The quality of obstetric care in family practice: are family physicians as safe as obstetricians?

A literature review on the quality of obstetric care in family practice was conducted to determine whether family physicians are as competent in providing obstetric care as obstetricians. Three types of studies were reviewed: case series, historical cohorts, and population-based studies. No conclusion on the quality of obstetric care in family practice can be drawn from the available studies because of research design limitations. Available evidence suggests, however, that family physicians are as safe as obstetricians when delivering babies, particularly when they concentrate their efforts on providing personal prenatal care, refer high-risk pregnant women appropriately, and practice less technologically oriented care on women who deliver normal-weight babies. In addition, no evidence emerged that family physicians provided significantly poorer obstetric care than obstetricians. In fact, the results from population-based studies suggest that family physicians may be safer than obstetricians in delivering normal-weight infants because of their hypothesized less use of technological interventions in that low-risk group of patients. Further studies, especially prospective randomized trials in which the outcomes are assessed in a blinded fashion and case mix is rigorously controlled, are needed to provide a definitive answer. As practical, ethical, and economic constraints are likely to preclude such studies, the case-control design may provide a reasonable alternative.     

The promotion of private health insurance and its implications for the social organisation of healthcare: a case study of private sector obstetric practice in Chile

This paper examines some of the implications of the process of privatisation of a national healthcare system for the delivery, organisation and, ultimately, the outcome of services. Through a case study of obstetric care in Chile, we illuminate the relationships between the macro-level of political decisions, the meso-level of the organisations through which government reforms were enacted, and the micro-level of clinical practice. We show that, for a significant proportion of Chilean women seeking maternity care, privatisation has led to expanded access and to ostensibly highly-personalised relationships with specialists. However, because of the fragmentation of maternity services, the altered work patterns for obstetricians occasioned by changes in healthcare financing and the relatively weak market position of most obstetricians, this personalised care is dependent on highly technologised obstetric practices. By examining the specific organisational arrangements under which private maternity care is conducted in Chile we shed light on the connection between privately-funded maternity care and high caesarean section rates in this setting.     

Closure of rural hospital obstetric units in Missouri.

We studied 65 rural hospitals in Missouri that provided obstetric services in 1986. The hospitals were divided into three groups on the basis of their physician obstetric staff: family or general practitioners only (38 hospitals), family practitioners and obstetricians (22 hospitals), and obstetricians only (five hospitals). From birth certificate data, we detected a decline in the mean number of births in all groups of rural hospitals comparing 1980-1983 with 1984-1987. Births in family practice only hospitals declined most over the past four years (35%), whereas there was only a 4 percent decline in the number of births to rural Missouri women. In 1987, 10 of the 38 family practice only hospital obstetric units closed due to loss of physician services, whereas none of the other hospitals stopped providing obstetric care (X2 = 8.40, p less than 0.005). These findings suggest that rural hospitals with family and general practitioners exclusively on their obstetric staffs are at significant risk of closing their obstetric units.     

Can physicians be induced to resume obstetric practice?

BACKGROUND: Decreased numbers of obstetric providers during the last decade have limited access to obstetrics care, especially for some groups of women. Increasing or stabilizing the number of providers could increase access. METHODS: A questionnaire was mailed in 1989 to 1965 Washington State family physicians and obstetricians to determine their attitudes toward the practice of obstetrics. Sixty-six percent of physicians responded to the survey. RESULTS: Of those who had quit obstetrics in the previous 3 years, 42 percent of responding family physicians and 19 percent of responding obstetricians would consider resuming. Those family physicians willing to consider resuming their obstetric practices were more likely to have been in practice fewer years, employed by a health maintenance organization (HMO), or located in a rural area. A majority of all respondents cited excessive malpractice premiums and fear of malpractice suit as reasons for stopping obstetric practice. Family physicians willing to consider resuming obstetrics were more concerned about the overall number of obstetric providers in their area. Rural family physicians willing to consider resuming obstetrics listed poor backup or shared call more often as a reason they had quit. CONCLUSIONS: Attention targeted to the concerns of family physicians who have been in practice for a short time, who work for HMOs, or who are in rural practice might help induce some physicians to resume obstetrics.     

