乌鸦传媒

Women who gave birth using midwifery-model care had fewer postpartum emergency department (ED) visits than those who had conventional obstetrics-model care, a Canadian retrospective study of more than 100,000 women found.

In the midwifery model, 6.7% of women had an unscheduled ED visit within the first 42 days postpartum compared with 8.4% of those in the traditional obstetrics model (adjusted relative risks [aRR] 0.78, 95% CI 0.73-0.83), reported Carla Sorbara, RM, MPP, MSc, of North York General Hospital in Toronto, and colleagues.

Those in the midwifery model also had fewer ED visits in the first week postpartum (aRR, 0.71, 95% CI 0.65-0.77) and lower odds of a low-acuity ED visit within 42 days postpartum (aRR 0.73, 95% CI 0.64 to 0.82), authors wrote .

Those who had spontaneous vaginal birth or assisted vaginal birth had a lower risk of ED visits within 42 days in the midwifery model (aRR 0.72, 95% CI 0.66-0.78 and aRR 0.70, 95% CI 0.60-0.82, respectively). However, there was no significant association for cesarean birth.

"While all women in Ontario have access to fully funded antenatal, intrapartum, and postpartum care, the emphasis on early postpartum care under the provincially funded and regulated midwifery model may be associated with a reduction in ED use postpartum," the authors concluded.

In the midwifery-model group, 41% had a transfer of intrapartum care to an obstetrician and "a lower relative risk of ED use was seen comparing midwifery-model vs obstetrics-model among women who did not require transfer of care, but not among those who did," the authors wrote.

Canada has universal healthcare and Ontario's government-funded midwifery program has existed for 30 years. However, midwives and obstetricians work in different care models. The midwifery model "prioritizes 24-hour on-call service, postpartum home visits, and continuity of care," the authors noted. Midwives also have group practices, visit patients several times in the first week after birth, and continue these visits into the 6-week postpartum period to help with breastfeeding, wound care, and check for concerning developments.

Meanwhile, obstetric providers offer antenatal care in a clinic and women are discharged 24 to 48 hours after birth. There is usually only one routine follow-up visit at 6 weeks postpartum, so any care for complications tends to take place in the ED or a family medicine office. Sorbara told 乌鸦传媒 that research has shown that many women skip their 6-week visit, indicating a "gap in postpartum care for moms with the traditional obstetrical model."

In the study, those in the midwifery model received a median of 7 postpartum visits, while those in the obstetrics-model had a median of 0.

"That kind of confirms for us that these visits could have been prevented possibly by access to appropriate postpartum follow-up from a provider in the community," she noted.

Cynthia Gyamfi-Bannerman, MD, MS, department chair of obstetrics, gynecology, and reproductive sciences at UC San Diego Health, told 乌鸦传媒 that "those of us who care for pregnant people during delivery and in the postpartum period have wanted the ability to see our patients more closely for years, but the models of healthcare, particularly in the United States, are not consistent with that desire" and that they "believed that more access to care would be better in the postpartum period, and this study adds evidence to support that notion."

Gyamfi-Bannerman also noted that what is still not known is "whether this is related to the provider (midwives or physicians) or the access by the provider model. I would surmise that it's the latter."

In this retrospective population-based cohort study, primiparous, low-risk women ages 11 to 50 who gave birth in an Ontario hospital between April 1, 2012 and February 1, 2018 were studied. Women who had missing data about their body mass index or gestational age at birth, who used the family physician model of care, and those with unknown perinatal care clinician type were excluded, as were those without a valid insurance number. There were 81,871 women (78%) in the obstetric group and 23,124 (22%) in the midwifery group.

The primary outcome was any unscheduled ED visit 42 days postpartum or less. Any ED visits within 7 days of the index hospital discharge date, admission to hospital within 42 days of hospital discharge, and low-acuity ED visits within 42 days were secondary outcomes.

The authors noted several limitations, including the observational study design. Also, why people went to the ED was not evaluated, though past studies have cited abdominal pain, wound-related issues, and urinary issues as common reasons for going to the ED after birth.

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