Comparison of Labor and Delivery Care Provided by Certified Nurse-Midwives and Physicians: A Systematic Review, 1990 to 2008

Wound management provided by advanced practice nurses: a scoping review

OBJECTIVE

The objective of the review was to map the similarities and differences in the wound care practices of nurse practitioners, clinical nurse specialists, and advanced practice registered nurses, globally.

INTRODUCTION

Advanced practice nurses have graduate education and advanced scope of practice. Adding advanced wound care training to their skill set provides an opportunity for advanced practice nurses to provide wound care.

INCLUSION CRITERIA

This review considered for inclusion studies of advanced practice nurses globally who are registered nurses with graduate-level education and advanced training (certification/education) in wound care in any setting.

METHODS

The review was conducted using JBI methodology for scoping reviews. The databases searched included MEDLINE, CINAHL, ProQuest Nursing and Allied Health, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Scopus, and ProQuest Dissertations and Theses. To reflect changes in the advanced practice nursing scope of practice, searches were limited to articles published from 2011 onward. Articles in languages other than English were translated. Two reviewers independently reviewed titles and abstracts; relevant sources were retrieved in full and screened for eligibility against the inclusion criteria. An additional independent reviewer resolved any disagreements. Data were extracted using a data extraction tool. Extracted data included similarities and differences in wound care practice (type of wound, practice setting, treatments).

RESULTS

There were 2504 abstracts screened, and 158 articles were screened at full text. Seven articles were included in this review: 3 sources from the United States, 2 from Australia, and 1 each from Canada and The Netherlands. All 7 sources focused on nurse practitioners. Wound care education varied from certification in wound ostomy to a master's education in wounds. The practice setting varied; there were 2 primary care clinics, 2 community clinics, a wound care center; a suburban hospital, and a study that included tertiary, community, and residential care. Treatments varied, but the sources specific to pressure injuries discussed assessments, cleansing, dressings, topical products, and offloading surfaces/equipment. One source examined the impact of hiring nurse practitioners as wound care consultants. Sources that discussed treatments for various wounds described comprehensive assessments, diagnostic investigations, referrals, wound management, and medications prescribed.

CONCLUSIONS

This review outlined the characteristics of advanced practice nurses providing wound care and their practice settings, types of wounds, and treatments provided. Many articles on advanced practice nurses with advanced wound care expertise lack a description of the graduate-level education and/or the specifics regarding wound care certification. This prevents comparison of advanced practice nurses with each other and with other providers regarding the impact that advanced practice nurses have on the health care system in relation to wound care, including cost, access to services, and patient satisfaction.

CPD providers can positively impact practice by better understanding how APNs are educated, licenced, and certified

Advanced practice nurses (APNs) care for various patient populations in a wide variety of settings. The four types of APNs in the USA (certified nurse practitioner, clinical nurse specialist, certified nurse-midwife, and certified registered nurse anaesthetist) have differences and commonalities related to education, licensure, and certification. Care provided by APNs has been demonstrated to be of high quality, and APNs are active and engaged participants in continuing professional development (CPD) as CPD is required to maintain licensure and board certification. APNs also frequently function as clinical and academic faculty.

Influence of the maternity unit and region of delivery on episiotomy practice in France: a nationwide population-based study

INTRODUCTION

Our objective was to identify factors associated with episiotomy practice in France, in particular, characteristics of the maternity units and regions of delivery.

MATERIAL AND METHODS

We performed a national cross-sectional population-based study in all French maternity units in 2016 including 9284 women with vaginal delivery. Our outcome was the performance of an episiotomy. After stratification for parity, associations of episiotomy practice with individual and organizational characteristics and the region of delivery were estimated with multilevel logistic regression models. The variability in maternity unit episiotomy rates explained by the characteristics studied was estimated by the proportional change in variance.

RESULTS

A total of 19.9% of the women had an episiotomy. The principal factors associated with episiotomy practice were maternal and obstetric and delivery in a maternity unit with <2000 annual deliveries. After adjusting for individual, obstetric and organizational characteristics, the practice of episiotomy was strongly associated with women's region of delivery. Additionally, women's individual characteristics did not explain the significant variability in episiotomy rates between maternity units (P < 0.001) but maternity unit characteristics partly did (proportion of variance explained: 7.2% for primiparas and 13.6% for multiparas) and regional differences still more (18% and 30.7%, respectively).

CONCLUSIONS

Episiotomy practices in France in 2016 varied strongly between maternity units, largely due to regional differences. Targeted actions by the regional perinatal care networks may reduce the national episiotomy rate and standardize practices.

Maternity care clinician inclusion in Medicaid Accountable Care Organizations

BACKGROUND

Medicaid Accountable Care Organizations (ACO) are increasingly common, but the network breadth for maternity care is not well described. The inclusion of maternity care clinicians in Medicaid ACOs has significant implications for access to care for pregnant people, who are disproportionately insured by Medicaid.

PURPOSE

To address this, we evaluate obstetrician-gynecologists (OB/GYN), maternal-fetal medicine specialists (MFM), certified nurse midwives (CNM), and acute care hospital inclusion in Massachusetts Medicaid ACOs.

METHODOLOGY/APPROACH

Using publicly available provider directories for Massachusetts Medicaid ACOs (n = 16) from December 2020 -January 2021, we quantify obstetrician-gynecologists, maternal-fetal medicine specialists, CNMs, and acute care hospital with obstetric department inclusion in each Medicaid ACO. We compare maternity care provider and acute care hospital inclusion across and within ACO type. For Accountable Care Partnership Plans, we compare maternity care clinician and acute care hospital inclusion to ACO enrollment.

RESULTS

Primary Care ACO plans include 1185 OB/GYNs, 51 MFMs, and 100% of Massachusetts acute care hospitals, but CNMs were not easily identifiable in the directories. Across Accountable Care Partnership Plans, a mean of 305 OB/GYNs (median: 97; range: 15-812), 15 MFMs (Median: 8; range: 0-50), 85 CNMs (median: 29; range: 0-197), and half of Massachusetts acute care hospitals (median: 23.81%; range: 10%-100%) were included.

CONCLUSION AND PRACTICE IMPLICATIONS

Substantial differences exist in maternity care clinician inclusion across and within ACO types. Characterizing the quality of included maternity care clinicians and hospitals across ACOs is an important target of future research. Highlighting maternal healthcare as a key area of focus for Medicaid ACOs-including equitable access to high-quality obstetric providers-will be important to improving maternal health outcomes.

Maternal and neonatal outcomes of trial of labor compared with elective cesarean delivery according to predicted likelihood of vaginal delivery

OBJECTIVE

The vaginal birth after cesarean (VBAC) calculator developed by the Maternal-Fetal Medicine Units Network (MFMU) helps to identify the likelihood of VBAC. We sought to compare adverse maternal and neonatal outcomes of trial of labor after cesarean (TOLAC) to those of elective cesarean delivery after stratifying by VBAC likelihood.

