Freestanding midwifery units versus obstetric units: does the effect of place of birth differ with level of social disadvantage?

BACKGROUND Social inequity in perinatal and maternal health is a well-documented health problem even in countries with a high level of social equality. We aimed to study whether the effect of birthplace on perinatal and maternal morbidity, birth interventions and use of pain relief among low risk women intending to give birth in two freestanding midwifery units (FMU) versus two obstetric units in Denmark differed by level of social disadvantage. METHODS The study was designed as a cohort study with a matched control group. It included 839 low-risk women intending to give birth in an FMU, who were prospectively and individually matched on nine selected obstetric/socio-economic factors to 839 low-risk women intending OU birth. Educational level was chosen as a proxy for social position. Analysis was by intention-to-treat. RESULTS Women intending to give birth in an FMU had a significantly higher likelihood of uncomplicated, spontaneous birth with good outcomes for mother and infant compared to women intending to give birth in an OU. The likelihood of intact perineum, use of upright position for birth and water birth was also higher. No difference was found in perinatal morbidity or third/fourth degree tears, while birth interventions including caesarean section and epidural analgesia were significantly less frequent among women intending to give birth in an FMU. In our sample of healthy low-risk women with spontaneous onset of labour at term after an uncomplicated pregnancy, the positive results of intending to give birth in an FMU as compared to an OU were found to hold for both women with post-secondary education and the potentially vulnerable group of FMU women without post-secondary education. In all cases, women without post-secondary education intending to give birth in an FMU had comparable and, in some respects, more favourable outcomes when compared to women with the same level of education intending to give birth in an OU. In this sample of low-risk women, we found that the effect of intended place on birth outcomes did not differ with women's level of education. CONCLUSION FMU care appears to offer important benefits for birthing women with no additional risk to the infant. Both for women with and without post-secondary education, intending to give birth in an FMU significantly increased the likelihood of a spontaneous, uncomplicated birth with good outcomes for mother and infant compared to women intending to give birth in an OU. All women should be provided with adequate information about different care models and supported in making an informed decision about the place of birth.