Effect of a collaborative interdisciplinary maternity care program on perinatal outcomes

Background:

The number of physicians providing maternity care in Canada is decreasing, and the rate of cesarean delivery is increasing. We evaluated the effect on perinatal outcomes of an interdisciplinary program designed to promote physiologic birth and encourage active involvement of women and their families in maternity care.

Methods:

We conducted a retrospective cohort study involving 1238 women who attended the South Community Birth Program in Vancouver, Canada, from April 2004 to October 2010. The program offers comprehensive, collaborative, interdisciplinary care from family physicians, midwives, community health nurses and doulas to a multiethnic, low-income population. A comparison group, matched for neighbourhood of residence, maternal age, parity and gestational age at delivery, comprised 1238 women receiving standard care in community-based family physician, obstetrician and midwife practices. The primary outcome was the proportion of women who underwent cesarean delivery.

Results:

Compared with women receiving standard care, those in the birth program were more likely to be delivered by a midwife (41.9% v. 7.4%, p < 0.001) instead of an obstetrician (35.5% v. 69.6%, p < 0.001). The program participants were less likely than the matched controls to undergo cesarean delivery (relative risk RR] 0.76, 95% confidence interval CI] 0.68–0.84) and, among those with a previous cesarean delivery, more likely to plan a vaginal birth (RR 3.22, 95% CI 2.25–4.62). Length of stay in hospital was shorter in the program group for both the mothers (mean ± standard deviation 50.6 ± 47.1 v. 72.7 ± 66.7 h, p < 0.001) and the newborns (47.5 ± 92.6 v. 70.6 ± 126.7 h, p < 0.001). Women in the birth program were more likely than the matched controls to be breastfeeding exclusively at discharge (RR 2.10, 95% CI 1.85–2.39).

Interpretation:

Women attending a collaborative program of interdisciplinary maternity care were less likely to have a cesarean delivery, had shorter hospital stays on average and were more likely to breastfeed exclusively than women receiving standard care.In the last 2 decades, Canada has seen a dramatic reduction in the number of physicians providing maternity care.^1,2 Reasons for this decline have included liability concerns, lifestyle issues and perceived competence.³ A large proportion of obstetricians and family physicians who practise maternity care will reach retirement age in the next 10 years.⁴ The reduction in maternity care providers has been linked with hospital closures in rural settings and increasing difficulty in accessing obstetric care for women in all settings.⁴ Although the introduction of regulated midwifery promises some relief, midwives currently attend less than 10% of births.⁵Recent times have also seen a dramatic increase in the rates of interventions during childbirth, particularly cesarean delivery, which has risen from 17% in the 1990s to 28% in 2009 in Canada.⁶ This increase has occurred despite a lack of evidence that maternal and neonatal outcomes are improved with cesarean delivery.^7–10 Increasing rates of surgical delivery have placed an added burden on care provider resources, because of the associated intrapartum and postpartum complications¹¹ and increased length of stay in hospital.¹²In addition, increasing diversity, especially in urban settings, has made the delivery of maternity care more challenging. In the province of British Columbia, 16% of the population speaks neither official language at home.¹³ This proportion is as high as 32% in Vancouver, the province’s largest city and the setting of our study. There is evidence that immigrant women are at increased risk of receiving obstetric interventions and less likely to breastfeed.^14,15In response to these issues, the South Community Birth Program was established to provide comprehensive, collaborative maternity care from family physicians, midwives, community health nurses and doulas to a multiethnic, low-income population. The program aims to promote physiologic birth while encouraging women and their families to assume an active role in their maternity care. In the current study, we evaluated the impact of the program on perinatal outcomes.