Factors influencing changes in obstetric care provided by family physicians: a national study

In an effort to determine the factors underlying changes in obstetric practice by family physicians, a random sample of 505 residency-trained family physicians was surveyed by mailed questionnaire. Of the 329 who responded, 65% had at some time practiced obstetrics, but only 45% were practicing obstetrics at the time of the survey. Rising malpractice insurance premiums and fear of lawsuit were factors most likely to influence a family physician's decision to cease obstetric practice. Lifestyle concerns and the number of obstetricians practicing in the area were also important factors for all family physicians. Important differences were found between family physicians who never delivered babies and those who had at some time practiced obstetrics. Family physicians who have given up obstetric practice were found to feel well trained and competent in this practice. Since changes in obstetric practice patterns have had an adverse effect on the obstetric care of women in rural areas and for the medically indigent, these findings have important public health implications.     

Loss of a rural hospital obstetric unit: a case study.

As family and general practitioners who provide a substantial portion of the obstetric care in rural areas quit their obstetric practice, small rural hospital obstetric units are at risk of closing. Using a case study design, we examined the impact of the loss of obstetric services at a small rural hospital in Missouri. This unit was the site of delivery for less than one-half of the infants born to women living within its service area. However, it was the most likely source of care for women who were young, undereducated and unmarried (p less than 0.01). Evidence derived from birth certificates showed that women who delivered there had good perinatal outcomes compared with local women who delivered at larger hospitals. A gradual decline in the number of physicians providing obstetric care preceded the closing of the hospital unit. Women from the hospital service area who presented late for prenatal care were twice as likely to have had a low birthweight infant in the year after the local hospital unit closed (16.7% versus 7.4%), although this difference and other comparisons of outcomes were not statistically significant.     

Dutch obstetric care: home or hospital, midwife or gynaecologist?

The Dutch obstetric system is traditionally characterized by extensive primary health services, supported by more specialized care. Midwives and GPs are responsible for normal deliveries, obstetricians for the deliveries considered high risk. Home deliveries are fairly common. Over the last decade this relatively positive approach to reproduction has threatened to give place to methods that seem to oppose the goals of health promotion. The percentage of home deliveries has declined from 57% in 1970 to 35% in 1985. The distinction between normal and pathological pregnancies and deliveries has become more blurred. A growing number of women with a normal pregnancy are giving birth in hospital. In sparsely populated regions, primary health care is inadequate, but this explains only part of this development. As far as parents-to-be have a choice, little is known about their considerations and about the role of different professional groups in how they choose. Between the various medical professions, competition arises about the division of tasks and about the hierarchical relation to one another. The role of obstetricians has become more important, GPs are losing ground, while midwives retain their share in practising obstetric care. Rivalry between different professional groups has been stimulated by the decline in the birth rate and the increase in the number of professionals. The increased number of pregnant women whose pregnancy and delivery is defined as 'pathological' reflects the continuing process of medicalization. Different developments may explain this process: the increase in hospital births, progress in medical science, the older age of women having their first baby.(ABSTRACT TRUNCATED AT 250 WORDS)     

Dutch obstetric care: home or hospital, midwife or gynaecologist?

The Dutch obstetric system is traditionally characterized byextensive primary health services, supported by more specializedcare. Midwives and GPs are responsible for normal deliveries,obstetricians for the deliveries considered high risk. Homedeliveries are fairly common. Over the last decade this relatively positive approach to reproductionhas threatened to give place to methods that seem to opposethe goals of health promotion. The percentage of home deliverieshas declined from 57% in 1970 to 35% in 1985. The distinctionbetween normal and pathological pregnancies and deliveries hasbecome more blurred. A growing number of women with a normalpregnancy are giving birth in hospital. In sparsely populatedregions, primary health care is inadequate, but this explainsonly part of this development. As far as parents-to-be havea choice, little is known about their considerations and aboutthe role of different professional groups in how they choose. Between the various medical professions, competition arisesabout the division of tasks and about the hierarchical relationto one another. The role of obstetricians has become more important,GPs are losing ground, while midwives retain their share inpractising obstetric care. Rivalry between different professionalgroups has been stimulated by the decline in the birth rateand the increase in the number of professionals. The increased number of pregnant women whose pregnancy and deliveryis defined as ‘pathological’ reflects the continuingprocess of medicalization. Different developments may explainthis process: the increase in hospital births, progress in medicalscience, the older age of women having their first baby. The policy of the Dutch government is traditionally to supportprimary obstetric health care. This tendency has recently beenreinforced because of financial considerations. It is difficultto predict developments in the future. Will the Dutch obstetricsystem be further medicalized or will health-promoting tendenciesbe strengthened?     

