1. Selina Wallis (was Nylander)~ May 2009
The Incidence of Women giving birth in Liverpool in 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

2. 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

3. Aims This study aimed to:
Calculate the incidence of vaginal, non assisted births in the Liverpool Women’s Hospital (LWH) between 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)

4. 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 weeks from to 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).

5. Results
Demographics

6. 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

7. Breastfeeding

8. 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 ( )
17.5
<0.0001 NB
0.84 ( )
3.28
0.07
PBNO
1.78 ( )
5.34
0.02
Age (<28)
0.79 ( )
11.03
0.0009
Multiparity
1.59 ( )
43.8
Ethnicity (White)
1.66 ( )
49.76
* Women that had previously stated an intention to breastfeed
**PBNO Physiological Births without active management of the third stage

9. 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 ( )
33.2
<0.0001 NB
0.64 ( )
20.2
PBNO
1.24 ( )
0.7
0.41
Age (<28)
0.44 ( )
113.5
Multiparity
1.25 ( )
8.3
0.0039
Ethnicity (White)
0.46 ( )
66.9

10. Perineal Tearing

11. 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 ( )
6.65
0.0099
Age (<28)
0.54 ( )
176.9
<0.0001
Multiparity
0.31 ( )
556.6
0.0039
Birth weight (<3240g)
0.58 ( )
140.3
Gestation (<40W)
0.87 ( )
9.55
0.002

12. 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 ( )
71.24
<0.0001
Birth Weight (<3240g)
0.45 ( )
15.2
Multiparity
0.25 ( )
56.6
Gestation (<40W)
0.14
0.7

13. Blood Loss

14. 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 ( )
47.18
<0.0001
Multiparity
0.69 ( )
11.6
0.0007
Ethnicity (White)
0.63 ( )
12.9
0.0003
Birth Weight (<3240g)
0.60 ( )
18.4
Gestation (<40W)
0.88 ( )
0.96
0.33

15. Newborn Condition

16. 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

17. aOR (95% CI)
Chi Sq P
APGAR 1 Min <7
CVB
1.69 ( )
58.2
<0.0001 NB
1.58 ( )
31.1
PBNO
0.54 ( )
4.31
0.037
APGAR 5 Min <7
Chi
2.03 ( )
13.02
0.0003
Base Excess >8
1.49 ( )
29.16
Cord pH <7.1
1.90 ( )
12.99
Resuscitation
1.79 ( )
60.4
1.65 ( )
32.5
0.49 ( )
4.59
0.032

18. Discussion
The incidence of physiological birth in Liverpool in 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.

19. 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.

20. selina@deverra.co.uk www.deverra.co.uk
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