STUDY DESIGN

This was a retrospective cohort study of all women whose primary low transverse segment cesarean delivery and subsequent singleton term delivery with vertex presentation occurred at an academic center from January 2009 to June 2018. Only data from the second pregnancy were analyzed. The final analysis included 835 women. The MFMU VBAC calculator was used to assess the likelihood of VBAC. The two primary outcomes were composite adverse maternal (death or severe maternal complications) and neonatal outcomes (perinatal death or severe neonatal complications). The analyses were stratified based on the VBAC likelihood (less than 60% and 60-100%). Multivariable logistic regression was used to calculate adjusted odds ratio (OR) and 95% confidence interval (CI), controlling for predefined covariates.

RESULTS

Among women with VBAC likelihood less than 60%, TOLAC compared with elective cesarean was associated with increased odds of the primary adverse maternal outcome (16.4% vs. 4.2%; adjusted OR 4.60 [95%CI 1.48-14.35]) and the primary adverse neonatal outcome (17.8% vs. 6.3%; adjusted OR 3.93 [95%CI 1.31-11.75]). Among women with VBAC likelihood of 60-100%, TOLAC compared with elective cesarean was associated with decreased odds of the primary adverse maternal outcome (6.4% vs. 11%; adjusted OR 0.47 [95%CI 0.25-0.89]) and similar odds of the primary adverse neonatal outcome (6.7% vs. 8.3%; adjusted OR 0.98 [95%CI 0.52-1.84]).

CONCLUSIONS

Among women with a history of a primary low transverse cesarean delivery, those who underwent TOLAC compared to those who had elective cesarean had increased odds of adverse maternal and neonatal outcomes when VBAC likelihood was less than 60%.

Advancing quality and safety of perinatal services in India: opportunities for effective midwifery integration

India has made significant progress in improving maternal and child health. However, there are persistent disparities in maternal and child morbidity and mortality in many communities. Mistreatment of women in childbirth and gender-based violence are common and reduce women's sense of safety. Recently, the Government of India committed to establishing a specialized midwifery cadre: Nurse Practitioners in Midwifery (NPMs). Integration of NPMs into the current health system has the potential to increase respectful maternity care, reduce unnecessary interventions, and improve resource allocation, ultimately improving maternal-newborn outcomes. To synthesize the evidence on effective midwifery integration, we conducted a desk review of peer-reviewed articles, reports and regulatory documents describing models of practice, organization of health services and lessons learned from other countries. We also interviewed key informants in India who described the current state of the healthcare system, opportunities, and anticipated challenges to establishing a new cadre of midwives. Using an intersectional feminist theoretical framework, we triangulated the findings from the desk review with interview data to identify levers for change and recommendations. Findings from the desk review highlight that benefits of midwifery on outcomes and experience link to models of midwifery care, and limited scope of practice and prohibitive practice settings are threats to successful integration. Interviews with key informants affirm the importance of meeting global standards for practice, education, inter-professional collaboration and midwifery leadership. Key informants noted that the expansion of respectful maternity care and improved outcomes will depend on the scope and model of practice for the cadre. Domains needing attention include building professional identity; creating a robust, sustainable education system; addressing existing inter-professional issues and strengthening referral and quality monitoring systems. Public and professional education on midwifery roles and scope of practice, improved regulatory conditions and enabling practice environments will be key to successful integration of midwives in India.

Bridging the Chasm between Pregnancy and Health over the Life Course: A National Agenda for Research and Action

BACKGROUND

Many pregnant people find no bridge to ongoing specialty or primary care after giving birth, even when clinical and social complications of pregnancy signal need. Black, indigenous, and all other women of color are especially harmed by fragmented care and access disparities, coupled with impacts of racism over the life course and in health care.

METHODS

We launched the initiative "Bridging the Chasm between Pregnancy and Health across the Life Course" in 2018, bringing together patients, advocates, providers, researchers, policymakers, and systems innovators to create a National Agenda for Research and Action. We held a 2-day conference that blended storytelling, evidence analysis, and consensus building to identify key themes related to gaps in care and root causes of inequities. In 2019, more than 70 stakeholders joined six working groups to reach consensus on strategic priorities based on equity, innovation, effectiveness, and feasibility.

FINDINGS

Working groups identified six key strategic areas for bridging the chasm. These include: 1) progress toward eliminating institutional and interpersonal racism and bias as a requirement for accreditation of health care institutions, 2) infrastructure support for community-based organizations, 3) extension of holistic team-based care to the postpartum year and beyond, with integration of doulas and community health workers on the team, 4) extension of Medicaid coverage and new quality and pay-for-performance metrics to link maternity care and primary care, 5) systems to preserve maternal narratives and data across providers, and 6) alignment of research with women's lived experiences.

CONCLUSIONS

The resulting agenda presents a path forward to remedy the structural chasms in women's health care, with key roles for advocates, policymakers, researchers, health care leaders, educators, and the media.

Race, Medicaid Coverage, and Equity in Maternal Morbidity

BACKGROUND

Severe maternal morbidity (SMM) affects 50,000 deliveries in the United States annually, with around 1.5 times the rates among Medicaid-covered relative to privately covered deliveries. Furthermore, large racial inequities exist in SMM for non-Hispanic Black women and Hispanic women with rates being 2.1 and 1.4 times higher than White women, respectively. This study aimed to compare the differences in SMM among women of different races/ethnicities and delivery insurance types. Quantifying the rates of SMM based on the intersection of race/ethnicity and insurance status can help to elucidate how multiple forms of oppression and racism may contribute to the substantial inequities in SMM among Black women.

METHODS

Using hospital discharge data from the Healthcare Cost and Utilization Project National Inpatient Sample (years 2016 and 2017), we conducted multivariate logistic models to evaluate equity in maternal outcomes among women with different primary payers, overall and stratified by race/ethnicity.

RESULTS

We found a rate of SMM equal to 138.3 per 10,000 deliveries. Differences in the rate of SMM among non-Hispanic Black, non-Hispanic Asian, and Hispanic women relative to White women were lower among Medicaid-covered deliveries relative to deliveries of all payer types. For example, among all payers, Black women had 2.17 (221.3 vs. 102.1 per 10,000) times the rate of SMM compared with White women; however, among Medicaid-covered deliveries, Black women had 1.84 (227.3 vs. 123.2) times the rate. Despite increased risk associated with Medicaid coverage (adjusted odds ratio, 1.12; 95% confidence interval, 1.07-1.16), the risk was no longer significant in the stratified regression including Black women (adjusted odds ratio, 1.06; 95% confidence interval, 0.98-1.15).

CONCLUSIONS

Our findings suggest that Black women with Medicaid do not have higher rates of SMM relative to Black women with private insurance. National and state policy efforts should continue to focus on addressing structural racism and other socioeconomic drivers of adverse maternal outcomes, including barriers to high-quality care among women with Medicaid coverage.

Challenges in the Triage Care of Low-Risk Laboring Patients: A Comparison of 2 Models of Practice

Triage and the timing of admission of low-risk pregnant women can affect the use of augmentation, epidural, and cesarean. The purpose of this analysis was to explore these outcomes in a community hospital by the type of provider staffing triage. This was a retrospective cohort study of low-risk nulliparous women with a term, vertex fetus laboring in a community hospital. Bivariate and multivariable statistics evaluated associations between triage provider type and labor and birth outcomes. Patients in this sample (N = 335) were predominantly White (89.5%), with private insurance (77.0%), and married (71.0%) with no significant differences in these characteristics by triage provider type. Patients admitted by midwives had lower odds of oxytocin augmentation (adjusted odds ratio [aOR] = 0.50, 95% confidence interval [CI] = 0.29-0.87), epidural (aOR = 0.29, 95% CI = 0.12-0.69), and cesarean birth (aOR = 0.308, 95% CI = 0.14-0.67), compared with those triaged by physicians after controlling for patient characteristics and triage timing. This study provides additional context to midwives as labor triage providers for healthy, low-risk pregnant individuals; however, challenges persisted with measurement. More research is needed on the specific components of care during labor that support low-risk patients to avoid medical interventions and poor outcomes.

