Transcript Folie 1 - Kennispoort Verloskunde

Normal Birth
als onderzoeksterrein
Normal Birth – an area of research
Midwifery Research Unit
Dr. Mechthild M. Gross
My office…
Europe
and my colleagues …
Midwifery Research Unit
Dr. Mechthild M. Gross
Antenatal care in Germany
• Lead professional: obstetrician
• Shared care: midwife/
obstetrician
• Covered by Health insurance
• Maternity document: Mutterpass
• Standard antenatal care
Midwifery Research Unit
Dr. Mechthild M. Gross
Hospital birth in Germany
• Private and public hospitals
• Employed midwives
• Contracted midwives
• Midwife presence
required by law
Midwifery Research Unit
Dr. Mechthild M. Gross
Homebirth and birth centre care
• Independent midwives only
• Team structure possible
• Costs mainly covered by
health insurance
• Approx 1%
• Quality assurance for
out-of-hospital-births
Midwifery Research Unit
Dr. Mechthild M. Gross
Research during Normal Birth
Outcome
Duration
Midwifery Research Unit
Dr. Mechthild M. Gross
Research during Normal Birth
Outcome
Duration
Midwifery Research Unit
Dr. Mechthild M. Gross
Randomised Studies
Intervention
Outcome
Controls
Midwifery Research Unit
Dr. Mechthild M. Gross
Intrapartum factors influencing birth duration
Amniotomy
Epidural
Support
Admission
Vertical
positioning
Duration
Groß MM Antes G. Wissenschaftliche Evidenz aus systematischen Übersichtsarbeiten zum Gebären. Z Geburtsh Neonatol 2003; 207: 17-23
Midwifery Research Unit
Dr. Mechthild M. Gross
Research during Normal Birth
Outcome
Duration
Midwifery Research Unit
Dr. Mechthild M. Gross
Process orientated care
Outcome
Duration
Pain
Wellbeing
Midwifery Research Unit
Dr. Mechthild M. Gross
Wellbeing during labour
Pain
Fitness
VAS
10
bath
cervix
9 cm
analgesia
8
oxytocin
epidural
9
cervix
fully
7
6
5
4
3
2
1
0
8:00
10:00
12:00
14:00
16:00
18:00
20:00
22:00
Time
Gross MM Hecker H Keirse MJNC. An evaluation of pain and “fitness” during labor and its acceptability to women. Birth 2005; 32: 122-128
Midwifery Research Unit
Dr. Mechthild M. Gross
New Interest in Labour Progression
Troendle & Zhang, US-NIH
Vahratian A et al. 2006; “methodological challenges in studying labour progression”;
suggested how to assess the duration from one cervical centimeter to the result of the next
vaginal examination (as an independent factor)
Vahratian A et al. 2006; impact of parity on course of labor; difference between primiparae
and multiparae
Vahratian A et al. 2005; risk of caesarean delivery in electively induced primiparae is 2.3
higher compared to non induced primiparae, epidural is used as a time-varying covariate
Hoffman MK et al. 2006; comparison of labour progression between induced and non
induced multiparous women
Smith, UK-Cambridge
Smith G 2001; first time that “time to event analysis” is used in the field of human
reproduction (“normal duration of human pregnancy”)
Smith G et al. 2003; caesarean section and risk of unexplained stillbirth in subsequent
pregnancy. Lancet 362: 1779-1784
Smith G 2005; review on estimating risks of perinatal death, “indeed labor itself can be
treated as the event”
Midwifery Research Unit
Dr. Mechthild M. Gross
…and how long will it take?
Midwifery Research Unit
Dr. Mechthild M. Gross
Research question
The aim of the current study was to investigate how
intrapartum interventions are associated with labour
duration.
Midwifery Research Unit
Dr. Mechthild M. Gross
Methods
Midwifery Research Unit
Dr. Mechthild M. Gross
Germany
Midwifery Research Unit
Dr. Mechthild M. Gross
Setting of the ProGeb-Study
-a state-wide longitudinal study on process-oriented
care during the childbearing process,
-96 hospitals with maternity services in Lower Saxony,
-64,000 births per year,
-involves a detailed documentation,
-contact to midwifery teams.
