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WOMBI-338; No. of Pages 6 Women and Birth xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
A comparison of midwife-led care versus obstetrician-led care for low-risk women in Japan Mariko Iida a,*, Shigeko Horiuchi a,b, Kumiko Nagamori a,b a b
Department of Midwifery in St. Luke’s International University, Japan St. Luke’s Birth Clinic, Japan
A R T I C L E I N F O
Article history: Received 29 November 2013 Received in revised form 24 April 2014 Accepted 2 May 2014 Keywords: Pregnant women Low-risk Midwife-led Obstetric outcomes Postpartum depression
A B S T R A C T
Background: Continuity of midwife-led care is recommended in maternity care because of its various positive outcomes. In Japan, midwife-led care is receiving broad attention as well. In order to popularise midwifery care within the entire system of perinatal care in Japan, there is a need to show evidence that continuity of midwife care for women will bring about positive outcomes. Aim: The objectives of this study were to compare the health outcomes of women and infants who received midwife-led care with obstetrician-led care in Japan. Methods: This was an observational study using non-random purposive sampling with a survey questionnaire. Settings where midwife-led care and obstetrician-led care were chosen by purposive samples. Participants were low-risk women who received antenatal care and delivered a termsingleton-infant at the participating settings during the research period. Measurements were: Women-centred care pregnancy questionnaire, Stein’s maternity blues questionnaire, and Edinburgh Postnatal Depression Scale. Findings: Midwife-led care was perceived by women to be beneficial and had no adverse outcomes compared to obstetrician-led care. Main findings are: (1) Perception of Women-centred care was higher; (2) Less premature rupture of membranes, and the Apgar scores of the infants were similar; (3) Exclusively breast-feeding during hospitalisation and at one-month postpartum; (4) Stein’s maternity blues scale scores was lower in women who received midwife-led care than those who received obstetrician-led care. Conclusions: Continuity of midwife-led care was perceived by women to be beneficial and had no adverse outcomes. Therefore, midwife-led care in low-risk pregnancy could be applicable and recommended. ß 2014 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
1. Introduction Continuity of care, especially continuity of midwife-led care is recommended in maternity care1,2 because of its various positive outcomes for the woman and infant. In Japan, midwife-led care is receiving broad attention as well. Japan’s Ministry of Health, Labour and Welfare3 announced a vision whereby obstetricians and midwives should work collaboratively. Their report said that midwives should attempt to develop midwife-led care units in hospitals to manage normal births where they can work in
* Corresponding author at: St. Luke’s International University, 10-1 Akashi-cho, Chuo-ku, Tokyo 104-0044, Japan. Tel.: +81 3 5550 2265/3 5550 2372; fax: +81 3 5550 2372. E-mail address: [email protected] (M. Iida).
collaboration with obstetricians and also share their expertise with them. Towards this end, outcomes regarding midwifery care should enhance collaborative efforts. 2. Literature review Researchers have conducted studies to evaluate the effectiveness of midwife-led (MW) care compared to obstetrician-led (OB) care.4–11 Studies report that women’s satisfaction with care was higher among women who received MW care compared to those who received OB care and the obstetric outcomes were the same or better.12,13 A Cochrane review14 which included 13 studies comparing midwifery-led continuity models of care with other models of care concluded that although there are cautions, positive outcomes demonstrate that women should be offered midwife-led continuity of care. In addition, Tracy et al.,15 reported that
http://dx.doi.org/10.1016/j.wombi.2014.05.001 1871-5192/ß 2014 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Please cite this article in press as: Iida M, et al. A comparison of midwife-led care versus obstetrician-led care for low-risk women in Japan. Women Birth (2014), http://dx.doi.org/10.1016/j.wombi.2014.05.001
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WOMBI-338; No. of Pages 6 M. Iida et al. / Women and Birth xxx (2014) xxx–xxx
2
caseload midwifery care is safe and cost-effective compared to standard maternity care. While in Japan, there is a study that evaluated the continuous psychological support provided by midwives,16 there are no studies that measure both the physical and emotional outcomes regarding the continuity of MW-led care. Even so, some hospitals in Japan are establishing MW-led care units as part of the regular hospital services because of the decreasing number of obstetricians. Even the number of facilities in Japan where women could give birth was affected by a dwindling number of obstetricians. The facilities decreased 36% from 3991 in 1996 to 2567 in 2008, respectively.17 To decrease the burden on obstetricians and to fully use midwives, Japan’s Ministry of Health, Labour and Welfare announced a vision to increase in-hospital midwife-led care units. The Japanese Nursing Association is working towards the implementation of this system of care as well.18 Although the number of settings which provides in-hospital midwife-led care units are gradually increasing, these are few in number compared to the total. In order to popularise midwifery care within the entire system of perinatal care in Japan, there is a need to show evidence that continuity of MW-led care for women will bring about positive outcomes. The objectives of this study were to compare the health outcomes of women and infants who received MW-led care with OB-led care. Specifically, this study asked: (1) is there a difference in women’s perception of care, (2) are there differences in obstetric outcomes; physical outcomes, breast-feeding status, and mood status. 3. Participants and methods 3.1. Study design This was an observational study using non-random purposive sampling with a survey questionnaire. 3.2. Participants The inclusion criteria of the participants were: (1) low-risk women who received antenatal care delivering a term-singletoninfant at the participating settings during the research period, February to October in 2011; (2) women who could read and write Japanese and (3) women who consented to participate in the study. Excluded women were those who had a caesarean section or who were in seriously poor physical condition.
