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

BMJ 1996; 312 doi: http://dx.doi.org/10.1136/bmj.312.7030.554 (Published 02 March 1996) Cite this as: BMJ 1996;312:554
  1. J S Tucker, research fellowa,
  2. M H Hall, consultant gynaecologist and obstetricianb,
  3. P W Howie, professorc,
  4. M E Reid, senior lecturerd,
  5. R S Barbour, senior lecturere,
  6. C du V Florey, professora,
  7. G M McIlwaine, consultant in public healthf
  1. a Department of Epidemiology and Public Health, University of Dundee, Ninewells Hospital and Medical School, Dundee DD1 9SY
  2. b Department of Obstetrics and Gynaecology, Aberdeen Maternity Hospital, Aberdeen AB9 2ZA
  3. c Department of Obstetrics and Gynaecology, University of Dundee
  4. d Departments of Public Health and Social and Economic Research, University of Glasgow, Glasgow G12 8RZ
  5. e Department of Public Health Medicine, University of Hull, Hull HU6 7RX
  6. f Department of Public Health, Greater Glasgow Health Board, Glasgow G2 4JT
  1. 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

  • 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.

  • Conflict of interest None.

  • Accepted 21 December 1995
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