Differences in the obstetric practices of obstetricians and family physicians in Washington State

In response to the obstetric malpractice crisis, both obstetrician-gynecologists and family physicians have raised their fees and preferentially selected lower risk patients. In addition, large numbers of general and family physicians have left obstetric practice altogether. The impact of these responses was explored by examining the differences in the demographic and clinical profile of patients served by these two disciplines in the State of Washington. Eighty-five percent (45,540) of all complete records from 1983 births attended by physicians in the State of Washington were matched to physician specialty information. These births represent 67% of the total deliveries in Washington State in 1983. Although twice as many general and family physicians as obstetricians were practicing obstetrics, obstetricians delivered 2.5 times as many infants as did general and family physicians. Obstetricians served an older patient population with more low-birthweight infants, multiple births, and complications of pregnancy than family physicians. General and family physicians were more likely to care for minorities, teenagers, and unmarried and rural mothers. Obstetricians cared for patients with higher medical risks, whereas general and family physicians provided care to more socially vulnerable and geographically isolated populations. To the extent that general and family physicians are differentially abandoning obstetric practice because of the current malpractice crisis, access to care for rural and socially vulnerable groups may deteriorate rapidly.     

Review of antenatal testing policies and practice for HIV and hepatitis C infection

OBJECTIVE: To investigate antenatal HIV and HCV testing policy and practice in Australia. METHODS: A survey of private obstetricians and general practitioners (GPs) affiliated with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists and directors of obstetric units in public hospitals was undertaken. Surveys were mailed to 40% and 20% random samples of private obstetricians and GPs, respectively, and all public hospital obstetric units. The questionnaires included information on type of antenatal policy, proportion of women tested for HIV and HCV, and number of HIV and HCV-positive women receiving antenatal care. RESULTS: Of the 995 surveys distributed, 847 (85%) were returned. Of these 847, 277 (33%) were returned from practitioners or hospitals no longer involved in antenatal care. The response rates from the remaining practitioners (n=570) included 87% from private obstetricians, 78% from GPs, and 71% from public hospitals. The proportion of private obstetricians, GPs and public hospitals with an antenatal testing policy for HIV was 62%, 42% and 44%, and for HCV 65%, 41% and 39%, respectively. Universal offer of antenatal testing among private obstetricians, GPs and public hospitals was 47%, 62% and 23% for HIV and 54%, 46% and 23% for HCV, respectively. During 1999, an estimated 33% of pregnant women were tested for HIV and 37% for HCV. Based on reported numbers of women in antenatal care, prevalence rates were estimated at 0.23 per 1,000 and 13 per 1,000, for HIV and HCV, respectively. CONCLUSIONS: Antenatal testing policy and practice varies widely in Australia. The lack of uniformity may reflect differing policies among clinical and public health bodies.     

Paying the price: the cost and consequences of emergency obstetric care in Burkina Faso

Substantial healthcare expenses can impoverish households or push them further into poverty. In this paper, we examine the cost of obstetric care and the social and economic consequences associated with exposure to economic shocks up to a year following the end of pregnancy in Burkina Faso. Burkina Faso is a low-income country with poor health outcomes and a poorly functioning health system. We present an inter-disciplinary analysis of an ethnographic study of 82 women nested in a prospective cohort study of 1013 women. We compare the experiences of women who survived life-threatening obstetric complications ('near-miss' events) with women who delivered without complications in hospitals. The cost of emergency obstetric care was significantly higher than the cost of care for uncomplicated delivery. Compared with women who had uncomplicated deliveries, women who survived near-miss events experienced substantial difficulties meeting the costs of care, reflecting the high cost of emergency obstetric care and the low socioeconomic status of their households. They reported more frequent sale of assets, borrowing and slower repayment of debt in the year following the expenditure. Healthcare costs consumed a large part of households' resources and women who survived near-miss events continued to spend significantly more on healthcare in the year following the event, while at the same time experiencing continued cost barriers to accessing healthcare. In-depth interviews confirm that the economic burden of emergency obstetric care contributed to severe and long-lasting consequences for women and their households. The necessity of meeting unexpectedly high costs challenged social expectations and patterns of reciprocity between husbands, wives and wider social networks, placed enormous strain on everyday survival and shaped physical, social and economic well-being in the year that followed the event. In conclusion, we consider the implications of our findings for financing mechanisms for maternity care in low-income settings.     

