General practice
Should obstetricians see women with normal pregnancies? A multicentre randomised controlled trial of routine antenatal care by general practitioners and midwives compared with shared care led by obstetricians
Cite this as:
BMJ
1996;312:554
- J S Tucker, research fellowa,
- M H Hall, consultant gynaecologist and obstetricianb,
- P W Howie, professorc,
- M E Reid, senior lecturerd,
- R S Barbour, senior lecturere,
- C du V Florey, professora,
- G M McIlwaine, consultant in public healthf
- a Department of Epidemiology and Public Health, University of Dundee, Ninewells Hospital and Medical School, Dundee DD1 9SY
- b Department of Obstetrics and Gynaecology, Aberdeen Maternity Hospital, Aberdeen AB9 2ZA
- c Department of Obstetrics and Gynaecology, University of Dundee
- d Departments of Public Health and Social and Economic Research, University of Glasgow, Glasgow G12 8RZ
- e Department of Public Health Medicine, University of Hull, Hull HU6 7RX
- f Department of Public Health, Greater Glasgow Health Board, Glasgow G2 4JT
- Correspondence to: Ms Tucker.
- Accepted 21 December 1995
Abstract
Objective: To compare routine antenatal care provided by general practitioners and midwives with obstetrician led shared care.
Design: Multicentre randomised controlled trial.
Setting: 51 general practices linked to nine Scottish maternity hospitals.
Subjects: 1765 women at low risk of antenatal complications.
Intervention: Routine antenatal care by general practitioners and midwives according to a care plan and protocols for managing complications.
Main outcome measures: Comparisons of health service use, indicators of quality of care, and women's satisfaction.
Results: Continuity of carer was improved for the general practitioner and midwife group as the number of carers was less (median 5 carers v 7 for shared care group, P<0.0001) and the number of routine visits reduced (10.9 v 11.7, P<0.0001). Fewer women in the general practitioner and midwife group had antenatal admissions (27% (222/834) v 32% (266/840), P<0.05), non-attendances (7% (57) v 11% (89), P<0.01) and daycare (12% (102) v 7% (139), P<0.05) but more were referred (49% (406) v 36% (305), P<0.0001). Rates of antenatal diagnoses did not differ except that fewer women in the general practitioner and midwife group had hypertensive disorders (pregnancy induced hypertension, 5% (37) v 8% (70), P<0.01) and fewer had labour induced (18% (149) v 24% (201), P<0.01). Few failures to comply with the care protocol occurred, but more Rhesus negative women in the general practitioner and midwife group did not have an appropriate antibody check (2.5% (20) v 0.4% (3), P<0.0001). Both groups expressed high satisfaction with care (68% (453/663) v 65% (430/656), P=0.5) and acceptability of allocated style of care (93% (618) v 94% (624), P=0.6). Access to hospital support before labour was similar (45% (302) v 48% (312) visited labour rooms before giving birth, P=0.6).
Conclusion: Routine specialist visits for women initially at low risk of pregnancy complications offer little or no clinical or consumer benefit.
Key messages
Key messages
Care by general practitioners and midwives improved continuity of care: there were fewer carers, non-attendances, and hospital admissions, and marginally fewer routine visits than with specialist led shared care; incidences of hypertension, proteinuria, pre-eclampsia, and induction of labour were also lower
Overall there were few deviations from the care protocol, but a greater proportion of Rhesus negative women in the general practitioner and midwife group did not have an appropriate check for antibodies
The women in both trial groups were equally highly satisfied with all aspects of their care; only a small minority of women in the general practitioner and midwife group said they would have liked to have seen a hospital doctor but did not
Although there was no net benefit from routine specialist antenatal visits, over half of women developed some complication during their pregnancy; in the general practitioner and midwife model of care, low risk women see a specialist when required and not at predefined routine visits
Footnotes
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Funding Health Services and Public Health Research Committee of the Scottish Office Home and Health Department (grant No K/OPR/2/2/D63). The views expressed are those of the authors.
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Conflict of interest None.
- Accepted 21 December 1995
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