Data Collection
Hospital-based births: 6 months
Out-of-hospital births: 12 months
47 maternity units in hospitals (n=3963)
11 free standing birth centres (n=232)
46 home birth midwives (n=243)
total n= 4438
•Informed Consent
Approvals
by the Ethics Committee of Hanover Medical University
by the State-wide Ethics Committee for Public Hospitals in Lower Saxony
•Support / Logistics
Centre for Quality and Management in Health Care of the Medical Chamber of
Lower Saxony
•Inclusion
Cephalic presentation in singleton pregnancies > 34 weeks
Midwifery Research Unit
Dr. Mechthild M. Gross
Data Management in the ProGeb Study
Midwifery Research Unit
Dr. Mechthild M. Gross
Hospital Births
Some variables have missing data.
np (n=2090)
Out-of-hospital-Births
mp (n=1873)
np (n=187)
mp (n=288)
Demographic data
Maternal age in years – median (min/ max)
28 (14.5/ 43.5)
31.5 (18/ 45)
30 (15/44)
33 (19/ 46)
Worked during pregnancy – n (%)
601 (66.2)
316 (38.8)
125 (67.2)
130 (45.8)
A-level vs. other school degrees – n (%)
247(32.2)
213 (33.2)
129 (72.9)
185 (69.0)
1,435(85.2)
1,205 (80.2)
179 (95.7)
276 (96.5)
Antenatal classes – n (%)
752 (70.5)
385 (40.2)
160 (86.0)
145 (50.7)
Midwife chosen by woman – n (%)
242 (20.0)
176 (15.8)
175 (93.6)
265 (92.7)
(Partially) provided by midwife – n (%)
182 (17.5)
137 (14.6)
171 (91.9)
270 (94.1)
1169 (55.9)
1007 (53.8)
129 (69.0)
199 (69.1)
SROM before onset of labour – n (%)
531 (25.5)
295 (15.8)
33 (19.5)
34 (12.1)
Low workload (<=3) vs. high (>3) – n (%)
343 (64.2)
371 (74.3)
83 (51.2)
160 (73.7)
1065 (51.0)
952 (50.9)
91 (48.7)
153 (53.1)
3423
3538
3500
3650
52 (41.5/ 59)
52 (40.5/ 61.5)
52 (44/ 58)
53 (44/ 60)
35 (26.5/ 40.5)
35 (28/ 39.5)
35 (32/ 39.5)
35 (26/ 39)
Country of origin: Germany vs. other – n (%)
Mode of antenatal care
General obstetrical data
No antenatal risk associated factors – n (%)
Newborn-related data
Gender (male) – n (%)
Birth weight (gram) – median (min/ max)
Length (cm) – median (min/ max)
Head circumference (cm) – median (min/ max)
Midwifery Research Unit
Dr. Mechthild M. Gross
Hospital Births
Some variables have missing data.
np (n=2090)
mp (n=1873)
Out-of-hospital-Births
np (n=187)
mp (n=288)
Birth
Births without induction, oxytocin, epidural,
episiotomy – n (%)
321 (15.3)
859 (45.9)
135 (72.2)
262 (91.0)
1497 (71.6)
1764 (94.2)
165 (88.2)
283 (98.3)
Operative vaginal delivery – n (%)
216 (10.3)
31 (1.7)
5 (2.7)
0 (0)
Caesarean section – n (%)
377 (18.0)
78 (4.2)
11 (5.9)
4 (1.4)
1727 (82.7)
1642 (87.7)
144 (79.1)
239 (83.3)
483 (23.3)
265 (14.3)
n/a
n/a
Neonatal resuscitation required – n (%)
125 (6.0)
67 (3.5)
11 (5.9)
6 (2.1)
Admission to NICU – n (%)
140 (6.7)
79 (4.2)
9 (4.8)
3 (1.0)
Intact perineum – n (%)
815 (39.0)
984 (47.1)
88 (47.1)
160 (55.6)
Perineal tears – n (%)
412 (19.7)
595 (31.8)
74 (39.6)
120 (41.7)
Anal sphincter damage – n (%)
58 (2.8)
22 (1.2)
4 (2.1)
6 (2.1)
Postpartum hemorrhage(>1000ml) – n (%)
26 (1.2)
12 (0.6)
3 (1.6)
3 (1.0)
Spontaneous birth – n (%)
Newborn
APGAR = 10 (5 min.) – n (%)
Birth asphyxia (pH <7.20) – n (%)
Mother
Midwifery Research Unit
Dr. Mechthild M. Gross
Hospital Births
Some variables have missing data.
