General practitioners and their role in maternity care

During the last century the perception of pregnancy and childbirth has changed from a normal, physiological life-event to a potentially dangerous condition. Maternity care has become more and more obstetrical care, focussed on pathology and complications. The involvement of general practitioners (GPs) in maternity care is strongly reduced and almost everywhere the same reasons are found: interference with lifestyle and interruption of office routine, fear of litigation and costs of malpractice insurance, insufficient training and insufficient numbers of cases to retain competency. In Canada, the USA, and to a lesser extent in Australia and New Zealand, GPs still providing intrapartum care are GP-obstetricians rather than maternity care providers. They provide low-risk as well as high-risk obstetrical care, especially in rural areas with few specialist obstetricians. In Europe, GPs do not provide high-risk obstetrical care. Instead they emphasize their role as generalist, and compete with midwives for a central role in maternity care for women with an uncomplicated pregnancy. The ongoing medicalisation of childbirth and the changing attitudes towards the demands of maternity care practice have diminished the role of GPs or family physicians. If they want to stay involved in maternity care in the future they need to cooperate with midwives, preferably in shared care programs.     

Midwives as Providers of Prenatal Care in Finland—Past and Present

This study analyzes the role of the midwife in prenatal care by exploring the history of the midwifery profession in Finland and by interviewing midwives. Midwifery education started in Finland in the beginning of the 19th century due to the utilitarian population policy aiming to reduce the high infant mortality rate. Because of a shortage of physicians professional midwives attained an important status in the care of births. With industrialization a state-directed welfare policy with state-subsidized health care developed. After World War II, the midwifery were legally defined as care during pregnancy, delivery, and the postpartum period. In the 1950s, the scope of work of midwifery was further altered because hospital deliveries had become routine. Some midwives provided prenatal care in ambulatory maternity health centers while others worked in hospitals managing normal childbirths. Separate midwifery education ended in 1968 and resumed 1986. Since 1972, public health nurses have increasingly provided prenatal and postnatal care in maternity centers, and specialized nurses have managed normal childbirths. In the future, public health nurses may totally replace midwives in prenatal care, and the role of midwives may return to care of normal deliveries. Midwife interviews revealed the "medicalization" of pregnancy caused both by physicians and midwives' own medical concept of pregnancy and by clients' demands for good care.     

Midwives as providers of prenatal care in Finland--past and present

This study analyzes the role of the midwife in prenatal care by exploring the history of the midwifery profession in Finland and by interviewing midwives. Midwifery education started in Finland in the beginning of the 19th century due to the utilitarian population policy aiming to reduce the high infant mortality rate. Because of a shortage of physicians professional midwives attained an important status in the care of births. With industrialization a state-directed welfare policy with state-subsidized health care developed. After World War II, the midwifery were legally defined as care during pregnancy, delivery, and the postpartum period. In the 1950s, the scope of work of midwifery was further altered because hospital deliveries had become routine. Some midwives provided prenatal care in ambulatory maternity health centers while others worked in hospitals managing normal childbirths. Separate midwifery education ended in 1968 and resumed 1986. Since 1972, public health nurses have increasingly provided prenatal and postnatal care in maternity centers, and specialized nurses have managed normal childbirths. In the future, public health nurses may totally replace midwives in prenatal care, and the role of midwives may return to care of normal deliveries. Midwife interviews revealed the "medicalization" of pregnancy caused both by physicians and midwives' own medical concept of pregnancy and by clients' demands for good care.     

An indicator of adverse pregnancy outcome in France: not receiving maternity benefits.

STUDY OBJECTIVE--The aim was to compare the social characteristics, the pregnancy outcome, and the antenatal care of women in France who did not receive maternity benefits to women who did. These benefits (860 FF, approx 86 pounds per month) are given to every pregnant woman, starting in the second trimester. Payments are made on the condition that at least three antenatal visits are made, the first being before the end of the first trimester. DESIGN--The study involved a random sample of women who were interviewed after delivery during their stay in hospital. Data on pregnancy outcome were collected from medical records. SETTING--The study was carried out in four public maternity units in different regions of France. PARTICIPANTS--1692 women were included in the analysis (86.8% of the selected sample). Of 257 exclusions, 40 had multiple pregnancies, 189 had missing data, and 28 did not answer the question concerning maternity benefits. MEASUREMENTS AND MAIN RESULTS--4.3% of the women did not receive any maternity benefits. These women lived in poorer social conditions than the women who received the benefits. They had a higher preterm delivery rate, after controlling for risk factors in a logistic regression. Women without maternity benefits were characterised by a lower level of care, yet the majority began their antenatal care during the first trimester or had more than six visits. CONCLUSIONS--Not receiving maternity benefits during pregnancy is an index of an underprivileged situation and a risk factor for pregnancy outcome.     