Specialty bias in obstetric care for high-risk socioeconomic groups in Maine

From 1982 to 1984, 46,501 infants were born in Maine hospitals in 46,286 deliveries, of which 6,343 were born to women on state Medicaid (Title 19), and 6,307 were born to women with no health insurance. In comparison with others born in Maine during those years, more infants in these presumed low socioeconomic groups died, were transferred immediately to other hospitals, had low birthweights, or were readmitted to a hospital within 30 days of birth. Of all deliveries, 105 family physicians or general practitioners performed 22 percent, 82 obstetricians performed 69 percent, and 16 osteopathic physicians performed 5 percent; but of Medicaid deliveries, obstetricians delivered only 59 percent, while family physicians-general practitioners and osteopaths did commensurately more. The decreased proportion of Medicaid patients cared for by obstetricians was especially prominent in Maine's urban hospital service areas. Pediatricians, on the other hand, cared for the same proportion of Medicaid children as they did all children in all hospital service areas in the state. The distribution of low socioeconomic, higher obstetric risk patient groups among various medical specialties as demonstrated in these data should be considered by health planners, malpractice insurers, and health insurers including state Medicaid programs.     

Questioning the indicators of need for obstetric care

The difficulties in measuring maternal mortality have led to a shift in emphasis from indicators of health to indicators of use of health care services. Furthermore, the recognition that some women need specialist obstetric care to prevent maternal death has led to the search for indicators measuring the met need for obstetric care. Although intuitively appealing, the conceptualization and definition of the need for obstetric care is far from straightforward, and there is relatively little experience so far in the use and interpretation of indicators of service use or need for obstetric care. In this paper we review indicators of service use and need for obstetric care, and briefly discuss data collection issues.     

孕产妇产科出血原因分析

目的 了解医院孕产妇产科出血原因,为今后采取针对性的预防和干预措施提供依据.方法 收集某院2007 ～2010年108例因产科出血病例的资料,分析孕产妇产科出血的相关原因.结果 孕妇产科出血的原因构成比顺位依次为:产后出血(76.85％)、子宫破裂(10.19％)、前置胎盘(8.33％)、异位妊娠(4.63％);而导致孕产妇产后出血的原因顺位依次为:胎盘因素(61.45％)、软产道裂伤(20.48％)、产后宫缩乏力(10.84％)、凝血障碍(7.23％).年龄(x2=117.0,P＜ 0.001)、文化程度(x2=103.3,P＜0.001)、产检次数(x2=55.21,P＜0.001)及产后出血时间(x2=81.15,P＜0.001)与产科出血的发生有一定的关联性.结论 各级妇幼保健机构应加强孕产妇管理及高危孕产妇的筛查、转诊,产后24 h内加强对产妇的监护及观察,及时处理异常将会减少产后出血的发生.     

Identifying ways to increase seasonal influenza vaccine uptake among pregnant women in China: A qualitative investigation of pregnant women and their obstetricians

BackgroundPregnant women are at higher risk for complications from influenza infection. Nevertheless, seasonal influenza vaccination among pregnant women in China is low. A better understanding of perceptions of pregnant women and their physicians, and factors influencing decisions about receiving seasonal influenza vaccine could be used to develop effective strategies for improving seasonal influenza vaccine uptake during pregnancy.MethodsWe recruited pregnant women from 9 hospitals located in 5 cities across China to participate in focus group interviews. Obstetricians from the same hospitals were recruited for one on one in-depth interviews. We collected information about perceptions of barriers and motivating factors for utilizing seasonal influenza vaccine during pregnancy. We systematically analyzed the information using qualitative methods.ResultsWe conducted 18 focus groups with 108 pregnant women and interviewed 18 obstetricians. Awareness about the use of influenza vaccine during pregnancy was minimal in both subject groups. None of the pregnant women had received influenza vaccine during pregnancy and none of the obstetricians had recommended influenza vaccine for their patients. Both groups noted insufficient knowledge about influenza infection and benefits of the vaccine, concerns about vaccine safety, and lack of local data related to vaccine use in Chinese pregnant women. Obstetricians cited the lack of a national policy as a major barrier to recommending seasonal influenza vaccine to pregnant women. Pregnant women cited not receiving a recommendation for vaccination from healthcare workers as an additional barrier.ConclusionOur findings highlight the immediate need to increase awareness and knowledge about the risks of influenza infection and the benefits and safety of seasonal influenza vaccination among both pregnant women and obstetricians in China. Obstetricians interviewed stated that the development and implementation of a national policy prioritizing pregnant women for seasonal influenza vaccination would facilitate their willingness to recommend seasonal influenza vaccine to pregnant women.     

