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Prenatal care : a comparative evaluation of nurse-midwives and general practitioners Buhler, Patricia Lynn 1985

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PRENATAL CARE: A COMPARATIVE EVALUATION OF NURSE-MIDWIVES AND GENERAL PRACTITIONERS By P a t r i c i a Lynn Buhler B.S.N., The University of B r i t i s h Columbia, 1976 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE (Health Services Planning and Administration) i n THE FACULTY OF GRADUATE STUDIES Department of Health Care and Epidemiology We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September 1985 ©Patricia Lynn Buhler, 1985 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r an advanced degree a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I agree t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y purposes may be g r a n t e d by t h e head o f my department o r by h i s o r h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . P. #ynn B u h l e r Department O f H e a l t h c a r e P l a n n i n g & E p i d e m i o l o g y The U n i v e r s i t y o f B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date September 16, 1985 DE-6 (3/81) ABSTRACT The practice of midwifery by those other than physicians i s i l l e g a l i n Canada and de s p i t e recommendations of nursing, medical and consumer groups, no t r i a l s evaluating the effectiveness of the nurse-midwife as a member of the modern o b s t e t r i c a l team have occurred here. To demonstrate a nurse-midwifery model, four nurse-midwives provided primary care to f o r t y -seven childbearing women and t h e i r f a m i l i e s over a twenty-two month period i n a maternity teaching h o s p i t a l . This c l i n i c presented a unique opportunity for comparing the prenatal care provided by nurse-midwives with that of general practitioners who attended de l i v e r i e s in the same setting. U t i l i z i n g a r e t r o s p e c t i v e chart a u d i t , case c o n t r o l study design, the n u r s e - m i d w i f e cases (NM cases) were each matched to two general p r a c t i t i o n e r c o n t r o l s (GP c o n t r o l s ) through the use of the h o s p i t a l ' s p e r i n a t a l data base. The matching c h a r a c t e r i s t i c s included low r i s k status, date of delivery, age, parity, gravidity, previous pregnancy losses and census t r a c t income. P r e n a t a l c r i t e r i a that had been developed and tested i n "The B u r l i n g t o n Randomized C l i n i c a l T r i a l o f the Nurse Practitioner" for assessing the quality of care were reviewed and updated for t h i s study. With these c r i t e r i a two blinded abstractors audited the p r e n a t a l record forms of a l l the subjects and scored them as e i t h e r "superior", "adequate" or "inadequate". Seventy-seven percent of the records of the NM cases received a "s u p e r i o r " score, where as 60% of the GP c o n t r o l s ' records received an " i n a d e q u a t e " s c o r e ( x ^ = 18.02, p < .01). O v e r a l l , the g e n e r a l mn practitioners' records indicated more e r r a t i c care than those of the nurse-midwives. Although the p h y s i c i a n s met most of the i n i t i a l assessment c r i t e r i a , they f a i l e d to meet the c r i t e r i a t h a t evaluated the ongoing ( i i ) routine assessment process by recording an inadequate number of prenatal v i s i t s (36%), or by omitting urine test results (38$) and blood pressure readings (21%). No differences were found in variables relating to labour and delivery with the exception of the incidence of episiotomies. The results indicate that nurse-midwives as part of an obstetrical team are able to provide safe prenatal care to a low risk population in a Canadian urban context,and that their records are thorough and more consistent than those of general practitioners. ( i i i ) TABLE OF CONTENTS PAGE NO. Abstract i i Table of Contents iv List of Tables v i i List of Figures v i i i Acknowledgement ix Chapter 1 . Introduction 1 1.1 Statement of the Problem 1 1.2 Setting 3 1.3 Purpose 6 1.4 Research Question 7 1.5 Thesis Outline 7 Chapter 2. Quality of Care - Literature Review 9 2.1 Ambulatory Setting 9 2.2 Nurse-Midwifery Care 17 Chapter 3- Prenatal Care - Literature Review 25 3.1 Development and Goals of Modern Prenatal Care 25 3.2 Prenatal Care - General Discussions - Literature Review 27 3.3 Prenatal Care - Effectiveness Studies -Literature Review 29 (iv) TABLE OF CONTENTS (Continued) PAGE NO. Chapter 4. Methodology 43 4.1 Definitions 43 4.2 The Instrument - Selection, Application and Validity 45 4.3 Modification of the Criteria 50 4.4 Study Design 53 4.5 Reliability 60 Chapter 5. Results 65 5.1 Matched Variables 65 5.2 Unmatched Variables 66 5.3 Prenatal Criteria Assessment 70 5.4 Patterns of Care 73 Chapter 6. Discussion 78 6.1 Methodology Discussion 78 6.2 Results Discussion 82 6.3 Limitations 89 Chapter 7. Implications 91 7.1 Feasibility and Application of the Research Method 91 7.2 Implications for Planning 93 7.3 Conclusion 98 Bibliography (v) 99 TABLE OF CONTENTS (Continued) PAGE NO. Appendixes Appendix A. Low Risk Criteria 105 Appendix B.1 Burlington Prenatal Criteria 107 Appendix B.2 Updated Burlington Prenatal Criteria 110 Appendix B.3 Adapted Burlington Prenatal Criteria 113 Appendix C. Questionnaire 114 Appendix D. British Columbia's Prenatal Record Form 121 Appendix E.1 Abstraction Form 124 Appendix E.2 Coding Guide 127 Appendix F.1 Determination of Sample Size (for 90% power) in a Matched Pair Study 136 Appendix F.2 Calculation of Power Estimate of Matched Study Based on m-Discordant Pairs 137 Appendix F.3 Mantel-Haenszel Estimate of the Odds Ratio 138 and Power Estimate (Present Study) Appendix G Kappa Calculations 139 (vi) L i s t of Tables PAGE NO. Table 4.1 Table 4.2 Table 4.3 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 5.5 Table 5.6 Table 5.7 Table 5.8 Table 5.9 Table 6.1 Sample Frequencies of Eight Possible Outcomes for Matched Triplets (Case, Control , Control ) 1 2 Frequency of Discrepancies in Inter-rater Reliability Assessment Frequency of Discrepancies in Intra-rater Reliability Assessment Means of Matching Variables for NM Cases and GP Controls Prenatal Attendance Variables (Unmatched) For NM Cases and GP Controls Percentage of Labour Variables for NM Cases and GP Controls Percentage of Fetal Monitoring Activities and Forceps Use for NM Cases and GP Controls Percentage of Perineum Condition for NM Cases and GP Controls 59 61 62 65 66 67 68 69 71 Frequency of Eight Possible UBPC Outcomes Among Case-Control Triplets (Case, Control , Control ) 1 2 Frequency of Eight Possible ABPC Score Outcomes Among Case-Control Triplets (Case, Control , Control ) 71 1 2 Frequency of UBPC Score Outcomes for NM Cases and GP Controls 72 Frequency of ABPC Score Outcomes for NM Cases and GP Controls 72 Proportions of Adequate and Superior Scores Achieved with the Burlington Randomized Clinical Trial (BRCT) Criteria for Prenatal Care in Three Studies 83 (vii) List of Figures PAGE NO. Figure 5.1 Proportions of the Number of "Superior" Indications Found per Chart for NM Cases GP Controls With UBPC and 73 Figure 5.2 Proportions of the Number of "Inadequate" Indications per Chart for NM Cases and GP Controls with UBPC 74 Figure 5.3 Proportions of "Inadequate" Scores per Cri t e r i o n (UBPC and ABPC) for NM Cases and GP Controls Figure 5.4 Proportions of Intermediate Conditions Found For NM Cases and GP Controls 75 76 ( v i i i ) ACKNOWLELX^ JMENT This research was supported i n part by the N a t i o n a l H e a l t h Research and Development Program through a N a t i o n a l Fellowship to P a t r i c i a Lynn Buhler. (ix) CHAPTEB 1 Introduction 1.1 Statement of the Problem Over the past decade, s e v e r a l o r g a n i z a t i o n s have recommended the introduction of nurse-midwives into various o b s t e t r i c a l care s e t t i n g s i n Canada. I d e a l l y , the t r i a l period would be accompanied by e v a l u a t i v e research which examined the safety, quality, acceptability, and costs of t h i s a l t e r n a t i v e care g i v e r . These recommendations are based on the positive experiences of other i n d u s t r i a l i z e d countries where midwives are an integral part of the health care system (e.g. U.S.A., Netherlands, Great B r i t a i n , etc.) (Federal Task Force Report 1984:30; K e i r s e 1982; Robinson, Golden and Bradley 1982). Support f o r t h i s innovation i n hea l t h care d e l i v e r y i n Canada i s found i n nursing schools, nursing a s s o c i a t i o n s , health consumer organizations and with many obstetricians, perinatalogists and pediatricians (Carty 1985; Midwifery Fact Sheet 1981; Korn 1980; Task Committee Report 1979). P r o f e s s i o n a l nursing a s s o c i a t i o n s have a c t i v e l y encouraged the development of the nurse-midwife r o l e since 1973. The Canadian Nurses Associations (CNA) in 1974, the Registered Nurses Association of Ontario in 1973, the Registered Nurses Association of B r i t i s h Columbia (RNABC) in 1979 and CNA's submission to the Health Services Review — The Hal l Commission i n 1980, a l l recommended a r o l e f o r the midwife i n o b s t e t r i c a l care i n Canada (Hurlburt 1981). The RNABC published a Task Committee Report (1979) e n t i t l e d , "The Future of Nurse-Midwifery i n B r i t i s h Columbia" which d e t a i l e d the standards of p r a c t i c e f o r nurse-midwives as w e l l as t h e i r functions, knowledge, s k i l l s , and roles i n various health care settings. / 2 In addition to these recommendations, the recent Federal Task Force on High R i s k P r e g n a n c i e s and P r e n a t a l Record Systems (1984), whose participants included obstetricians, perinatalogists and nurse s p e c i a l i s t s , b r i e f l y reviewed the evaluation research on nurse-midwifery and noted that none existed i n Canada. They concluded that: " I t would seem that there i s a complementary role for each of the three: (the) nurse i n reproductive care, (the) f a m i l y p h y s i c i a n , and (the) o b s t e t r i c i a n . Any system w i l l be most e f f i c i e n t when personnel are u t i l i z e d a p p r o p r i a t e l y according to t h e i r l e v e l of t r a i n i n g " (Federal Task Force Report 1984:31). They recommended that: "Whereas the role of the nurse i n reproductive care i s recognized in many c o u n t r i e s , i t has not yet been agreed upon i n Canada, and t h e r e f o r e the Committee proposes the establishment of a N a t i o n a l Task Force to address t h i s important issue " (Federal Task Force Report 1984:31). Many pregnant women are questioning the t r a d i t i o n a l s t y l e of the doctor-patient relationship and are seeking active p a r t i c i p a t i o n i n health care a c t i v i t i e s . Some of these women want the s e r v i c e s of p r o f e s s i o n a l nurse-midwives, p a r t i c u l a r l y i f delivery could occur i n a f l e x i b l e hospital s e t t i n g (Diers 1982; Enkin and Chalmers 1982b; G i l l e s p i e 1981; Lindheim 1981; Powis 1981; R i s i n g and L i n d e l l 1982; Weatherston, Carty, Rice and T i e r 1985). They f e e l that nurse-midwives o f f e r an a l t e r n a t i v e s t y l e of care which they pre f e r . The Dean of the School of Nursing at Yale has described the values of nurse-midwives as including: a genuine interest i n the health of women, emphasis on patient p a r t i c i p a t i o n and low intervention with good c l i n i c a l judgement; attention to the "soft" non-medical aspects of care; concentration on the p a t i e n t i n the context of her l i v i n g environment; continuity of care giver; emphasis on early intervention and /3 prevention; and a degree of excellence of care which supports a source of personal power (Diers 1980). These values appeal to health care consumers who want to be informed and active participants in the child- bearing process. Despite this broad base of support, funding for the demonstration and evaluation of a nurse-midwifery model in Canada has not been forthcoming. Resistance to this innovation in health care delivery lie s in two areas: (a) In provincial ministries of health where i t is anticipated that nurse-midwives will cause "add on" rather than "substitutive" costs and therefore increase demands on health care budgets, and (b) in medical associations and colleges where general practitioners actively lobby to restrict the practice of nurse-midwives because they perceive them as competitors in the health care market (Carty, Gordon and Rice 1981; Position on Midwifery 1984). This resistance has so far effectively frustrated most Canadian attempts of a t r i a l of a nurse-midwifery model in a modern obstetrical care setting. 1.2 Setting A limited demonstration of a nurse-midwifery model has been undertaken in Canada in an academic setting (Carty et al. 1984). The School of Nursing (University of British Columbia) and the Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology (University of British Columbia) in conjunction with the Grace Hospital Nursing Department established the "Low-Risk Clinic" in 1982. A precursor to the clinic was the "Hands on Clinic for Nursing Instructors" at the Vancouver General /4 Hospital (VGH) which functioned for one year prior to the amalgamation of the VGH's and Grace Hospital's maternity services in 1982. The team of care g i v e r s i n the Low-Risk C l i n i c c o n s i s t e d of four nurse-midwives and four obstetricians; the nurse-midwives functioned as the primary care givers. Although no e x p l i c i t funding supported the Low-Risk C l i n i c , the Grace Hospital provided space and c l e r i c a l support i n the out-patient area of the hospital. A large component of the nurse-midwives time was volunteered. The purpose of the c l i n i c was threefold: 1. To provide "hands on" practice for nursing instructors, enabling them to maintain t h e i r c l i n i c a l expertise. 2. To provide care which would be both safe and sa t i s f y i n g to the families involved i n the pregnancy and b i r t h and which would avoid interventions whenever possible. 3. To demonstrate that nurse-midwives could work as an integral part of the o b s t e t r i c a l team i n the Canadian health care system, and at the same time recognize that nurse-midwives had a s i g n i f i c a n t and unique contribution to make to the health care of the woman and her family during the perinatal period (Carty et a l . 