Certified Nurse-Midwives in Rural Kansas Hospitals: A Survey of Senior Hospital Administrators

INTRODUCTION

Little is known about the nurse-midwifery workforce in rural Kansas hospitals, despite Kansas facing a shortage of primary care physicians providing maternity care rurally. This study investigated the current number of hospitals with certified nurse-midwives (CNMs) with privileges to attend births in Kansas hospitals located in frontier, rural, and densely settled rural counties and anticipated trends in the size of the CNM workforce at hospitals over the next 5 years.

METHODS

Electronic surveys were distributed to senior hospital administrators at 94 hospitals in rural Kansas from June to July 2019. The survey included both open and closed-ended questions related to scope of CNM privileges, collaborative agreements, and forecasted trends in the CNM workforce in rural Kansas.

RESULTS

Fifty-six hospitals completed the survey. Only one hospital reported having CNM-attended births. Twenty-eight of 37 hospital administrators agreed CNMs should have collaborative agreements with physicians. Most respondents did not anticipate the number of CNMs with privileges to increase at their hospitals over the next 5 years.

DISCUSSION

Future research should focus on understanding the factors limiting CNM expansion in rural Kansas, because CNMs represent an untapped, additional maternity care workforce for rural Kansas.

Comparison of Nurse-Midwife and Physician Birth Outcomes in the Military Health System

The purpose of this study is to identify the socioeconomic and demographic characteristics of women cared for by Certified Nurse-Midwives (CNMs) versus physicians in the Military Health System (MHS) and compare birth outcomes between provider types. The MHS is one of America's largest and most complex health care systems. Using the Military Health System Data Repository, this retrospective study examined TRICARE beneficiaries who gave birth during 2012-2014. Analysis included frequency of patients by perinatal services, descriptive statistics, and logistic regression analysis by provider type. To account for differences in patient and pregnancy risk, odds ratios were calculated for both high-risk and general risk population. There were 136,848 births from 2012 to 2014, and 30.8% were delivered by CNMs. Low-risk women whose births were attended by CNMs had lower odds of a cesarean birth, induction/augmentation of labor, complications of birth, postpartum hemorrhage, endometritis, and preterm birth and higher odds of a vaginal birth, vaginal birth after cesarean, and breastfeeding than women whose births were attended by physicians. These results have implications for the composition of the women's health workforce. In the MHS, where CNMs work to the fullest scope of their authority, CNMs attended almost 4 times more births than our national average. An example to other U.S. systems and high-income countries, this study adds to the growing body of evidence demonstrating that when CNMs practice to the fullest extent of their education, they provide quality health outcomes to more women.

Factors Associated with Unplanned Primary Cesarean Birth: Secondary Analysis of the Listening to Mothers in California Survey

BACKGROUND

In many countries, cesarean section has become the most common major surgical procedure. Most nations have high cesarean birth rates, suggesting overuse. Due to the excess harm and expense associated with unneeded cesareans, many health systems are seeking approaches to safe reduction of cesarean rates. Surveys of childbearing women are a distinctive and underutilized source of data for examining factors that may contribute to cesarean reduction.

METHODS

To identify factors associated with unplanned primary cesarean birth, we carried out a secondary analysis of the Listening to Mothers in California Survey, limited to the subgroup who had not had a previous cesarean birth and did not have a planned primary cesarean (n = 1,964). Participants were identified through birth certificate sampling and contacted initially by mail and then by telephone, text message and email, as available. Sampled women could participate in English or Spanish, on any device or with a telephone interviewer. Following bivariate demographic, knowledge and attitude, and labor management analyses, we carried out multivariable analyses to adjust with covariates and identify factors associated with unplanned primary cesarean birth.

RESULTS

Whereas knowledge, attitudes, preferences and behaviors of the survey participants were not associated with having an unplanned primary cesarean birth, their experience of pressure from a health professional to have a cesarean and a series of labor management practices were strongly associated with how they gave birth. These practices included attempted induction of labor, early hospital admission, and labor augmentation. Women's reports of pressure from a health professional to have a primary cesarean were strongly related to the likelihood of cesarean birth.

CONCLUSIONS

While women largely wish to avoid unneeded childbirth interventions, their knowledge, preferences and care arrangement practices did not appear to impact their likelihood of an unplanned primary cesarean birth. By contrast, a series of labor management practices and perceived health professional pressure to have a cesarean were associated with unplanned primary cesarean birth. Improving ways to engage childbearing women and implementing changes in labor management and communication practices may be needed to reduce unwarranted cesarean birth.

Regional variation in Black infant mortality: The contribution of contextual factors

BACKGROUND

Compared to other racial/ethnic groups, infant mortality rates (IMR) are persistently highestamong Black infants in the United States, yet there is considerable regional variation. We examined state and county-level contextual factors that may explain regional differences in Black IMR and identified potential strategies for improvement.

METHODS AND FINDINGS

Black infant mortality data are from the Linked Birth/Infant Death files for 2009-2011. State and county contextual factors within social, economic, environmental, and health domains were compiled from various Census databases, the Food Environment Atlas, and the Area Health Resource File. Region was defined by the nine Census Divisions. We examined contextual associations with Black IMR using aggregated county-level Poisson regression with standard errors adjusted for clustering by state. Overall, Black IMR varied 1.5-fold across regions, ranging from 8.78 per 1,000 in New England to 13.77 per 1,000 in the Midwest. In adjusted models, the following factors were protective for Black IMR: higher state-level Black-White marriage rate (rate ratio (RR) per standard deviation (SD) increase = 0.81, 95% confidence interval (CI):0.70-0.95), higher state maternal and child health budget per capita (RR per SD = 0.96, 95% CI:0.92-0.99), and higher county-level Black index of concentration at the extremes (RR per SD = 0.85, 95% CI:0.81-0.90). Modeled variables accounted for 35% of the regional variation in Black IMR.

CONCLUSIONS

These findings are broadly supportive of ongoing public policy efforts to enhance social integration across races, support health and social welfare program spending, and improve economic prosperity. Although contextual factors accounted for about a third of regional variation, further research is needed to more fully understand regional variation in Black IMR disparities.