3.3. Sample size Previous studies12,13 indicated that the score of the Women’s Centred Care pregnancy (WCC-preg) questionnaire at birth centres was 233.3 points and at hospitals 199.8 points (p < .001, SD = 31.6). It was assumed that the birth centres provided continuity of MW-led care and the hospitals provided OB-led care. Setting alpha = .01, power = .9, the sample size ended up to be 58 women in total. Although 58 women would be enough to measure the main outcome, the 50-item WCC-preg questionnaire is still in its early use. Therefore, it is important to conduct a factor analysis, with at least five times the number of participants needed.19 Considering the dropout rate to be 20% from the preliminary studies, an adequate sample size for each group would be 156 women. 3.4. Settings There were two settings for each type of care. All four settings were in an urban part of Tokyo, Japan. Characteristics of MW-led and OB-led care groups are shown in Table 1. 3.4.1. MW-led care group In this purposive sample women received continuity of MW care in one of two midwifery clinics. A small team of midwives provided continuity of antenatal, intrapartum, and postpartum care. If any risk occurs, women would be transferred. This is because the law dictates that when midwives work independently from obstetricians, they may only manage low-risk women and normal births. 3.4.2. OB-led care group Women in this group received care mainly from obstetricians with attendance by midwives and nurses in one of two hospitals. This group’s care was provided with different caregivers across the antenatal, intrapartum, and postpartum period. The obstetrician is the one who has the final approval for the care provided. 3.5. Procedure for conducting the study The Research Ethics Committee at St. Luke’s College of Nursing, Tokyo, Japan (no. 10-065), and St. Luke’s International Hospital, Tokyo, Japan (no. 10-123) approved this study. Women who were hospitalized at the place where they gave birth at least three-days postpartum, were asked to participate.
Table 1 Characteristics of midwife and obstetrician led care groups.
Target women Lead caregiver Other staff System of care Continuity of care from midwife
Medical intervention Other characteristics of care
Schedule of antenatal checkups
Midwife-led care group
Obstetrician-led care group
Low-risk women Midwife (MW) OB provides care at least three times during the antenatal period Same MW or a team MW provides care Refer to OB when needed Intend to provide continuity of care throughout the maternity period
Low-risk women Obstetrician (OB) MW and nurse (NS) OB mainly provides antenatal care MW or NS provide health advice when needed Depends on shifts Intrapartum and postpartum care will be provided by OB, MW, and NS Conduct when needed
At the minimum or refer to OB, e.g. coded Prescription, transfer to obstetricians when needed Standard care provided at the setting Sufficient time for each antenatal visit Provide specific advice to support women’s Early detection, rapid cure of risk condition good physical condition Recommended to receive approximately 14 antenatal checkups: three times until 11 weeks gestation, once in every 4 weeks from 12 to 23 weeks gestation, once in every 2 weeks from 24 to 35 weeks gestation, and once a week from 36 weeks gestation to delivery (Japan Society of Obstetrics and Gynecology (2011). Guidelines for obstetrical practice in Japan: Japan Society of Obstetrics and Gynecology (JSOG) and Japan Association of Obstetricians and Gynecologists (JAOG) 2011 edition)
Please cite this article in press as: Iida M, et al. A comparison of midwife-led care versus obstetrician-led care for low-risk women in Japan. Women Birth (2014), http://dx.doi.org/10.1016/j.wombi.2014.05.001
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Women are usually hospitalized at least four days after a vaginal birth in Japan. In addition, they were asked to answer a questionnaire at their one-month check-up. A small token was provided each time for participation. After the researcher collected the questionnaire from the collecting box, data was collected from the medical record, as well. Numbers were written on the questionnaires to match the first questionnaire (after three-days postpartum) and the second questionnaire (at one-month postpartum). Since women chose where to receive care by themselves, blinding was not possible. 3.6. Outcome measurements Women were asked to answer an 83-item questionnaire while they were hospitalized and a 11-item questionnaire at their one-month check-up. If the women answered the first questionnaire, the researcher gathered 12 items from the medical record. Gathered outcomes are as follows. 3.6.1. Women’s characteristics There were seven items asking women about: age, parity, and preparation of physical condition: careful to keep warm, and other four items. ‘Careful to keep warm’ was asked because it is reported that women’s sensitivity to cold (hiesho) influences obstetric outcomes.20,21 This was rated using a 5-point Likert-type scale: (1) not at all, to (5) very careful. 3.6.2. Nature of care Women were asked to answer 10 items about the actual care they received, which were extracted from previous studies.12,13,20–24
