An evaluation of Interprofessional group antenatal care: a prospective comparative study.

BACKGROUND: Maternal and neonatal outcomes are influenced by the nature of antenatal care. Standard pregnancy care is provided on an individual basis, with one-on-one appointments between a client and family doctor, midwife or obstetrician. A novel, group-based antenatal care delivery model was developed in the United States in the 1990s and is growing in popularity beyond the borders of the USA. The purpose of this study was to evaluate outcomes in clients receiving interprofessional group perinatal care versus interprofessional individual care in a Canadian setting. METHODS: Clients attending the South Community Birth Program (SCBP), an interprofessional, collaborative, primary care maternity program, offering both individual and group care, were invited to participate in the study. Pregnancy knowledge and satisfaction scores, and perinatal outcomes were compared between those receiving group versus individual care. Chi-square tests, general linear models and logistic regression were used to compare the questionnaire scores and perinatal outcomes between cohorts. RESULTS: Three hundred three clients participated in the study. Group care was comparable to individual care in terms of mode of birth, gestational age at birth, infant birth weight, breastfeeding rates, pregnancy knowledge, preparedness for labour and baby care, and client satisfaction. The rates of adverse perinatal outcomes were extremely low amongst SCBP clients, regardless of the type of care received (preterm birth rates ~5%). Breastfeeding rates were very high amongst all study participants (> 78% exclusive breastfeeding), as were measures of pregnancy knowledge and satisfaction. CONCLUSIONS: This is the first Canadian study to compare outcomes in clients receiving interprofessional group care versus individual care. Our observation that interprofessional group care outcomes and satisfaction were as good as interprofessional individual care has important implications for the antenatal care of clients and for addressing the projected maternity provider crisis facing Canada, particularly in small and rural communities. Further study of group-based care including not only client satisfaction, but also provider satisfaction, is needed. In addition, research into the role of interprofessional care in meeting the needs and improving perinatal outcomes of different populations is necessary.

Models of organization of maternity care by midwives in Canada: a descriptive review.

Most provinces in Canada now offer regulated midwifery, but the way services are delivered across the country varies. The Canadian Midwifery Regulators Consortium has identified a need to examine the different ways in which care is being organized; this is to determine what elements are essential to maintain and where flexibility is desirable, in order to promote growth of the profession and maximize the contribution of midwifery to the provision of services. In April 2012 a planning meeting (funded by Canadian Institutes of Health Research) brought together midwifery leaders, researchers, regulators, and lead clinicians of several maternity service programs across Canada. The various approaches to organizing care were discussed and three of the programs presented were selected for this descriptive review because of their unique approaches and ability to respond to the needs of communities and of care providers within those communities who strive to deliver sustainable maternity care. The programs include an interprofessional group-care approach in British Columbia, an expanded scope of practice in an underserved community in the Northwest Territories, and an interprofessional collaboration of primary maternity caregivers in Nova Scotia. Each is discussed in terms of the population served, the program itself, and the fit of that microsystem within the larger health care system. The organization of maternity care must address the needs of communities and providers alike to make the greatest contribution. Through collaborative and creative organizational approaches, midwives have an opportunity to contribute in a meaningful way and increase their impact on the provision of services.

Effect of a collaborative interdisciplinary maternity care program on perinatal outcomes.

BACKGROUND: The number of physicians providing maternity care in Canada is decreasing, and the rate of cesarean delivery is increasing. We evaluated the effect on perinatal outcomes of an interdisciplinary program designed to promote physiologic birth and encourage active involvement of women and their families in maternity care. METHODS: We conducted a retrospective cohort study involving 1238 women who attended the South Community Birth Program in Vancouver, Canada, from April 2004 to October 2010. The program offers comprehensive, collaborative, interdisciplinary care from family physicians, midwives, community health nurses and doulas to a multiethnic, low-income population. A comparison group, matched for neighbourhood of residence, maternal age, parity and gestational age at delivery, comprised 1238 women receiving standard care in community-based family physician, obstetrician and midwife practices. The primary outcome was the proportion of women who underwent cesarean delivery. RESULTS: Compared with women receiving standard care, those in the birth program were more likely to be delivered by a midwife (41.9% v. 7.4%, p < 0.001) instead of an obstetrician (35.5% v. 69.6%, p < 0.001). The program participants were less likely than the matched controls to undergo cesarean delivery (relative risk [RR] 0.76, 95% confidence interval [CI] 0.68-0.84) and, among those with a previous cesarean delivery, more likely to plan a vaginal birth (RR 3.22, 95% CI 2.25-4.62). Length of stay in hospital was shorter in the program group for both the mothers (mean ± standard deviation 50.6 ± 47.1 v. 72.7 ± 66.7 h, p < 0.001) and the newborns (47.5 ± 92.6 v. 70.6 ± 126.7 h, p < 0.001). Women in the birth program were more likely than the matched controls to be breastfeeding exclusively at discharge (RR 2.10, 95% CI 1.85-2.39). INTERPRETATION: Women attending a collaborative program of interdisciplinary maternity care were less likely to have a cesarean delivery, had shorter hospital stays on average and were more likely to breastfeed exclusively than women receiving standard care.