1984:1). /5 The B.C. College of Physicians and Surgeons was informed of the Low-Risk Clinic and approved the c l i n i c a l activities of the nurse-midwives: medical functions undertaken by nurse-midwives, such as delivery of the baby, were regarded as "physician delegated" functions, and they were carried out by the nurse-midwives with medical supervision. Over a period of two years, 51 women were enrolled in the Low-Risk Clinic at the Grace Hospital. In this setting the nurse-midwives emphasized the unique needs of the family and attempted to protect the importance of the childbearing experience. The nurse-midwives chose to use a family centered approach integrated with emotional support, counselling, and teaching. Throughout the childbearing process they encouraged active parental participation and offered continuity of care and accessibility in their style of practice. It was their belief that eventual economic and legal support for nurse-midwifery would come from clinical demonstration. The entire research component of the Low-Risk Clinic and the Hands-on-Clinic consisted of a summation of descriptive and outcome variables for both clinics and a satisfaction study involving the first third (23) of the patients seen by the nurse-midwives. In their study, analysis of the outcome variables can only remain descriptive due to the relatively small number of women seen at the two clinic settings when compared to the rest of the childbearing population in the area. The results of the satisfaction study were used to provide the nurse-midwives with feedback in the early stages of the clinic's development. A l l of these data were presented in a report entitled "The Low-Risk Clinic : Family Care Based on the Midwifery Model, 1981-1984" (Carty et al. 1984). / 6 1.3 Purpose The general purpose of t h i s study i s to provide i n i t i a l data that evaluates the quality of care that nurse-midwives provided i n a Canadian setting. Evidence of safe and adequate care w i l l support and l e g i t i m i z e the expansion of nursing into the f i e l d of nurse-midwifery (Diers and Burst 1983). When considering (a) the recommendations of professional, consumer, and p u b l i c p o l i c y o r g a n i z a t i o n s that the r o l e of nurse-midwives be explored; (b) the unique existance of the Low-Risk C l i n i c i n the Canadian health care system; and (c) the absence of Canadian data evaluating nurse-midwifery care, further evaluation of the Low-Risk Clinic's experience i s c l e a r l y warranted. Moreover such data would provide information that could c o n t r i b u t e to p o l i c y s t u dies examining a l t e r n a t i v e h e a l t h care d e l i v e r y systems and innovations i n nursing practice. Since physicians are the l e g i t i m a t e care g i v e r s to c h i l d b e a r i n g f a m i l i e s , medical standards of care are the most appropriate c r i t e r i a for an i n i t i a l evaluation of the care provided by nurse-midwives: to establish c r e d i b i l i t y , nurse-midwives have to provide at l e a s t equivalent care to that of general practitioners. C r i t e r i a developed t o e v a l u a t e the e f f e c t i v e n e s s of nurse p r a c t i t i o n e r s i n a Canadian f a m i l y p r a c t i c e s e t t i n g ( S i b l e y et a l . 1975) were chosen for application to t h i s study. The selected c r i t e r i a evaluated the quality of prenatal care as evidenced by the patient's medical record, and were based on a medical model. These e x p l i c i t c r i t e r i a examine the /7 process of the care provided, and enable comparisions between d i f f e r e n t care g i v e r s . Unfortunately the c r i t e r i a only assess a l i m i t e d aspect of the p r e n a t a l care at the Low-Risk C l i n i c . However, a f t e r questions of sa f e t y and adequacy are resolved, f u r t h e r research can explore the i n t r a p a r t a l and p o s t p a r t a l periods, as w e l l as the d i f f e r e n t p r a c t i c e models of nurse-midwives and physicians. 1.4 Research Question The s p e c i f i c purpose of t h i s study i s to compare the process of prenatal care provided to low r i s k pregnant women by nurse-midwives and general practictioners with the following research hypothesis: The nurse-midwives at the "Low-Risk Clinic" in the Grace Hospital provide more effective prenatal care than general practitioners who deliver in the same setting, as evidenced by the fact that more of the nurse-midwives prenatal records are rated "adequate" or "superior" using the Burlington Prenatal Criteria. 1.5 Thesis Outline The thesis i s organized in the following manner. Chapter 2 discusses the q u a l i t y of care l i t e r a t u r e by f i r s t examining general research i n t o ambulatory s e t t i n g s and then by s p e c i f i c a l l y r eviewing research which evaluates the e f f e c t i v e n e s s of nurse-midwives i n various s e t t i n g s . In Chapter 3 , the effectiveness of prenatal care i s discussed with a review of /8 the literature that attempts to identify predictive indicators of prenatal outcomes. The methodology of the study is presented in Chapter 4 with discussions on both the instrument and modification to the cr i t e r i a , as well as, a detailed description of the study design and it's r e l i a b i l i t y . The results are presented in Chapter 5 and discussed with comparable research in Chapter 6. The thesis closes with discussions and the implications and f e a s i b i l i t y of the study's methodology, and the implications of the study's results on effecting the legitimacy, feasibility and support for the issue of incorporating the nurse-midwife into the Canadian health care system. /9 CHAPTER 2 Quality of Care - Literature Review 2 . 1 Ambulatory Setting The elements involved in evaluating the qua l i t y of care that practitioners provide has been outlined and defined by Donabedian (1967) and Sanazaro (1980), among others. I n i t i a l development in t h i s f i e l d of research focused on care provided in hospitals and examined outcome factors such as rates of post-operative i n f e c t i o n . In the 1950's methodologies applied to q u a l i t y of care research i n hos p i t a l settings were c l a r i f i e d . (Sheps, M. 1953). In the past twenty years qua l i t y of care research has broadened to include evaluations of primary care i n ambulatory settings. More recently t h i s research has examined the care provided by d i f f e r e n t care givers. The emergence of the nurse practitioner and the physician's assistant and their role overlap with physicians in primary care has become a new focus of quality of care research. An assessment of the q u a l i t y of care provided by d i f f e r e n t health professionals in a primary care setting faces the same issues and methods problems outlined by Donabedian (1967). He recommended for example, that a definition of quality be established early in the research because i t has a profound influence on the approaches and methods one chooses to assess the care. He reviewed approaches that can be taken, and identified (a) outcome of care, (b) process of care and, (c) assessment of structure, as three broad areas for research. He noted l i m i t a t i o n s with each approach, particularly in linking process to structure, or outcome to structure. /10 However, Donabedian recommended considering factors, related to a l l three (process - outcome - structure) when designing assessment research. He also described sources and methods for obtaining the desired information (e.g. c l i n i c a l records) and noted some limitations of the data sources (e.g. completeness). The next issue that Donabedian addressed was identification of the generalizability of the research which is accomplished by defining the universe to be sampled. For example, he stated that i f one is evaluating the "capacity of a specified group of providers to provide care" (Donabedian 1967:174) then one needs to achieve a representative sample of providers in the study but not necessarily a representative sample of their care. He f e l t that in this situation i t was more important to uniformly select significant dimensions of care. As an example, he suggested that evaluation in areas of particular stress might be more revealing of weaknesses in the new care giver than evaluation in more general and less stressful situations (Donabedian 1967:174). In another part of his paper, Donabedian discussed the measurement of quality; he noted that i t usually involved the development of a standard. He also discussed questions of validity, reliability and bias with regard to the specific standards developed and the evaluation process in general. Donabedian's paper closed with a presentation of logical and economic efficiency. He stated that these two concepts have a prominent role in quality of care research. Logical efficiency was defined as "the use of information to arrive at decisions" (Donabedian 1967:192). He identified /11 access to information as well as duplication of information by the care giver as relevant issues in the evaluation. Economic efficiency was defined as being concerned with "the relationships between inputs and outputs and asks whether a given output is produced at least cost" (Donabedian 1967:192). He felt that economic efficiency tended to examine more general questions of cost to the community or the society. At the present time identification of economic efficiency is an important consideration when evaluating innovations in health care delivery such as new technologies or new care givers. Sanazaro in a recent publication, reviewed the history of "Quality Assessment and Quality Assurance in Medical Care" (1980), particularly with respect to the p o l i t i c a l and policy changes in U.S. health care funding that have occurred over the past ten years. Generally he found that the assessment and assurance studies that were done to meet these licensing and funding requirements were not good examples of research. He stated that, "The effect has been to replicate a much criticized practice in the medical literature: publication of ideas or premature conclusions based on small, uncontrolled or biased studies, leading to widespread application of methods that are subsequently discredited or found to be ineffective" (Sanazaro 1980:60). In his review of the literature Sanazaro concluded that further development of process and outcome evaluations were necessary, but at the same time information was currently available to allow the development of more meaningful research. He identified many problems with the current /12 research, and noted that "studies of physician performance have not produced standardized methods of reliably evaluating actual performance in the care of patients" (Sanazaro 1980:60). He recommended several "agenda items" for the development of better approaches to quality assessment and assurance of the medical care review program. Many of these included recommendations for research into relationships between physician knowledge and performance, and the development of evaluation methods that promoted them, but at the same time provided reliable and valid data on quality of care (e.g. computer software systems). Other issues which recur in the literature that considers the evaluation of care giver performance include the reliablity of methods for evaluation, the validity of the medical record, and the development of standards. These issues, while often interrelated, will now be discussed separately. The reliability of various methods of evaluating the quality of care in specific settings is not resolved. As noted earlier, Donabedian described the process - outcome - structure model for quality of care research in the sixties, and this model remains relevant today. However, questions concerning the validity of "process versus outcome" indicators of quality continue to be debated (e.g. Brook 1979; McAuliff 1979). This debate influences choices regarding both methods and study designs. The consensus in the literature has been that assessment in both areas is necessary for the most comprehensive reviews, and that further research is needed to delineate the relationships between process and outcome factors. (Sanazaro 1980). /13 Sheps and Robertson also discussed the relationship between caregiver and patient outcomes, and they concluded that "...this issue is relevant primarily when the criteria for care evaluation are being developed. Once elaborated, such criteria can be used without reference to patient outcomes i f ...the objective is to assess the quality of care given" (Sheps and Robertson 1984:885). Kessner, Kalk and Singer (1973) facilitated the design of evaluations of primary care in ambulatory settings with the development of "tracers" (indicator conditions). Kessner et al. stated: For measuring the functions of a health care system, the tracers needed are discrete, identifiable health problems - each shedding light on how particular parts of the system work, not in isolation, but in relation to one another. The basic assumption remains the same — namely, how a physician or team of physicians routinely administers care for common ailments w i l l be an indicator of the general quality of care and efficacy of the system delivering that care. (Kessner et a l . 1973:189). This method moved evaluations away from assessing every v i s i t for every illness, to the much more manageable situation of sampling conditions. Kessner et. al furthermore discussed the need for knowledge of the context in which indicator conditions would be applied so that their representativeness could be maximized. Several researchers have incorporated Kessner's indicator conditions into evaluations of ambulatory care settings and discussed the implications of its use. (e.g. Hulka, Kupper and Cassel 1976; Sibley et al. 1975; Sheps, S., and Robertson 1984). Sibley et al. (1975:51) noted that uniformity with individual indicator /14 conditions among primary practitioners cannot be expected while Hulka et al. (1976:1177) found differences in level of management by practitioners with certain indicator conditions but not with others. Sheps and Robertson (1984:885) stated that since the indicator condition only allows an evaluation of a sample of care given "generalizability to other clinical problems may be limited." Kessner et al. specifically outlined the criteria for the selection of good indicator conditions and developed their use for application to medical chart audits. This method measures both processes and outcomes of care. A limitation of this method however "...is the assumption that good medical records are a requisite for good medical practice" (Kessner et al. 1973:193). The validity of the medical record in indicating the quality of care provided to the patient is a second issue which is frequently debated. Romm and Putman investigated this question and found few studies "which compared what actually took place during the v i s i t with the patient's record" (Romm and Putman 1981:310). In their limited study they noted that on average 59% of the items mentioned in either the record or the transcript of the visit were found in both sources, however, 92% agreement was found in the area of chief complaint. Generally they found that physicians did not include in the medical record information about family, social situation or other past medical history present in the transcript, while they included information on lab tests and treatment plans in the medical record which was not present in the transcript. The format of the medical record affects the validity; a standardized format permits a comparison between care giver and/or patients which would /15 otherwise be d i f f i c u l t . The variation in medical record format from practice to practice is a particular problem when evaluating ambulatory primary care settings (Hulka et al. 1976). Choosing indicator conditions which may u t i l i z e a standard form (e.g. prenatal care) or evaluating a setting in isolation of other settings has resolved this problem in some studies. The a b i l i t y of the medical record to mirror the quality of care actually provided continues to be an issue. Conclusions have tended toward including an audit of the medical record as only one