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‘Usual’ nursing or midwifery care are unlikely to be the same.
- Edwin R. van Teijlingen, Jillian C.M. Ireland (1 September 2008)
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Re: ‘Usual’ nursing or midwifery care are unlikely to be the same.
- Ellen D. Hodnett (3 September 2008)
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Edwin R. van Teijlingen, reader in Public Health School of Medicine & Dentistry, University of Aberdeen, Aberdeen, AB25 2ZD Scotland, UK, Jillian C.M. Ireland
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The randomised controlled trial (RCT) of hospital-based labour assessment reported by Hodnett and colleagues found very little difference between “usual nursing or midwifery care or a minimum of one hour of care by a nurse or midwife trained in structured care, consisting of a formalised approach to assessment of and interventions for maternal emotional state, pain, and fetal position” [1]. This RCT is a worthwhile study of a complex intervention which may help reduce unnecessary medical/obstetrical interventions. This study treats British midwifery and North-American nursing care as being the same. The paper claims that “In North America the units were staffed by nurses and in the UK by midwives, but the approach to care was the same”. However, these professions are of a very different nature. Nurses are trained to deal with pathology and their caring approach reflects this. Midwives deal with normality, i.e. the notion that pregnancy is not a disease, but a normal aspects of most women’s life cycle, this leads to a very different approach to caring. Therefore, sending someone home in early labour is likely to have a different meaning for a midwife than an obstetric nurse. Moreover, in the US, in 2004, midwives attended 7.9% of all births [2]. In England (2005-2006) the proportion of midwife attended births was 64.0% [3]. Whilst midwifery has only recently (1993) been recognised as a profession in Canada [4]. The participating hospitals are distributed unevenly between the three countries with eight in Canada, ten in the US and only one in Wales and one in England. Considering the vast differences in the health care systems in the US, Canada and the UK, we question the wisdom of including two UK NHS hospitals as sites for recruitment. We don’t question the uniformity of the training of the midwives and nurses providing the components of ‘structured’ care, although the paper is vague about whether or not staff was randomly selected or whether individual hospitals trained their most dedicated or keenest staff to deliver the intervention. We do, however, question the potential variety in ‘usual’ care provided by nurses in North America and midwives in the UK. References 1. Hodnett ED, Stremler R, Willan AR, Weston JA, Lowe NK, Simpson KR, Fraser WD, Gafni A the SELAN (Structured Early Labour Assessment and Care by Nurses) Trial Group, Effect on birth outcomes of a formalised approach to care in hospital labour assessment units: international, randomised controlled trial, Brit Med J 2008; 337: a1021 2. Richardson A, Mmata C. NHS Maternity Statistics, England: 2005-06, the Information Centre, 2007. See: www.ic.nhs.uk/webfiles/publications/maternity0506/NHSMaternityStatsEngland200506_fullpublication%20V3.pdf 3. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Kirmeyer S. Births: Final data for 2004, National Vital Statistics Reports; 2006; Vol. 55 (1). See: www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_01.pdf 4. Sandall J, Bourgeault IL, Meijer WJ, Schüecking BA. Deciding who cares: Winners and losers in the late twentieth century. In: DeVries R., Benoit C, van Teijlingen ER, Wrede S. (eds.) Birth by Design: Pregnancy, maternity care, and midwifery in North America and Europe, London: Routledge, 2001: 119. Competing interests: None declared |
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Ellen D. Hodnett, Professor & Heather M. Reisman Chair in Perinatal Nursing Research Lawrence S. Bloomberg Faculty of Nursing, 155 College St., Suite 130, Toronto, Canada M5T 1P8
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Midwives at both UK hospitals assured us at the outset that their labour assessment units, and the staff in them, functioned in the same way as the North American units. We do not dispute the differences in training of nurses and midwives, but staff who work in hospitals are subject to institutional norms and policies, and we found no evidence that nursing care is different from midwifery care in hospital labour assessment units. If in-hospital midwifery care were sufficiently different to affect birth outcomes, we would have expected to see higher spontaneous vaginal birth rates in the UK hospitals, but their rates were actually at the low end of the spectrum, compared to the other 18 hospitals. Furthermore the UK hospitals enrolled only 129 women, of whom 67 were allocated to usual care. Thus the contribution to the usual care group (n=2501) was negligible from a statistical standpoint and could not have materially affected the results. As we stated in the Discussion (second paragraph), the staff who were trained to provide structured care were volunteers. The 505 structured care providers represented 27% of the total staffing complement over the course of the trial. We are currently conducting a follow-up study at the two hospitals with the largest treatment effects, to determine if training all staff in structured care will improve spontaneous vaginal birth rates under “real world” conditions. Results will be available in mid-2009. Competing interests: Principal Investigator of the trial |
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