The attitudes of Canadian maternity care practitioners towards labour and birth: many differences but important similarities.

OBJECTIVE: Collaborative, interdisciplinary care models have the potential to improve maternity care. Differing attitudes of maternity care providers may impede this process. We sought to examine the attitudes of Canadian maternity care practitioners towards labour and birth. METHODS: We performed a cross-sectional web- and paper-based survey of 549 obstetricians, 897 family physicians (400 antepartum only, 497 intrapartum), 545 nurses, 400 midwives, and 192 doulas. RESULTS: Participants responded to 43 Likert-type attitudinal questions. Nine themes were identified: electronic fetal monitoring, epidural analgesia, episiotomy, doula roles, Caesarean section benefits, factors decreasing Caesarean section rates, maternal choice, fear of vaginal birth, and safety of birth mode and place. Obstetrician scores reflected positive attitudes towards use of technology, in contrast to midwives' and doulas' scores. Family physicians providing only antenatal care had attitudinal scores similar to obstetricians; family physicians practising intrapartum care and nurses had intermediate scores on technology. Obstetricians' scores indicated that they had the least positive attitudes towards home birth, women's roles in their own births, and doula care, and they were the most concerned about the consequences of vaginal birth. Midwives' and doulas' scores reflected opposing views on these issues. Although 71% of obstetricians supported regulated midwifery, 88.9% were against home birth. Substantial numbers of each group held attitudes similar to dominant attitudes from other disciplines. CONCLUSION: To develop effective team practice, efforts to reconcile differing attitudes towards labour and birth are needed. However, the overlap in attitudes between disciplines holds promise for a basis upon which to begin shared problem solving and collaboration.

Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician.

BACKGROUND: Studies of planned home births attended by registered midwives have been limited by incomplete data, nonrepresentative sampling, inadequate statistical power and the inability to exclude unplanned home births. We compared the outcomes of planned home births attended by midwives with those of planned hospital births attended by midwives or physicians. METHODS: We included all planned home births attended by registered midwives from Jan. 1, 2000, to Dec. 31, 2004, in British Columbia, Canada (n = 2889), and all planned hospital births meeting the eligibility requirements for home birth that were attended by the same cohort of midwives (n = 4752). We also included a matched sample of physician-attended planned hospital births (n = 5331). The primary outcome measure was perinatal mortality; secondary outcomes were obstetric interventions and adverse maternal and neonatal outcomes. RESULTS: The rate of perinatal death per 1000 births was 0.35 (95% confidence interval [CI] 0.00-1.03) in the group of planned home births; the rate in the group of planned hospital births was 0.57 (95% CI 0.00-1.43) among women attended by a midwife and 0.64 (95% CI 0.00-1.56) among those attended by a physician. Women in the planned home-birth group were significantly less likely than those who planned a midwife-attended hospital birth to have obstetric interventions (e.g., electronic fetal monitoring, relative risk [RR] 0.32, 95% CI 0.29-0.36; assisted vaginal delivery, RR 0.41, 95% 0.33-0.52) or adverse maternal outcomes (e.g., third- or fourth-degree perineal tear, RR 0.41, 95% CI 0.28-0.59; postpartum hemorrhage, RR 0.62, 95% CI 0.49-0.77). The findings were similar in the comparison with physician-assisted hospital births. Newborns in the home-birth group were less likely than those in the midwife-attended hospital-birth group to require resuscitation at birth (RR 0.23, 95% CI 0.14-0.37) or oxygen therapy beyond 24 hours (RR 0.37, 95% CI 0.24-0.59). The findings were similar in the comparison with newborns in the physician-assisted hospital births; in addition, newborns in the home-birth group were less likely to have meconium aspiration (RR 0.45, 95% CI 0.21-0.93) and more likely to be admitted to hospital or readmitted if born in hospital (RR 1.39, 95% CI 1.09-1.85). INTERPRETATION: Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.

The Collaboration for Maternal and Newborn Health: interprofessional maternity care education for medical, midwifery, and nursing students.

The Collaboration for Maternal and Newborn Health, a multidisciplinary group of maternity care providers from the University of British Columbia (UBC), received funding from Health Canada to develop interprofessional education programs for health care students. Medical, midwifery, and nursing students from UBC were invited to participate in the three programs described in this article. The Interprofessional Student Doula Support Program, a year-long program for 15 students, combines classroom learning about marginalized women with on-call doula support to attend births. The Interprofessional Normal Labour and Birth Workshop is a 5-hour event, comprised of lectures and hands-on stations about normal labour, birth, and the immediate postpartum period. The Maternity Care Club Hands-on Night occurs twice a year, and students gather to practice at maternity care stations in a casual setting. A total of 467 participants over 3 years completed evaluations of their experiences. Students rate these programs very highly in terms of benefits of multidisciplinary collaboration. Providing students with opportunities to engage with other health care disciplines enhances interest in the professions of maternity care and the benefits of collaboration.