The rhetoric of "natural" in natural childbirth: childbearing women's perspectives on prolonged pregnancy and induction of labour

It is widely known that the notion of prolonged pregnancy, defined medically as 41+ or 42+ weeks gestation, has been hotly debated within the medical and midwifery communities for many decades. Within this debate, pregnant women's voices have rarely been heard. Presented here are the results of a qualitative study of self-care in pregnancy, birth and lactation with a non-random sample of women in British Columbia, Canada. A panel of 27 women was interviewed in the third trimester of pregnancy, and 23 of the same participants were re-interviewed post-partum (50 interviews in total). Interviews were tape-recorded, transcribed, and analyzed thematically. Many of the women said they favoured a natural birth and were opposed to labour induction at the time of the first interview. Yet all but one of the ten women who went beyond 40 weeks gestation used self-help measures to stimulate labour. These women did not perceive prolonged pregnancy as a medical problem per se. Rather they saw it as an inconvenience, a worry to their friends, families and maternity care providers, and a prolongation of physical discomfort. The findings are interpreted by examining the literature on the medicalization/healthicization of childbirth.     

Rising multiple maternity rates and medical management of subfertility: better information is needed

Multiple maternity rates rose rapidly from the mid-1970s onwards in many Western countries. This has major public heath implications, as multiple pregnancies can lead to many problems for the mothers and their children. Ovarian stimulation and assisted reproductive technology (ART) play a major role in these trends but there are few data about them. Consistently defined multiple maternity rates, including twin and triplet maternity rates are needed annually for each country in order to monitor time trends and make international comparisons. In order to assess the contribution of ovarian stimulation and ART to trends in multiple maternities and to monitor their impact on pregnancy outcome, fuller and more consistent data are needed. These could be collected from ART centres and other care providers, or through medical birth registries or national surveys.     

Pregnant Women's Fear of Childbirth in Midwife- and Obstetrician-Led Care in Belgium and the Netherlands: Test of the Medicalization Hypothesis

Fear of childbirth has gained importance in the context of increasing medicalization of childbirth. Belgian and Dutch societies are very similar but differ with regard to the organization of maternity care. The Dutch have a high percentage of home births and low medical intervention rates. In contrast, home births in Belgium are rarer, and the medical model is more widely used. By comparing the Belgian and Dutch maternity care models, the association between fear of childbirth and medicalization can be explored. For this study an antenatal questionnaire was completed by 833 women at 30 weeks of pregnancy. Fear of childbirth was measured by a shortened Dutch version of the Childbirth Attitudes Questionnaire. A four-dimensional model with baby-related, pain and injuries-related, general and personal control-related, and medical interventions and hospital care-related fear, fitted well in both countries. Multiple regression analysis showed no country differences, except that Belgian women in midwife-led care were more fearful of medical interventions and hospital care than the Dutch. For the other dimensions, both Belgian and Dutch women receiving midwifery care reported less fear compared to those in obstetric antenatal care. Hence, irrespective of the maternity care model, antenatal care providers are crucial in preventing fear of childbirth.     