3
coefficient alpha for the 13 items was .74 indicating high internal consistency. 3.6.5. Health outcomes at one-month check-up Health outcomes were breast-feeding (one item) and mental health (10 items). Mental health was measured using the Edinburgh Postnatal Depression Scale (EPDS)28 which was translated into Japanese by Okano et al.,29 Validity and reliability of this scale was previously confirmed.29 This scale consists from 10 items and the rating differs according to the item. Scores range from 0 to 30 points. In Japan, women are considered to be at high risk of having postpartum depression if they rated higher than 9 points.29 The coefficient alpha for the 10 items was .81 and indicated high internal consistency. 3.7. Analysis Data were analysed as follows: (1) Descriptive statistics were used to summarise the participant’s background. (2) Chi-square test was used to compare categorical data and t-test test was used to compare continuous data if participant’s background differed among the continuity of MW-led care group and the OB-led care group. When using t-test, the variables were examined for the same variance using the Levene’s test. (3) Chi-square test and t-test test was used to compare the outcomes of the MW-led care group and the OB-led care group. Data were analysed using SPSS version 19.0J.
4. Findings A total of 281 women responded during hospitalisation (response rate 90.1%). Of these, 280 women were included in the analysis. Questionnaires were distributed to 277 women at their one-month check-up (it was not possible to distribute to three women because they cancelled their one-month check-up or they visited another office). Responses of all 238 women were included in the analysis for one month.
3.6.3. Evaluation of care (during hospitalisation) Evaluation of care was measured by using the WCC-preg questionnaire (50 items) and asking about their satisfaction with care (two items). There were 52 items in total. The WCC-preg questionnaire is a questionnaire to measure women’s perception of the received WCC.25 Women’s perception of WCC was measured because WCC is a concept that supports maternity care.2 The 50-item questionnaire contains a 5-point Likert-type scale: (1) I strongly disagree, to (5) I strongly agree. Scores ranged from 50 to 250 points. From the original factor analysis using promax rotation, six factors emerged; (1) feelings of encouragement, (2) being respected, (3) trusting the caregiver, (4) effective interaction, (5) help in decision-making, and (6) nonthreatening manner. The correlation coefficient of the test-retest was .55.25 Analysis was conducted using the original six factors as explained above. The Cronbach’s alpha for the total items was .98 for this study and indicated high internal consistency. The coefficient alpha for each of the factors was fairly high ranging from .71 to .95. Two items asked women to rate their satisfaction with care during the antenatal period and during the intrapartum period using a 10-point Likert-type scale: (1) I was very unsatisfied, to (10) I was very satisfied.
4.2.1. Nature of care provided Nature of care provided differed significantly between the groups (Table 2). Women in the MW-led group had more than 30 min for their antenatal care and they talked the same amount as the caregiver than those in the OB-led group.
3.6.4. Health outcomes during hospitalisation There were 26 items regarding obstetric outcomes and mental health. The researcher documented 12 obstetric outcome items from the medical record and one item about their breast-feeding status. Mental health was measured using the Stein’s maternity blues (Stein’s MB) scale26 which was translated into Japanese by Okano et al.,27 Validity and reliability of this scale was previously confirmed.27 This scale consists of 13 items and the rating differs according to the item. Scores ranged from 0 to 26 points. Women are considered to have maternity blues if they rated higher than 8 points.25 The
4.2.2. Specific advice given Specific advice given to women at antenatal care differed between groups; all showed a significant difference. Over 80% of the women in the MW-led group received advice about keeping warm, dietary intake, and exercise (98.0%, 93.3%, and 83.9% respectively), while it was 61.8%, 65.6%, and 51.9% respectively in the OB-led group (all p < .001). Although statistically more women in the MW-led group received advice about resting and taking a nap, neither group reached more than 50% (MW-led: 34.7% and 45.6% respectively; OB-led: 32.8% and 25.2% respectively, all p < .001) (Table 2).
