Title: The Birthplace in England Research Programme: further analyses to enhance policy and service delivery decision-making for planned place of birth
Funder: Department of Health (England)

Abstract: Data to be used in this follow-on study include:- The Birthplace prospective national cohort which includes data on 79774 births from over 95% of Trusts in England. Variables include maternal characteristics risk factors in pregnancy labour care intrapartum transfer details and maternal and neonatal outcomes by planned place of birth at the start of labour care.- Staffing and configuration data collected as part of the Healthcare Commission Maternity Services Review 2007 and the Birthplace 2010 mapping survey.- Further staffing and organisational data collected in the form of daily staffing and workload logs alongside the Birthplace cohort study.- Birth registration statistics relating to number of births by unit and unit type for 2008 and 2009 Outcome measuresThe main outcome measures to be used in these analyses are:Maternal:• Straightforward vaginal birth defined as birth without caesarean section forceps or ventouse delivery 3rd/4th degree perineal trauma or blood transfusion (i.e. without complications that may affect future births)• ‘Normal birth’ defined as birth with none of the following : induction of labour; epidural or spinal analgesia; general anaesthetic; forceps or ventouse; caesarean section; episiotomy.• Instrumental delivery (ventouse or forceps) and/or ventouse delivery and forceps delivery separately • Intrapartum caesarean section• Third or Fourth degree perineal traumaNeonatal:• Apgar score less than seven at five minutesIntrapartum transfers:• Transfer in labour • Transfer during labour or immediately after birthOther maternal and perinatal outcomes will be reported where relevant and appropriate.The following will be used as potential explanatory variables:Maternal characteristicsAge; ethnic group; understanding of English; marital or partner status; BMI in pregnancy; Index of multiple deprivation (IMD) quintile; parity; gestation at delivery.Unit characteristics:• Number of births per year • Unit bed / bed space capacity• Staffing • Distance from OU and travel time to OU (for FMUs only)• Age of the unit (years of operation as an FMU AMU or OU)Trust-level characteristics: • Number of home births as a proportion of all births in the Trust• Number of home births or FMU births as a proportion of all births in the TrustStatistical MethodsLogistic regression will be used to calculate odds ratios and confidence intervals for binary outcomes. We will report the number of events the number of births the weighted incidence an unadjusted odds ratio and an adjusted odds ratio controlling for maternal characteristics as appropriate. Robust variance estimation will be used to allow for the clustered nature of the data within units/trusts. Probability weights will be incorporated to account for differences in the probability of a woman being selected for inclusion in the study arising from differences in each unit/trust’s period of participation and the stratum specific probabilities of selection of OUs. For specified objectives multilevel modelling will be used to model the clustering within units and trusts explicitly as a random variable fitting women as level one and units/trusts as level two in the hierarchy. The intracluster correlation coefficient will be calculated and between-unit variability estimated. Funnel plots will also be used to assess the variability for each outcome and to identify units which are outliers (6).95% confidence intervals will be used throughout. We acknowledge that the analysis will be exploratory in nature and will involve multiple testing; we will take this into consideration when interpreting the results. The statistical analysis of each objective is described separately in the attached detailed research proposal.


Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: REPRODUCTIVE HEALTH AND CHILDBIRTH