Mary McGinley

Randomised, controlled trial of efficacy of midwife-managed care

BACKGROUND Midwife-managed programmes of care are being widely implemented although there has been little investigation of their efficacy. We have compared midwife-managed care with shared care (ie, care divided among midwives, hospital doctors, and general practitioners) in terms of clinical efficacy and womens satisfaction. METHODS We carried out a randomised controlled trial of 1299 pregnant women who had no adverse characteristics at booking (consent rate 81.9%). 648 women were assigned midwife-managed care and 651 shared care. The research hypothesis was that compared with shared care, midwife-managed care would produce fewer interventions, similar (or more favourable) outcomes, similar complications, and greater satisfaction with care. Data were collected by retrospective review of case records and self-report questionnaires. Analysis was by intention to treat. FINDINGS Interventions were similar in the two groups or lower with midwife-managed care. For example, women in the midwife-managed group were less likely than women in shared care to have induction of labour (146 [23.9%] vs 199 [33.3%]; 95% CI for difference 4.4-14.5). Women in the midwife-managed group were more likely to have an intact perineum and less likely to have had an episiotomy (p = 0.02), with no significant difference in perineal tears. Complication rates were similar. Overall, 32.8% of women were permanently transferred from midwife-managed care (28.7% for clinical reasons, 3.7% for non-clinical reasons). Women in both groups reported satisfaction with their care but the midwife-managed group were significantly more satisfied with their antenatal (difference in mean scores 0.48 [95% CI 0.41-0.55]), intrapartum (0.28 [0.18-0.37]), hospital-based postnatal care (0.57 [0.45-0.70]), and home-based postnatal care (0.33 [0.25-0.42]). INTERPRETATION We conclude that midwife-managed care for healthy women, integrated within existing services, is clinically effective and enhances womens satisfaction with maternity care.

Changing childbirth, I and II

1. A break or faltering of fetal growth as measured by serial ultrasound or fundal height measurements; 2. For late onset of asymmetric IUGR, evidence of recent loss of adipose tissue, sometimes inferred from ratio of length to abdominal circumference. but perhaps more reliably inferred from clinical signs of recent subcutaneous tissue loss at delivery, such as a wrinkly skin with a deficit of adipose tissue; 3. The relation of birthweight for gestational age compared with that of siblings in the absence of persistent pathological growth retarding factors affecting all pregnancies. 4. The relation of birthweight for gestational age relative to that of the source population : that is, population birthweight centile which is frequently expressed as a dichotomy, SGA or not-SGA. The fourth observation is the least valid, the most easily available and therefore used most often. However, SGA is only associated with IUGR, which means that while the group of SGA infants includes a higher proportion of IUGR infants than will be found in appropriately grown (AGA) or large for gestational age (LGA) infants, some SGA infants will have attained their optimal birthweight and some AGA and LGA infants may have failed to reach their optimal birthweight. The use of SGA as a surrogate measure for IUGR should be confined to statistical (epidemiological) studies from which we can infer a worse outcome in terms of mortality (Battaglia & Lubchenco 1967) or spastic cerebral palsy (Blair & Stanley 1992) from among those who are IUGR than among those who are not. However, we have no means of knowing which individuals are IUGR simply from their birthweight for gestational age percentile position (Blair & Stanley 1992, p. 99). While Chard, Yoong and Macintosh demonstrate an appreciation of the distinction between IUGR and SGA, the two terms are then confused by their definition of IUGR in terms of birthweight centiles. In contrast, Battaglia and Lubchenco (1967) do not use the term IUGR. If the distinction between SGA and IUGR is rigorously maintained, the problems raised by Chard, Yoong and Macintosh disappear. The proportion of SGA in a population is fixed by definition. The proportion of IUGR (if it can ever be defined as a dichotomous variable) will vary with the health of that population and may even be zero in genetically normal infants born at term to healthy mothers following normal pregnancies. However, since our observation of gestational health is far from perfect and genetic screening neither all-encompassing nor universal, the perfect pregnancy can never be assured. Thus the possibility of IUGR at term must always be considered.