np (n=2090)
Out-of-hospital-Births
mp (n=1873)
np (n=187)
mp (n=288)
Interventions/ events during labour and
birth
Spontaneous onset of labour (SOL) – n (%)
1478 (70.7)
1412 (75.4)
174 (93)
269 (93.4)
810 (38.8)
772 (41.2)
110 (65.1)
209 (74.4)
4.4 (0.2/ 35.45)
2.25 (0.05/ 22.2)
4.3 (0.0/ 23.5)
2.2 (0.0/ 20.1)
Vertical positioning in 1st stage – per
duration of 1st stage (%) – median (min/
max)
33.3 (0/ 100)
42.9 (0/ 100)
54.2 (0/ 100)
61.2 (0/ 100)
Vertical positioning in 2nd stage – per
duration of 2nd stage (%) – median (min/
max)
23.0 (0/ 100)
32.5 (0/ 100)
56.3 (0/ 100)
33.3 (0/ 100)
Transfer to hospital during labour – n (%)
n/a
n/a
49 (26.2)
13 (4.5)
7.05 (0.5/ 63.8)
4.15 (-0.05/ 91.6)
7.6 (0.9/ 40.5)
4.1 (0.2/ 55.7)
0.75 (0/ 4.45)
0.2 (0/ 3.6)
1.0 (0/ 9.8)
0.2 (0/ 4.0)
Intrapartal spontaneous rupture of
membranes (SRM) – n (%)
Presence of midwife – sum of all intervals
(hours) – median (min/ max)
Duration of first stage in vaginal births
(hours) – median (min/ max)
Duration of second stage in spontaneous
vaginal births (hours) – median (min/ max)
Midwifery Research Unit
Dr. Mechthild M. Gross
Hospital Births
Some variables have missing data.
np (n=2090)
Out-of-hospital-Births
mp (n=1873)
np (n=187)
mp (n=288)
Non-pharmacological interventions
Intermittent auscultation (yes/ no) – n (%)
105 (5.0)
60 (3.2)
170 (90.9)
267 (92.7)
2051 (98.4)
1817 (97.3)
67 (35.8)
76 (26.4)
Immersion in water (0/ >=1) – n (%)
545 (29.0)
245 (15.3)
126 (67.4)
128 (44.4)
Massage – n (%)
137 (22.5)
92 (16.5)
46 (24.6)
66 (22.9)
Complementary remedies – n (%)
410 (19.6)
275 (14.7)
108 (57.8)
92 (31.9)
Vaginal exam (0-2/ >2) – n (%)
214 (10.0)
379 (19.3)
52 (27.8)
133 (46.2)
Intrapartal amniotomy – n (%)
718 (34.4)
783 (41.8)
24 (14.2)
34 (12.1)
1383 (66.2)
1261 (67.3)
69 (36.9)
94 (32.6)
412 (19.7)
116 (6.2)
7 (3.7)
2 (0.7)
13 (0.6)
7 (0.4)
14 (7.5)
44 (15.3)
871 (41.7)
290 (15.5)
24 (12.8)
4 (1.4)
Oxytocin augmentation of labour – n (%)
1096 (52.4)
505 (27.6)
6 (3.2)
0 (0.0)
Pharmacological analgesia – n (%)
1325 (63.4)
809 (43.2)
16 (8.6)
11 (3.8)
727 (34.8)
233 (12.4)
2 (1.1)
1 (0.3)
ECG (0/ >=1 time) – n (%)
Initiation of active pushing – n (%)
Fundal pressure – n (%)
‘Hands-off’ for perineum protection – n (%)
Episiotomy – n (%)
Pharmacological interventions
Regional anesthesia – n (%)
Midwifery Research Unit
Dr. Mechthild M. Gross
Hospital Births
Some variables have missing data.