4.1. Characteristics of participants Women in the MW-led group were significantly older (M = 33.2, SD = 4.3) than women in the OB-led group (M = 31.7, SD = 4.3) (p = .005). However, when divided by years under 34 and over 35, there was no statistical difference. Neither did parity differ between the groups. 4.2. Nature of care provided and specific advice
Please cite this article in press as: Iida M, et al. A comparison of midwife-led care versus obstetrician-led care for low-risk women in Japan. Women Birth (2014), http://dx.doi.org/10.1016/j.wombi.2014.05.001
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Table 2 Characteristics of participants and nature of care provided N = 280. MW-led (n = 149) n Age Mean [SD] Parity Primipara Multipara Characteristics of antenatal care (N = 279) Time spent for antenatal care Min 10 10 < min < 30 30 min Amount of conversation at antenatal care Caregiver talked more I talked more Talked the same amount Specific advice given Keeping warm Dietary intake Exercise Resting Taking a sleep Preparing physically for childbirth Number of women answering ‘very careful’ Keeping warm Eat a well-balanced diet Exercise regularly ** ***
OB-led (n = 131)
p-Value
Chi- square or t-value
(%)
n
(%)
33.2
[4.3]
31.7
[4.3]
2.8
.005
60 89
(40.3) (59.7)
68 63
(51.9) (48.1)
3.8
0.051
6 67 76
(4.0) (45.0) (51.0)
70 58 2
(53.8) (44.6) (1.5)
124.0
.000
***
13 26 109
(8.8) (17.6) (73.6)
72 3 56
(55.0) (2.3) (42.7)
75.5
.000
***
146 139 125 81 68
(98.0) (93.3) (83.9) (54.4) (45.6)
81 86 68 43 33
(61.8) (65.6) (51.9) (32.8) (25.2)
59.4 33.7 33.3 13.1 12.6
.000 .000 .000 .000 .000
***
119 55 99
(79.9) (36.9) (66.4)
70 25 64
(53.4) (19.1) (48.9)
25.9 20.3 14.6
.000 .000 .006
***
**
n.s.
*** *** *** ***
*** **
p < .01. p < .001.
4.3. Preparing physically for childbirth Three out of five items regarding women’s physical preparation during pregnancy differed between groups. The item which showed the most difference was ‘keeping warm’: 79.9% women in the MW-led group were ‘very careful’ (p < .001) while it was 53.4% of those in the OB-led group. Others were ‘eat a wellbalanced diet’ (p < .001), and ‘exercise regularly’ (p = .006). ‘Keep a regular schedule’ and ‘careful not to get too tired’ were similar between the groups. 4.4. Perception of care Women’s scores of WCC-preg questionnaire were fairly high; although, women in the MW-led group showed significantly
higher scores with the WCC-preg questionnaire than women in the OB-led group (p < .001) (Table 3). When comparing WCC-preg questionnaire’s factor’s total scores, in all six factors the MW-led group showed a significantly higher score than the OB-led group. Women in the MW-led group rated their satisfaction with care significantly higher (p < .001) than the OB-led group in all three periods. 4.5. Obstetric outcomes: physical outcomes Obstetric outcomes are described in Table 4. Because of the characteristics of the settings which provide MW-led care, all women had spontaneous birth, which means they did not receive any kind of analgesia or pharmacological procedures. Most of the women (91.6%) in the OB-led group had spontaneous birth and
Table 3 Perception of care N = 280. Perception of care
WCC-preg questionnaire Being respected Feelings of encouragement Effective interaction Help in decision-making Trusting the caregiver Non-threatening manner Satisfaction with care During antenatal care During labour and birth After birth (during hospitalisation) (N = 236)
MW-led (n = 149)
OB-led (n = 131)
t-Test
p-Value
[30.1] [6.8] [9.5] [8.8] [3.4] [3.9] [2.1]
10.9 12.0 10.7 8.8 8.5 7.7 3.8
.000*** .000*** .000*** .000*** .000*** .000*** .000***
[1.7] [1.8] [1.7]
10.5 6.0 5.8
.000*** .000*** .000***
Mean
[SD]
Mean
[SD]
238.8 47.9 57.2 62.2 18.5 39.1 14.0
[14.1] [3.0] [3.9] [4.1] [2.2] [1.9] [1.7]
207.5 40.2 47.6 54.9 15.6 36.2 13.1
9.1 9.7 9.3
[1.1] [.8] [1.8]
7.2 8.7 7.7
WCC-preg questionnaire: scores range from 50 to 250. Satisfaction with care: scores range from 1 to 10. *** p < .001.
