School of Nursing & Midwifery, University of Dundee, Dundee, UK.
Birth. 2010 Dec;37(4):280-7. doi: 10.1111/j.1523-536X.2010.00422.x.
An earlier matched cohort study in the United Kingdom found a significantly higher perinatal mortality rate for births booked under an independent midwife compared with births in National Health Service units (1.7% [25/1,508] vs 0.6% [45/7,366]). This study examined independent midwives' management and decision making in the 15 instances of perinatal death that occurred at term.
Thematic analysis of independent midwives' case notes was performed in instances of perinatal mortality. Semi-structured interviews were conducted with the midwives concerned.
Home birth was attempted in 13 of the 15 cases. Significant (often multiple) antenatal risk factors were identified in 13 cases, including twin pregnancy, planned vaginal births after cesarean section, breech presentations, and maternal illness. Several women had declined some or all routine antenatal screening. Three deaths occurred before labor onset. Postmortem results were known in only four cases; many causes of death remained unexplained. Professional consensus was that seven deaths were unpreventable; elective cesarean section may have changed the outcome in eight cases. However, the pregnant women had declined this option; some were reported to be avoiding National Health Service care because of previous bad experiences. Transfer to hospital care, when it occurred, was often problematic. Care management was judged to be clinically acceptable within the parameters set by the mothers' choices.
Information about clinical processes (and outcomes) is essential if informed decisions are to be made. The women in this review had reportedly accepted the potential consequences of their high-risk situations. If reality is to match rhetoric about "patient" autonomy, such decision making in high-risk situations must be accepted.
英国的一项早期匹配队列研究发现，与在国民保健服务机构分娩相比，由独立助产士接生的围产期死亡率显著更高（1.7%[25/1508]比 0.6%[45/7366]）。本研究检查了在足月时发生的 15 例围产死亡事件中独立助产士的管理和决策。
对围产死亡的独立助产士病例记录进行主题分析。对相关助产士进行半结构化访谈。
在 15 例病例中尝试了家庭分娩。在 13 例中发现了显著的（通常是多种）产前危险因素，包括双胎妊娠、剖宫产术后阴道分娩、臀位和产妇疾病。一些妇女拒绝了部分或全部常规产前筛查。有 3 例死亡发生在分娩开始前。只有 4 例已知尸检结果；许多死因仍未解释。专业共识是 7 例死亡是不可预防的；选择性剖宫产可能改变了 8 例病例的结局。然而，孕妇拒绝了这个选择；一些人因为以前的不良经历而避免接受国民保健服务。当发生向医院转移时，往往存在问题。护理管理被认为在母亲选择所设定的参数范围内具有临床可接受性。
如果要做出明智的决策，就必须了解临床过程（和结果）的信息。本综述中的妇女据报道已经接受了其高危情况的潜在后果。如果现实要与关于“患者”自主权的言论相匹配，那么在高危情况下必须接受这种决策。