component of an overall review of the quality of care until further research defines the area. (Donabedian 1967; Sanazaro 1980). Other researchers have contended that good medical records are a minimal requirement for providing adequate care (Kessner et al. 1973). Sanazaro stated however, that technical care provided by physicians would continue to be assessed by chart audits based on explicit criteria. (Sanazaro 1980:51). The development of standards employed in quality of care research has evolved along with the methodology. Initially, standards were implicit and applied by peers who judged medical care or medical records against their personal knowledge and experience. The later development of explicit standards provided more consistent and reliable evaluations and enabled replication of studies. However, the standards were often developed by experts in the f i e l d and defined "optimal care" which in many settings resulted in an unrealistic appraisal of the quality of care provided (Brook and Appel 1973:1328). The "optimal care standards" brought into question the validity of this style of assessment (Donabedian 1967:178; Sanazaro /16 1980:43). In the last decade, "minimal explicit consensus c r i t e r i a " for particular indicator conditions have been developed for assessing care giver performance in ambulatory settings (Hulka et al. 1976; Sibley et al. 1975). Participation by primary care givers in developing these criteria have improved their validity and applicability. Hulka et al. found that with two of the four indicator conditions they studied, the minimal explicit consensus c r i t e r i a could discriminate among varying levels of physician performance (Hulka et al. 1975:1173). Sibley et al. found that the use of minimal explicit criteria provided results that were: (a)"...in close agreement with the outcome measurements of mortality and physical, social, and emotional function done on the same study subjects...", (b) that there was internal consistency among the three approaches used in the study, and (c) that there was high inter-observer agreement using the criteria for scoring the practices (Sibley et al. 1975:51). Evaluation methods of care giver performance in primary ambulatory care settings are developing. The use of minimal explicit consensus cr i t e r i a to evaluate the medical record appears to be a reliable method, particularly i f the record has a consistant format. The identification of appropriate indicator conditions facilitates this type of evaluation and i t encourages the measurement of both process and outcome factors. At the same time, measurement of processes to the exclusion of outcome factors with previously established c r i t e r i a further expands the horizons of quality of care research and enables evaluation of such areas as caregiver models, patterns of practice, adequacy of practitioner's education, and innovations in health care delivery systems. To allow comparison of results /17 and to define method flexibility, some quality of care researchers should now turn to replicating good studies by using the same standards and methods but applying these to different problems in a variety of settings. 2.2 Nurse-Midwifery Care The body of literature which has evaluated the quality of nurse-midwifery care has employed a broad range of methods. As with quality of care studies in general, the various methods and c r i t e r i a used in nurse-midwifery evaluations applied varied measures of effectiveness, which has limited the comparability of the studies. However, Diers has presented this evaluative literature as a case study because i t promoted the legitimacy of nurse-midwifery in the U.S.. She stated that "To properly understand the nurse-midwifery effectiveness/evaluation literature, 'effectiveness' has to be understood in the historical context of nurse-midwifery practice when the study was done. ... Effectiveness has generally meant program effectiveness as determined in each case by whatever reason a nurse-midwife was being brought into a situation" (Diers 1983:69). That is, definitions of effectiveness were the definitions of quality, as evaluations and descriptions of programs often did not included specific criteria for measuring quality, (e.g. morbidity and mortality rates). A great deal of the nurse-midwifery literature has been descriptive and presents testimonials of physicians and nurse-midwives on the improved quality of services that resulted from the introduction of the new care giver into their community or practice. (Burnett 1972; Gatewood and Stewart 1975; Haire 1981; Thiede 1971). Other articles have related tangentially /18 to issues of quality of care. An example is Record and Greenlick's (1975) discussion of physician receptivity at a Kaiser Permanente Health Centre of new health professionals (i.e. certified nurse-midwife, physician assistant and pediatric nurse practitioner). They concluded that the new care givers receptivity was directly dependant on whether he or she was perceived as role-elevating or role-threatening by the physicians. A second example is an early study by Ford, Searat and Silver (1966) in which patient, satisfaction with an expanded role for public health nurses was studied. Their results indicated high patient satisfaction with seeing a public health nurse for prenatal and well baby care, in conjunction with seeing a physician. (Substituting the nurse for the doctor was not an option in the study, and the results reported were preliminary). A few studies were found in which outcomes of pregnancy were compared "before and after" the establishment of a nurse-midwifery service. The reports of the Frontier Nursing Service are the earliest example of this type of evaluation. They reported a substantial drop in infant and maternal morbidity and mortality rates with the introduction of nurse-midwives into rural Kentucky in the 1930's. Reid and Morris commented that "the several analyses of infant and maternal morbidity and mortality rates that have been conducted suggest that, in general, the health status of infants delivered by this nurse-midwife program is superior to that of other infants born in Kentucky or the nation as a whole" (Reid and Morris 1979:491). /19 In another e a r l y study, Levy, W i l k i n s o n and Marine (1971) examined morbidity and m o r t a l i t y rates before, during and a f t e r a demonstration nurse-midwifery program i n ru r a l C a l i f o r n i a . During the three years that the s e r v i c e functioned, r a t e s of prematurity and neonatal m o r t a l i t y decreased substantially at the nurse-midwives' hospital, and they increased after the program ended. In a comparison hospital i n a nearby community, the r a t e s stayed the same throughout the time of the study. Also during the program, rates of prenatal care increased and then diminished when the program ended. P o s s i b l e confounding v a r i a b l e s were explored by the authors, f o r example, a s h i f t i n the r i s k s tatus of the maternity population, changes i n medical personnel i n the communities, changes i n the rates of unusual events, such as, nursery epidemics or multiple birthrates, but none were discovered that could account for the differences found. A more r e c e n t study by Reid and M o r r i s (1979) examined the effectivenesss and the cost effectivenesss of a nurse-midwife program i n a poor r u r a l population. The authors compared the b i r t h outcomes of the target population to those i n the surrounding counties with a retrospective study design, before and a f t e r the program was introduced. They also estimated the expenditures f o r p e r i n a t a l care f o r each population. The data sources i n t h i s study included v i t a l s t a t i s t i c s , b i r t h c e r t i f i c a t e s , h o s p i t a l s t a t i s t i c s and records, and nurse-midwives' c l i n i c records, as well as expenditure information from hospital and government programs. The authors found decreases i n the rat e s of i n f a n t m o r t a l i t y , neonatal m o r t a l i t y , low b i r t h w e i g h t and short g e s t a t i o n a l age, as w e l l as a reduction i n expenditures for perinatal care. The retrospective c o l l e c t i o n /20 of data from various sources for the different groups place severe limitations on this study. However, the authors acknowledged this and concluded that a prospective study would be the next appropriate step for further clarifying nurse-midwives' effectiveness and cost effectiveness. In another example of a "before and after" study design, Ross (1981) examined the impact of a nurse-midwifery program on an isolated American Indian population by evaluating the uti l i z a t i o n of services and the outcomes of pregnancy. The author audited prenatal, labour and delivery records as well as the charts of a l l children less than one year of age that were admitted to the community's hospital. Overall the author concluded that the differences in outcome measures indicated that the addition of the nurse-midwifery program improved the maternal-infant care services provided, which contributed to the improvement in maternal and infant health. He found that utilization of services increased, the length of postpartum h o s p i t a l i z a t i o n decreased, and the incidence of hospitalization of infants remained similar but their length of stay was reduced. The common source of data for the study populations supported reliability of the data. Other studies have evaluated the effectiveness of nurse-midwives by comparing them to other medical care givers, usually medical school residents, house staff, or obstetricians. Runnerstrom's prospective study was the f i r s t to investigate "The effectiveness of nurse-midwives in a supervised hospital environment" (Runnerstrom 1969:41) and to compare outcome variables of care between nurse-midwife interns and obstetrical /21 residents. Several problems were present in the method and analysis of the study which made the conclusions unreliable. In particular, no definition was provided for the c r i t e r i a of "uncomplicated prognosis" which was a prerequisite for inclusion in the nurse-midwife group. Criteria for inclusion into the obstetrical residents group was also not mentioned, and women were enrolled into the study throughout the pregnancy cycle (60% were enrolled at the time of delivery). In addition to these problems, the characteristics of the two patient groups were not described, so their comparability cannot be determined. Runnerstrom's most startling finding, however, was that the nurse-midwives had a spontaneous vaginal delivery rate of 90% while the obstetrical residents had a 58% operative delivery rate. In a well designed study, Slome et al (1976) analyzed prenatal, intrapartal and immediate postpartal outcomes of low risk patients who were randomly allocated to either nurse-midwife or resident staff care in a hospital setting in Mississippi. The use of explicit c r i t e r i a for inclusion of patients in the study, as well as the selection procedure, and the random allocation to the care giver, produced two comparable but different sized groups of patients. The data was abstracted from the medical records and the reliability of the abstraction was determined. The study included 298 patients who saw nurse-midwives and 140 patients who saw physicians. No discussion was presented on the power of the study. Slome et al found no differences between the two groups prenatal outcomes, however the nurse-midwives' patients attended their /22 appointments more often (94%) than the resident staff's patients (80%), and a higher proportion of the nurse-midwives' patients had more v i s i t s than were scheduled compared to the residents' patients. The authors also found that the nurse-midwives performed more tests for urinary t r a c t infections and i n v e s t i g a t e d more p a t i e n t s f o r diabetes. D i f f e r e n c e s i n labour and delivery outcomes were few except that the residents had a higher incidence (3x) of low forceps use. The i n f a n t outcomes were a l s o very s i m i l a r between the two care g i v e r groups. The authors concluded that the data i n d i c a t e d t h a t i n t h i s h o s p i t a l s e t t i n g , p r e n a t a l , i n t r a p a r t a l and postpartal care provided by nurse-midwives with physician consultant back-up produced health outcomes equivalent to t r a d i t i o n a l physician services. Two additional studies were found which i d e n t i f i e d pregnancy outcome differences between nurse-midwives and physicians. D i l l o n et a l . (1978) r e t r o s p e c t i v e l y compared nures-midwives' and o b s t e t r i c i a n s * care at a h o s p i t a l i n New York. However, the study design d i d not incl u d e an assessment of the r i s k s tatus of the p a t i e n t s , t h e r e f o r e , the two study groups may not have been comparable. Their f i n d i n g s included a lower op e r a t i v e d e l i v e r y r a t e and high p a t i e n t s a t i s f a c t i o n w i t h the nurse-midwives group. In another retrospective study Neeson, Patterson, Mercer and May (1983) examined pregnancy outcomes of a high r i s k adolescent population who attended a nurse-midwife c l i n i c or an o b s t e t r i c a l residents c l i n i c . The s e l e c t i o n process of p a t i e n t s f o r the two care g i v e r groups was diff e r e n t , as the nurse-midwives' c l i n i c received early r e f e r r a l s from a pediatric c l i n i c while the o b s t e t r i c a l residents c l i n i c saw adolescents who attended the outpatient c l i n i c . The mean age, gravidity and week of /23 gestation at first prenatal visit were significantly different between the two groups. The selection process contributed confounding variables and obscured the differences in care giver approaches. Unfortunately the authors did not discuss this problem but instead concentrated on the differences in care and the differences in outcomes. No studies were found which evaluated the effectiveness of nurse-midwives by examining the process of care that they provided. Occasionally, the number of prenatal visits was counted or an analysis of investigative procedures was presented (e.g. Slome et al. 1976). Otherwise the literature focused entirely on outcome variables and inferred causal relationships between care giver and outcome. Except in a few cases this assumption was not valid because poor study design introduced bias, confounding variables, or unreliable data sources. The focus on outcome variables is not unique to evaluations of nurse-midwives. Yankauer and Sullivan reported that one author reviewed 40 studies examining the quality of care provided by new health professionals; 21 studies compared their care to that of physicians. "Measures of quality in the 21 studies included process in 4 studies, outcome in 12, patient satisfaction in 12 and agreement with physician in 4 (examining the same patient)". This review concluded that "In a l l cases, care rendered by the new health professional was equal to or, in the use of patient satisfaction and possibly compliance, superior to that provided by physicians." The author pointed out however, that some studies had problems with design and validity but that the major concern was problems with generalizability or applicability on a large scale (Yankauer and Sullivan 