Please cite this article in press as: Iida M, et al. A comparison of midwife-led care versus obstetrician-led care for low-risk women in Japan. Women Birth (2014), http://dx.doi.org/10.1016/j.wombi.2014.05.001
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Table 4 Obstetric outcomes and interventions by type of care. MW-led (n = 149)
OB-led (n = 131)
N
n
(%)
n
(%)
280 280
149 0
(100) (.0)
120 11
(91.6) (8.4)
— —
280 280 280 280 279
0 0 9 2 22
(.0) (.0) (6.0) (1.3) (14.9)
14 27 33 51 33
(10.7) (20.6) (25.2) (38.9) (25.2)
— — 20.1 — 4.7
WOMBI-338; No. of Pages 6 Women and Birth xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
A comparison of midwife-led care versus obstetrician-led care for low-risk women in Japan Mariko Iida a,*, Shigeko Horiuchi a,b, Kumiko Nagamori a,b a b
Department of Midwifery in St. Luke’s International University, Japan St. Luke’s Birth Clinic, Japan
A R T I C L E I N F O
Article history: Received 29 November 2013 Received in revised form 24 April 2014 Accepted 2 May 2014 Keywords: Pregnant women Low-risk Midwife-led Obstetric outcomes Postpartum depression
A B S T R A C T
Background: Continuity of midwife-led care is recommended in maternity care because of its various positive outcomes. In Japan, midwife-led care is receiving broad attention as well. In order to popularise midwifery care within the entire system of perinatal care in Japan, there is a need to show evidence that continuity of midwife care for women will bring about positive outcomes. Aim: The objectives of this study were to compare the health outcomes of women and infants who received midwife-led care with obstetrician-led care in Japan. Methods: This was an observational study using non-random purposive sampling with a survey questionnaire. Settings where midwife-led care and obstetrician-led care were chosen by purposive samples. Participants were low-risk women who received antenatal care and delivered a termsingleton-infant at the participating settings during the research period. Measurements were: Women-centred care pregnancy questionnaire, Stein’s maternity blues questionnaire, and Edinburgh Postnatal Depression Scale. Findings: Midwife-led care was perceived by women to be beneficial and had no adverse outcomes compared to obstetrician-led care. Main findings are: (1) Perception of Women-centred care was higher; (2) Less premature rupture of membranes, and the Apgar scores of the infants were similar; (3) Exclusively breast-feeding during hospitalisation and at one-month postpartum; (4) Stein’s maternity blues scale scores was lower in women who received midwife-led care than those who received obstetrician-led care. Conclusions: Continuity of midwife-led care was perceived by women to be beneficial and had no adverse outcomes. Therefore, midwife-led care in low-risk pregnancy could be applicable and recommended. ß 2014 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
1. Introduction Continuity of care, especially continuity of midwife-led care is recommended in maternity care1,2 because of its various positive outcomes for the woman and infant. In Japan, midwife-led care is receiving broad attention as well. Japan’s Ministry of Health, Labour and Welfare3 announced a vision whereby obstetricians and midwives should work collaboratively. Their report said that midwives should attempt to develop midwife-led care units in hospitals to manage normal births where they can work in
* Corresponding author at: St. Luke’s International University, 10-1 Akashi-cho, Chuo-ku, Tokyo 104-0044, Japan. Tel.: +81 3 5550 2265/3 5550 2372; fax: +81 3 5550 2372. E-mail address: [email protected] (M. Iida).
collaboration with obstetricians and also share their expertise with them. Towards this end, outcomes regarding midwifery care should enhance collaborative efforts. 2. Literature review Researchers have conducted studies to evaluate the effectiveness of midwife-led (MW) care compared to obstetrician-led (OB) care.4–11 Studies report that women’s satisfaction with care was higher among women who received MW care compared to those who received OB care and the obstetric outcomes were the same or better.12,13 A Cochrane review14 which included 13 studies comparing midwifery-led continuity models of care with other models of care concluded that although there are cautions, positive outcomes demonstrate that women should be offered midwife-led continuity of care. In addition, Tracy et al.,15 reported that
http://dx.doi.org/10.1016/j.wombi.2014.05.001 1871-5192/ß 2014 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Please cite this article in press as: Iida M, et al. A comparison of midwife-led care versus obstetrician-led care for low-risk women in Japan. Women Birth (2014), http://dx.doi.org/10.1016/j.wombi.2014.05.001
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WOMBI-338; No. of Pages 6 M. Iida et al. / Women and Birth xxx (2014) xxx–xxx
2
caseload midwifery care is safe and cost-effective compared to standard maternity care. While in Japan, there is a study that evaluated the continuous psychological support provided by midwives,16 there are no studies that measure both the physical and emotional outcomes regarding the continuity of MW-led care. Even so, some hospitals in Japan are establishing MW-led care units as part of the regular hospital services because of the decreasing number of obstetricians. Even the number of facilities in Japan where women could give birth was affected by a dwindling number of obstetricians. The facilities decreased 36% from 3991 in 1996 to 2567 in 2008, respectively.17 To decrease the burden on obstetricians and to fully use midwives, Japan’s Ministry of Health, Labour and Welfare announced a vision to increase in-hospital midwife-led care units. The Japanese Nursing Association is working towards the implementation of this system of care as well.18 Although the number of settings which provides in-hospital midwife-led care units are gradually increasing, these are few in number compared to the total. In order to popularise midwifery care within the entire system of perinatal care in Japan, there is a need to show evidence that continuity of MW-led care for women will bring about positive outcomes. The objectives of this study were to compare the health outcomes of women and infants who received MW-led care with OB-led care. Specifically, this study asked: (1) is there a difference in women’s perception of care, (2) are there differences in obstetric outcomes; physical outcomes, breast-feeding status, and mood status. 3. Participants and methods 3.1. Study design This was an observational study using non-random purposive sampling with a survey questionnaire. 3.2. Participants The inclusion criteria of the participants were: (1) low-risk women who received antenatal care delivering a term-singletoninfant at the participating settings during the research period, February to October in 2011; (2) women who could read and write Japanese and (3) women who consented to participate in the study. Excluded women were those who had a caesarean section or who were in seriously poor physical condition.