Out-of-hospital-Births
np (n=2090)
mp (n=1873)
np (n=187)
mp (n=288)
-6.4
(-1162.5/ -0.05)
-4.7
(-117.7/ -0.15)
-5.0 (-40.0/ -0.3)
-6.3 (-40.0/ -0.5)
3.15
(0/ 90.9)
6.0 (0/ 37.8)
3.8 (0/ 53.8)
0.7
(-78.6/ 72.1)
3.0 (-19.5/ 27.5)
1.8 (-16.9/ 48.0)
n/c
n/c
n/c
n/c
n/c
n/c
Median time difference (min/ max) between
onset of labour defined by midwife (reference)
and …
…spontaneous rupture of membranes before
onset of labour)
… inrapartal spontaneous rupture of membranes
(hours)
… onset of care (hours)
4.6
(0/ 61.75)
0.5
(-116.95/ 65.05)
… intrapartal amniotomy (hours)
5.75
(0.1/ 54.95)
3.55
(0.0/ 64.5)
… oxytocin augmentation (hours)
6.0
(0.0/ 53.35)
3.8
(0.0/ 74.0)
4.7
(-3.5/ 49.95)
3.35
(-3.75/ 27.95)
… epidural anesthesia (hours)
Midwifery Research Unit
Dr. Mechthild M. Gross
Midwife chosen by woman (in%)
Yes
100,0
93,6
No
92,7
80,7
79,4
80,0
60,0
40,0
20,6
19,3
Nulliparae
Multiparae
20,0
7,3
6,4
0,0
Nulliparae
Multiparae
Out-of-Hospital-Births
Out-of-Hospital-Births:
Hospital Births:
Midwifery Research Unit
Dr. Mechthild M. Gross
n (Nulliparae) = 187;
n (Nulliparae = 596;
Hospital Births
n (Multiparae) = 286
n (Multiparae) = 544
Antenatal Care provided by Midwife (in%)
Yes
100,0
No
94,1
91,9
83,0
79,8
80,0
60,0
40,0
20,2
17,0
20,0
8,1
5,9
0,0
Nulliparae
Multiparae
Nulliparae
Out-of-Hospital-Births
Out-of-Hospital-Births:
Hospital Births:
Midwifery Research Unit
Dr. Mechthild M. Gross
n (Nulliparae) = 187;
n (Nulliparae = 596;
Multiparae
Hospital Births
n (Multiparae) = 288
n (Multiparae) = 544
Perineal Protection (in%)
Yes
100,0
No
99,6
99,4
92,5
84,7
80,0
60,0
40,0
15,3
20,0
7,5
0,6
0,4
0,0
Nulliparae
Multiparae
Nulliparae
Out-of-Hospital-Births
Out-of-Hospital-Births:
Hospital Births:
Midwifery Research Unit
Dr. Mechthild M. Gross
n (Nulliparae) = 187; n (Multiparae) = 288
n (Nulliparae = 2090; n (Multiparae) = 1873
Multiparae
Hospital Births
Transfer rates to Hospital
Out-of-Hospital-Births
Nulliparae
n
%
n
%
49
26,2
13
4,5
187
100,0
288
100,0
AUG: n (E) = 187;
Midwifery Research Unit
Dr. Mechthild M. Gross
Multiparae
n (M) = 288
Symptoms of onset of labour
Midwifery Research Unit
Dr. Mechthild M. Gross
Diagnosing onset of labour
"Diarrhoea, stomach ache, vaginal cramps,
back pain, all at the same time."
Gastro-intestinal
Non-recurrent pain
Gross MM et al. Women‘s Recognition of the Spontaneous Onset of Labor. Birth 2003; 30: 267-271
Midwifery Research Unit
Dr. Mechthild M. Gross
Percent
Frequencies
of
Symptoms
units
Recurrent pain
38.5
60.8
Non-recurrent
24.9
30.9
Watery loss
12.7
21.7
Bloody loss
8.9
15.2
Digestive
2.7
4.6
Emotional
3.0
5.1
Sleeping
6.0
7.4
Others
3.3
5.5
369
217
Total number
Gross MM et al. Women‘s Recognition of the Spontaneous Onset of Labor. Birth 2003; 30: 267-271
Midwifery Research Unit
Dr. Mechthild M. Gross
women
Interval between onset of labour defined by midwife vs.
woman
Duration of labour
Nullip n=550
Multip n=505
1st duration as defined by women in labour – Md
(min, max)
11h (1.25h,
5.7d)
6.5h (48m, 9.6d)
1st duration as defined by midwives – Md (min,
max)
7h (1h, 2.2d)
4h (12m, 4.2d)
Interval between onset of labour defined by woman
vs. midwife - Md in hours (min, max in hours,
days)
2h (-5.5d, 1.5d)
45m (-9.4d,
19h)
Joint agreement on labour onset woman vs.
midwife – n (%)
158 (28.5)
199 (29.4)
Midwifery Research Unit
Dr. Mechthild M. Gross
Interval between symptoms and onset of labour
defined by midwife vs. nullipara
Emotional symptoms
Rupture of membranes
Burian RA et al. Onset of Labor: Women’s Experiences and Midwives’ Assessment in Relation to First Stage Duration. In Preparation
Midwifery Research Unit
Dr. Mechthild M. Gross
Hazard ratio related to onset of labour defined by
midwife vs. nullipara
adjusted for confounders
Burian RA et al. Onset of Labor: Women’s Experiences and Midwives’ Assessment in Relation to First Stage Duration. In Preparation
Midwifery Research Unit
Dr. Mechthild M. Gross
Presence of midwife
Midwifery Research Unit
Dr. Mechthild M. Gross
Cumulative presence of midwife since onset of care
Midwifery Research Unit
Dr. Mechthild M. Gross
Total Duration of Midwife Presence
Starting point: first occasion of care during active labour
Nulliparae
Multiparae
% of births
70,0
61
60,0
50,0
40,0
35
31
27
30,0
21
20,0
10
9
10,0
2
3
0
2
1
0,0
up to 3 hrs.