Delivery care by obstetric nurses in maternity hospitals linked to the Rede Cegonha, Brazil - 2017

This study aimed to assess whether nurses' presence in delivery care in maternity hospitals linked to the Rede Cegonha program promotes access to best obstetric practices during labor and delivery. We conducted an evaluative study in 2017 in all 606 SUS maternity hospitals that joined this strategic policy in all Brazilian states. We collected data from maternity hospital managers and puerperae. The analysis was performed at two levels: hospital with or without a nurse in delivery care; and professionals that attended vaginal delivery, whether doctors or nurses. We used best practices and interventions for vaginal deliveries and cesarean section rates as dependent variables. We included 5.016 subjects for analyses of vaginal deliveries and 9.692 to calculate cesarean section rates. Multiple regressions were adjusted for geographic region, maternity hospital size, and puerperae skin color and parity. Maternity hospitals with nurses in delivery care used more the partograph and less oxytocin, lithotomy, episiotomy, and cesarean section. Deliveries attended by nurses had more frequent use of the partograph and a lower likelihood of lithotomy and episiotomy. The inclusion of nurses in vaginal delivery care has successfully brought women closer to a more physiological and respectful delivery.

Variation of intrapartum care and cesarean rates among practitioners attending births of low-risk, nulliparous women

BACKGROUND

Variation in hospital cesarean birth rates across the United States is likely because of differences in practitioner practice patterns. Yet, few studies conducted in the last twenty years have examined the relationships between practitioner characteristics and the use of intrapartum interventions and cesarean birth. The objective of this study was to examine associations among practitioner characteristics and the use of amniotomy, epidural, oxytocin augmentation, and cesarean birth in low-risk women with spontaneous onset of labor.

METHODS

A secondary analysis was performed using data collected by the Consortium on Safe Labor. The sample included nulliparous term singleton vertex (NTSV) births with spontaneous onset of labor (n = 13 196) from 2002 to 2007 across eight hospitals. Generalized linear mixed models were conducted to examine outcomes.

RESULTS

The cesarean birth rate ranged from 7.2% to 18.9% across hospitals and from 0% to 53.3% across physicians. Practice type (P < .05) and specialty type (P < .0001) were associated with physician cesarean birth rates. Compared with obstetrician/gynecologists, midwives were nearly twice as likely to use no intrapartum interventions (relative risk 1.80 [CI 95 1.45-2.24]) and 26% less likely to use amniotomy-epidural-oxytocin (0.74 [0.62-0.89]). Family practice physicians had a 21% lower likelihood of using amniotomy-epidural-oxytocin (0.79 [0.67-0.94]) and a 53% lower likelihood of performing cesarean births (0.47 [0.35-0.63]).

CONCLUSIONS

Wide variation in hospital and physician cesarean birth rates was observed in this sample of low-risk, nulliparous women. Practitioner practice type and specialty were significantly associated with the use of intrapartum interventions. Interprofessional practitioner education could be one strategy to reduce variation of intrapartum care and cesarean birth.

Comparison of Midwifery and Obstetric Care in Low-Risk Hospital Births

OBJECTIVE

To compare midwife and obstetrician labor practices and birth outcomes in women with low-risk pregnancies delivered in the hospital.

METHODS

We conducted a retrospective cohort study of singleton births of 37 0/7-42 6/7 weeks of gestation at 11 hospitals between January 1, 2014, and December 31, 2018. Exclusions included intrapartum transfer from home-birth center, antepartum stillbirth, previous cesarean delivery, practitioner other than midwife or obstetrician, prelabor cesarean, prepregnancy maternal disease, and pregnancy complications or risk factors. Interventions (induction, artificial rupture of membranes, epidural, oxytocin, and episiotomy), mode of delivery, maternal outcomes (third- or fourth-degree laceration, postpartum hemorrhage, blood transfusion, and severe maternal morbidity), and newborn outcomes (shoulder dystocia, 5-minute Apgar score less than 7, resuscitation at delivery, birth trauma, and neonatal intensive care unit admission) were examined by practitioner type. We used modified Poisson regression models adjusted for individual confounders to assess risk ratios, stratified by parity, for health care provider type and perinatal outcomes.

RESULTS

The study cohort comprised 23,100 births (3,816 midwife and 19,284 obstetrician). Compared with obstetricians, midwifery patients had significantly lower intervention rates, an approximately 30% lower risk of cesarean delivery in nulliparous patients (adjusted relative risk [aRR] 0.68; 95th% CI 0.57-0.82), and an approximately 40% lower risk of cesarean in multiparous patients (aRR 0.57; 95th% CI 0.36-0.89). Operative vaginal birth was also less common in nulliparous patients (aRR 0.73; 95th% CI 0.57-0.93) and multiparous patients (aRR 0.30; 95th% CI 0.14-0.63). Shoulder dystocia was more common in multiparous patients receiving midwifery care (aRR 1.42; 95th% CI 1.04-1.92).

CONCLUSIONS

In low-risk pregnancies, midwifery care in labor was associated with decreased intervention, decreased cesarean and operative vaginal births, and, in multiparous women, an increased risk for shoulder dystocia. Greater integration of midwifery care into maternity services in the United States may reduce intervention in labor and potentially even cesarean delivery, in low-risk pregnancies. Larger research studies are needed to evaluate uncommon but important maternal and newborn outcomes.

Outcomes of trial of labor after cesarean birth by provider type in low-risk women

BACKGROUND

One approach to decreasing the cesarean birth rate in the United States is to increase the availability of birth attendants, including certified nurse-midwives (CNMs), who offer trial of labor after cesarean (TOLAC). We examined associations between provider type and mode of birth for women attempting vaginal birth after cesarean (VBAC).

METHODS

We performed a retrospective cohort study at a United States academic medical center using prospectively-collected data (2005-2012). We included healthy women with term singleton vertex pregnancies after one or two prior cesareans who were managed by obstetricians or CNMs. We assessed unplanned cesarean birth by provider type using univariate and logistic regression and examined labor interventions and predicted VBAC success.

RESULTS

Overall VBAC success was 88% for 502 included patients. Unplanned cesarean rates were similar by provider type. Black race, no prior VBAC, recurring clinical indication for cesarean, labor augmentation/induction, and any Pitocin use were associated with increased unplanned cesarean. Higher parity and early-term gestational age at delivery were associated with decreased unplanned cesarean. Postpartum hemorrhage and composite maternal morbidity were increased with unplanned cesarean, but there was no difference in neonatal outcome by mode of delivery or provider type. Obstetricians had slightly higher composite adverse maternal outcomes. Nomogram-predicted VBAC success but not provider type was associated with unplanned cesarean.

CONCLUSIONS

Unplanned cesarean was similar for patients attempting labor after cesarean managed by midwives or obstetricians. Increasing the number of CNMs who manage TOLAC may help decrease the high rate of cesareans.

The "Cocoon," first alongside midwifery-led unit within a Belgian hospital: Comparison of the maternal and neonatal outcomes with the standard obstetric unit over 2 years

OBJECTIVES

Our aim was to compare maternal and neonatal outcomes of women with a low-risk pregnancy attending the "Cocoon," an alongside midwifery-led birth center and care pathway, with women with a low-risk pregnancy attending the traditional care pathway in a tertiary care hospital in Belgium.

METHODS

We performed a retrospective cohort study of maternal and neonatal outcomes of women with a low-risk pregnancy who chose to adhere to the Cocoon pathway of care (n = 590) and women with a low-risk pregnancy who chose the traditional pathway of care (n = 394) from March 1, 2014, to February 29, 2016. We performed all analyses using an intention-to-treat approach.