Pregnant women's fear of childbirth in midwife- and obstetrician-led care in Belgium and the Netherlands: test of the medicalization hypothesis

Fear of childbirth has gained importance in the context of increasing medicalization of childbirth. Belgian and Dutch societies are very similar but differ with regard to the organization of maternity care. The Dutch have a high percentage of home births and low medical intervention rates. In contrast, home births in Belgium are rarer, and the medical model is more widely used. By comparing the Belgian and Dutch maternity care models, the association between fear of childbirth and medicalization can be explored. For this study an antenatal questionnaire was completed by 833 women at 30 weeks of pregnancy. Fear of childbirth was measured by a shortened Dutch version of the Childbirth Attitudes Questionnaire. A four-dimensional model with baby-related, pain and injuries-related, general and personal control-related, and medical interventions and hospital care-related fear, fitted well in both countries. Multiple regression analysis showed no country differences, except that Belgian women in midwife-led care were more fearful of medical interventions and hospital care than the Dutch. For the other dimensions, both Belgian and Dutch women receiving midwifery care reported less fear compared to those in obstetric antenatal care. Hence, irrespective of the maternity care model, antenatal care providers are crucial in preventing fear of childbirth.     

Schwangerenvorsorge in Deutschland

Prenatal care in Germany is based on a nationwide standardized program of care for pregnant women. Besides support and health counseling, it comprises prevention or early detection of diseases or unfavorable circumstances with risks for mother and child. Prenatal care is regulated by law and structured by directives and standard procedures in maternity guidelines (Mutterschafts-Richtlinien). This includes information and counseling of future mothers on offers of psychosocial and medical assistance in normal pregnancies as well as in unplanned or unwanted pregnancies. Further aspects are clinical examinations and risk determinations for genetic variations or direct genetic analysis. During pregnancy, medical history, clinical examination, and blood testing are part of the sophisticated program, which includes at least three standardized sonographic examinations at 10, 20, and 30 weeks of gestation. The maternity passport allows a pregnant woman to carry the most relevant information on her pregnancy and her personal risks with her. For 45 years now, women in Germany are used to carrying their Mutterpass. Societal changes have influenced the central goals of maternity care: In the beginning, the mortality of mother and child had to be reduced. Today, maternal morbidity and impaired development of the child are the center of interest, with expansion to familial satisfaction. The reduction in the mortality and morbidity of both the mother and the child during pregnancy, delivery, and postpartum can be attributed to prenatal care. Thus, investment in a program of nationwide structured prenatal care seems to be worthwhile—despite the lack of evidence concerning its effectiveness.     

Does a referral from home to hospital affect satisfaction with childbirth? A cross-national comparison

Background  

The Belgian and Dutch societies present many similarities but differ with regard to the organisation of maternity care. The Dutch way of giving birth is well known for its high percentage of home births and its low medical intervention rate. In contrast, home births in Belgium are uncommon and the medical model is taken for granted. Dutch and Belgian maternity care systems are compared with regard to the influence of being referred to specialist care during pregnancy or intrapartum while planning for a home birth. We expect that a referral will result in lower satisfaction with childbirth, especially in Belgium.     

Family Physicians in the Maternity Care Workforce: Factors Influencing Declining Trends

Family physicians provide access to maternity care for a disproportionate share of rural and urban underserved communities. This paper aims to determine trends in maternity care provision by family physicians and the characteristics of family physicians that provide maternity care. We used American Board of Family Medicine survey data collected from every family physician during application for the Maintenance of Certification Examination to determine the percentage of family physicians that provided maternity care from 2000 to 2010. Using a cross-sectional study design, logistic regression analysis was performed to examine association between maternity care provision and various physician demographic and practice characteristics. Maternity care provision by family physicians declined from 23.3 % in 2000 to 9.7 % in 2010 (p < 0.0001). Family physicians who were female, younger and US medical graduates were more likely to practice maternity care. Practicing in a rural setting (OR = 2.2; 95 % CL 2.1–2.4), an educational setting (OR = 6.4; 95 % CL 5.7–7.1) and in either the Midwest (OR = 2.6; 95 % CL 2.3–2.9) or West (OR = 2.3; 95 % CL 2.1–2.6) were the strongest predictors of higher likelihood of providing maternity care. While family physicians continue to play an important role in providing maternity care in many parts of the United States, the steep decline in the percentage of family physicians providing maternity care is concerning. Formal collaborations with midwives and obstetrician-gynecologists, malpractice reform, payment changes and graduate medical education innovations are potential avenues to explore to ensure access to maternity care.     

Antenatal care and maternal demographic and social characteristics. Evolution in France between 1972 and 1976.