>3 to 6 hrs.
>6 to 9 hrs.
>9 to 12 hrs.
>12 to 15 hrs.
>15 hrs.
Ayerle GM et al. Midwife Attendance during Labour and its Relation to Interventions and Mode of Birth. In Preparation
Midwifery Research Unit
Dr. Mechthild M. Gross
Midwife Presence per Duration of Birth (percent)
Starting point: first occasion of care during active labour
Nulliparae
Multiparae
% of births
70,0
62
63
60,0
50,0
40,0
30,0
23
19
20,0
11
10,0
14
4
4
0,0
0-25%
>25-50%
>50-75%
>75-100%
Ayerle GM et al. Midwife Attendance during Labour and its Relation to Interventions and Mode of Birth. In Preparation
Midwifery Research Unit
Dr. Mechthild M. Gross
Intrapartum varying interventions
Midwifery Research Unit
Dr. Mechthild M. Gross
Intrapartum varying Interventions
Amniotomie
Amniotomy, Oxytocin, Epidural Analgesia
1
0
t
Prozesszeit
Midwifery Research Unit
Dr. Mechthild M. Gross
When are Interventions performed?
Nulliparae n=2090
Amniotomy, Oxytocin, Epidural
3h
Midwifery Research Unit
Dr. Mechthild M. Gross
When are Interventions performed?
Nulliparae n=2090
Multiparae n=1873
Amniotomy, Oxytocin, Epidural
3h
Midwifery Research Unit
Dr. Mechthild M. Gross
3h
Steps of Data Analysis for 1st and 2nd stage
1. Univariate Analysis
2. Multivariate Analysis I: Demographic factors, riskassociated factors, child-related factors, induction
3. Multivariate Analysis II: All significant factors
4. Multivariate Analysis III: Backward selection
Midwifery Research Unit
Dr. Mechthild M. Gross
Modelling 1st Stage – Nulliparae
After Backward Selection
Variable
HR
p-Value
Clinical Interpretation
Gestational Age [years]
0.985
<0.001
First Stage ↑
No antepartum risks
1.279
<0.001
First Stage ↓
Oxytocin Induction
0.756
0.011
First Stage ↑
Fetal Birthweight [100g]
0.987
0.021
First Stage ↑
Intrapartum Amniotomy
2.727
<0.001
First Stage ↓
Epidural Analgesia
0.515
0.006
First Stage ↑
Epidural Analgesia * Time
1.380h
0.004
Association ↑ with ↓ Time
Intrapartum Oxytocin * Time
1.279
<0.001
Association ↑ with ↓ Time
Midwifery Research Unit
Dr. Mechthild M. Gross
Modelling 1st Stage - Nulliparae
Ful Cervical Dilation
Epidural Analgesia
5
Primiparae;
Onset of laborOxytocin
---> Ful cervical dilation
Intrapartum
3
2
1
0
hazard ratio
4
Intrapartum Amniotomy
Intrapartum Regional Anaesthesia
Intrapartum Oxytocin
Oxytocin Induction
Gestational Age [week]
No Anamnestic Risk
Fetal Birthweight [100g]
0
5
10
time [hours after onset of labour]
Midwifery Research Unit
Dr. Mechthild M. Gross
15
20
Modelling 1st Stage - Nulliparae
Ful Cervical Dilation
Caesarean during 1st Stage
Primiparae;
Onset of labor ---> CS during first stage
Epidural
Analgesia
5
5
Primiparae;
Onset of labor --->
Ful cervical dilation
Intrapartum
Oxytocin
4
Intrapartum Amniotomy
Intrapartum Regional Anaesthesia
Intrapartum Oxytocin
Oxytocin Induction
Fetal Sex (female)
Fetal Birthweight [100g]
2
3
hazard ratio
3
2
1
1
0
0
hazard ratio
4
Intrapartum Amniotomy
Intrapartum Regional Anaesthesia
Intrapartum Oxytocin
Oxytocin Induction
Gestational Age [week]
No Anamnestic Risk
Fetal Birthweight [100g]
0
5
10
time [hours after onset of labour]
Midwifery Research Unit
Dr. Mechthild M. Gross
15
20
0
