Midwifery-model care linked to reduced emergency department use

Postpartum emergency department (ED) use is decreased by midwifery-model care, according to a recent study published in JAMA Network Open.

Takeaways

The study highlights a notable reduction in postpartum emergency department (ED) visits among women receiving midwifery-model care compared to standard obstetrics care, suggesting a potential benefit of this approach in maternal healthcare.
Patients in the midwifery-model group received more extensive postpartum care, including multiple home or office visits within the first week and throughout the 6-week postpartum period, likely contributing to the decrease in ED visits.
Women receiving midwifery care tended to be younger, with lower rates of obesity and immigration, indicating potential demographic variations between the two care models.
While both care models showed similar rates of certain clinical indicators, differences were observed in other areas such as folic acid use and episiotomy rates, suggesting nuanced differences in care practices.
The study underscores the importance of considering access to postpartum care, particularly among patients receiving standard obstetrics care, suggesting potential strategies for improving health care delivery in this population.

Research in 2018 indicated 1 or more ED visit within 10 days postpartum in Ontario, Canada, among approximately 5% of women who gave birth. Additionally, a US study reported low acuity among 75% of postpartum women visiting the ED, with under 25% undergoing hospital admission.

In the Ontario Midwifery Program, midwives collaborate with obstetricians and family medicine teams to provide 24-hour on-call service, postpartum home visits, and continuity of care. Patients undergoing midwifery care receive multiple midwife visits at home or in the midwife’s office within the first week of birth, followed by visits in the 6-week postpartum period.

To evaluate postpartum ED use among patients receiving a perinatal midwifery-model vs a standard obstetrics model, investigators conducted a retrospective cohort study. Data about in-patient, ED, and ambulatory visits was obtained from health administrative databases.

Participants included primiparous, low risk pregnant women aged 11 to 50 years delivering at an Ontario hospital from April 1, 2012, to February 1, 2018. Low-risk status was determined by having a singleton live birth at 34 weeks’ gestation or more.

Exclusion criteria included missing body mass index, gestational age at birth, or Ontario Health Insurance Plan (OHIP) number, receiving family physician model care, and unknown perinatal care clinician type.

ICES analyzed patient records, with information obtained from multiple linked Ontario health administrative databases. These include the Discharge Abstract Database for admissions, procedures, and transfers, the National Ambulatory Care Reporting System for ED visits, and the OHIP database for physician billings.

Additional data obtained included immigration status, patient demographics and deaths, neighborhood maternal resources, and midwifery and obstetric patient characteristics. An unscheduled ED visit within 42 days postpartum was reported as the primary outcome of the analysis.

Secondary outcomes included an ED visit within 7 days after discharge, hospital admission within 42 days after discharge, and low-acuity ED visit within 42 days. Stratifications based on mode of birth and intrapartum transfer of care were also performed.

There were 104,995 women included in the final analysis, 78% of whom received obstetric-model care and 22% of whom received midwifery-model care. Those in the obstetric-model group were more often older, obese, living in an urban area, and had immigrated to Canada than those in the midwifery-model group.

While most care indicators were similar between both groups, differences were found for certain indicators between the midwifery-model group and obstetric-model group. This included prenatal class attendance at 64% vs 41.4%, respectively, folic acid use at 94.6% vs 76.9%, respectively, and episiotomy at 12.5% vs 19.2%, respectively.

Spontaneous vaginal delivery was reported in 61.1% of the midwifery-model group vs 53.8% of the obstetrics-model group. Assisted vaginal delivery was reported in 12.3% vs 17%, respectively.

A median 7 postpartum visits by a midwife were reported by patients in the midwifery-model group, vs a median 0 postpartum visits by an obstetrician reported by those in the obstetrics-model group. In comparison, an unscheduled ED visit within 42 days postpartum was reported by 6.7% and 8.4%, respectively, with an adjusted relative risk of 0.78.

Similar results were seen for the rate of an ED visit within 7 days or less, at 3.2% in the midwifery-model group and 4.5% in the obstetrics-model group. A low acuity ED visit within 42 days postpartum had rates of 1.8% vs 2.3%, respectively. However, the risk of hospital readmission did not differ between groups.

The highest risk of postpartum ED use was reported for cesarean birth, with no significant association based on care model. However, differences between the midwifery-model group and obstetrics-model group were observed for spontaneous and assisted vaginal delivery, with risks of an ED visit lower for both modes in the midwifery-model group.

These results indicated less postpartum ED use following midwifery-model care vs obstetrics-model care. Investigators recommended consideration for improving access to postpartum care among patients receiving obstetrics-model care.

Sorbara C, Ray JG, Darling EK, Chung H, Podolsky S, Stukel TA. Postpartum emergency department use following midwifery-model vs obstetrics-model care. JAMA Netw Open. 2024;7(4):e248676. doi:10.1001/jamanetworkopen.2024.8676