How do physicians and midwives manage the third stage of labor?

BACKGROUND: Current practice guidelines recommend active management of the third stage of labor. We compared practices of three maternity care provider disciplines in management of third-stage labor and the justifications for their approach. METHODS: This study is a cross-sectional survey of maternity practitioners in usual practice settings in British Columbia. All 199 obstetricians, all 82 midwives, and a random sample of family physicians practicing intrapartum maternity care (one-third, or 346) were surveyed The three main outcome measures by discipline were the method preferred in managing third-stage labor, the reasons given for the chosen method, and views on the appropriateness of the current third-stage labor guideline. RESULTS: The overall response rate was 57.8 percent. Response rates indicating that the participants were "aware of guideline" were the following: obstetricians, 85.3 percent; family physicians, 53.7 percent; and midwives, 97.8 percent. Response rates indicating that the participants "agreed with guideline" were the following: obstetricians, 95.2 percent; family physicians, 97.6 percent; and midwives, 51.2 percent. Response rates indicating that "oxytocin should be given with anterior shoulder" were the following: obstetricians, 71.1 percent; family physicians, 68.3 percent; and midwives, 26.7 percent. Response rates indicating that "routine active management of third stage of labor should be the norm" were the following: obstetricians, 79.2 percent; family physicians, 60.2 percent; and midwives, 17 percent. All results were statistically significant (p < 0.01). CONCLUSIONS: A major difference was found between physicians and midwives in the management of third-stage labor. Physicians routinely implemented active management of the third stage of labor; midwives preferred expectant approaches, principally based on women's preference. Provincial data did not show differences in postpartum hemorrhage or transfusion rates by practitioner type.

Do maternity care provider groups have different attitudes towards birth?

OBJECTIVE: To compare family physicians', obstetricians' and midwives' self-reported practices, attitudes and beliefs about central issues in childbirth. DESIGN: Mail-out questionnaire. SETTING/POPULATION; All registered midwives in the province, and a sample of family physicians and obstetricians in a maternity care teaching hospital. Response rates: 91% (n = 50), 69% (n = 97) and 89% (n = 34), respectively. METHODS: A postal survey. MAIN OUTCOME MEASURES: Twenty-three five-point Likert scale items (strongly agree to strongly disagree) addressing attitudes toward routine electronic fetal monitoring, induction of labour, epidural analgesia, episiotomy, doulas, vaginal birth after caesarean section (VBACs), birth centres, provision educational material, birth plans and caesarean section. RESULTS: Cluster analysis identified three distinct clusters based on similar response to the questions. The 'MW' cluster consisted of 100% of midwives and 26% of the family physicians. The 'OB' cluster was composed of 79% of the obstetricians and 16% of the family physicians. The 'FP' cluster was composed of 58% the family physicians and 21% the obstetricians. Members of the 'OB' cluster more strongly believed that women had the right to request a caesarean section without maternal/fetal indications (P < 0.001), that epidurals early in labour were not associated with development of fetal malpositions (P < 0.001) and that increasing caesarean rates were a sign of improvement in obstetrics (P < 0.001). The 'OB' cluster members were more likely to say they would induce women as soon as possible after 41 3/7 weeks of gestation (P < 0.001) and were least likely to encourage the use of birth plans (P < 0.001). The 'MW' cluster's views were the opposite of the 'OBs' while the 'FP' cluster's views fell between the 'MW' and 'OB' clusters. CONCLUSIONS: In our environment, obstetricians were the most attached to technology and interventions including caesarean section and inductions, midwives the least, while family physicians fell in the middle. While generalisations can be problematic, obstetricians and midwives generally follow a defined and different approach to maternity care. Family physicians are heterogeneous, sometimes practising more like midwives and sometimes more like obstetricians.

An evaluation of process and protocols for planned home birth attended by regulated midwives in British Columbia.

Midwifery emerged as a self-regulated profession in British Columbia in the context of a 2-year demonstration project beginning in 1998. The project evaluated accountability among midwives, defined as the provision of safe and appropriate care and maintenance of standards of communication set by the College of Midwives of British Columbia. Adherence to protocols was measured by using documentation designed specifically for the Home Birth Demonstration Project. Hospital and transport records for selected clients were reviewed by an expert committee. Outcomes among Home Birth Demonstration Project clients were compared with outcomes among women eligible for home birth but planning to deliver in hospital. Adherence to clinical and communication protocols was 96% or higher. Planned home birth was not associated with an increase in risk but prevalence of adverse outcomes was too low to be studied with precision. Recommendations of an expert review committee have been implemented or are under review. Midwives have demonstrated a high degree of compliance with reporting requirements and protocols. Comparisons of birth outcomes of planned home versus hospital births, while supporting home birth as a choice for women, were limited in scope and require ongoing study. Integration of home birth has been a dynamic process with guidelines and policy continuing to evolve.