A study was carried out on representative samples of 11 254 births in France in 1972 and 4685 births in 1976. Women were interviewed after delivery to obtain information about the medical care they had received during pregnancy. Inadequate antenatal care was defined as: first antenatal visit after the first trimester of pregnancy, or total number of visits fewer than the required minimum, or no visit to an obstetrician or the hospital maternity team. In 1972, the problem of inadequate care occurred mainly in very young women, or in those of high parity or with short birth intervals when the father's social class had been taken into account. Social status was also an important factor independently of a woman's demographic characteristics. These inequalities persisted in 1976 despite the policy adopted in 1972 to improve antenatal care for high-risk women.     

"Humanizing" childbirth: the discovery and implementation of bonding theory

Recent changes in methods of childbirth attendance represent one example of an emerging emphasis on the humanization of medical treatment. Although many have observed this trend toward humanization, the process of medical accommodation--including rationales provided for change, the nature and limitations of humanization, and the consequences of "humanized" medicine--is not well understood. This paper explores the process of medical accommodation by focusing on the ways in which the issue of parent-infant bonding has contributed to the humanization of obstetric care. The bonding issue has provided a rationale for change in a specialty area facing criticisms on several fronts. Acknowledging consumer demands for change in traditional styles of maternity care, medical professionals have responded by offering alternative programs based largely in the conclusions of research on the attachment process. It is demonstrated that these medically proposed alternatives suffer from many organizational constraints and that the emphasis on bonding fostered by these new programs has potentially negative consequences.     

Using medical care: the views and experiences of high-risk mothers.

Two recurrent unsolved problems of health services practice and policy in modern industrial countries are those of social class inequalities and user dissatisfaction. This article presents data related to these issues drawn from a sample of British childbearing women deemed "at risk" by health professionals. A third focus is on the relationship between past experiences of maternity care, and the patterns of service provision and perceptions of needs and satisfaction revealed in a subsequent pregnancy. Findings show a tendency for patterns of care to be differentiated by social class, with working class women generally receiving comparatively poor service. Satisfaction with general practitioner (community-based) prenatal care is higher than with hospital care. The more socially disadvantaged women in the sample are more likely to be dissatisfied with their medical care. The three major pregnancy needs highlighted by the sample women are for more continuity of care, more sympathetic medical care, and help with household finances. Adverse previous childbearing experiences are related to more dissatisfaction in the subsequent pregnancy.     

A local maternity care system in South West England under review.

Since the Cranbrook Report in 1959 there has been a steady increase in the proportion of institutional confinements in England and Wales and a steady decrease in perinatal mortality. This association should not be regarded as evidence of cause and effect nor as justification for continuing the Cranbrook policies for the provision of maternity care throughout the 1970s. Due weight must be given to other factors, including improvements in the general health and education of the population and advances in standards of medical care affecting all parts of the maternity services. The present study examines current performance of a local maternity care system and analyzes some 3700 confinements which took place in a Health Care District (formerly a Hospital Management Committee area) in South West England during 1970. The local resources consisted of a consultant obstetric unit, a Special Care Baby Unit, five general practitioner units and the associated medical and nursing staff, and two Local Authority domiciliary midwife services. An expectant mother may call upon a variety of resources in pregnancy, during delivery, and in the puerperium. The concept is developed of the "stream" of care received by the mother and the case histories are analyzed in these terms. The deliveries are classified in terms of nonintervention and intervention at delivery. Perinatal mortality is not in itself an adequate measure of the overall performance of a local maternity care system so other performance indices are used. These are based upon the extent to which the resources available diverge between booking and actual usage. Results obtained indicate that existing policies may be less than optimal and alternatives ought to be considered.     

An evaluation of the impact of maternity care coordination on Medicaid birth outcomes in North Carolina.

BACKGROUND. Care coordination is an important component of the enhanced prenatal care services provided under the recent expansions of the Medicaid program. The effect of maternity care coordination services on birth outcomes in North Carolina was assessed by comparing women on Medicaid who did and did not receive these services. METHODS. Health program data files, including Medicaid claims paid for maternity care coordination, were linked to 1988 and 1989 live birth certificates. Simple comparisons of percentages and rates were supplemented by a logistic regression analysis. RESULTS. Among women on Medicaid who did not receive maternity care coordination services, the low birth weight rate was 21% higher, the very low birth weight rate was 62% higher, and the infant mortality rate was 23% higher than among women on Medicaid who did receive such services. It was estimated that, for each $1.00 spent on maternity care coordination, Medicaid saved $2.02 in medical costs for newborns up to 60 days of age. Among the women who did receive maternity care coordination, those receiving it for 3 or more months had better outcomes than those receiving it for less than 3 months. CONCLUSIONS: These results suggest that maternity care coordination can be effective in reducing low birth weight, infant mortality, and newborn medical care costs among babies born to women in poverty.     