RESULTS

In this setting, the cesarean birth rate was 10.3% compared with 16.0% in the traditional care pathway (adjusted odds ratios [aOR] 0.42 [95% CI 0.25-0.69]), the induction rate was 16.3% compared with 30.5% (0.46 [0.30-0.69]), the epidural analgesia rate was 24.9% compared with 59.1% (0.15 [0.09-0.22]), and the episiotomy rate was 6.8% compared with 14.5% (0.31 [0.17-0.56]). There was no increase in adverse neonatal outcomes. Intrapartum and postpartum transfer rates to the traditional pathway of care were 21.1% and 7.1%, respectively.

CONCLUSIONS

Women planning their births in the midwifery-led unit, the Cocoon, experienced fewer interventions with no increase in adverse neonatal outcomes. Our study gives initial support for the introduction of similar midwifery-led care pathways in other hospitals in Belgium.

Preventing Cesarean Birth in Women with Obesity: Influence of Unit-Level Midwifery Presence on Use of Cesarean among Women in the Consortium on Safe Labor Data Set

INTRODUCTION

Maternal obesity is associated with slow labor progression and unplanned cesarean birth. Midwives use fewer medical interventions during labor, and the women they care for have lower cesarean birth rates, compared with low-risk, matched groups of women cared for by physicians. The primary aim of this study was to examine associations between midwifery unit-level presence and unplanned cesarean birth in women with different body mass index (BMI) ranges. Unit-level presence of midwives was analyzed as a representation of a unique set of care practices that exist in settings where midwives work.

METHODS

A retrospective cohort study was conducted using Consortium on Safe Labor data from low-risk, healthy women who labored and gave birth in medical centers with (n = 9795) or without (n = 13,398) the unit-level presence of midwives. Regression models were used to evaluate for associations between unit-level midwifery presence and 1) the incidence of unplanned cesarean birth and 2) in-hospital labor durations with stratification by maternal BMI and adjustment for maternal demographic and pregnancy factors.

RESULTS

The odds of unplanned cesarean birth among women who gave birth in centers with midwives were 16% lower than the odds of cesarean birth among similar women at who gave birth at centers without midwives (adjusted odds ratio, 0.84; 95% CI, 0.77-0.93). However, women whose BMI was above 35.00 kg/m2 at labor admission had similar odds of cesarean birth, regardless of unit-level midwifery presence. In-hospital labor duration prior to unplanned cesarean was no different by unit-level midwifery presence in nulliparous women whose BMI was above 35.00 kg/m2 .

DISCUSSION

Although integration of midwives into the caregiving environment of medical centers in the United States was associated with overall decrease in the incidence of cesarean birth, increased maternal BMI nevertheless remained positively associated with these outcomes.

Midwifery presence in United States medical centers and labor care and birth outcomes among low-risk nulliparous women: A Consortium on Safe Labor study

BACKGROUND

The presence of midwives in a health system may affect perinatal outcomes but has been inadequately described in United States settings. Our objective was to compare labor processes and outcomes for low-risk nulliparous women birthing in United States medical centers with interprofessional care (midwives and physicians) versus noninterprofessional care (physicians only).

METHODS

We conducted a retrospective cohort study using Consortium on Safe Labor data from low-risk nulliparous women who birthed in interprofessional (n = 7393) or noninterprofessional centers (n = 6982). Unadjusted, adjusted (age, race, health insurance type), propensity-adjusted, and propensity-matched logistic regression models were used to compare outcomes.

RESULTS

There was concordance across logistic regression models, the most restrictive and conservative of which were propensity-matched models. With this approach, women at interprofessional medical centers, compared with women at noninterprofessional centers, were 74% less likely to undergo labor induction (risk ratio [RR] 0.26; 95% CI 0.24-0.29) and 75% less likely to have oxytocin augmentation (RR 0.25; 95% CI 0.22-0.29). The cesarean birth rate was 12% lower at interprofessional centers (RR 0.88; 95% CI 0.79-0.98). Adverse neonatal outcomes occurred in only 0.3% of births and were thus too rare to be modeled.

CONCLUSIONS

The care processes and birth outcomes at interprofessional and noninterprofessional medical centers differed significantly. Nulliparous women receiving care at interprofessional centers were less likely to experience induction, oxytocin augmentation, and cesarean than women at noninterprofessional centers. Labor care and birth outcome differences between interprofessional and noninterprofessional centers may be the result of the presence of midwives and interprofessional collaboration, organizational culture, or both.

Intrapartum Care and Experiences of Women with Midwives Versus Obstetricians in the Listening to Mothers in California Survey

Introduction

Many studies based on hospital records or vital statistics have found that childbearing women experience benefits of lower rates of intervention with midwifery care versus obstetric care during labor and birth. Surveys of women's views and experiences can provide a richer analysis when comparing intrapartum care of midwives and obstetricians.

Methods

This study was a secondary analysis of data from the population‐based Listening to Mothers in California survey. The sample, which was representative of 2016 California hospital births, was drawn from birth certificate files and oversampled midwife‐attended births. Women responded to the survey in English or Spanish on any device or with a telephone interviewer. The present analysis is based on 1421 of the 2539 participants who identified a midwife or obstetrician as their attendant at a vaginal birth. A bivariate analysis of demographic, attitudinal, and intrapartum variables was conducted. A multivariable model included sociodemographic and attitudinal variables as covariates.

Results

Bivariate analyses found significant socioeconomic differences by type of intrapartum care provider, with women in California attended by midwives more likely to be well educated and privately insured than women attended by obstetricians. Women with midwife birth attendants were less likely to report experiencing various intrapartum medical interventions, less likely to experience pressure to have epidural analgesia, and more likely to report that staff encouraged the woman's decision making. Adjusted odds ratios found that women with midwives were less likely to experience medical interventions, including attempted labor induction; labor augmentation; and use of pain medications, epidural analgesia, and intravenous fluids; and less likely to report pressure to have labor induction or epidural analgesia. Women cared for by midwives were more likely to experience any nonpharmacologic pain relief measures and nitrous oxide and to agree that hospital staff encouraged their decision making.

Discussion

Using women's own reports of their care experiences and adjusting for possible differences in women's attitudes and case mix, we found that midwifery care of women who had vaginal births was associated with reduced use of medical interventions and increased women's decisional latitude during labor and birth.

A novel classification for evaluating episiotomy practices: application to the Burgundy perinatal network

Background

Though the rate of episiotomy has decreased in France, the overall episiotomy rate was 20% in the 2016 national perinatal survey. We aimed to develop a classification to facilitate the analysis of episiotomy practices and to evaluate whether episiotomy is associated with a reduction in the rate of obstetric anal sphincter injuries (OASIS) for each subgroup.

Methods

This population-based study included all the deliveries that occurred in the Burgundy Perinatal Network from 2011 to 2016. The main outcome was episiotomy, which was identified thanks to the French Common Classification of Medical Procedures. An ascending hierarchical cluster analysis was performed to build the classification. A clinical audit using the classification was conducted yearly in all obstetric units. The episiotomy rates were described throughout the study period for each subgroup of the classification. The OASIS rates were evaluated by subgroup and the association between mediolateral episiotomy and OASIS was investigated for each subgroup.