3.3. Sample size Previous studies12,13 indicated that the score of the Women’s Centred Care pregnancy (WCC-preg) questionnaire at birth centres was 233.3 points and at hospitals 199.8 points (p < .001, SD = 31.6). It was assumed that the birth centres provided continuity of MW-led care and the hospitals provided OB-led care. Setting alpha = .01, power = .9, the sample size ended up to be 58 women in total. Although 58 women would be enough to measure the main outcome, the 50-item WCC-preg questionnaire is still in its early use. Therefore, it is important to conduct a factor analysis, with at least five times the number of participants needed.19 Considering the dropout rate to be 20% from the preliminary studies, an adequate sample size for each group would be 156 women. 3.4. Settings There were two settings for each type of care. All four settings were in an urban part of Tokyo, Japan. Characteristics of MW-led and OB-led care groups are shown in Table 1. 3.4.1. MW-led care group In this purposive sample women received continuity of MW care in one of two midwifery clinics. A small team of midwives provided continuity of antenatal, intrapartum, and postpartum care. If any risk occurs, women would be transferred. This is because the law dictates that when midwives work independently from obstetricians, they may only manage low-risk women and normal births. 3.4.2. OB-led care group Women in this group received care mainly from obstetricians with attendance by midwives and nurses in one of two hospitals. This group’s care was provided with different caregivers across the antenatal, intrapartum, and postpartum period. The obstetrician is the one who has the final approval for the care provided. 3.5. Procedure for conducting the study The Research Ethics Committee at St. Luke’s College of Nursing, Tokyo, Japan (no. 10-065), and St. Luke’s International Hospital, Tokyo, Japan (no. 10-123) approved this study. Women who were hospitalized at the place where they gave birth at least three-days postpartum, were asked to participate.
Table 1 Characteristics of midwife and obstetrician led care groups.
Target women Lead caregiver Other staff System of care Continuity of care from midwife
Medical intervention Other characteristics of care
Schedule of antenatal checkups
Midwife-led care group
Obstetrician-led care group
Low-risk women Midwife (MW) OB provides care at least three times during the antenatal period Same MW or a team MW provides care Refer to OB when needed Intend to provide continuity of care throughout the maternity period
Low-risk women Obstetrician (OB) MW and nurse (NS) OB mainly provides antenatal care MW or NS provide health advice when needed Depends on shifts Intrapartum and postpartum care will be provided by OB, MW, and NS Conduct when needed
At the minimum or refer to OB, e.g. coded Prescription, transfer to obstetricians when needed Standard care provided at the setting Sufficient time for each antenatal visit Provide specific advice to support women’s Early detection, rapid cure of risk condition good physical condition Recommended to receive approximately 14 antenatal checkups: three times until 11 weeks gestation, once in every 4 weeks from 12 to 23 weeks gestation, once in every 2 weeks from 24 to 35 weeks gestation, and once a week from 36 weeks gestation to delivery (Japan Society of Obstetrics and Gynecology (2011). Guidelines for obstetrical practice in Japan: Japan Society of Obstetrics and Gynecology (JSOG) and Japan Association of Obstetricians and Gynecologists (JAOG) 2011 edition)
Please cite this article in press as: Iida M, et al. A comparison of midwife-led care versus obstetrician-led care for low-risk women in Japan. Women Birth (2014), http://dx.doi.org/10.1016/j.wombi.2014.05.001
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Women are usually hospitalized at least four days after a vaginal birth in Japan. In addition, they were asked to answer a questionnaire at their one-month check-up. A small token was provided each time for participation. After the researcher collected the questionnaire from the collecting box, data was collected from the medical record, as well. Numbers were written on the questionnaires to match the first questionnaire (after three-days postpartum) and the second questionnaire (at one-month postpartum). Since women chose where to receive care by themselves, blinding was not possible. 3.6. Outcome measurements Women were asked to answer an 83-item questionnaire while they were hospitalized and a 11-item questionnaire at their one-month check-up. If the women answered the first questionnaire, the researcher gathered 12 items from the medical record. Gathered outcomes are as follows. 3.6.1. Women’s characteristics There were seven items asking women about: age, parity, and preparation of physical condition: careful to keep warm, and other four items. ‘Careful to keep warm’ was asked because it is reported that women’s sensitivity to cold (hiesho) influences obstetric outcomes.20,21 This was rated using a 5-point Likert-type scale: (1) not at all, to (5) very careful. 3.6.2. Nature of care Women were asked to answer 10 items about the actual care they received, which were extracted from previous studies.12,13,20–24
