Prenatal care : a comparative evaluation of nurse-midwives and general practitioners

The practice of midwifery by those other than physicians is illegal in Canada and despite recommendations of nursing, medical and consumer groups, no trials evaluating the effectiveness of the nurse-midwife as a member of the modern obstetrical team have occurred here. To demonstrate a nurse-midwifery model, four nurse-midwives provided primary care to forty-seven childbearing women and their families over a twenty-two month period in a maternity teaching hospital. This clinic presented a unique opportunity for comparing the prenatal care provided by nurse-midwives with that of general practitioners who attended deliveries in the same setting. Utilizing a retrospective chart audit, case control study design, the nurse-midwife cases (NM cases) were each matched to two general practitioner controls (GP controls) through the use of the hospital's prenatal data base. The matching characteristics included low risk status, date of delivery, age, parity, gravidity, previous pregnancy losses and census tract income. Prenatal criteria that had been developed and tested in "The Burlington Randomized Clinical Trial of the Nurse Practitioner" for assessing the quality of care were reviewed and updated for this study. With these criteria two blinded abstractors audited the prenatal record forms of all the subjects and scored them as either "superior", "adequate" or "inadequate". Seventy-seven percent of the records of the NM cases received a "superior" score, where as 60% of the GP controls' records received an "inadequate" score [mathematical formula omitted] Overall, the general practitioners' records indicated more erratic care than those of the nurse-midwives. Although the physicians met most of the initial assessment criteria, they failed to meet the criteria that evaluated the ongoing routine assessment process by recording an inadequate number of prenatal visits (36%), or by omitting urine test results (38$) and blood pressure readings (21%). No differences were found in variables relating to labour and delivery with the exception of the incidence of episiotomies. The results indicate that nurse-midwives as part of an obstetrical team are able to provide safe prenatal care to a low risk population in a Canadian urban context, and that their records are thorough and more consistent than those of general practitioners.

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