Results

Our analyses included 81,290 pregnant women. The classification comprised 7 subgroups: ₍₁₎ nulliparous single cephalic at term, ₍₂₎ nulliparous single cephalic at term with instrumental delivery, ₍₃₎ multiparous single cephalic at term, ₍₄₎ multiparous single cephalic at term with instrumental delivery, ₍₅₎ all preterm deliveries (< 37 weeks gestation), ₍₆₎ all breech deliveries, ₍₇₎ all multiple deliveries.

Episiotomy rates ranged from 6.2% in Group 3 to 40.9% in Group 2. From 2011 to 2016, every group except breech deliveries experienced a significant decrease in episiotomy rates, ranging from − 28.1 to − 61.0%.

The prevalence of OASIS was the highest in Groups 2 (3.0%) and 4 (2.2%). Overall OASIS rates did not significantly differ with episiotomy use (P = 0.25). However, we found that the use of episiotomy was associated with a reduction in OASIS rates in Groups 1 and 2 (odds ratio 0.6 [95% CI 0.4–0.9] and 0.4 [0.3–0.5], respectively). This reduction was only observed in Group 4 with forceps delivery (odds ratio 0.4 [0.1–0.9]).

Conclusion

We developed the first classification for the evaluation of episiotomy practices based on 7 clinically relevant subgroups. This easy-to-use tool can help obstetricians and midwives improve their practices through self-assessment.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2424-2) contains supplementary material, which is available to authorized users.

Characteristics of stakeholder involvement in systematic and rapid reviews: a methodological review in the area of health services research

OBJECTIVE

Engaging stakeholders in reviews is considered to generate more relevant evidence and to facilitate dissemination and use. As little is known about stakeholder involvement, we assessed the characteristics of their engagement in systematic and rapid reviews and the methodological quality of included studies. Stakeholders were people with a particular interest in the research topic.

DESIGN

Methodological review.

SEARCH STRATEGY

Four databases (Medline, Embase, Cochrane database of systematic reviews, databases of the University of York, Center for Reviews and Dissemination (CRD)) were searched based on an a priori protocol. Four types of reviews (Cochrane and non-Cochrane systematic reviews, rapid and CRD rapid reviews) were retrieved between January 2011 and October 2015, pooled by potential review type and duplicates excluded. Articles were randomly ordered and screened for inclusion and exclusion criteria until 30 reviews per group were reached. Their methodological quality was assessed using AMSTAR and stakeholder characteristics were collected.

RESULTS

In total, 57 822 deduplicated citations were detected with potential non-Cochrane systematic reviews being the biggest group (56 986 records). We found stakeholder involvement in 13% (4/30) of Cochrane, 20% (6/30) of non-Cochrane, 43% (13/30) of rapid and 93% (28/30) of CRD reviews. Overall, 33% (17/51) of the responding contact authors mentioned positive effects of stakeholder involvement. A conflict of interest statement remained unmentioned in 40% (12/30) of non-Cochrane and in 27% (8/30) of rapid reviews, but not in Cochrane or CRD reviews. At most, half of non-Cochrane and rapid reviews mentioned an a priori study protocol in contrast to all Cochrane reviews.

CONCLUSION

Stakeholder engagement was not general practice, except for CRD reviews, although it was more common in rapid reviews. Reporting factors, such as including an a priori study protocol and a conflict of interest statement should be considered in conjunction with involving stakeholders.

Cost-effectiveness analysis of natural birth and elective C-section in supplemental health

OBJECTIVE

To conduct a cost-effectiveness analysis of natural childbirth and elective C-section for normal risk pregnant women.

METHODS

The study was conducted from the perspective of supplemental health, a health subsystem that finances private obstetric care, represented in Brazil by health plan operators. The reference populations were normal risk pregnant women, who could undergo natural childbirth or elective C-section, subdivided into primiparous and multiparous women with previous uterine scar. A decision analysis model was constructed including choice of delivery types and health consequences for mother and newborn, from admission for delivery to maternity hospital discharge. Effectiveness measures were identified from the scientific literature, and cost data obtained by consultation with health professionals, health plan operators’ pricing tables, and pricing reference publications of health resources.

RESULTS

Natural childbirth was dominant compared with elective C-section for primiparous normal risk pregnant women, presenting lower cost (R$5,210.96 versus R$5,753.54) and better or equal effectiveness for all evaluated outcomes. For multiparous women with previous uterine scar, C-section presented lower cost (R$5,364.07) than natural childbirth (R$5,632.24), and better or equal effectiveness; therefore, C-section is more efficient for this population.

CONCLUSIONS

It is necessary to control and audit C-sections without clinical indication, especially with regard to primiparous women, contributing to the management of perinatal care.

The Effect of Prior Work Experiences on the Preparation and Employment of Early-Career Midwives

INTRODUCTION

Strategic recruitment, preparation, distribution, and retention of US midwives requires a solid body of knowledge about midwives' education and workforce experiences. Although half of US midwifery education programs currently require or prefer prior registered nurse (RN) employment, data are lacking about whether and how these criteria influence efforts to scale up the workforce to meet reproductive care workforce shortages and maldistributions.

METHODS

This cross-sectional research used an online survey, developed using the framework of Social Cognitive Career Theory. Early-career midwives were contacted through the American College of Nurse-Midwives electronic mailing list and social media during the fall of 2016. Statistical analysis allowed for linkage of data related to the following constructs: personal characteristics, prior RN employment, educational experiences, employment situations, career perceptions, and future plans.

RESULTS

All participants (N = 244) were certified nurse-midwives. Compared with those without prior RN employment, midwives with prior RN employment were more likely to enroll part-time in distance programs and complete single majors or degrees. During enrollment, the 2 groups experienced the same degree of mentorship and cultural support and were similarly likely to attend 30 births and to pass the certification examination on first attempt. In the workforce, those with prior RN employment were 6 years older and more likely to work full-time. The 2 groups demonstrated no significant differences in their career perspectives or future career plans.

DISCUSSION

Despite anecdotal concerns about training midwives who lack RN work experience, an individual without prior RN employment offers the workforce an employee who completes midwifery education at a younger age, may be educated more quickly, and is more likely to have earned a dual major or degree. Those with prior RN employment are more likely to work full-time. Both groups may offer benefits to education and the workforce.

A Literature Review of Midwifery-Led Care in Reducing Labor and Birth Interventions

Certified nurse-midwives are usually recognized as independently practicing advanced practice registered nurses because they provide maternity care to pregnant women in various states. In the United States, certified nurse-midwives are historically underused. Culture favors physician-led care, with 90% of all births attended by physicians. Midwifery-led care is considered high-touch/low-intervention and is guided by a philosophy of care that regards pregnancy and childbirth as normal life events for most women. Evidence from the literature supports midwifery-led care as being safe, effective, and associated with fewer interventions.

[Budgetary impact of spontaneous vaginal delivery and elective cesarean section without clinical indication in BrazilImpacto presupuestario del parto vaginal espontáneo y de la cesárea electiva sin indicación clínica en Brasil]

Objetivos

Estimar o impacto orçamentário do excesso de cesarianas sem indicação clínica em comparação ao parto vaginal para gestantes de risco habitual no Sistema Único de Saúde (SUS) no Brasil.