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coefficient alpha for the 13 items was .74 indicating high internal consistency. 3.6.5. Health outcomes at one-month check-up Health outcomes were breast-feeding (one item) and mental health (10 items). Mental health was measured using the Edinburgh Postnatal Depression Scale (EPDS)28 which was translated into Japanese by Okano et al.,29 Validity and reliability of this scale was previously confirmed.29 This scale consists from 10 items and the rating differs according to the item. Scores range from 0 to 30 points. In Japan, women are considered to be at high risk of having postpartum depression if they rated higher than 9 points.29 The coefficient alpha for the 10 items was .81 and indicated high internal consistency. 3.7. Analysis Data were analysed as follows: (1) Descriptive statistics were used to summarise the participant’s background. (2) Chi-square test was used to compare categorical data and t-test test was used to compare continuous data if participant’s background differed among the continuity of MW-led care group and the OB-led care group. When using t-test, the variables were examined for the same variance using the Levene’s test. (3) Chi-square test and t-test test was used to compare the outcomes of the MW-led care group and the OB-led care group. Data were analysed using SPSS version 19.0J.
4. Findings A total of 281 women responded during hospitalisation (response rate 90.1%). Of these, 280 women were included in the analysis. Questionnaires were distributed to 277 women at their one-month check-up (it was not possible to distribute to three women because they cancelled their one-month check-up or they visited another office). Responses of all 238 women were included in the analysis for one month.
3.6.3. Evaluation of care (during hospitalisation) Evaluation of care was measured by using the WCC-preg questionnaire (50 items) and asking about their satisfaction with care (two items). There were 52 items in total. The WCC-preg questionnaire is a questionnaire to measure women’s perception of the received WCC.25 Women’s perception of WCC was measured because WCC is a concept that supports maternity care.2 The 50-item questionnaire contains a 5-point Likert-type scale: (1) I strongly disagree, to (5) I strongly agree. Scores ranged from 50 to 250 points. From the original factor analysis using promax rotation, six factors emerged; (1) feelings of encouragement, (2) being respected, (3) trusting the caregiver, (4) effective interaction, (5) help in decision-making, and (6) nonthreatening manner. The correlation coefficient of the test-retest was .55.25 Analysis was conducted using the original six factors as explained above. The Cronbach’s alpha for the total items was .98 for this study and indicated high internal consistency. The coefficient alpha for each of the factors was fairly high ranging from .71 to .95. Two items asked women to rate their satisfaction with care during the antenatal period and during the intrapartum period using a 10-point Likert-type scale: (1) I was very unsatisfied, to (10) I was very satisfied.
4.2.1. Nature of care provided Nature of care provided differed significantly between the groups (Table 2). Women in the MW-led group had more than 30 min for their antenatal care and they talked the same amount as the caregiver than those in the OB-led group.
3.6.4. Health outcomes during hospitalisation There were 26 items regarding obstetric outcomes and mental health. The researcher documented 12 obstetric outcome items from the medical record and one item about their breast-feeding status. Mental health was measured using the Stein’s maternity blues (Stein’s MB) scale26 which was translated into Japanese by Okano et al.,27 Validity and reliability of this scale was previously confirmed.27 This scale consists of 13 items and the rating differs according to the item. Scores ranged from 0 to 26 points. Women are considered to have maternity blues if they rated higher than 8 points.25 The
4.2.2. Specific advice given Specific advice given to women at antenatal care differed between groups; all showed a significant difference. Over 80% of the women in the MW-led group received advice about keeping warm, dietary intake, and exercise (98.0%, 93.3%, and 83.9% respectively), while it was 61.8%, 65.6%, and 51.9% respectively in the OB-led group (all p < .001). Although statistically more women in the MW-led group received advice about resting and taking a nap, neither group reached more than 50% (MW-led: 34.7% and 45.6% respectively; OB-led: 32.8% and 25.2% respectively, all p < .001) (Table 2).