1982:263-4). /24 The Burlington Randomized Trial of the Nurse Practitioner is an example of a study in which the process of care provided by a new health professional is compared to that of physicians. In this study the evaluation of the process of care with indicator conditions and explicit c r i t e r i a was only one component of the comparison. In the overall study design, several outcome factors were also analyzed (Sibley et al. 1975). This study found that nurse practitioners provided equivalent prenatal care to that of a control group of physicians, as well as another community group of physicians (Sibley et al. 1975:47). Future research which investigates the quality of care provided by nurse-midwives would be improved i f i t utilized similar methods such as Sibley et al's. Including an evaluation of the process of care could provide valuable information on d i f f e r e n t styles of practice and furthermore, could investigate the logical efficiency and economic efficiency that Donabedian describes as an essential component of quality of care research. Such innovations in study designs would create more meaningful data for determining the effectiveness of the nurse-midwife in the health care system. /25 CHAPTER 3 Prenatal Care - Literature Review 3.1 Development and Goals of Modern Prenatal Care Routine prenatal v i s i t s , now a common experience of childbearing women, began in the f i r s t quarter of this Century. Prior to this time, prenatal care was limited to one or two visits by a physician or a midwife and focused on diet and discomforts of pregnancy. In the second quarter of the Century the medical development of prenatal care proceeded. Routine urine testing was introduced and used for screening pre-eclampsia and gestational diabetes. Physical and abdominal examinations became more common, and fetal heart auscultation was initiated. By the late 1940s, the majority of pregnant women in most western industrialized countries were receiving prenatal care either in out-patient clinics, physicians offices, or at home. The pattern of care was more or less universal and included a schedule of frequent prenatal visits at which the patient was weighed, her urine tested, her blood pressure taken, and her abdomen examined. In the latter part of pregnancy, the fetal heart rate was also assessed. (Oakley 1982a,1982b). Current pattern of prenatal care are similar but now include "risk assessment" and more screening procedures as a result of medical technological advances. The development of risk scoring, "which is a numerical weighting of individual and combined risk factors" (Federal Task Force Report 1984:19), has resulted in the publication of several guides, but their ability to modify perinatal outcomes has remained controversial (Casson and Sennett 1984; Federal Task Force Report 1984). However, risk /26 assessment has developed in recent years with the identification of certain predictive factors which identify patients who have an increased risk of an adverse outcome. Many factors (such as a previous low birth weight infant, previous congenital anomolies, maternal age, grand multiparity, very low socio-economic status, alcoholism and heavy smoking) are generally accepted as being associated with adverse outcomes, while other factors (such as occupation, toxic exposures, early antepartum bleeding and post-term pregnancy) continue to be debated in the literature.^ The major new technologies that are involved in prenatal care include ultrasound, fetal monitoring and amniotic fluid assays. These technologies a l l provide detailed information on the well-being of the fetus and are used in varying degrees by different practitioners. If medical textbooks indicate current medical thinking, general expectations of the benefits of prenatal care are high. One author stated that The fundamental goals of prenatal care remain the same: (1) to maintain or improve the health of the pregnant woman, (2) to promote the optimal health of the fetus and infant, (3) to promote the optimal development of the family in accepting a new member, and (4) to be cost effective" (Bachman 1983:145). Another medical author more generally wrote that "the goal of antenatal care is to prevent deviations from the normal and to detect and reverse them when they arise" (Caplan 1982:104). And a third author instructed medical students on the purpose of prenatal /27 care by s t a t i n g , "As a r e s u l t of c a r e f u l examination of the pregnant p a t i e n t at frequent i n t e r v a l s throughout the period of ge s t a t i o n , abnormalities can be detected and dealt with before d i f f i c u l t i e s arise, and c a t a s t r o p h i c occurances can be almost e l i m i n a t e d " (Danford 1982:363). These statements have a l l placed an emphasis on the process of pre n a t a l care and have implied that medical surveillance during the prenatal period i s a factor which promotes maternal and f e t a l health. 3.2 Prenatal Care - General Discussions - Literature Review A search f o r s c i e n t i f i c l i t e r a t u r e examining any component of the prenatal care process indicate that few studies investigate t h i s aspect of pregnancy. However, some papers were found which presented r e l e v a n t discussions on various aspects of prenatal care. Enkin and Chalmers (1982c) i n an e x c e l l e n t overview discu s s current medical knowledge regarding advice, therapies and interventions commonly given or experienced during the p r e n a t a l period. They a l s o i d e n t i f i e d a tendency toward poor r e l a t i o n s h i p s between h e a l t h p r o f e s s i o n a l s and c l i e n t s , and suggested these factors as contributing to the d i s s a t i s f a c t i o n many prenatal c l i e n t s experienced in England. A recent supplement to Acta O b s t e t r i c a and Gynecologia Scandinavia (1983) a l s o presented a general discussion of prenatal care with a focus on the increasing "medicalization" of the experience. I t was accompanied by an extensive bibliography which included many a r t i c l e s on psychosocial aspects of pregnancy. / 2 8 A few recen t a r t i c l e s , a l l c i t e d i n Enk ins and Chalmers (1982a) t e x t , E f f e c t i v e n e s s and S a t i s f a c t i o n i n A n t e n a t a l C a r e , were p a r t i c u l a r l y i n f o r m a t i v e o f p r e n a t a l care con ten t . Grant and Mohide (1982) p resented a genera l a n a l y s i s o f p r e n a t a l care as a sc reen ing program. They i nc luded a d i s c u s s i o n on t h e e f f e c t i v e n e s s o f d i a g n o s t i c t e s t s by r e v i e w i n g t h e c u r r e n t l i t e r a t u r e on f e t a l movement c o u n t i n g . I n two a r t i c l e s Redman p r e s e n t e d t h e c u r r e n t u n d e r s t a n d i n g and s c r e e n i n g p r a c t i c e s f o r p r e -ec lamps ia (1982b) and the i s s u e s o f i t s management and t rea tment (1982a). The l i t e r a t u r e was r e v i e w e d by L u m l e y and A s t o r y (1982) i n a pape r w h i c h c o n s i d e r e d p r e g n a n c y i n a s s o c i a t i o n w i t h s e x u a l a c t i v i t y , c i g a r e t t e s , a l c o h o l , f ood , e x e r c i s e , work, h o l i d a y s and anx ie t y . In t h i s a r t i c l e the a u t h o r s e x p r e s s e d a c o n c e r n about p r o f e s s i o n a l a d v i c e w h i c h i s commonly g i ven w i thou t c o n s i d e r a t i o n f o r the environment i n which the woman e x i s t s (e.g. her economic envi ronment) . They concluded tha t most o f the adv ice i s based on very weak resea rch . In o ther a r t i c l e s i n the volume, Chalmers and Enk in rev iewed the cu r ren t l i t e r a t u r e and med i ca l p r a c t i c e s o f the p r e n a t a l i n t e r v e n t i o n s o f Rh i m m u n i z a t i o n , p r e p a r a t i o n f o r b r e a s t f e e d i n g and e x t e r n a l c e p h a l i c v e r s i o n (1982) as w e l l as the symptomat ic t rea tments w i t h a n t i e m e t i c s , a n t a c i d s , l a x a t i v e s and c a l c i u m s u p p l e m e n t s ( E n k i n s and C h a l m e r s 1982c). A l l t h e s e p a p e r s a r e u s e f u l c o n t r i b u t i o n s t o d i s c u s s i o n s on t h e app rop r i a t e content o f r o u t i n e p r e n a t a l ca re . However they did- not address the o v e r a l l i s s u e o f the va lue o f p r e n a t a l ca re . /29 3-3 Prenatal Care - Effectiveness Studies - Literature Review Underlying many discussions and studies i s the assumption that prenatal care attendance was a predictor of good perinatal outcome. As stated earlier, prenatal care i s commonly believed to promote the health of the mother and fetus/infant. Interestingly, the research which has examined i t s ' effectiveness does not clearly support this belief. Prenatal evaluative research has tended to i d e n t i f y associations between attendance and individual indicators of effectiveness, such as low birth weight and infant or maternal mortality or morbidity. These studies also tended to identify the quantity of care as an important factor, but did not include an evaluation of the quality of the prenatal care provided or identify social-economic status as a potential confounding factor. A few exceptions existed in studies which considered the process and the productivity of the care as well as, the social-economic status of the study population. In the remainder of this chapter, the literature which has addressed the effectiveness of prenatal care w i l l be reviewed. However, l i k e prenatal care in general, few studies were found that s p e c i f i c a l l y investigated the issue of prenatal care effectiveness. First, two recent studies that u t i l i z e d v i t a l s t a t i s t i c s of large populations w i l l be presented. They w i l l be followed by several studies that examined smaller prenatal populations using a variety of methods. Gortmaker (1979) analyzed a l l the births and infant death records in New York City in 1968 (90,339 births) and established estimates of the /30 impact that v a r i a t i o n s i n the qu a n t i t y of pre n a t a l care had upon the re l a t i v e r i s k of low b i r t h weight, neonatal, and post-neonatal mortality. He c o n t r o l l e d f o r a wide v a r i e t y of " a v a i l a b l e " s o c i a l , demographic and medical factors in the analysis in an attempt to approximate the design of a prospective study i n which patients were randomly assigned to prenatal care or no pre n a t a l care. The adequacy of prenatal care was based on c r i t e r i a that adjusted the number and the timing of prenatal care v i s i t s to gestation period. Conclusive causative relationships were not i d e n t i f i e d due to the r e t r o s p e c t i v e l i m i t a t i o n s of the data, but a s s o c i a t i o n s d i d exist. He found that "white mothers who delivered on a general service and a l l black mothers, experienced substantially increased r i s k s [of low b i r t h weight i n f a n t s ] when r e c e i v i n g inadequate p r e n a t a l care" (Gortmaker 1979:653). He also found that prenatal care exhibited l i t t l e relationship to neonatal and post-neonatal m o r t a l i t y once b i r t h weight and other variables were controlled, suggesting that the impact of prenatal care on i n f a n t m o r t a l i t y may only be through i t s ' i n f l u e n c e on b i r t h weight. He further pointed out that the relationship between lack of prenatal care and low b i r t h weight could be p a r t i a l l y or t o t a l l y explained by the s e l f s e l e c t i o n of women i n t o p r e n a t a l care, i n d i c a t i n g that women who do not seek pr e n a t a l care may share other v a r i a b l e s such as inadequate d i e t , smoking, d r i n k i n g or drug abuse, which were not a v a i l a b l e f o r a n a l y s i s . Due to the l i m i t a t i o n s of the information available for t h i s study i t was not p o s s i b l e to reach conclusions about the r e l a t i o n s h i p s between the quantity of prenatal care and outcomes of pregnancy. The author correctly stated that only an association between birthweight and prenatal care can be developed, however the s c a r c i t y of d e t a i l e d data made even t h i s very hypothetical. /31 In a similar study design, Greenberg (1983) analyzed a l l U.S. birth certificate records for 1977 in an attempt to explore relationships of prenatal care and sociodemographic characteristics, and "to demonstrate that misleading conclusions can be drawn from summary measures of antenatal care health impact" (Greenberg 1983:797). The exposure variable of prenatal care was classified as either "some" or "no" care on the birth certificates. Sociodemographic variables considered in the analysis were maternal race (black or white) and education (4 11 years or > 12 years). The outcome variable analyzed was birth weight. By estimating the relative risk with an odds ratio of prenatal care abstention in relation to low birth weight (LBW) for each social stratum in the study, Greenberg was able to estimate the etiologic fraction which he defined as "the proportion of LBW deliveries in a specified population which may be attributed to prenatal care abstention" (Greenberg 1983:798). Greenberg concluded that about 5% of a l l LBW deliveries among black, less-educated women may be attributed in part to abstention from prenatal care, whereas, only <1% of all LBW deliveries among white highly-educated women could be attributed to the abstention from prenatal care. This analysis enabled Greenberg to conclude that the health impact of prenatal attendance varied between social stratums, and that the social environment of the study population was an important consideration when assessing prenatal care efficacy. Greenberg appropriately pointed out the limitations of this study: (a) vital statistics records did not provide information on a l l variables of interest, (b) reliability of variables studied may be challenged, and (c) /32 the population at risk was limited to live births, excluding pregnancies terminated by induced or spontaneous abortions and stillbirths. With these limitations in mind he concluded that a l l study populations faired better with prenatal care and "from a public health perspective, the greatest reduction in adverse pregnancy outcome may be anticipated from prenatal services which are directed at socially disadvantaged women" (Greenberg 1983:800). (In this study i t should be noted that the exposure variable of interest, prenatal care, was at best a gross indicator of quantity of prenatal care and that Greenberg was comparing birth weight outcomes between women who received no prenatal care at all to those who received any type of prenatal care). In a third study, Ryan, Sweeney and Solola (1980) investigated the relationship of prenatal care to perinatal outcome retrospectively in a hospital population, over a six month period. The authors stated that the study population was racially and socio-economically homogeneous, as 80% of the population was black and 84% medically indigent. The exposure variable prenatal care, was divided into two groups, with "0 to 3 prenatal visits" in one group (1,102 patients), and "4 or more prenatal visits" in the other group (2,027 patients). No information on the source of the data, the setting, or the content of the prenatal care was provided. Several