Métodos

A análise se baseou em um modelo estático. A população de referência foi a de gestantes de risco habitual. O horizonte temporal foi de 5 anos. Utilizou-se um modelo de regressão de Poisson para projetar o número de nascidos vivos de 2016 a 2020. O cálculo do custo direto da cesariana eletiva e do parto vaginal foi baseado em dois estudos prévios, nos quais foi calculado o valor esperado dos procedimentos através de um modelo de decisão analítico que incluiu as intercorrências clínicas da internação até a alta da maternidade. O cenário de referência dessa análise considerou 29% de cesarianas em excesso no país.

Resultados

O custo total da assistência ao parto e nascimento para as primíparas e multíparas sem cicatriz uterina no cenário de referência foi de US$ 707,5 milhões para o ano de 2016. No cenário 1 (melhor cenário), que considerou apenas o parto vaginal para essas gestantes, houve uma redução de custos de US$ 76,5 milhões ao ano. Para multíparas, a comparação do cenário de referência com o melhor cenário gerou economia de mais de US$ 4 milhões ao ano.

Conclusões

Os resultados indicam que o incentivo ao parto vaginal gera economia.

Progression of care among women who use a midwife for prenatal care: Who remains in midwife care?

BACKGROUND

Prenatal care provided by midwives provides a safe and cost-effective alternative to care provided by physicians. However, no studies have evaluated the frequency of women who leave midwifery care, in a hospital setting. Our study objectives were to measure the frequency of transfers of care to physicians, to describe the sociodemographic and pregnancy-related characteristics of women who transferred to the care of a physician during prenatal care and at delivery, and to assess correlates of these transfers.

METHODS

We used electronic medical records to perform a retrospective cohort study of women who delivered at The Ohio State University Wexner Medical Center (OSUWMC) and had at least one prenatal care visit within OSUWMC's network. We report descriptive findings, using proportions and means with standard deviations. We used logistic regression, with Firth's bias correction as necessary, to assess correlates of transferring to a physician during prenatal care and at delivery.

RESULTS

Most women who initiated prenatal care with a midwife remained in midwifery care throughout delivery, with 4.7% transferring to a physician during prenatal care, and an additional 21.4% transferring to a physician during delivery. After adjusting for pregnancy-related factors, the black race was statistically significantly associated with leaving midwifery care during prenatal care (adjusted odds ratio AOR 3.0 [95% CI 1.4-6.6]) and delivery (AOR 2.5 [95% CI 1.5-4.3]).

CONCLUSION

Findings indicate that most women remain in midwifery care throughout pregnancy, but raise important questions with respect to the possible role that race has in pregnancy care.

Mapping integration of midwives across the United States: Impact on access, equity, and outcomes

METHODS

Our multidisciplinary team examined published regulatory data to inform a 50-state database describing the environment for midwifery practice and interprofessional collaboration. Items (110) detailed differences across jurisdictions in scope of practice, autonomy, governance, and prescriptive authority; as well as restrictions that can affect patient safety, quality, and access to maternity providers across birth settings. A nationwide survey of state regulatory experts (n = 92) verified the 'on the ground' relevance, importance, and realities of local interpretation of these state laws. Using a modified Delphi process, we selected 50/110 key items to include in a weighted, composite Midwifery Integration Scoring (MISS) system. Higher scores indicate greater integration of midwives across all settings. We ranked states by MISS scores; and, using reliable indicators in the CDC-Vital Statistics Database, we calculated correlation coefficients between MISS scores and maternal-newborn outcomes by state, as well as state density of midwives and place of birth. We conducted hierarchical linear regression analysis to control for confounding effects of race.

RESULTS

MISS scores ranged from lowest at 17 (North Carolina) to highest at 61 (Washington), out of 100 points. Higher MISS scores were associated with significantly higher rates of spontaneous vaginal delivery, vaginal birth after cesarean, and breastfeeding, and significantly lower rates of cesarean, preterm birth, low birth weight infants, and neonatal death. MISS scores also correlated with density of midwives and access to care across birth settings. Significant differences in newborn outcomes accounted for by MISS scores persisted after controlling for proportion of African American births in each state.

CONCLUSION

The MISS scoring system assesses the level of integration of midwives and evaluates regional access to high quality maternity care. In the United States, higher MISS Scores were associated with significantly higher rates of physiologic birth, less obstetric interventions, and fewer adverse neonatal outcomes.

Women's Health Outpatient Care Teams: Focus on Advanced Practice Providers

Team-based care in the outpatient women's health setting has the potential to help alleviate the demand for women's health care providers and to deliver improved quality of care to the growing population of US women. Although teamwork is necessary in the current health care system, most of the current obstetrics and gynecology and advanced practice provider (APP) workforce were not trained for collaborative practice. Core competencies for building an effective outpatient women's health care team are explained and current evidence regarding the specific role of APPs in women's health care is reviewed.

Who Uses a Midwife for Prenatal Care and for Birth in the United States? A Secondary Analysis of Listening to Mothers III

BACKGROUND

Although midwife care is slowly but consistently increasing in the United States, not much is known regarding women who use a midwife. Our objectives were to compare the sociodemographic and health history characteristics, and the quality of patient-provider communication, between women who used a midwife and those who used a physician for prenatal care and/or birth.

METHODS

We performed a cross-sectional analysis of the nationally representative Listening to Mothers III survey. We report descriptive findings using weighted proportions and means with standard deviations. We used the two one-sided tests procedure to assess the equivalence of women who used midwives and those who used physicians.

RESULTS

Nearly 13% of women used a midwife for prenatal care or as a birth attendant. Women who used a midwife for prenatal care were similar to women who used a physician in most sociodemographic and health history characteristics, as well as their patient-provider communication scores, with the exception of the percentage of White (61.7 ± 5.0 [midwives], 54.3 ± 1.5 [physicians]) and married women (68.7 ± 4.9 [midwives], 60.6 ± 1.5 [physicians]). Women who used a midwife as a birth attendant were similar to women who used a physician as a birth attendant in most characteristics, with the exception of age over 35 years (7.5 ± 1.6 [midwives], 15.7 ± 1.1 [physicians]) and Special Supplemental Nutrition Program for Women, Infants, and Children support (56.8 ± 4.9 [midwives], 50.0 ± 1.6 [physicians]).

CONCLUSIONS

Women who use midwives are similar to those who use physicians and our findings do not confirm the common perception that midwife patients are a self-selected group of wealthier, more educated women.

Competitive effects of scope of practice restrictions: Public health or public harm?

The demand for healthcare professionals is predicted to grow significantly over the next decade. Securing an adequate workforce is of primary importance to ensure the health and wellbeing of the population in an efficient manner. Occupational licensing laws and related restrictions on scope of practice (SOP) are features of the market for healthcare professionals and are also controversial. At issue is a balance between protecting the public health and removing anticompetitive barriers to entry and practice. In this paper, we examine the case of SOP restrictions for certified nurse midwives (CNMs) and evaluate the effects of changes in states' SOP laws on markets for CNMs and on maternal and infant outcomes. We find that SOP laws are neither helpful nor harmful in regards to health outcomes but states that have no SOP-based barriers have lower rates of induced labor and Cesarean section births. We discuss the implications for state policy.