4.1. Characteristics of participants Women in the MW-led group were significantly older (M = 33.2, SD = 4.3) than women in the OB-led group (M = 31.7, SD = 4.3) (p = .005). However, when divided by years under 34 and over 35, there was no statistical difference. Neither did parity differ between the groups. 4.2. Nature of care provided and specific advice
Please cite this article in press as: Iida M, et al. A comparison of midwife-led care versus obstetrician-led care for low-risk women in Japan. Women Birth (2014), http://dx.doi.org/10.1016/j.wombi.2014.05.001
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Table 2 Characteristics of participants and nature of care provided N = 280. MW-led (n = 149) n Age Mean [SD] Parity Primipara Multipara Characteristics of antenatal care (N = 279) Time spent for antenatal care Min 10 10 < min < 30 30 min Amount of conversation at antenatal care Caregiver talked more I talked more Talked the same amount Specific advice given Keeping warm Dietary intake Exercise Resting Taking a sleep Preparing physically for childbirth Number of women answering ‘very careful’ Keeping warm Eat a well-balanced diet Exercise regularly ** ***
OB-led (n = 131)
p-Value
Chi- square or t-value
(%)
n
(%)
33.2
[4.3]
31.7
[4.3]
2.8
.005
60 89
(40.3) (59.7)
68 63
(51.9) (48.1)
3.8
0.051
6 67 76
(4.0) (45.0) (51.0)
70 58 2
(53.8) (44.6) (1.5)
124.0
.000
***
13 26 109
(8.8) (17.6) (73.6)
72 3 56
(55.0) (2.3) (42.7)
75.5
.000
***
146 139 125 81 68
(98.0) (93.3) (83.9) (54.4) (45.6)
81 86 68 43 33
(61.8) (65.6) (51.9) (32.8) (25.2)
59.4 33.7 33.3 13.1 12.6
.000 .000 .000 .000 .000
***
119 55 99
(79.9) (36.9) (66.4)
70 25 64
(53.4) (19.1) (48.9)
25.9 20.3 14.6
.000 .000 .006
***
**
n.s.
*** *** *** ***
*** **
p < .01. p < .001.
4.3. Preparing physically for childbirth Three out of five items regarding women’s physical preparation during pregnancy differed between groups. The item which showed the most difference was ‘keeping warm’: 79.9% women in the MW-led group were ‘very careful’ (p < .001) while it was 53.4% of those in the OB-led group. Others were ‘eat a wellbalanced diet’ (p < .001), and ‘exercise regularly’ (p = .006). ‘Keep a regular schedule’ and ‘careful not to get too tired’ were similar between the groups. 4.4. Perception of care Women’s scores of WCC-preg questionnaire were fairly high; although, women in the MW-led group showed significantly
higher scores with the WCC-preg questionnaire than women in the OB-led group (p < .001) (Table 3). When comparing WCC-preg questionnaire’s factor’s total scores, in all six factors the MW-led group showed a significantly higher score than the OB-led group. Women in the MW-led group rated their satisfaction with care significantly higher (p < .001) than the OB-led group in all three periods. 4.5. Obstetric outcomes: physical outcomes Obstetric outcomes are described in Table 4. Because of the characteristics of the settings which provide MW-led care, all women had spontaneous birth, which means they did not receive any kind of analgesia or pharmacological procedures. Most of the women (91.6%) in the OB-led group had spontaneous birth and
Table 3 Perception of care N = 280. Perception of care
WCC-preg questionnaire Being respected Feelings of encouragement Effective interaction Help in decision-making Trusting the caregiver Non-threatening manner Satisfaction with care During antenatal care During labour and birth After birth (during hospitalisation) (N = 236)
MW-led (n = 149)
OB-led (n = 131)
t-Test
p-Value
[30.1] [6.8] [9.5] [8.8] [3.4] [3.9] [2.1]
10.9 12.0 10.7 8.8 8.5 7.7 3.8
.000*** .000*** .000*** .000*** .000*** .000*** .000***
[1.7] [1.8] [1.7]
10.5 6.0 5.8
.000*** .000*** .000***
Mean
[SD]
Mean
[SD]
238.8 47.9 57.2 62.2 18.5 39.1 14.0
[14.1] [3.0] [3.9] [4.1] [2.2] [1.9] [1.7]
207.5 40.2 47.6 54.9 15.6 36.2 13.1
9.1 9.7 9.3
[1.1] [.8] [1.8]
7.2 8.7 7.7
WCC-preg questionnaire: scores range from 50 to 250. Satisfaction with care: scores range from 1 to 10. *** p < .001.
Please cite this article in press as: Iida M, et al. A comparison of midwife-led care versus obstetrician-led care for low-risk women in Japan. Women Birth (2014), http://dx.doi.org/10.1016/j.wombi.2014.05.001
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Table 4 Obstetric outcomes and interventions by type of care. MW-led (n = 149)
OB-led (n = 131)
N
n
(%)
n
(%)
280 280
149 0
(100) (.0)
120 11
(91.6) (8.4)
— —
280 280 280 280 279
0 0 9 2 22
(.0) (.0) (6.0) (1.3) (14.9)
14 27 33 51 33
(10.7) (20.6) (25.2) (38.9) (25.2)
— — 20.1 — 4.7
