Postpartum Emergency Department Use Following Midwifery-Model vs Obstetrics-Model Care.

Importance: Emergency department (ED) use postpartum is a common and often-preventable event. Unlike traditional obstetrics models, the Ontario midwifery model offers early care postpartum. Objective: To assess whether postpartum ED use differs between women who received perinatal care in midwifery-model care vs in traditional obstetrics-model care. Design, Setting, and Participants: This retrospective population-based cohort study took place in Ontario, Canada, where public health care is universally funded. Participants included women who were low risk and primiparous and gave birth to a live baby in an Ontario hospital between 2012 and 2018. Data were collected from April 2012 to March 2018 and analyzed from June 2022 to April 2023. Exposures: Perinatal care clinician, namely, a midwife or obstetrician. Main Outcome and Measures: : Any unscheduled ED visit 42 days postpartum or less. Poisson regression models compared ED use between women with midwifery-model care vs obstetrics-model care, weighting by propensity score-based overlap weights. Results: Among 104 995 primiparous women aged 11 to 50 years, those in midwifery-model care received a median (IQR) of 7 (6-8) postpartum visits, compared with 0 (0-1) visits among those receiving obstetrics-model care. Unscheduled ED visits 42 days or less postpartum occurred for 1549 of 23 124 women (6.7%) with midwifery-model care compared with 6902 of 81 871 women (8.4%) with traditional obstetrics-model care (adjusted relative risks [aRR], 0.78; 95% CI, 0.73-0.83). Similar aRRs were seen in women with a spontaneous vaginal birth (aRR, 0.71; 95% CI, 0.65-0.78) or assisted vaginal birth (aRR, 0.70; 95% CI, 0.59-0.82) but not those with a cesarean birth (aRR, 0.94; 95% CI, 0.86-1.03) or those with intrapartum transfer of care between a midwife and obstetrician (aRR, 0.94; 95% CI, 0.87-1.04). ED use 7 days or less postpartum was also lower among women receiving midwifery model care (aRR, 0.70; 95% CI, 0.65-0.77). Conclusions and Relevance: In this cohort study, midwifery-model care was associated with less postpartum ED use than traditional obstetrics-model care among women who had low risk and were primiparous, which may be due to early access to postpartum care provided by Ontario midwives.

Trends in very early discharge from hospital for newborns under midwifery care in Ontario from 2003 to 2017: a retrospective cohort study.

BACKGROUND: Very early discharge from hospital is an element of Ontario midwifery care. Our aim in the present study was to describe the frequency of very early hospital discharge for newborns in Ontario midwifery care over time. METHODS: We conducted a retrospective population-based cohort study, including all midwife-attended singleton term cephalic newborns delivered by spontaneous vaginal birth at Ontario hospitals between April 2003 and February 2017. Our primary outcome was very early hospital discharge (< 6 h after birth) for newborns. Secondary outcomes were pediatric consultation before hospital discharge, phototherapy before hospital discharge and readmission for treatment of jaundice. We used generalized linear mixed models to estimate the relation between maternal, neonatal and hospital factors and very early discharge, while accounting for clustering by hospital. RESULTS: The study cohort included 101 852 newborns born at 89 hospitals. Between 2003/04 and 2016/17, the unadjusted rate of very early discharge decreased from 34.3% to 30.7%. This trend was not significant after adjustment for covariates (odds ratio 1.0, 95% confidence interval 0.99-1.0). Unadjusted rates of pediatric consultation, phototherapy and readmission for jaundice all rose slightly over the study period. Hospital-specific risk-adjusted frequencies of very early discharge ranged from 5% (n = 1479) to 83% (n = 3459) across the 75 Ontario hospitals with at least 100 newborns included in the study cohort. INTERPRETATION: Hospital-level factors contributed to the observed decrease in crude rates of very early discharge for midwifery clients. Wide variation in these rates across Ontario hospitals points to room for improvement to make more efficient use of health care resources by promoting optimal levels of very early discharge.