variables were analyzed including socio-economic factors, maternal age, birth order, marital status, place of residence, trimester in which care was initiated, education, and i n i t i a l risk assessment. The authors found that the two groups were similar with the exceptions of the /33 following variables. The "0 to 3 prenatal visits'* group had a higher neonatal mortality ratio and s t i l l b i r t h ratio, and a higher incidence of low birth weight infants than the "4 or more prenatal v i s i t s " group. The authors concluded that the absence of adequate prenatal care had influenced these outcomes. Unfortunately the authors did not adjust their analysis for the number of prenatal v i s i t s in relation to gestational age. This omission biased the results, as a premature delivery of necessity l i m i t s a patients opportunities to attend prenatal care. In addition to this oversight, the authors provided very l i t t l e methodological information, consequently i t i s d i f f i c u l t to evaluate the study's r e l i a b i l i t y , v a l i d i t y , and generalizability. Several evaluative studies of Maternal and Infant Care Programs (MIC) and Improved Pregnancy Outcome Projects (IPO) in the U.S. have recently been reported in the l i t e r a t u r e . A major thrust of the program i s providing prenatal care to low socio-economic populations. Many of the programs have been underway since the mid-60s. The MIC programs are federally supported and evaluative research has recently become a necessary aspect of the funding process. A l l of the studies noted here were retrospective, and relied on program records and v i t a l s tatistics for data. To evaluate effectiveness, they a l l selected comparison populations in the general geographic area where the program was not available. Most of these studies found an association with poor prenatal attendance and low b i r t h weight infants. They also i d e n t i f i e d the poor I i /34 uneducated young black or hispanic mother as being at greatest r i s k and for whom the program was most e f f e c t i v e . The i n d i v i d u a l programs var i e d and included maternal n u t r i t i o n a l supplements and other interventions which are not t y p i c a l of routine prenatal care. Peoples and Siegel (1983) evaluated an MIC program i n North Carolina. They found the program had l i t t l e e f f e c t when they examined the whole population, but an analysis by maternal r i s k status found that the greatest program impact was on the population at highest r i s k . The authors recommended more s c r u t i n y of sub-populations i n future prenatal program evaluation projects. Kotelchuck, Schwartz, Anderka and F i n i s o n (1984) found program par t i c i p a t i o n associated with a decrease i n low b i r t h weight and neonatal mortality and an increase i n gestational age as well as a reduction i n the incidence of prenatal care. The major focus of the program they examined was maternal n u t r i t i o n during pregnancy, and i t i s not clear i n the a r t i c l e how other aspects of prenatal care or attendance were evaluated. In another study Peoples, Grimson and Daughtry (1984) evaluated an IPO project i n North Carolina i n which no effect was found on the incidence of low b i r t h weight among program participants. In the discussion Peoples et a l . suggested that the ru r a l locale and the high turnover among s t a f f may have contributed to these findings. In general a l l three studies were l i m i t e d by t h e i r data. V i t a l s t a t i s t i c s can be a poor source of information and may present d i f f i c u l t i e s with r e l i a b i l i t y . The l i m i t a t i o n s are compounded when v i t a l s t a t i s t i c s are the only source of matching characteristics for a comparison population. /35 Nutting, Barrick and Logue (1979) evaluated a maternal child health care (MCH) program by examining the process and outcomes of the care provided to program users, as well as the program's impact on a l l prenatal patients in the community. The authors studied the MCH program, which was located on a poor Indian reserve in Arizona, by retrospectively identifying and examining high risk and low risk cohort groups before and after implementation of the program. The target population of the program was high risk mothers as defined by age, gravidity, and previous pregnancy losses. With existing prenatal records from a variety of settings (with some available on a computerized Health Information System), the authors found that standard measures of utilization and productivity indicated that the program was successful. For example, the mean week of gestation during which prenatal care was sought decreased from 24.6 weeks to 21.8 weeks and the average number of prenatal v i s i t s increased from 5.8 vi s i t s to 7.4 visits. Measures of the process of prenatal care with established criteria (prenatal work-up rate, pregnancy assessment rate, anemia screening rate, pre-eclampsia screening rate) indicated that the quality of care had improved with the implementation of the program. However, an evaluation of the high risk group in the community-at-large indicated that the program did not effect this group's pregnancy outcomes and instead, improved outcomes for the low risk group in the community. The focus of the evaluation, which included the surrounding community as well as the program participants, and the use of criteria for assessing the content of the care provided was unique among the studies reviewed which evaluated U.S. / 3 6 government funded prenatal programs. The setting of the study limited the generalizability of the results to similar low income isolated communities, but the methodology could be adapted to broader population bases. Harris (1982) was one of the few authors who has examined the overall question of whether prenatal medical care had favourably influenced the outcome of pregnancy. In the analysis four distinct relationships were examined: (a) prenatal care and duration of pregnancy, (b) prenatal care and unobserved fetal survival characteristics , (c) prenatal care and the rate of intrauterine growth (birth weight) and (d) prenatal care and infant mortality. In an extensive review of the literature the author concluded that these "four main issues underlie the controversy about prenatal care and pregnancy outcome" (Harris 1982:46). Very briefly, he concluded that (a) the relationship between timing of prenatal visits and deviation of pregnancy has been poorly characterized; (b) the risks of early termination of pregnancy varied considerably among unborn infants; (c) the frequently observed correlation between quantity of prenatal care and birthweight lacked a convincing biological or behavioural explanation, and (d) past analyses of prenatal care have not squarely confronted a c r i t i c a l point about the recent decline in U.S. neonatal and infant mortality rates (Harris suggests that this decline may be a secular trend, that has no relationship to prenatal care). (Harris 1982:46-47). Utilizing vital statistics data from a population of black women in Massachusetts, Harris developed statistical models which included several variables in the analysis to identify factors which influenced pregnancy outcome. He found that prenatal care prevented preterm deliveries by /37 increasing gestation by approximately one week, but that the influence of prenatal care on birth weight was only weakly positive and statistically insignificant. He also found that v i t a l s t a t i s t i c s data l i m i t e d application to his models which investigated (a) the influence of fetal selection on duration of pregnancy, and (b) the timing of prenatal care and birth weight specific mortality. In both cases too many assumptions were necessary for the author to be able to make conclusions. Harris clearly indicated that the population he studied was not representative of the general population, however, further application of his models to other large studies using vital statistics may clarify some of the issues he has identified. He recommended narrowly focussed clinically designed studies of prenatal interventions as a feasible approach to future studies. In England, Hall, Chng and MacGillvray (1980), and Hall and Chng (1982) studied prenatal care effectiveness in a different manner. Utilizing a l l available prenatal records for one year in a large community in Scotland (1,907 of a possible 2,168 records), the authors explored client records to answer the question of whether routine prenatal care was worthwhile. In their study they specifically determined: (a) the percentage of high risk patients identified at their f i r s t prenatal v i s i t , (b) the extent to which abnormal conditions of mother and baby were detected by routine care and at what gestational stage, (c) the productivity of the prenatal visits, (d) the frequency with which problems occurred in spite of prenatal care, and (e) the rate of specialized investigations. /38 Two types of care were available to women i n the study. The majority of women (65%) attended an outpatient prenatal c l i n i c at a hospital where they received care from a variety of health professionals. The other women in the study (35%) experienced shared care in that they were seen pr i m a r i l y by t h e i r general practitioners and o c c a s i o n a l l y attended a h o s p i t a l out-p a t i e n t c l i n i c . O v e r a l l the authors concluded that p r o f e s s i o n a l expectations of prenatal care were u n r e a l i s t i c . S p e c i f i c a l l y , the eff i c i e n c y of the f i r s t p r e n a t a l v i s i t f o r i d e n t i f y i n g higher r i s k p a t i e n t s v a r i e d w i t h the co n d i t i o n . For example, 77% of the women w i t h s i g n i f i c a n t medical c o n d i t i o n s (e.g. chronic r e n a l , r e s p i r a t o r y , or c a r d i o v a s c u l a r disease, etc.) were noted, whereas only 26% of the 174 cases of previous post-partum hemorrhage were noted. (Hall and Chng 1982:63). They also found that the ma j o r i t y of emergency h o s p i t a l admissions during pregnancy occurred i n spite of routine prenatal care, indicating that i t may not be possible to prevent or detect the c o n d i t i o n s t h a t cause emergency a d m i s s i o n . Furthermore, H a l l et a l . found that l e s s than h a l f of the a c t u a l cases of intrauterine growth retardation (IUGR) were detected prenatally, and that 30% of the cases of pre-eclampsia presented for the f i r s t time i n labour or the puerperium and t h e r e f o r e were not detected by pr e n a t a l care. The authors also determined that productivity of the prenatal v i s i t s which they do not d e f i n e , was very low p r i o r to 34 weeks g e s t a t i o n , e s p e c i a l l y i n detecting pre-eclampsia and IUGR among healthy low r i s k multiparas. They established that for every correctly diagnosed case of IUGR, 2.5 cases were f a l s e l y diagnosed, and that for every case of pre-eclampsia or hypertension diagnosed another 1.3 cases were f a l s e l y diagnosed. /39 H a l l et a l . concluded that the r o u t i n e p r e n a t a l care they evaluated was i n e f f i c i e n t . They recommended a more f l e x i b l e prenatal schedule that addressed the rea l benefits of the screening process (a) by providing more d e t a i l e d care to women on t h e i r i n i t i a l v i s i t , (b) by f o l l o w i n g p a t i e n t s with s p e c i f i c r i s k factors appropriately, and (c) by providing less routine unproductive care to low r i s k women. The authors presented a convincing argument for more patient t a i l o r e d care and they suggested that i t would improve both patient.satisfaction and productivity. H a l l et a l . d i d not present any l i m i t a t i o n s of t h e i r study except by noting i n a conclusion that "the study has not d i r e c t l y considered the e f f i c a c y of pr e n a t a l care, but rather has attempted to d e l i n e a t e those areas i n which b e n e f i t might reasonably be expected" ( H a l l and Chng 1 9 8 2 : 6 6 ) . The process of the chart a u d i t was not described i n the two a r t i c l e s reviewed. The format, completeness and l e g i b i l i t y of the prenatal records were not indicated, which prevented the reader from assessing the v a l i d i t y and r e l i a b i l i t y of the data. Although the authors' review of the p r e n a t a l record introduced new concepts of p r o d u c t i v i t y and e f f i c i e n c y i n t o the e v a l u a t i o n of pre n a t a l care, they d i d not present or discuss comparisons of p r o d u c t i v i t y and eff i c i e n c y between the two groups of patients (i.e. hospital out-patients or shared care p a t i e n t s ) , between the d i f f e r e n t r i s k groups i n t h e i r population,or between providers. At the time of t h e i r study i t was w e l l documented that strong associations existed between pregnancy outcomes and maternal r i s k status. Presumably r i s k status data was collected for the evaluation of the f i r s t prenatal v i s i t . /40 A final criticism is that the authors provided no discussion on the levels of productivity which the medical profession and other health care professionals and consumers considered minimally acceptable for the diagnoses of pre-eclampsia, IUGR, and malpresentation. Hall et al. suggested that the finding of a productivity of <1% in pre-eclampsia screening prior to 34 weeks gestation indicated that routine screening of previously normotensive multigravidas earlier than 34 weeks was not worthwhile. No other studies were found which identified the general issue of productivity of the routine prenatal v i s i t . However, in Redman's discussion on pre-eclampsia diagnosis, he stated that "...even i f the screening of 5,000 pregnant women at 28 weeks gestation prevents just one maternal death, most pregnant women would want to be so protected, even though in retrospect more than 90% of the v i s i t s would have been non-productive" (Redman 1982b:77). In general, Hall et al.'s research was extremely useful because i t examined the process of prenatal care and provided detailed data with which the effectiveness of this major and costly screening program could begin to be evaluated. Their research was not directly generalizable to a Canadian context where prenatal care is usually provided by a physician in a private office rather than by a variety of personnel in an out-patient c l i n i c . However, this research has promoted the development of more specific prenatal care objectives and has introduced a model for evaluation. A 1 In c o n c l u s i o n , the general e f f i c a c y of p r e n a t a l care i s not w e l l established. As indicated, i t i s assumed by most health care professionals to be an important factor i n promoting good pregnancy outcomes. However, l i t t l e e x p l o r a t i o n i n t o the area has occurred. A l l the studies reviewed were retrospective i n design as no prospective c l i n i c a l t r i a l s s p e c i f i c a l l y i n v e s t i g a t i n g p r e n a t a l care e f f e c t i v e s s were found. The use of v i t a l s t a t i s t i c s and various prenatal records also l i m i t e d these studies because of the i r r e g u l a r i t y of recording and r e p o r t i n g that accompanied them. Furthermore, these data sources and study designs eliminated consideration of many factors which may be c r u c i a l to determining prenatal effectiveness such as the content and q u a l i t y of the care received, the care g i v e r s background, and the p a t i e n t s ' s a t i s f a c t i o n w i t h the p r e n a t a l care. As a res u l t of inadequate research, conclusions regarding the need for and the e f f e c t i v e n e s s of p r e n a t a l care as i t i s r o u t i n e l y provided today were impossible. U n t i l more decisive studies are completed, evaluations of the quality of the prenatal care process must be based on standards developed by the professional bodies who normally provide that care. NOTES: 1. For more complete listing see Chapter III, "Evaluation of Predictors, Interventions and Outcome Variables" in Federal Task Force Report (1984). High Risk Pregnancies and Prenatal Record Systems. Health and Welfare Canada. / 4 3 CHAPTER 4 Methodology A retrospective case-control design was used to examine the quality of prenatal care provided to a group of women cared for by nurse-midwives and a comparable group of women cared f o r by general p r a c t i t i o n e r s . The standardized provincial prenatal record form located i n the hospital chart was reviewed for a l l patients i n the study using established c r i t e r i a for prenatal care. Each record was abstracted for the presence or absence of the c r i t e r i a and was s c o r e d as e i t h e r "adequate", " s u p e r i o r " or "inadequate". The labour and d e l i v e r y record was al s o abstracted f o r general outcome factors. 