For Low-Risk Women, Care From a Nurse-Midwife Is a Safe Option in Pregnancy
For women with a low risk of perinatal complications, care involving collaboration between a certified nurse-midwife and a physician, and the option of delivering at a birth center, is as safe as traditional physician-based care and entails the use of fewer medical procedures.1 In a prospective study of nearly 3,000 low-income women, those who received collaborative care and those who received traditional care had similar rates of major maternal and neonatal complications. Interventions such as cesarean delivery and the use of epidural anesthesia were significantly less common in the collaborative care group than among women who received traditional care.
Study participants were low-income women who enrolled for prenatal care before 33 weeks' gestation at any of several San Diego sites in 1994-1996. Those in the collaborative care group attended sites where obstetricians and nurse-midwives were part of the same practice, comprehensive services (including case management and social services) were offered and women at low perinatal risk were given the option of delivering at a large freestanding birth center. Those in the traditional care group saw obstetricians or obstetric residents at prenatal clinics or private physician offices, and delivered in hospitals.
The analyses, including 1,808 women receiving collaborative care and 1,149 receiving traditional care, were based primarily on data from medical records. Analysts examined maternal and neonatal medical outcomes and use of resources; they calculated risk differences, adjusted for potentially confounding variables, to assess the statistical significance of apparent disparities between the groups.
Because enrollment criteria were designed to ensure comparability of the two groups at baseline, their background profiles were generally similar. In each group, about one in five women were teenagers and most of the rest were in their 20s or early 30s, slightly more than half had given birth before, four in 10 were married and fewer than one in five had a postsecondary education. The proportions who were Hispanic, came from Mexico and spoke only Spanish were significantly larger among women receiving collaborative care (55-86%) than among those getting traditional care (26-61%). Similar proportions of both groups reported smoking during pregnancy, but the proportions reporting alcohol use while pregnant and a history of substance abuse were higher among those being cared for in a traditional practice than among those receiving collaborative care. Overall, 16-17% of each group were at risk of adverse perinatal outcomes because of complications in a previous pregnancy or a major medical problem (chronic hypertension or renal disease, diabetes, heart disease of HIV infection).
Major complications before, during and after delivery occurred at the same rate in both groups of women, but abnormalities in the fetal heart rate were significantly more common in the traditional care group (19%) than in the collaborative care group (11%). Technical interventions such as oxytocin augmentation, epidural anesthesia, narcotic analgesia, intravenous fluid, fetal monitoring and episiotomy were used significantly more frequently in the traditional than the collaborative group; less-technical resources (oral fluids or food, ambulation, and tub bath or shower) were used more often in the collaborative group.
Women in collaborative care had a higher rate than others of normal vaginal delivery (81% vs. 63%), and lower rates of cesarean (11% vs. 19%) or assisted vaginal delivery (8% vs. 18%). Forty-four percent of women receiving collaborative care, compared with 12% receiving traditional care, spent less than 24 hours in the birth center or hospital; 10% and 16%, respectively, spent more than 72 hours at the facility where they delivered.
A number of characteristics were related to the type of care women received. During pregnancy, emergency-room visits were more common among women getting physician-based care, and use of comprehensive services was more common among those in collaborative care. The proportions of women beginning prenatal care in the first trimester and receiving an intermediate level of care were lower among those attending a collaborative practice (37% and 7%, respectively) than among those seeing physicians (44% and 12%); the proportion receiving inadequate prenatal care, however, did not differ between groups. Finally, 92% of women in collaborative care breast-fed after leaving the delivery site, compared with 83% of those who received physician-based care.
Infants born to women in the two study groups were similar with regard to gestational age, birth weight and size; Apgar scores and rates of major neonatal complications also were the same regardless of type of care received. Rates of admission to neonatal intensive care, use of ventilation and readmission of the infant did not differ by type of care; however, sepsis workup with up to three days of antibiotic treatment occurred more frequently in the traditional care group than in the collaborative care group (5% vs. 2%).
The researchers conclude that collaborative care with the option of delivering at a birth center and traditional prenatal care "are different health care service routes to a common end point: safe outcomes for mothers and infants." They add that because collaborative care uses fewer expensive resources and procedures than traditional care, "managed care organizations, local and state governments, and obstetric providers should consider inclusion of collaborative management/birth center programs in their array of covered or offered services."—D. Hollander
1. Jackson DJ et al., Outcomes, safety, and resource utilization in a collaborative care birth center program compared with traditional physician-based perinatal care, American Journal of Public Health, 2003, 93(6):999-1006.