Rosenstein Melissa G, Nijagal Malini, Nakagawa Sanae, Gregorich Steven E, Kuppermann Miriam
Departments of Obstetrics, Gynecology, and Reproductive Sciences, Medicine, and Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, Prima Medical Foundation, Novato, and Marin General Hospital, Greenbrae, California; and the Department of Obstetrics and Gynecology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.
Obstet Gynecol. 2015 Oct;126(4):716-723. doi: 10.1097/AOG.0000000000001032.
To examine the association between expanded access to collaborative midwifery and laborist services and cesarean delivery rates.
This was a prospective cohort study at a community hospital between 2005 and 2014. In 2011, privately insured women changed from a private practice model to one that included 24-hour midwifery and laborist coverage. Primary cesarean delivery rates among nulliparous, term, singleton, vertex women and vaginal birth after cesarean delivery (VBAC) rates among women with prior cesarean delivery were compared before and after the change. Multivariable logistic regression models estimated the effects of the change on the odds of primary cesarean delivery and VBAC; an interrupted time-series analysis estimated the annual rates before and after the expansion.
There were 3,560 nulliparous term singleton vertex deliveries and 1,324 deliveries with prior cesarean delivery during the study period; 45% were among privately insured women whose care model changed. The primary cesarean delivery rate among these privately insured women decreased after the change, from 31.7% to 25.0% (P=.005, adjusted odds ratio [OR] 0.56, 95% confidence interval [CI] 0.39-0.81). The interrupted time-series analysis estimated a 7% drop in the primary cesarean delivery rate in the year after the expansion and a decrease of 1.7% per year thereafter. The VBAC rate increased from 13.3% before to 22.4% afterward (adjusted OR 2.03, 95% CI 1.08-3.80).
The change from a private practice to a collaborative midwifery-laborist model was associated with a decrease in primary cesarean rates and an increase in VBAC rates.
II.
探讨扩大协作助产服务和产科医生服务的可及性与剖宫产率之间的关联。
这是一项于2005年至2014年在一家社区医院开展的前瞻性队列研究。2011年，参加私人保险的女性的护理模式从私人执业模式转变为包含24小时助产服务和产科医生服务的模式。比较了转变前后初产妇、足月、单胎、头位产妇的初次剖宫产率以及有剖宫产史女性的剖宫产术后阴道分娩（VBAC）率。多变量逻辑回归模型估计了这种转变对初次剖宫产和VBAC几率的影响；中断时间序列分析估计了扩大服务前后的年发生率。
研究期间共有3560例初产妇足月单胎头位分娩以及1324例有剖宫产史的分娩；其中45%发生在护理模式发生改变的参加私人保险的女性中。这些参加私人保险的女性的初次剖宫产率在转变后有所下降，从31.7%降至25.0%（P = 0.005，调整优势比[OR]为0.56，95%置信区间[CI]为0.39 - 0.81）。中断时间序列分析估计，扩大服务后的第一年初次剖宫产率下降了7%，此后每年下降1.7%。VBAC率从之前的13.3%升至之后的22.4%（调整OR为2.03，95%CI为1.08 - 3.80）。
从私人执业模式转变为协作助产 - 产科医生模式与初次剖宫产率降低及VBAC率升高有关。
II级。