Comparison of Births by Provider, Place, and Payer in New Hampshire

This study examines maternity care in a rural state by birth attendant, place of birth, and payer of birth. It is a secondary analysis of birth certificate data in New Hampshire between the years 2005 and 2012. Results revealed that in New Hampshire, the majority of births occurred in the hospital setting (98.6%). Physicians attended 75.8% of births, certified nurse midwives attended 17%, and certified professional midwives attended 1%. Medicaid coverage was the payer source for 28% of all births, compared with 44.9% nationally. Women with a private payer source were more likely than women with Medicaid or other payer sources to have a cesarean section. The findings demonstrate quality of care outcomes among a range of clinicians and settings, providing a policy argument for expanding maternity care options.

Factors associated with recovery from 1 minute Apgar score <4 in live, singleton, term births: an analysis of Malaysian National Obstetrics Registry data 2010-2012

BACKGROUND

The neonatal Apgar score at 5 min has been found to be a better predictor of outcomes than the Apgar score at 1 min. A baby, however, must pass through the first minute of life to reach the fifth. There has been no research looking at predictors of recovery (Apgar scores ≥7) by 5 min in neonates with 1 min Apgar scores <4.

METHODS

An analysis of observational data was conducted using live, singleton, term births recorded in the Malaysian National Obstetrics Registry between 2010 and 2012. A total of 272,472 live, singleton, term births without congential anomalies were recorded, of which 1,580 (0.59%) had 1 min Apgar scores <4. Descriptive methods and bi- and multi-variable logistic regression were used to identify risk factors associated with recovery (5 min Apgar score ≥7) from 1 min Apgar scores <4.

RESULTS

Less than 1% of births have a 1 min Apgar scores <4. Only 29.4% of neonates with 1 min Apgar scores <4 recover to a 5 min Apgar score ≥7. Among uncomplicated vaginal deliveries, after controlling for other factors, deliveries by a doctor of neonates with a 1 min Apgar score <4 had odds of recovery 2.4 times greater than deliveries of neonates with a 1 min Apgar score <4 by a nurse-midwife. Among deliveries of neonates with a 1 min Apgar score <4 by doctors, after controlling for other factors, planned and unplanned CS was associated with better odds of recovery than uncomplicated vaginal deliveries. Recovery was also associated with maternal obesity, and there was some ethnic variation - in the adjusted analysis indigenous (Orang Asal) Malaysians had lower odds of recovery.

CONCLUSIONS

A 1 min Apgar score <4 is relatively rare, and less than a third recover by five minutes. In those newborns the qualification of the person performing the delivery and the type of delivery are independent predictors of recovery as is maternal BMI and ethnicity. These are associations only, not necessarily causes, and they point to potential areas of research into health systems factors in the labour room, as well as possible biological and cultural factors.

Perspectives: Using Results from HRSA's Health Workforce Simulation Model to Examine the Geography of Primary Care

OBJECTIVE

Inform health planning and policy discussions by describing Health Resources and Services Administration's (HRSA's) Health Workforce Simulation Model (HWSM) and examining the HWSM's 2025 supply and demand projections for primary care physicians, nurse practitioners (NPs), and physician assistants (PAs).

DATA SOURCES

HRSA's recently published projections for primary care providers derive from an integrated microsimulation model that estimates health workforce supply and demand at national, regional, and state levels.

PRINCIPAL FINDINGS

Thirty-seven states are projected to have shortages of primary care physicians in 2025, and nine states are projected to have shortages of both primary care physicians and PAs. While no state is projected to have a 2025 shortage of primary care NPs, many states are expected to have only a small surplus.

CONCLUSIONS

Primary care physician shortages are projected for all parts of the United States, while primary care PA shortages are generally confined to Midwestern and Southern states. No state is projected to have shortages of all three provider types. Projected shortages must be considered in the context of baseline assumptions regarding current supply, demand, provider-service ratios, and other factors. Still, these findings suggest geographies with possible primary care workforce shortages in 2025 and offer opportunities for targeting efforts to enhance workforce flexibility.

Maternity Outcomes in Manitoba Women: A Comparison between Midwifery-led Care and Physician-led Care at Birth

BACKGROUND

Registered midwives, obstetricians/gynecologists, and general or family practice physicians (GPs) provide maternity care across Canada. Few North American studies have assessed whether maternity outcomes differ across these three groups. This study compared maternal and neonatal outcomes of low-risk pregnant women whose birth was attended by registered midwives, obstetricians/gynecologists, and family practice physicians in Winnipeg, Manitoba from 2001/02 to 2012/13.

METHODS

Descriptive statistics and logistic regression were used to examine differences in types of intervention, mode of delivery, and outcomes by provider type among low-risk women. Logistic regression models controlled for socio-demographic and birth-related covariates.

RESULTS

Low-risk births comprised 83,774 (48.7%) of total births (n = 171,910). The adjusted odds ratio (aOR), (95% confidence interval) for midwife vs OB/GYN showed women who had a midwife attend the birth had reduced odds of having an episiotomy 0.47 (0.40-0.54), epidural 0.25 (0.23-0.27), and cesarean delivery 0.13 (0.10-0.16) and their infants had less Neonatal Intensive Care Unit admissions 0.28 (0.18-0.43). The aOR for GP versus OB/GYN showed women who had a GP had reduced odds of having an epidural/spinal 0.83 (0.79-0.88) and cesarean delivery 0.44 (0.40-0.48).

CONCLUSIONS

The effectiveness of Manitoba maternity services can be improved with increased use of integrated midwifery services. Future research should examine how midwifery and physician-led models of care differ, and the influence of these differences on birth outcomes and cost-effectiveness to the health care system. Improvement of data tracking systems is also needed.

The Association of Expanded Access to a Collaborative Midwifery and Laborist Model With Cesarean Delivery Rates

OBJECTIVE

To examine the association between expanded access to collaborative midwifery and laborist services and cesarean delivery rates.

METHODS

This was a prospective cohort study at a community hospital between 2005 and 2014. In 2011, privately insured women changed from a private practice model to one that included 24-hour midwifery and laborist coverage. Primary cesarean delivery rates among nulliparous, term, singleton, vertex women and vaginal birth after cesarean delivery (VBAC) rates among women with prior cesarean delivery were compared before and after the change. Multivariable logistic regression models estimated the effects of the change on the odds of primary cesarean delivery and VBAC; an interrupted time-series analysis estimated the annual rates before and after the expansion.

RESULTS

There were 3,560 nulliparous term singleton vertex deliveries and 1,324 deliveries with prior cesarean delivery during the study period; 45% were among privately insured women whose care model changed. The primary cesarean delivery rate among these privately insured women decreased after the change, from 31.7% to 25.0% (P=.005, adjusted odds ratio [OR] 0.56, 95% confidence interval [CI] 0.39-0.81). The interrupted time-series analysis estimated a 7% drop in the primary cesarean delivery rate in the year after the expansion and a decrease of 1.7% per year thereafter. The VBAC rate increased from 13.3% before to 22.4% afterward (adjusted OR 2.03, 95% CI 1.08-3.80).

CONCLUSION

The change from a private practice to a collaborative midwifery-laborist model was associated with a decrease in primary cesarean rates and an increase in VBAC rates.

LEVEL OF EVIDENCE

II.