5
10
time [hours after onset of labour]
15
20
Modelling Second Stage –
Nulliparae
Intrapartum Amniotomy
5
Epidural
Analgesia
Primiparae; Ful cervical
dilation ---> Spontaneous
delivery
Spontaneous
Birth
3
2
1
0
hazard ratio
4
Intrapartum Amniotomy
Intrapartum Regional Anaesthesia
VBAC-Status
Maternal Age [years]
Fetal Birthweight [100g]
0
5
10
time [hours after onset of labour]
Midwifery Research Unit
Dr. Mechthild M. Gross
15
20
Vaginal-operative Birth
5
Primiparae; Ful cervical dilation ---> Vaginal-operative birth
Modelling Second Stage –
Nulliparae
Intrapartum Oxytocin
4
3
hazard ratio
5
Epidural
Analgesia
Primiparae; Ful cervical
dilation ---> Spontaneous
delivery
Spontaneous
Birth
1
2
Intrapartum Amniotomy
Intrapartum Regional Anaesthesia
Intrapartum Oxytocin
Fetal Head Circumference [cm]
Fetal Birthweight [100g]
0
0
3
2
1
0
5
10
time [hours after onset of labour]
Midwifery Research Unit
Dr. Mechthild M. Gross
5
10
time [hours after onset of labour]
0
hazard ratio
4
Intrapartum Amniotomy
Intrapartum Regional Anaesthesia
VBAC-Status
Maternal Age [years]
Fetal Birthweight [100g]
15
20
15
20
Vaginal-operative Birth
5
Primiparae; Ful cervical dilation ---> Vaginal-operative birth
Modelling Second Stage –
Nulliparae
Intrapartum Oxytocin
4
3
hazard ratio
2
Intrapartum Amniotomy
Intrapartum Regional Anaesthesia
Intrapartum Oxytocin
Fetal Head Circumference [cm]
Fetal Birthweight [100g]
5
1
Epidural
Analgesia
Primiparae; Ful cervical
dilation ---> Spontaneous
delivery
Spontaneous
Birth
4
0
Intrapartum Amniotomy
Intrapartum Regional Anaesthesia
VBAC-Status
Maternal Age [years]
Fetal Birthweight [100g]
0
5
10
15
20
time [hours after onset of labour]
Caesarean Section
Oxy
3
1
1
2
hazard ratio
2
4
3
Intrapartum Oxytocin
VBAC-Status
Maternal Age [year]
Fetal Birthweight [100g]
0
0
hazard ratio
5
Primiparae; Ful cervical dilation ---> CS during second stage
0
5
10
15
20
0
time [hours after onset of labour]
Midwifery Research Unit
Dr. Mechthild M. Gross
5
10
time [hours after onset of labour]
15
20
Effective intrapartum Care
Qutcome  = Quality 
Midwifery Research Unit
Dr. Mechthild M. Gross
Effective intrapartum Care
Qutcome  = Quality 
Process ? = Quality ?
Midwifery Research Unit
Dr. Mechthild M. Gross
The Process of Birth
Maternal Wellbeing
Multiple Dimensions
Modelling
Midwifery Research Unit
Dr. Mechthild M. Gross
Contributors
German Research Council
MHH – Dep. of O&G, Repro.Med.
Prof. Dr. Peter Hillemanns
Centre for Quality and
Management in Health Care at
the Medical Chamber of Lower
Saxony
Paul Wenzlaff
Bärbel Lorenz
Standing Perinatal Committee of
Lower Saxony
Prof. Dr. Rüdiger Rauskolb
Ruhruniversität Bochum
Dr. Ulrich Pötter
Prof. Dr. G. Rohwer
Midwifery Research Unit
Dr. Mechthild M. Gross
Midwifery Association of Lower
Saxony
Elmire Frick, Uschi Fietz
Former Staff
Katja Stahl, Gertrud Ayerle, Susanne
Simon, Dr. Cornelia Frömke, Christiane
Schwarz
Students
Kirstin Hähnlein, Kathy Radtke
Midwifery Students
Hildesheim – Anna Ritter
Oldenburg – Maren Gerlach,
Alexandra Zahner
Braunschweig
Thuine
Midwifery Research Unit
Dr. Mechthild M. Gross
Midwifery Research Unit
Dr. Mechthild M. Gross