Department of Obstetrics, University Medical Center Utrecht, 3584 EA Utrecht, Netherlands.
BMJ. 2010 Nov 2;341:c5639. doi: 10.1136/bmj.c5639.
To compare incidences of perinatal mortality and severe perinatal morbidity between low risk term pregnancies supervised in primary care by a midwife and high risk pregnancies supervised in secondary care by an obstetrician.
Prospective cohort study using aggregated data from a national perinatal register.
Catchment area of the neonatal intensive care unit (NICU) of the University Medical Center in Utrecht, a region in the centre of the Netherlands covering 13% of the Dutch population.
Pregnant women at 37 weeks' gestation or later with a singleton or twin pregnancy without congenital malformations.
Perinatal death (antepartum, intrapartum, and neonatal) or admission to a level 3 NICU.
During the study period 37 735 normally formed infants were delivered at 37 weeks' gestation or later. Sixty antepartum stillbirths (1.59 (95% confidence interval 1.19 to 1.99) per 1000 babies delivered), 22 intrapartum stillbirths (0.58 (0.34 to 0.83) per 1000 babies delivered), and 210 NICU admissions (5.58 (4.83 to 6.33) per 1000 live births) occurred, of which 17 neonates died (0.45 (0.24 to 0.67) per 1000 live births). The overall perinatal death rate was 2.62 (2.11 to 3.14) per 1000 babies delivered and was significantly higher for nulliparous women compared with multiparous women (relative risk 1.65, 95% confidence interval 1.11 to 2.45). Infants of pregnant women at low risk whose labour started in primary care under the supervision of a midwife had a significant higher risk of delivery related perinatal death than did infants of pregnant women at high risk whose labour started in secondary care under the supervision of an obstetrician (relative risk 2.33, 1.12 to 4.83). NICU admission rates did not differ between pregnancies supervised by a midwife and those supervised by an obstetrician. Infants of women who were referred by a midwife to an obstetrician during labour had a 3.66 times higher risk of delivery related perinatal death than did infants of women who started labour supervised by an obstetrician (relative risk 3.66, 1.58 to 8.46) and a 2.5-fold higher risk of NICU admission (2.51, 1.87 to 3.37).
Infants of pregnant women at low risk whose labour started in primary care under the supervision of a midwife in the Netherlands had a higher risk of delivery related perinatal death and the same risk of admission to the NICU compared with infants of pregnant women at high risk whose labour started in secondary care under the supervision of an obstetrician. An important limitation of the study is that aggregated data of a large birth registry database were used and adjustment for confounders and clustering was not possible. However, the findings are unexpected and the obstetric care system of the Netherlands needs further evaluation.
比较由助产士在初级保健机构监管的低危足月妊娠与由产科医生在二级保健机构监管的高危妊娠的围产期死亡率和严重围产期发病率。
使用全国围产儿登记处汇总数据的前瞻性队列研究。
乌得勒支大学医学中心新生儿重症监护室（NICU）的集水区，该区域位于荷兰中心，覆盖荷兰人口的 13%。
孕 37 周或以上的单胎或双胎妊娠且无先天畸形的孕妇。
围产儿死亡（产前、产时和新生儿期）或入住 3 级 NICU。
在研究期间，37735 名正常胎儿在孕 37 周或以上分娩。60 例产前死胎（每 1000 例活产婴儿中 1.59（95%置信区间 1.19 至 1.99）），22 例产时死胎（每 1000 例活产婴儿中 0.58（0.34 至 0.83）），210 例 NICU 入院（每 1000 例活产婴儿中 5.58（4.83 至 6.33）），其中 17 例新生儿死亡（每 1000 例活产婴儿中 0.45（0.24 至 0.67））。总的围产儿死亡率为每 1000 例活产婴儿 2.62（2.11 至 3.14），与多产妇相比，初产妇的死亡率明显更高（相对风险 1.65，95%置信区间 1.11 至 2.45）。在初级保健机构由助产士监管下开始分娩的低危孕妇所分娩的婴儿，其与分娩相关的围产儿死亡风险显著高于高危孕妇所分娩的婴儿，高危孕妇在二级保健机构由产科医生监管下开始分娩（相对风险 2.33，1.12 至 4.83）。由助产士监管的妊娠与由产科医生监管的妊娠的 NICU 入院率没有差异。在分娩过程中由助产士转介给产科医生的孕妇所分娩的婴儿，其与分娩相关的围产儿死亡风险比由产科医生开始监管分娩的孕妇所分娩的婴儿高 3.66 倍（相对风险 3.66，1.58 至 8.46），且 NICU 入院风险高 2.5 倍（2.51，1.87 至 3.37）。
在荷兰，由助产士在初级保健机构监管下开始分娩的低危孕妇所分娩的婴儿，其与分娩相关的围产儿死亡风险高于高危孕妇所分娩的婴儿，且入住 NICU 的风险相同。本研究的一个重要局限性是使用了大型出生登记数据库的汇总数据，并且无法进行混杂因素和聚类的调整。然而，这些发现出乎意料，荷兰的产科保健系统需要进一步评估。
