Comparison of Midwifery Care to Medical Care in Hospitals in the Quebec Pilot Projects Study: Clinical Indicators

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ABSTRACT

The purpose of this study was to compare indicators of process and outcome of midwifery services provided in the Quebec pilot projects to those associated with standard hospital-based medical services. Women receiving each type of care (961 per group) were matched on the basis of socio-demographic characteristics and level of obstetrical risk: We found midwifery care to be associated with less obstetrical intervention and a reduction in selected indicators of maternal morbidity (caesarean section and severe perineal injury). Far neonatal outcome indicators; midwifery care was associated with a mixture of benefits and risks: fewer babies with preterm birth and low birthweight, but a trend toward a higher stillbirth ratio and more frequent requirement for neonatal resuscitation. The study design does not permit to conclude that the associations were causal in nature. However, the high stillbirth rate observed in the group of warren who were selected for midwife care raises concerns both regarding the appropriateness of the screening procedures for admission to such care and regarding the quality of care itself.

ABREGE

L'objectif de cette etude etait de comparer la nature et les effets des services de sages-femmes offerts Bans les maisons de naissance et mis en place daps le cadre de projets-pilotes au Quebec, aver les services medicaux courants dispenses duns des hopitaux. Au total, 1 922 femmes ont ete jumelees (961 par groupe) sur la base de leurs caracteristiques sociodemographiques et de leur risque obstetrical. Les resultats montrent que la pratique des sagesfemmes est associee a une utilisation moms frequente des interventions obstetricales et une reduction de certains indicateurs de morbidite (cesariennes et dechirures du perin& de 3` et 4e degre). Par contre les effets concernant La morbidite neonatale sont mitiges : moms de bebes prematures ou de pent poids a la naissance, mais une tendance vers un ratio plus eleve de mortinatalite et un besoin plus frequent de reanimation a la naissance. Le devil de l'etude ne permet pas de conclure a des associations de nature causale. Cependant, Ie taux taux de mortinatalite observe chez les femmes choisies pour recevoir les loins de sages-femmes souleve des preoccupations concernant la pertinence les procedures de selection pour l'admissibilite a ce type de spins et la qualite des spins euxmemes.

Controversy persists regarding the optimal care provider - physician or midwife for pregnant women at low obstetrical risk.1 Many studies comparing the outcomes of midwifery and medical care harbour methodological problems,2 including sample sizes that are too small to assess morbidity and mortality,3,4 failure to analyze results by intended place of delivery,5 and absence of a description of the roles of the different professionals involved in each type of care. There are only a few randomized studies.6-12 In non-randomized studies, differences in baseline characteristics between those receiving medical and midwifery care lead to difficulties in interpretation of results.

A recent meta-analysis of randomized clinical trials13 indicated that women receiving midwifery care experienced a lower risk of episiotomy (OR 0.69; 95%CI 0.61 - 0.77), a similar proportion of babies with abnormal 5-minute Apgar scores, but a non-significant trend toward an increase in perinatal mortality.

Randomized clinical trials represent the optimal design to insure the comparability of treatment groups. However in certain contexts, for reasons often related to the underlying beliefs and attitudes of care planners, providers or patients, trials cannot be carried out.14 Such was the case in the present study. The objective of the current study was to compare the process and outcomes of care for women who intended to deliver in the Quebec pilot project birth centres to those of women delivering under medical supervision in a hospital setting. Process indicators included the number of prenatal visits, and the use of obstetrical technologies in the ante- and intrapartum periods. …