Department of Women and Children's Health, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom.
Clinical Research Facility, Chelsea and Westminster NHS Foundation Trust, London, United Kingdom.
PLoS One. 2021 May 4;16(5):e0250947. doi: 10.1371/journal.pone.0250947. eCollection 2021.
Social factors associated with poor childbirth outcomes and experiences of maternity care include minority ethnicity, poverty, young motherhood, homelessness, difficulty speaking or understanding English, migrant or refugee status, domestic violence, mental illness and substance abuse. It is not known what specific aspects of maternity care work to improve the maternal and neonatal outcomes for these under-served, complex populations.
This study aimed to compare maternal and neonatal clinical birth outcomes for women with social risk factors accessing different models of maternity care. Quantitative data on pregnancy and birth outcome measures for 1000 women accessing standard care, group practice and specialist models of care at two large, inner-city maternity services were prospectively collected and analysed using multinominal regression. The level of continuity of care and place of antenatal care were used as independent variables to explore these potentially influential aspects of care. Outcomes adjusted for women's social and medical risk factors and the service attended.
Women who received standard maternity care were significantly less likely to use water for pain relief in labour (RR 0.11, CI 0.02-0.62) and have skin to skin contact with their baby shortly after birth (RR 0.34, CI 0.14-0.80) compared to the specialist model of care. Antenatal care based in the hospital setting was associated with a significant increase in preterm birth (RR 2.38, CI 1.32-4.27) and low birth weight (RR 2.31, CI 1.24-4.32), and a decrease in induction of labour (RR 0.65, CI 0.45-0.95) compared to community-based antenatal care, this was despite women's medical risk factors. A subgroup analysis found that preterm birth was increased further for women with the highest level of social risk accessing hospital-based antenatal care (RR 3.11, CI1.49-6.50), demonstrating the protective nature of community-based antenatal care.
This research highlights how community-based antenatal care, with a focus on continuity of carer reduced health inequalities and improved maternal and neonatal clinical outcomes for women with social risk factors. The findings support the current policy drive to increase continuity of midwife-led care, whilst adding that community-based care may further improve outcomes for women at increased risk of health inequalities. The relationship between community-based models of care and neonatal outcomes require further testing in future research. The identification of specific mechanisms such as help-seeking and reduced anxiety, to explain these findings are explored in a wider evaluation.
与不良分娩结局和产妇护理体验相关的社会因素包括少数族裔、贫困、年轻母亲、无家可归、语言障碍或英语理解能力差、移民或难民身份、家庭暴力、精神疾病和药物滥用。目前尚不清楚产妇护理工作的哪些具体方面可以改善这些服务不足、情况复杂的人群的母婴结局。
本研究旨在比较接受不同模式产妇护理的具有社会风险因素的妇女的母婴临床分娩结局。前瞻性收集了在两家大型市中心妇产医院接受标准护理、小组实践和专科护理的 1000 名妇女的妊娠和分娩结局测量的定量数据，并使用多项逻辑回归进行分析。护理的连续性水平和产前护理地点用作探索这些潜在有影响的护理方面的自变量。结果调整了妇女的社会和医疗风险因素以及所接受的服务。
与专科护理模式相比，接受标准产科护理的妇女在分娩时使用水缓解疼痛的可能性显著降低（RR 0.11，CI 0.02-0.62），并且在出生后不久与婴儿进行皮肤接触的可能性也显著降低（RR 0.34，CI 0.14-0.80）。在医院环境中进行的产前护理与早产（RR 2.38，CI 1.32-4.27）和低出生体重（RR 2.31，CI 1.24-4.32）显著增加有关，与社区为基础的产前护理相比，引产减少（RR 0.65，CI 0.45-0.95），尽管妇女存在医疗风险因素。亚组分析发现，在接受以医院为基础的产前护理的社会风险最高的妇女中，早产进一步增加（RR 3.11，CI1.49-6.50），这表明社区为基础的产前护理具有保护作用。
本研究强调了以连续性照顾者为重点的社区为基础的产前护理如何减少社会风险妇女的健康不平等，并改善母婴临床结局。研究结果支持当前增加助产士主导的护理连续性的政策举措，同时表明社区为基础的护理可能进一步改善处于健康不平等风险增加的妇女的结局。未来的研究需要进一步测试社区为基础的护理模式与新生儿结局之间的关系。本研究还探讨了更广泛的评估中解释这些发现的具体机制，如寻求帮助和减少焦虑。