Factors associated with perinatal morbidity and mortality in a sample of public and private maternity centers in the City of Rio de Janeiro, 1999-2001

This study compares socio-demographic factors, mothers' biological characteristics, and quality of care at maternity hospitals in the City of Rio de Janeiro, Brazil. A sample of 10,072 post-partum women in 47 hospitals was selected. Data were collected by interviewing mothers in the immediate post-partum and from medical records. The chi2 test was used to analyze homogeneity of ratios. Significant differences were found between patients in public and private hospitals in relation to family support, healthy habits during pregnancy, reproductive history, access to and satisfaction with prenatal care and delivery, and particularly adverse effects in the newborns. Private maternity hospitals showed better results, although they displayed excessive cesarean and neonatal inter-hospital transfer rates. The stratum consisting of public Federal and State maternity hospitals received women with greater morbidity, had lower neonatal transfer rates, and received a more positive assessment by clients of the Unified National Health System (SUS). Private maternity centers contracted out by the SUS were the ones that most refused treatment to patients, leading to delays in patient care for delivery.     

Prenatal care in Finland: from primary to tertiary health care?

Traditionally, the Finnish prenatal care system has been based on special maternity centers outside hospitals. In recent years, however, the use of hospital outpatient clinics has increased. The purpose of this study was to describe the use of the clinics and to see whether clinics serve as an addition or as an alternative to maternity centers. We used several different data sources (statistics, documents, interviews, questionnaires). The main source was data on visits for all women who gave birth in Helsinki in a five-week period in 1987. The content of care and means of care delivery differ between clinics and maternity centers. Clinics are technologically and provider-oriented without continuity of care. Clinics are not just referral centers for high-risk mothers; at least half of pregnant women visit them. Ultrasound screening is an important reason for use of the clinic. Background characteristics as well as the outcome of pregnancy were similar among women visiting a hospital clinic a maximum of one time (low users), two to three times, or four times or more (high users). Standardizing for the length of gestation, high users made fewer visits to maternity centers than did low users. Hospital clinic care now seems to replace care in maternity centers, and we found a weak trend toward a pluralistic prenatal care.     

A national audit to monitor and promote the uptake of clinical guidelines on the management of diabetes in pregnancy

Seeks to assess maternity care for women with Type 1 diabetes in relation to recommendations in a national clinical guideline using a criterion-based clinical audit. The audit covered all 22 consultant-led maternity units in Scotland, focusing on 268 completed pregnancies in women with Type 1 diabetes. Results are presented and discussed. Concludes that a national audit to monitor the impact of clinical guidelines proved feasible. Antenatal care is organised in line with guideline recommendations but there is lower provision of formal prepregnancy care. Pregnancy planning and periconceptual care fall short of recommendations but care during pregnancy is meticulous. Adverse pregnancy outcomes remain commoner than in non-diabetic pregnancies.     

Social support in pregnancy: The ‘soft’ way to increase birthweight?

This paper examines the thesis that social support in pregnancy is capable of affecting birthweight as one easily measurable aspect of pregnancy outcome. The focus of the paper is on birthweight, since low birthweight is a relatively stable and important factor in social inequalities in perinatal health. The paper reviews the published literature on social support in pregnancy including simple observational and nonrandomized intervention studies and also randomized controlled trials of 'social' interventions. The methodological problems associated with some of these studies are discussed. However, it is concluded that there is considerable evidence to suggest that intervention programmes aimed at improving the 'social' side of antenatal care are capable of affecting birthweight and other 'hard' measures of pregnancy outcome. It is suggested that traditional professional approaches to pregnancy which divide the medical from the social perspective, have acted to prevent recognition of this evidence and its relevance to maternity care policy.