Moral implications of obstetric technologies for pregnancy and motherhood

Drawing on sociological and anthropological studies, the aim of this article is to reconstruct how obstetric technologies contribute to a moral conception of pregnancy and motherhood, and to evaluate that conception from a normative point of view. Obstetrics and midwifery, so the assumption, are value-laden, value-producing and value-reproducing practices, values that shape the social perception of what it means to be a “good” pregnant woman and to be a “good” (future) mother. Activities in the medical field of reproduction contribute to “kinning”, that is the making of particular social relationships marked by closeness and special moral obligations. Three technologies, which belong to standard procedures in prenatal care in postmodern societies, are presently investigated: (1) informed consent in prenatal care, (2) obstetric sonogram, and (3) birth plan. Their widespread application is supposed to serve the moral (and legal) goal of effecting patient autonomy (and patient right). A reconstruction of the actual moral implications of these technologies, however, reveals that this goal is missed in multiple ways. Informed consent situations are marked by involuntariness and blindness to social dimensions of decision-making; obstetric sonograms construct moral subjectivity and agency in a way that attribute inconsistent and unreasonable moral responsibilities to the pregnant woman; and birth plans obscure the need for a healthcare environment that reflects a shared-decision-making model, rather than a rational-choice-framework.     

Interspecialty differences in the obstetric care of low-risk women.

OBJECTIVES: This study examined differences among obstetricians, family physicians, and certified nurse-midwives in the patterns of obstetric care provided to low-risk patients. METHODS: For a random sample of Washington State obstetrician-gynecologists, family physicians, and certified nurse-midwives, records of a random sample of their low-risk patients beginning care between September 1, 1988, and August 31, 1989, were abstracted. RESULTS: Certified nurse-midwives were less likely to use continuous electronic fetal monitoring and had lower rates of labor induction or augmentation than physicians. Certified nurse-midwives also were less likely than physicians to use epidural anesthesia. The cesarean section rate for patients of certified nurse-midwives was 8.8% vs 13.6% for obstetricians and 15.1% for family physicians. Certified nurse-midwives used 12.2% fewer resources. There was little difference between the practice patterns of obstetricians and family physicians. CONCLUSIONS: The low-risk patients of certified nurse-midwives in Washington State received fewer obstetrical interventions than similar patients cared for by obstetrician-gynecologists or family physicians. These differences are associated with lower cesarean section rates and less resource use.     

Cesarean sections: risk perception and indication by attending obstetricians in a public maternity hospital in Rio de Janeiro

The cesarean section rate in municipal public maternity hospitals in the city of Rio de Janeiro in the year of 2000 was 30.1%. With such a high rate, our hypothesis is that attending obstetricians in these units are indicating cesarean sections for reasons not restricted to clinical factors. The article aims to analyze physicians' representations of the inherent risks in cesarean sections that influence the medical decision for their indication. In this qualitative study, conducted through participant observation during ward duty and interviews with obstetricians, we observed that C-section indications by obstetricians are influenced by various non-obstetric factors, including insecurity about performing obstetric maneuvers, fragmented care, and fear of legal liability. The paper suggests that the widespread use of this intervention in private maternity services has fostered a practice in public obstetric services that compromises the quality of public health care and may jeopardize the health of women and infants.     

围产期保健卡在围产期保健管理中的应用

介绍南昌市卫生保健机构为已怀孕者及已孕流动人口建围产期保健卡,并通过围产期保健卡记录的诊疗信息对孕产妇的危险性进行评估,及时筛查高危孕产妇,并加强对孕产妇的系统管理.同时探讨在以后的工作中,应进一步加强规范化、信息化孕产妇围产期管理,争取建立妇幼保健数据库,提高围产期保健服务能力.