparous 39.4 41.9 35.1 37.3 <0.001 Multiparous 60.6 58 64.9 Average Age 28.57 27.87 28.30 White 84 82.2 79.17 39.0 Non White 15.9 17.8 20.8 Intention to AF 53.1 54.7 52 4.81 0.09 Intention to BF 46.9 45.3 48 Average Birth weight (g) 3521.7 3421.7 3382.2 112 <40 Weeks 30.6 39.1 54.6 224 >40 Weeks 69.4 60.9 45.4

Breastfeeding

Results- Breastfeeding on Delivery* CVB % NB % PB % PBNO** % Chi P BF 76.5 78 81.3 88.8 26.9 <0.001 Not Fed or AF 23.5 21.9 18.7 11.2 aOR (95% CI) Chi P CVB 0.73 (0.63-0.85) 17.5 <0.0001 NB 0.84 (0.70-1.01) 3.28 0.07 PBNO 1.78 (1.09-2.92) 5.34 0.02 Age (<28) 0.79 (0.68-0.91) 11.03 0.0009 Multiparity 1.59 (1.38-1.83) 43.8 Ethnicity (White) 1.66 (1.44-1.91) 49.76 * Women that had previously stated an intention to breastfeed **PBNO Physiological Births without active management of the third stage

Results- Breastfeeding on Discharge to Community CVB % NB % PB % PBNO % Chi P BF 80.4 87.2 83.4 49.2 <0.0001 Not Fed or AF 19.6 12.9 10.7 aOR (95% CI) Chi P CVB 0.62 (0.52-0.73) 33.2 <0.0001 NB 0.64 (0.52-0.77) 20.2 PBNO 1.24 (0.74-2.06) 0.7 0.41 Age (<28) 0.44 (0.38-0.51) 113.5 Multiparity 1.25 (1.07-1.45) 8.3 0.0039 Ethnicity (White) 0.46 (0.38-0.55) 66.9

Perineal Tearing

Results- Perineal tears- Intact vs. Any tear CVB % NB % PB % Chi P Intact 48.2 50.6 53.2 18.5 <0.0001 Any tear 51.8 49.5 46.8 aOR (95% CI) Chi P CVB 1.61 (1.03-1.25) 6.65 0.0099 Age (<28) 0.54 (0.49-0.59) 176.9 <0.0001 Multiparity 0.31 (0.28-0.34) 556.6 0.0039 Birth weight (<3240g) 0.58 (0.53-0.64) 140.3 Gestation (<40W) 0.87 (0.79-0.95) 9.55 0.002

Results- Severity of Perineal tears (First and Second vs Results- Severity of Perineal tears (First and Second vs. Third and fourth degree CVB % NB % PB % Chi P 1-2 Degree 92.6 98.7 99.3 147.1 <0.0001 3-4 Degree 7.4 1.3 0.7 aOR (95% CI) Chi P CVB 11.3 (6.5-19.5) 71.24 <0.0001 Birth Weight (<3240g) 0.45 (0.31-0.68) 15.2 Multiparity 0.25 (0.17-0.36) 56.6 Gestation (<40W) 0.14 0.7

Blood Loss

Results- Blood loss CVB % NB % PB % Chi P <500ml 95.4 97.7 98.1 65.8 <0.0001 >500ml 4.6 2.3 1.9 aOR (95% CI) Chi P CVB 2.34 (1.86-3.04) 47.18 <0.0001 Multiparity 0.69 (0.55-0.85) 11.6 0.0007 Ethnicity (White) 0.63 (0.49-0.81) 12.9 0.0003 Birth Weight (<3240g) 0.60 (0.48-0.76) 18.4 Gestation (<40W) 0.88 (0.69-1.13) 0.96 0.33

Newborn Condition

Results- Newborn Condition CVB % NB % PB % PBNO % Chi P APGAR 1 Min <7 13.2 12.4 8.1 4.5 934 <0.0001 APGAR 5 Min <7 1.6 1.25 0.8 13.5 0.0012 Cord pH <7.1 3.9 2.9 1.85 20.5 Base Excess <8 21.6 17 15.1 37.3 Needing Resuscitation 11.4 10.7 6.6 3.4 90.7

aOR (95% CI) Chi Sq P APGAR 1 Min <7 CVB 1.69 (1.48-1.94) 58.2 <0.0001 NB 1.58 (1.35-1.86) 31.1 PBNO 0.54 (0.29-0.96) 4.31 0.037 APGAR 5 Min <7 Chi 2.03 (1.38-2.98) 13.02 0.0003 Base Excess >8 1.49 (1.29-1.74) 29.16 Cord pH <7.1 1.90 (1.34-2.70) 12.99 Resuscitation 1.79 (1.54-2.06) 60.4 1.65 (1.39-1.96) 32.5 0.49 (0.26-0.94) 4.59 0.032

Discussion The incidence of physiological birth in Liverpool in 2005-07 was 24.5% 19.1% of women having their first baby had a physiological birth. Physiological birth was associated with- Greater odds of breastfeeding after delivery and on discharge Lower odds of having a post partum hemorrhage Lower odds of having a perineal tear Lower odds of babies being born in a compromised condition Limitations Residual confounding factors not adjusted for with the model This study can only show association between type of birth and health outcomes, not causality Multiple factors between groups could effect the outcomes so specific changes in practice cannot be suggested. This study does not address choice or satisfaction with type of birth.

Conclusion The current definition of ‘Normal birth’ audited in England includes interventions which may be associated with worse health outcomes for mothers and babies and therefore it is recommended that the definition of ‘Physiological Birth’ used in this study is adopted to provide a measure of the number of women giving birth without intervention in England. Strategies that support women to have ‘Physiological Births’ in Liverpool, and perhaps more widely, should be investigated by primary care, health professionals and public health practitioners.

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