4.1 Definitions Low Risk Patient: The patients i n t h i s study consist of women who were assessed i n early pregnancy as being e s s e n t i a l l y healthy w i t h no current medical or o b s t e t r i c a l problems, and with the p o t e n t i a l f o r continued normal progress. They had no past medical, surgical or ob s t e t r i c a l history noted on the pr e n a t a l record which would adversely i n f l u e n c e the course of the pregnancy or be unfavourably a f f e c t e d by i t , thus r e q u i r i n g s p e c i a l medical management, (see Appendix A for Low Risk C r i t e r i a ) . / 4 4 Exper imenta l Group: P r e g n a n t women a t t e n d i n g the n u r s e - m i d w i v e ' s " L o w - R i s k C l i n i c " a t Grace H o s p i t a l between J u l y 1982 and A p r i l 1984 who d e l i v e r e d a f t e r 32 weeks g e s t a t i o n . Comparison Group: Pregnant women who v i s i t e d f a m i l y p h y s i c i a n s f o r p r e n a t a l care a t the same t ime as the expe r imen ta l group and who d e l i v e r e d a f t e r 32 weeks g e s t a t i o n . The p h y s i c i a n s at tended t h e i r p a t i e n t s ' d e l i v e r y at Grace H o s p i t a l but p rov ided p r e n a t a l ca re i n t h e i r p r i v a t e o f f i c e s . Nurse-Midwives A s s o c i a t e d w i t h Low-Risk C l i n i c : G r a d u a t e s o f b o t h a s c h o o l o f m i d w i f e r y r e c o g n i z e d by t h e I n t e r n a t i o n a l Confedera t ion o f Midwives and o f an approved schoo l o f n u r s i n g w i t h c u r r e n t r e g i s t r a t i o n i n t h e P r o v i n c e o f B.C. In a d d i t i o n , t h e y had d e m o n s t r a t e d c l i n i c a l e x p e r t i s e i n p e r i n a t a l n u r s i n g as app roved by t h e o b s t e t r i c a l p h y s i c i a n team w o r k i n g i n l i a i s o n w i t h t h e n u r s e - m i d w i v e s and had d e m o n s t r a t e d a b i l i t i e s i n t e a c h i n g and c o u n s e l l i n g . ( C a r t y e t a l . 1984) . Four n u r s e - m i d w i v e s worked i n the Low-Risk C l i n i c . /45 Family Practitioner: A graduate of a recognized medical school and current r e g i s t r a t i o n w i t h the B.C. C o l l e g e o f P h y s i c i a n s and Surgeons. F a m i l y practitioners have highly variable backgrounds; some have s p e c i a l i s t t r a i n i n g i n f a m i l y medicine and/or o b s t e t r i c s and gynecology. No obstetricians were included i n the study. 4.2 The Instrument - Selection, Application and f a l i d i t y This study u t i l i z e d the prenatal care c r i t e r i a based on the Burlington randomized t r i a l of the nurse p r a c t i o n e r . (NAPS 1975). A group of researchers from McMaster University studied the quality of care provided by family physicians and nurse practitioners i n the Ontario community of Burlington i n the early nineteen seventies. In one aspect of thei r study the researchers focussed on the process of medical care by s e l e c t i n g indicator conditions and appraising the quality of the care provided with c r i t e r i a . They noted that the use of s p e c i f i c c r i t e r i a i n the medical audit had been used e x t e n s i v e l y i n h o s p i t a l s but that t h i s s t y l e of appraisal had rarely been applied to an ambulatory practice setting (Sibley et a l . 1975). The researchers s p e c i f i c a l l y s e l e c t e d indicator conditions i n which outcomes were influenced by management and the frequency of the occurrence was s u f f i c i e n t l y high to provide adequate data for analysis. Prenatal care was s e l e c t e d as one of ten i n d i c a t o r c o n d i t i o n s . In the c r i t e r i a the researchers wanted to include items which would indicate: /46 1. Observations that were considered essential for adequate monitoring of the patient's progress, 2. management decisions that would indicate sound c l i n i c a l judgement, and 3 . that the possible serious significance of apparently benign symptoms, signs, or laboratory findings would be recognized (Sibley et al. 1975:47). The specific criteria for each condition were selected and pretested by a peer advisory group composed of three family physicians working in a variety of practice settings. The goal was to establish c r i t e r i a that would reflect community standards for adequacy in primary care management. This group established the following c r i t e r i a as necessary for an "adequate" score for prenatal care in an uncomplicated pregnancy: (a) pelvic assessment, i f there was no previous history of a successful delivery; (b) past obstetrical history; (c) complete physical assessment within a 2-year period; (d) hemoglobin; (e) urinalysis at each v i s i t ; (f) monthly visits from the first through to the seventh month, visits every two weeks for the eighth month, then weekly vis i t s through to term; (g) record of weight at each visit; (h) record of blood pressure at each visit; (i) record of Rh status and of serological test for syphillis; and (j) a statement of gestational age (Sibley et al. 1975:48). If any of these cr i t e r i a were not met, the chart was scored "inadequate". In addition, fourteen intermediate stages of possible complications of pregnancy and /47 mandatory interventions were i d e n t i f i e d , which i f met, maintained the score of "adequate". A " s u p e r i o r " score was established i f at least one of four other c r i t e r i a was achieved (e.g. psychosocial i n t e r v i e w and pap smear record) (see Appendix B for complete Burlington Prenatal C r i t e r i a ) . The McMaster researchers concluded that the c r i t e r i a f o r measuring quality of care were v a l i d because "the three simultaneous approaches (the surveillance of the management of indicator conditions, the evaluation of c l i n i c a l use of drugs and the assessment of r e f e r r a l d e c i s i o n s ) gave c o n s i s t e n t l y s i m i l a r r e s u l t s about the r e l a t i v e performances of the practices compared and were in agreement with concurrent outcome studies" ( S i b l e y et a l . 1975:46). A review of various standards such as (a) G u i d e l i n e s f o r P r e n a t a l Care i n Canada - 1984 by the Society of Obstetricians and Gyneacologists of Canada (1984), (b) Standards f o r Obstetric-Gynecologic Services by the American College of O b s t e t r i c i a n s and Gynecologists (1982), and (c) Guidelines for Perinatal Care by the American Academy of Pediatrics (1983), indicated that the Burlington Prenatal C r i t e r i a s t i l l represents a relevant minimum l e v e l of care. However, a l l three associations recommended more frequent v i s i t s a f t e r 28 weeks and more comprehensive l a b o r a t o r y work. Changes i n some of the medical interventions were also noted. To assess the v a l i d i t y of the c r i t e r i a for family practice i n 1984 i n the Vancouver area, a questionnaire reviewing the B u r l i n g t o n P r e n a t a l C r i t e r i a was developed and informally circulated to a variety of colleagues p r a c t i s i n g o b s t e t r i c s by a general p r a c t i t i o n e r known to the researcher. / 4 8 The practitioners were not informed of the study. Seventeen general practitioners, and after completion of the study, four nurse-midwives in the Low-Risk Clinic completed the questionnaire, (see Appendix C for questionnaire). The response rate of the physicians was 70% and the average number of births they attended per month was 6.6, ranging from 2 to 15 births a month. The results of the survey indicated that generally the cr i t e r i a remained relevant; a l l the physicians agreed that the criteria required for an "adequate" score were applicable to their practices, and that the information required to meet the c r i t e r i a should be recorded on the provincial prenatal record form. Three physicians indicated that the four c r i t e r i a for "superior" care should be reconsidered as "adequate" care. Three other physicians commented that the "superior" criteria of "evidence of psychosocial interview" and "meeting of husband and wife together during pregnancy" would not be recorded on the prenatal form due to the lack of an appropriate space. In reviewing the intermediate conditions and interventions, 92% of the physicians stated that diuretics and sedation (Phenobarbital) were no longer applicable in prenatal care. Seventy-five percent indicated that the criterion and/or the interventions for "excessive weight gain" were not applicable. The survey also found that evidence of a dietary interview" and a "record of fundal height measurements in centimeters" should now be included in routine prenatal care. Seventy-five percent of the physicians f e l t that a dietary interview should be included in the "adequate" category, while 25% placed i t in the "superior" category. Fundal height / 4 9 measurements were placed i n the "adequate" category by 9 2 % of the physicians. The consistency of the responses to the questionnaire suggested that minimal updating of the Burlington Prenatal C r i t e r i a would provide appropriate c r i t e r i a f o r assessing general practioners prenatal care. The four nurse-midwives' questionnaires had s i m i l a r results except for the c r i t e r i o n of "pelvic assessment". Three nurse-midwives stated that a pelvic assessment was often indicated in prenatal care, however, they a l l f e l t that i t was not appropriate for determining the adequacy of the pelvis in primiparas. Only three physicians commented on t h i s issue. As indicated e a r l i e r , physicians i n the Province of B r i t i s h Columbia maintain prenatal records on a standardized form which provides e x p l i c i t space f o r recording a l l the i n f o r m a t i o n needed to achieve an "adequate" score using the B u r l i n g t o n c r i t e r i a (see Appendix D f o r B.C. P r e n a t a l Record). Other space i s a v a i l a b l e on the form f o r recording i n f o r m a t i o n which would achieve a "superior" score, however, the space i s not e x p l i c i t and i t i s l i m i t e d . Generally, physicians sent the prenatal record to the hospital i n the l a s t few weeks of pregnancy, whereas, the nurse-midwives maintained the i r records i n the o u t - p a t i e n t c l i n i c u n t i l labour commenced. I t was a n t i c i p a t e d that t h i s d i f f e r e n c e would increase the number of v i s i t s recorded by the nurse-midwives, exposing them to more ev a l u a t i o n and increasing t h e i r chances of achieving an "inadequate" score. However, t h i s /50 d i f f e r e n c e would a l s o increase t h e i r o p p o r t u n i t i e s to meet one of the superior c r i t e r i o n s and achieve a "superior" score. I t was decided that f o r the purpose of t h i s study, each p r e n a t a l record would be considered complete, and the abstractor evaluated the record as i f delivery occurred after the l a s t recorded prenatal v i s i t . I t was concluded that the B u r l i n g t o n P r e n a t a l C r i t e r i a provided a s o l i d b a s i s f o r the r e t r o s p e c t i v e e v a l u a t i o n of prenatal care i n t h i s setting. However, the peer review questionnaire and the review of other published standards suggested that a comprehensive updating of the c r i t e r i a was required. 4.3 Modification of the C r i t e r i a The peer review questionnaire plus a review of current o b s t e t r i c a l standards and o b s t e t r i c a l i n t e r v e n t i o n s i n d i c a t e d that the B u r l i n g t o n Prenatal C r i t e r i a should be updated as follows: Basic C r i t e r i a 1. G e s t a t i o n a l age should be r e f e r r e d to i n weeks rather than i n months, thus the frequency of v i s i t s was described as: - V i s i t s every 4 weeks from f i r s t prenatal v i s i t to 32 weeks - V i s i t s every 2 weeks from 32 weeks to 36 weeks - Weekly v i s i t s from 36 weeks to term /51 Intermediate State - complications of pregnancy 2. Albuminuria. - This was not defined, therefore the following definition was used: +1 (urine dipstick) or 30mg of protein on two successive urine tests. 3. Excessive weight gain-over 5 lbs (2.3 kg) per 4 weeks - Use of this criterion for weight gain was found to be unrealistic, particularly in the second trimester - The area of appropriate weight gain during pregnancy is a controversial topic. In order to identify extremely excessive weight gain in this patient population the criterion of:^3.6 kg (8 lbs) over 4 weeks, for two consecutive visits was used. - The administration of diuretics for excessive weight gain was deleted from the "appropriate" intervention l i s t . 4. Hypertension and Albuminuria and weight gain - The optional administration of diuretics was deleted from the "appropriate" intervention l i s t . 5. Weight gain and Albuminuria - The optional administration of sedation (Phenobarbital) was deleted from the "appropriate" intervention l i s t . /52 6. Inadequacy of pelvis in primipera - This category was deleted since c l i n i c a l examination is questionable as an indicator of adequacy of the pelvis. 