Yang Y Tony, Attanasio Laura B, Kozhimannil Katy B
Department of Health Administration and Policy, George Mason University, Fairfax, VA.
Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN.
Womens Health Issues. 2016 May-Jun;26(3):262-7. doi: 10.1016/j.whi.2016.02.003. Epub 2016 Mar 7.
Despite research indicating that health, cost, and quality of care outcomes in midwife-led maternity care are comparable with and in some case preferable to those for patients with physician-led care, midwifery plays a more important role in some U.S. states than in others. However, this variability is not well-understood.
This study estimates the association between state scope of practice laws related to the autonomy of midwifery practice with the certified nurse-midwifery (CNM) workforce, access to midwife-attended births, and childbirth-related procedures and outcomes.
Using multivariate regression models, we analyzed Natality Detail File data from births occurring from 2009 to 2011. Each state was classified regarding autonomous midwifery practice (not requiring supervision or contractual agreements) based on Lexis legal search.
States with autonomous practice laws had an average of 4.85 CNMs per 1,000 births, compared with 2.17 in states where CNM practice is subject to collaborative agreement. In states with autonomous CNM practice, women had higher odds of having a CNM-attended birth (adjusted odds ratio [AOR], 1.59; p = .004), compared with women in states where midwifery is subject to collaborative agreement. In addition, women in states with autonomous practice had lower odds of cesarean delivery (AOR, 0.87; p = .016), preterm birth (AOR, 0.87; p < .001), and low birth weight (AOR, 0.89; p = .001), compared with women in states without such practice.
States with regulations that support autonomous midwifery practice have a larger nurse-midwifery workforce, and a greater proportion of CNM-attended births. Correlations between autonomous practice laws and better birth outcomes suggest future policy efforts to enhance access to midwifery services may be beneficial to pregnancy outcomes and infant health.
尽管研究表明，由助产士主导的产科护理在健康、成本及护理结果质量方面与医生主导的护理相当，且在某些情况下更优，但助产护理在美国某些州所发挥的作用比其他州更为重要。然而，这种差异并未得到充分理解。
本研究估计与助产护理自主权相关的州执业范围法律与认证注册护士助产士（CNM）劳动力、获得助产士接生服务的机会以及分娩相关程序和结果之间的关联。
我们使用多元回归模型，分析了2009年至2011年出生的出生详细档案数据。根据律商联讯法律搜索，每个州按照自主助产护理执业（无需监督或合同协议）进行分类。
拥有自主执业法律的州每1000例出生平均有4.85名CNM，而CNM执业需遵循合作协议的州这一数字为2.17。在CNM自主执业的州，与助产护理需遵循合作协议的州的女性相比，前者由CNM接生的几率更高（调整优势比[AOR]为1.59；p = 0.004）。此外，与没有此类自主执业的州的女性相比，自主执业州的女性剖宫产（AOR为0.87；p = 0.016）、早产（AOR为0.87；p < 0.001）和低出生体重（AOR为0.89；p = 0.001）的几率更低。
支持自主助产护理执业的州拥有规模更大的注册护士助产士劳动力，且由CNM接生的比例更高。自主执业法律与更好的分娩结果之间的相关性表明，未来加强助产服务可及性的政策努力可能有益于妊娠结局和婴儿健康。
