In our study, women who received collaborative, multidisciplinary, community-based care in the South Community Birth Program were less likely to have a cesarean delivery, had shorter hospital stays on average and were more likely to breastfeed exclusively than women who received standard care.
Although our study design did not permit us to discern which components of the birth program were responsible for the observed differences, clinicians working in the program believe that their close working relationship, including their ability to discuss patient care facilitated by immediate and remote access to electronic medical records, fosters an environment in which they can continually support and learn from each other. Consistency in care is achieved through these discussions at monthly meetings and team retreats, as well as through adherence to local and national practice guidelines. Self-selection to work in the program by providers who are particularly committed to physiologic birth may also be a factor. As well, the CenteringPregnancy model of prenatal care has been shown to improve women’s knowledge about pregnancy.17
The frequency of cesarean delivery among women whose primary caregiver was a midwife or a family physician did not differ significantly between the groups. In the control group, 1.4 times as many women had an obstetrician as had a family physician as their primary care provider, and 4.4 times as many had an obstetrician as had a midwife. Because cesarean delivery was performed more frequently among women whose primary care involved an obstetrician than among those seen by a midwife or a family physician (1.6 times more frequently compared with either a midwife or family physician in the control group, and 3.3 and 3.1 times more frequently, respectively, in the program group), the difference in the overall frequency of cesarean delivery between the two groups may have been related to primary care by an obstetrician being more prevalent in the control group.
We observed more newborns who were large for gestational age in the program group than in the comparison group. Screening for gestational diabetes was conducted in both groups following national guidelines from the Society of Obstetricians and Gynecologists of Canada.22
However, because data were not available on the uptake of screening, we could not assess the possibility that differences in uptake betweeen groups may have contributed to the differences in birth weight.
Although findings of reduced obstetric interventions have been reported among midwife practices compared with physician-led maternity care units, we were not able to find reports of shared caseloads among midwives and physicians. Studies have reported reduced rates of cesarean delivery associated with collaborative care models; however, they were conducted in clinics in which midwives and obstetricians worked together but had their own distinct caseloads23
or in which nurses and allied health professionals supported physician-led care.24
Our study is limited by its nonrandomized design. We believe that much of the population from which we drew our participants would not have agreed to randomization and that a subgroup of women who may have agreed to randomization would not have been a representative sample. However, self-referral to the South Community Birth Program may have introduced selection bias. Future studies may be able to use a randomized design if selection bias can be minimized.
Information about race and ethnicity is currently not available in the hospital’s database. Outcomes from an earlier analysis (unpublished) in which we compared data for the first 500 participants in the birth program with a comparison group for which we did have ethnicity data were not confounded because the distribution of racial and ethnic groups was similar between groups. This initial cohort was part of our current sample.
The presence of a doula was not recorded in our data. However, North American trials have not shown benefit of support in labour in reducing the frequency of cesarean delivery.25
Finally, our study offered maternity care in an area previously underserved by providers. It is unclear whether our results are generalizable to areas that are well supplied with maternity care providers. Our program has recently been replicated in Surrey, a suburban area in British Columbia, and further evaluations will determine the relevance of our findings to other settings.
Women attending a collaborative program of maternity care, in which family physicians and midwives shared a patient caseload and worked closely with nurses and doulas, were less likely to have a cesarean delivery, had shorter hospital stays on average and were more likely to breastfeed exclusively than women who received standard care. These findings have important implications given the decreasing numbers of maternity care providers in Canada. Our findings should encourage the implementation and evaluation of this interdisciplinary approach in other settings.