7. Rising Rh t i t r e or anticipated problem - I f present, Rh immune globulin administered at 28 weeks i f the woman is Rh negative unsensitized and the father i s Rh positive was added to the "appropriate" interventions. As well as assessing the prenatal records with the Burlington c r i t e r i a updated as above, an adapted c r i t e r i a was established to examine more areas of prenatal care. Based on the survey of general practitioners, i t was considered reasonable to add the following c r i t e r i a to the requirements for an "adequate" score: 1. Evidence of a dietary interview 2. Must be a record of fundal height measurements in centimeters after 20 weeks gestation Thus two scores were determined for each chart: 1. Updated Burlington Prenatal C r i t e r i a (UBPC) and 2. Adapted Burlington Prenatal C r i t e r i a (ABPC). I t was f e l t that the two additional c r i t e r i a included in the ABPC would make the achievement of an "adequate" score more d i f f i c u l t , but that i t appropriately reflected current and expected general practitioner prenatal care (see Appendix B.2 and B.3 for UBPC and ABPC). /53 The Burlington c r i t e r i a were developed for assessment of the patient's chart i n the practitioner's o f f i c e . Therefore, requirements for the t e s t r e s u l t s f o r the i n t e r m e d i a t e m e d i c a l c o n d i t i o n s i n the h o s p i t a l c h a r t record were not expected. Any i n d i c a t i o n on the prenatal record that the required t e s t or examination was done was considered adequate. 4.4 Study Design S e t t i n g and Study Population Fifty-one women attended the Low-Risk C l i n i c at Grace Hospital between July 1982 and A p r i l 1984 where they received prenatal care from four nurse-midwives. The c l i n i c was located i n the out-patient area of the h o s p i t a l and i t was h e l d one af t e r n o o n a week. The p a t i e n t s were u s u a l l y s e l f -r e f e r r e d . They heard o f the c l i n i c through word o f mouth, or through professional contacts. "The couples who sought out the c l i n i c were w e l l -educated, well-informed, and high l y aware consumers..." (1/3 of the women were registered nurses) (Carty et a l . 1984:4-5). Prospective patients made an i n i t i a l v i s i t to discuss the philosophy of the c l i n i c , to b r i e f l y review t h e i r m e d i c a l and o b s t e t r i c a l h i s t o r y , and to d i s c u s s t h e i r reasons f o r wishing to be involved i n t h i s c l i n i c . Access to the c l i n i c was l i m i t e d to approximately four new patients per month. I f space was a v a i l a b l e , and i f the p a t i e n t had a low r i s k h i s t o r y and was i n agreement w i t h the nurse-midwives p h i l o s o p h y and approach, involvement i n the c l i n i c was o f f e r e d . A l l p a t i e n t s had p r o v i n c i a l medical health insurance and no ad d i t i o n a l fee was required. At /54 the next v i s i t further assessment of the patient and her pregnancy occurred i n conjunction w i t h one of the o b s t e t r i c i a n s associated with the nurse-midwives. For the remainder of the prenatal period the nurse-midwives were the patients' primary care providers. Selection of Controls U t i l i z i n g the " p e r i n a t a l data base", each nurse-midwife patient was matched to two family physician patients. The perinatal data base provides a summary of information on every patient admitted for delivery to Grace H o s p i t a l since January 1 9 8 3 . This record i s separate from the h o s p i t a l chart and i s organized by date and time of b i r t h . For de l i v e r i e s prior to January 1983 the hospital's delivery census was used for matching. The matching characteristics and process were as follows: 1. Date of d e l i v e r y - screening f o r a match began w i t h the next consecutive d e l i v e r y a f t e r the nurse-midwife's d e l i v e r y and proceeded for one week. I f no match was found, the week previous to the d e l i v e r y was screened which was then f o l l o w e d by the second week a f t e r the d e l i v e r y . This patt e r n was maintained u n t i l two matches were i d e n t i f i e d . Usually two or three weeks were reviewed to find two matches, however, 11% of the 88 control matches delivered more than two weeks before or after the nurse-midwife patient. 2. The primary practitioner in the control population was a family physician. 3 . P r e n a t a l care was i n i t i a t e d by twenty weeks g e s t a t i o n i n the control population and delivery occured after 32 weeks gestation. (Both numbers were set to c o i n c i d e w i t h the parameters of the cases). 4 . The patient met the low r i s k c r i t e r i a (see Appendix A) and had no history of caesarean section. 5 . Age - was matched to within 5 years of the nurse-midwife patient. 6. P a r i t y - was matched to the same number as the nurse-midwife patient. 7 . Previous pregnancy l o s s - was matched to e i t h e r ^ 2 previous pregnancy losses, or > 2 previous pregnancy losses. 8 . Gravidity - was matched to the same number as the nurse-midwife patient allowing for previous pregnancy losses noted above. 9 . 1980 Census t r a c t , average f a m i l y income + S.D. (estimated standard error of average income) + $ 1 , O O o J ( S t a t i s t i c s Canada 1 9 8 3 ) . ( P a t i e n t s were g e n e r a l l y matched to the same or nearby census t r a c t that met t h i s c r i t e r i a . A few patients i n outlying areas were matched to other outlying areas some distance apart.) Of the 51 women accepted into the Low-Risk C l i n i c between July 1982 and A p r i l 1984, four had spontaneous abortions before 20 weeks gestation. The remaining 47 nurse-midwife patients, were c a r e f u l l y matched to 94 general / 5 6 practitioner patients, s t r i c t l y following the above c r i t e r i a . Seventy-one f a m i l y p h y s i c i a n s p r o v i d e d care t o the comparison p o p u l a t i o n . Unfortunately only incomplete data was a v a i l a b l e on education l e v e l and occupations, so i t could not be used for matching. Abstraction and Scoring the Prenatal Record An a b s t r a c t i o n and coding form was developed and pretested by the researcher f o r t h i s study which enabled an a b s t r a c t o r to review a l l the prenatal record forms in the hospital chart, and to record the presence or absence of the Updated Burlington Prenatal C r i t e r i a (UBPC) and the Adapted Burlington Prenatal C r i t e r i a (ABPC) (see Appendix E.1 Abstraction Form, and Appendix E.2 f o r Coding Guide). The G e s t a t i o n a l weeks at each prenatal v i s i t w i t h an i n d i c a t i o n as to whether or not there was an accompanying record of weight, B.P., ur i n e and fundal height measurement were also transcribed. The abstractor was a baccalaureate nursing graduate with experience in maternity nursing. She was blinded to the hypothesis of the study but was informed that i t was a general examination of prenatal care. She was given a randomized l i s t of the one hundred and forty-one charts for the review. The abstractor blinded the abstraction and coding form by using i n v i s i b l e ink for the patient's name and chart number. Following the completion of the abstraction the researcher reviewed each form and scored the care t w i c e as e i t h e r "adequate", "superior" or "inadequate" using f i r s t the UBPC and then the ABPC. A f t e r a l l the forms were scored they were unblinded and i d e n t i f i e d , and given t h e i r appropriate study i d e n t i f i c a t i o n number. /57 Statistical Methodology The number of the cases available for this study was 47. The retrospective nature of the study, and the self selection of cases implied a need for matched controls. The better known formulas for s t a t i s t i c a l tests with such matched data require that the scores of the charts be reduced to a dichotomous "all-or-none" variable (i.e. an "adequate or superior" score versus an "inadequate" score), although a l l 3 levels of care can be used in more complicated tests. The s t a t i s t i c a l efficiency of the study was improved by matching 2 controls to each case. Ury (1975) states that the efficiency of k. controls per case to k controls per case equals : k (k + 1)/k (k +1). 2 1 2 . 2 1 (In particular, efficiency = 4/3 for 2 controls per case. If k = 1, and k = 2, then 2 1 k (k + 1)/k (k + 1 ) = 2(2)/(1)(3) = 4/3 = 1.333). 1 2 2 1 That i s , each 3 cases with 2 controls per case provide about as much information as would 4 cases with 1 control per case. Additional matched controls per case would further increase efficiency, but the marginal increase is small. (For example, the efficiency of 3 controls per case (k = 3) relative to 2 controls per case (k^ = 2) was 9/8, only 12.5% more efficient.) It was concluded that for this study, 2 controls would be matched to each case. / 5 8 Miettinen (1968) presented the analysis of matched pair design in the case of all-or-none responses and, in a later paper, the analysis of individual cases matched with multiple controls (Miettinen 1969). Pike and Morrow (1970) also presented the s t a t i s t i c a l analysis of case-control studies with an all-or-none variable, extending the general test developed by Mantel and Haenszel. Pike and Morrow noted a general confusion in the medical literature regarding analysis of retrospective studies which involved individual matching between the case and the control. The usual unmatched chi-square test categorized individuals rather than pairs and summarized the groups compared, ignoring the qualities of the individual matches. Pike and Morrow pointed out that the use of this s t a t i s t i c a l analysis and the corresponding sample size or power calculation was only appropriate i f the matching was irrelevant. The text by Schlesselman (1982) summarizes these authors and discusses the analysis of case-control studies for both unmatched and matched studies. In the present study, the "treatment groups" are the nurse-midwife cases (NM cases) and the general practitioner controls (GP controls). The level of care (i.e. "superior", "adequate" or "inadequate") is the observed p variable. Schlesselman discussed the specific situation of a study involving matched tripl e t s (i.e. case, control , control ) with a dichotomous .1 2 variable and presented the eight possible outcomes as follows: /59 Table 4.1, Sample Frequencies o f Eigh t P o s s i b l e Outcomes'for Matched T r i p l e t s (Case, Control-^ Control ) Outcome Frequency Outcome Frequency + + + n o + + - n l + - + n 2 + - - n 3 ^Adequate or Superior (+), Inadequate (-). (adapted from Schlesselman 1982:214) Triplets in which a l l outcomes are (+) or in which a l l outcomes are (-), play no role in the statistical analysis. The Mantel-Haenszel test of the null hypothesis with the odds ratio OF) equal to 1, (HQ :y = 1), against the two-sided alternative HA:Y j£1 utilizes the other six possible frequency outcomes as follows: Let + + + - u5 *7 N]_ = i n 1 + n 2 + 2(n 3 - n 4 ) - (n 5 + n g )]/3 and . N_ = 2[n, + n„ + n + n + n + n ]/9. 2 1 2 3 4 5 6 Then, Schlesselman (1982:215) gives 2 2 Xmh = ' ~ "^2 w i t n t h e " c o n t i n u i t y correction" or x 2 , = f^/N without the "continuity correction", mh i 2 2 Under the null hypothesis, -x has a chi-square distribution with one mh degree of freedom (Schlesselman 1982:215). /60 For a more powerful analysis of the score results using the original three ordered categories ("superior", "adequate", "inadequate") a generalized Mantel-Haenszel test (Mantel 1963) and a generalized Friedman rank test (Benard and van Elteren 1953), both with one degree of freedom, can be used to test the null hypothesis. Although 70 non-homogenous pairs are needed for a pair matched study to detect a two-fold odds ratio ( ^  = 2) with ct = .05 (one-sided) and 6 =.10, the improved efficiency of a t r i p l e t matched study reduces the non-homogenous t r i p l e t s to approximately 52 (see Appendix F.1). As noted earlier only 47 matched t r i p l e t s were available, thus the power of this study to detect an odds ratio of at least 2 (¥ = 2), with the hypothetical finding of 36 non-homogenous matched tr i p l e t s was found to be 75%. (Appendix F.2). 4.5 Reliability Throughout the abstraction and scoring process reliability testing was performed. Before beginning the abstraction, the researcher and the abstractor practiced on ten prenatal records in a family practice setting, not included in t h i s study and then compared and discussed the abstractions. This was followed by a pretrial for' inter-rater reliability at Grace Hospital where we both abstracted ten more charts. The assessment of the abstraction recording process examined whether the same data was recorded by both abstractors. No systematic errors were noted. Table 4.2. indicates the frequency with which discrepancies occurred. Each coding form required 54 boxes to be marked. /61 Table 4.2. Frequency of Discrepancies i n Inter-rater R e l i a b i l i t y Assessment Number of Discrepancies 0 1 2 3 4 5 6 7 < 7 Number of Charts Charts (N=10) 3 1 2 1 0 1 1 1 0 Hence there was a median value of 1 discrepancy (among 54 boxes per chart), and the average proportion of agreement between the two abstractors was 95.2% per chart, (average number of agreements per chart/total number of possible agreements per chart = 51.4 /54 = 95.2%, determining a KAPPA for this comparison was not appropriate). Following the abstraction and the assessment of the inter-rater r e l i a b i l i t y , the discrepancies were discussed. These results indicated consistent and similar recording between the two abstractors. Towards the end of the abstraction process the abstractor was given an additional l i s t of forty charts to review to determine intra-rater r e l i a b i l i t y . The l i s t contained twenty nurse-midwife charts and twenty family physician charts which had already been abstracted. Later in the study four of these charts were omitted from the analysis because they were mismatched, leaving thirty-six charts for comparison. Again, the assessment of the abstraction recording process was examined, but on this occasion the consistency of the abstractor was the focus. Table 4.3. indicates the frequency with which discrepancies occurred. Each coding form now required the abstractor to mark 49 boxes. /62 Table 4.3. Frequency of Discrepancies i n Intra-rater R e l i a b i l i t y Assessment Number of Discrepancies 0 1 2 3 4 5 6 7 8 9 10 11 >11 Number of Charts (N=36) 12 7 7 3 2, 4 0 0 0 0 0 1 0 Hence there was a median value of 1 discrepancy (among 49 boxes per chart), and the average proportion of agreement between the two abstractions was 96.1% per chart (47.1 /49 = 96.1%). Generally this assessment indicated consistent abstraction and no systematic errors were noted. However, one comparison indicated 11 discrepancies, and a further examination revealed that the abstractor had reviewed the prenatal records of two siblings rather than the same child's record twice, in the mother's chart. In the overall abstraction the appropriate prenatal record was identified by the mother's parity and gravida as well as the general dates of the study. Abstraction of the wrong prenatal record in the mother's chart was noted on one other occasion and the mistake was corrected. Prior to the researcher scoring any of the abstraction forms as "superior", "adequate" or "inadequate", a comparison was made between her scoring and that of a physician who had experience with the Burlington criteria. The forty charts abstracted for the intra-rater reliability test were scored by both the researcher and the physician. Each was blind to the others decision on the score during the process. Judging with the UBPC, there was 92.5% agreement (KAPPA = .80), and with the ABPC there was /63 95% agreement (KAPPA = .87). To determine the KAPPA (Laudis and Koch 1977), the score was adjusted to a dichotomous v a r i a b l e by combining "superior" and "adequate" scores and comparing i t to "inadequate" scores (see Appendix G for KAPPA calculations). Definitions of terms as follows: Family/Household Total Income: The total income of a census family or household is the sum of the total incomes of the members of that family or household. Average Income: The average family/household income refers to the weighted mean total income of families/households in 1980. Average income is calculated from unrounded data by d i v i d i n g the aggregate income of a group of families/households by the number of families/households in that group. Similarly, the average income of a group of non-family persons is calculated from unrounded data by dividing the aggregate income of the group by the number of a l l non-family persons 15 years and over in the group whether or not they reported income. However, the average income of individuals 15 years and over is calculated for only those individuals who reported income for 1980. Standard Error of Average Income: Refers to the estimated standard error of average income for an income size distribution (for total income, employment income, family income or household income). It is an estimate of the error introduced into these data due to the fact that they are collected only from a one in five random sample of households. When using these figures, the user can be reasonably certain that for the enumerated population, the true value (the value that would have been obtained had sampling not been used) lies within plus or minus twice the standard error and virtually certain that i t lies within plus or minus three times the standard error. These estimates do not include the effects of certain types of response error or systematic or coverage errors. Schlesselman's (1982:206) terminology of "disease/non-disease" refers to the treatment groups in this study, and his "exposed/non-exposed" categories refer to the levels of care. / 6 5 CHAPTER 5 Results 5.1 Matched Variables Patients who attended the nurse-midwives' Low-Risk clinic (NM cases) were matched to two patients seen by general practitioners (GP controls) on the c r i t e r i a of similar age (+ 5 years), equal parity, approximate gravidity (+2), approximate previous pregnancy losses (+2), similar or same census tract of residence, and date of delivery. After the study charts were abstracted, a review of the matching variables revealed 3 t r i p l e t sets (case, contro^, contro^ ) that contained an improper match, because the chart number obtained from the "perinatal data base" did not correspond to the actual chart. The 3 triplets that were affected (9 charts) were discarded, leaving 44 triplets for analysis. As expected l i t t l e difference was found between the matching variables for the two groups (Table 5.1.). The overall study population had a mean and median age of 28.5 years; 43% were primigravidas and 66% were primiparous. Table 5 - 1 . Means of Matching Variables for NM Cases and GP Controls Matching Criteria NM Cases GP Controls Age (Yrs.) Parity Gravidity Previous Pregnancy Losses 29.25 .54 1.97 .43 28.17 .54 1.93 .39 / 6 6 5.2 Unmatched Variables Prenatal Attendance Information abstracted from the charts describing prenatal attendance i n d i c a t e d t h a t on average the NM cases sought p r e n a t a l care e a r l i e r , experienced more pr e n a t a l v i s i t s , and were seen over a longer period of time than the GP c o n t r o l s (Table 5.2.). As a n t i c i p a t e d , the general practitioners sent the prenatal record to the hospital at approximately 37 weeks gestation. The nurse-midwives recorded an average of 2 additional v i s i t s per p a t i e n t with a range from 0 to 5 v i s i t s , a f t e r 37 weeks gestation. Table 5.2. Prenatal Attendance Variables (Unmatched) For NM Cases and GP Controls Prenatal Attendance NM Cases GP Controls 1st Prenatal v i s i t M week + (SD) 10.1 (+ 3.2) 11.3 (+ 3 . 4 ) Last Prenatal v i s i t M week + (SD) 39.0 (+ 2.0) 3 7 . 3 (+ 1.8) Number of recorded prenatal v i s i t s M + (SD) 13.4 (+ 2.3) 9.3 (+ 2.3) Number of weeks seen for prenatal care M + (SD) 28.8 (+ 4.0) 26.0 (+ 3.7) / 6 7 Labour and Delivery Data collected on the process and outcomes of labour and delivery revealed that a slightly higher proportion of the NM cases began labour spontaneously, and that essentially equal proportions of the two groups were induced (Table 5.3.). A higher proportion of the G.P. controls' labours were augmented with a r t i f i c i a l rupture of the membranes (14.8%) compared to the NM cases (6.8%). Table 5-3- Percentage of Labour Variables for NM Cases and GP Controls Labour Variable NM Cases (n=44) GP Controls (n=88) % (Actual No.) % (Actual No.) * No labour 2.3% (1) 5.7% (5) Spontaneous 79.5% (35) 70.5% (62) Induced 9.1% (4) 8.0% (7) Augmented 6.8% (3) 14.8% (13) Not recorded 2.3% (1) 1.1% (1) * Cesarean Section prior to the onset of labour. /68 The manner in which the fetus was monitored throughout labour was similar with approximately 50% of both groups receiving auscultation only. (Table 5.4.). Forceps assisted delivery was also equivalent and occurred in 15.9% of the study population. Table 5.4. Percentage of Fetal Monitoring A c t i v i t i e s and Forceps Use for NM Cases and GP Controls NM Cases (n=44) GP Controls (n=88) % (Actual No.) % (Actual No.) Fetal Monitoring Auscultation only 52.3% (23) 50.0% (44) External monitor 15.9% (7) 17.0% (15) and Auscultation Other monitoring 31.9% (14) 33.0% (29) Forceps Use None 84.1% (37) 84.1% (74) Low outlet 11.4% (5) 8.0% (7) Midrotation 4.5% (2) 6.8% (6) Not recorded 0 1.1% (1) / 6 9 The condition of the perineum postpartum differed between the two groups (Table 5.5.). The NM cases had a higher proportion of intact perineums and a much lower rate of episiotomies: GP controls received episiotomies 3 times more frequently than NM cases. However, the NM cases experienced a 1 1/2 times greater frequency of 1° tears, and a 1 1/2 times greater frequency of >1° tears than the GP controls. Overall the combination of an episiotomy and tear was more frequent in the GP controls. Table 5.5. Percentage of Perineum Condition for NM Cases and GP Controls Perineum Variable NM Cases (n=44) % (Actual No.) GP Control (n=88) % (Actual No.) Intact 13.6% (6) 8.0% (7) Episiotomy 13.6% (6) 37.5% (33) 1° Tear 34.1% (15) 20.0% (18) > 1° Tear 27.3% (12) 17.0% (15) Episiotomy and Tear 2.3% ( D 6.8% (6) Cesarean Section 9.1% (4) 9.1% (8) The proportions of vaginal deliveries (90.9%) and cesarean section deliveries (9.1%) were equivalent for the two groups. During the intrapartum period some patients shifted to a higher risk category and were no longer under the primary care of the nurse-midwife or general practitioner. Tables 5.3, 5.4, and 5.5 are presented as descriptions of the study populations and do not infer causal links between prenatal care and labour and delivery outcomes. 5.3 Prenatal Criteria Assessment /70 A review of the prenatal records with the Updated Burlington Prenatal Criteria (UBPC) and the Adapted Burlington Prenatal Criteria (ABPC) identified substantial differences between the two care giver groups: With the UBPC the following scores were achieved: NM cases - 77.3% superior, 6.8% adequate, and 15.9% inadequate; GP controls - 23.9% superior, 15.9% adequate, and 60.2% inadequate. With the ABPC the following scores were achieved: NM cases - 75.0% superior, 9.1% adequate, and 15.9% inadequate; GP controls - 22.7% superior, 13-6% adequate, and 63.6% inadequate. Only a minor shift in scores occurred with the adaptation of the criteria, (see Appendix B.2 and B.3 for cri t e r i a , and Appendix E.1 and E.2 for abstraction form and coding guide). The usual analysis of matched triplets requires these scores to be a dichotomous variable (Schlesselman 1982). Table 5.6 and Table 5.7 l i s t the sample frequencies of the eight possible triplet outcomes for the UBPC and the ABPC respectively, for which the scores have been reduced to: (+) "superior" or "adequate", and (-) "inadequate". The Mantel-Haenszel chi-square test found a significant difference between the NM cases and GP controls with both criteria. The NM cases achieved significantly more "superior" or "adequate" scores of the prenatal record than did the GP controls. /71 Table 5 . 6 . Frequency o f Eight Possible UBPC Outcomes1 Among Case-Control T r i p l e t s (Case, Control-^ C o n t r o l 2 ) Outcome Frequency Outcome Frequency + + + 4(nG) - + + 0(n ) 4 + + - 8(ni) - + - 2(n5) + - + 13(n2) - - + 4(n ) 6 + - - 12(n ) 3 1(n?) 1 "superior" or "adequate1 " (+), "inadequate" (-) 39/3 = 13, N 2= 78/9 = 8.7, 2 Xmh = : 18.0 (p < .005, two-sided) with "continuity correction" 2 Xmh = : 19.5 (p < .005, two-sided) without "continuity correction Table 5 .7 . Frequency o f Eight Possible ABPC Score Outcomes1 Among Case-Control T r i p l e t s (Case, Control^, Control 2 ) Outcome Frequency Outcome Frequency + + + 4(n ) o - + + 1(n ) 4 + + - 6(n2) - + - 2(n5) + - + 11(n2) - - + 3(n ) 6 + - - I6(n ) . 1(n?) 1 "superior" or "adequate1 "inadequate" (-) 2 N = 1 42/3 - 14, N = 2 78/9 = 8.7, 2 Xmh = ; 21.0 (p < .005, 1 two-sided) with "continuity correction" 2 m^h = : 22.6 (p < .005, two-sided) without "continuity correction1 /72 The scores can also be tested in their o r i g i n a l categories with a generalized Mantel-Haenszel test (Mantel 1963) and with a generalized Friedman rank test (Bernard and Van Elteren 1953) both with one degree of freedom. Tables 5.8 and 5.9 summarize the data for the individual scores ignoring the matching, and include these two statistical tests of significance. Table 5.8- Frequency of UBPC Score Outcomes for MM Cases and GP Controls Score NM Cases GP Controls Actual No. (%) Actual No. (%) Superior 34 (77.3%) 21 (23-9%) Adequate 3 ( 6.8%) 14 (15.9%) Inadequate 7 (15.9%) 53 (60.2%) 2 *mh = 27.59701 (p < .005, two-sided) generalized Mantel-Haenszel 2 Xmh = 24.60465 (p < .005, two-sided) generalized Friedman Table 5-9- Frequency of ABPC Score Outcomes for NM Cases and GP Controls Score NM Cases GP Controls Actual No. (%) Actual No. (%) Superior 33 (75.0%) 20 (22.7%) Adequate 4 ( 9.1%) 12 (13.6%) Inadequate 7 (15.9%) 56 (63.6%) 2 x mh = 29.1128 (p < .005, two-sided) generalized Mantel-Haenszel 2 Xmh = 24.9921 (p < .005, two-sided) generalized Friedman / 7 3 5.4 Patterns of Care Marked d i f f e r e n c e s were found i n t he p a t t e r n s o f c a r e f o r t h e two groups. Both the UBPC and the ABPC conta ined the same four i n d i c a t i o n s f o r a " s u p e r i o r " s c o r e . The m a j o r i t y o f t he NM c a s e s (63.6%) had two i n d i c a t i o n s p e r c h a r t f o r a " s u p e r i o r " s c o r e and t h e m a j o r i t y o f t h e GP c o n t r o l s (62.5%) had one i n d i c a t i o n per c h a r t , f o r a " s u p e r i o r " s c o r e . ( F i g u r e 5 .1 ) . Figure 5.1 Proportions of the Number of "Superior" Indications Found per Chart for NM Cases and GP Controls With UBPC 0 10 20 30 40 50 60 70 80% Many more i n d i c a t i o n s f o r an " i n a d e q u a t e " s c o r e were p o s s i b l e . The i n a b i l i t y o f the reco rd to meet the 10 b a s i c c r i t e r i a o f the UBPC or the 12 b a s i c c r i t e r i a o f t he ABPC, o r t o have an " i n a p p r o p r i a t e a c t i o n " w i t h an i n t e r m e d i a t e c o n d i t i o n r e s u l t e d i n an " inadequate" sco re . 77.3% o f the NM cases had no i n d i c a t i o n s on the p r e n a t a l reco rd f o r an " inadequate" score as compared t o 27.3% o f t h e GP c o n t r o l s . I n f a c t , h a l f o f t h e GP c o n t r o l s had > 2 i n d i c a t i o n s f o r an " i n a d e q u a t e " s c o r e , w i t h 10.3% h a v i n g ^ 5 " inadequate" i n d i c a t i o n s ( F i g u r e 5 .2) . Figure 5.2 Proportions of the Number of "Inadequate" Indications per Chart for MM Cases and GP Controls With UBPC The criteria which were most frequently scored "inadequate" included the record for "blood pressure" (21% of GP controls), record for "urine" (38% of GP controls), and "frequency of prenatal v i s i t s " (36% of GP controls). The NM cases had a similar pattern, but a lower proportion of "inadequate" indications, (e.g. BP - 2.3%, urine - 9.1%, v i s i t frequency -13.6%). (Figure 5.3). /75 Figure 5.3 Proportions of "Inadequate" Scores per C r i t e r i o n (UBPC and ABPC) for NM Cases and GP Controls CRITERIA P e l v i c Assessment — O b s t e t r i c a l H i s t o r y — ^ Complete P h y s i c a l I n i t i a l Haemoglobin — ^ 0 Rh S t a t u s — /, R e c o r d o f W e i g h t — 9 Record o f B.P Record o f D r i n e -% 5.7% (5) (0) §|19-1% (8) (0) U 4.5% (4) g2.3% (1) Frequency o f P r e n a t a l V i s i t s S tatement o f G e s t a t i o n a l Age F u n d a l H e i g h t -D i e t a r y I n t e r v i e w — '2.3% (1) i l 8 % C 7 ) NM Cases cS GP Controls 1 2.3% (2) 6.8% (6) _$Z3% CD |§21.6% 09) 33% (29) 22.7% (20) ||l3.6% (12) 0 10 20 30 40% Percentage of Omission /76 A review of the incidences of the intermediate conditions indicated a marked difference between the two groups. The NM cases contained 58 intermediate conditions within 44 charts whereas, the GP controls contained 28 intermediate conditions within 88 charts. (Figure 5.4). Hypertension, albuminuria and glucosuria were the only intermediate conditions evaluated that the abstractor was able to note from the ongoing prenatal record. The other conditions were identified i f a comment was made or an investigative test was reported. In the case of albuminuria, the nurse-midwives tended to order a urinalysis before two abnormal urine "dipstick tests" were established. As a result, the abstractor recorded the condition because the investigation was done. Figure 5.4 Proportions of Intermediate Conditions Found for NM Cases and GP Controls INTERMEDIATE CONDIT IONS 29.5% (13) D i s c h a r g e / P r u r i t i s 27.3 % (12) P o s s i b l e R u b e l l a C o n t a c t Rh T i t r e R i s i n g or A n t i c i p a t e d \ 25.1% (11) I i i 0 10 20 30 40 Incidence per 100 ^ i d e n t i f i e d i f u r i n a l y s i s i s present /77 The appropriate intervention was performed for a l l the intermediate conditions identified with the exception of four conditions found among the GP controls, which included 2 cases of "hypertension", 1 case of "discharge or pruritis", and 1 case of "possible rubella contact". Therefore, inappropriate action for an intermediate condition caused only 6% of the "inadequate" scores with the UBPC. In summary, two comparable patient groups were found to have significantly different prenatal record scores; the NM cases received "adequate" or "superior" scores more frequently than the GP controls. The Mantel-Haenszel estimate of the odds ratio (Schlesselman 1982:215) was 7.5 for the UBPC and the power of the study was greater than 99% (Appendix F.3). While both groups met the c r i t e r i a for the i n i t i a l prenatal assessment, patterns of care differed between the two groups: a higher proportion of the GP controls received inadequate scores in association with the ongoing recording of the prenatal assessment process. It was also found that the NM cases contained a higher proportion of intermediate conditions than the GP controls. /78 CHAPTER 6 Discussion 6 .1 Methodology Discussion A health record audit using e x p l i c i t c r i t e r i a and indicator conditions has been widely used as a methodology for investigating quality of care i n ambulatory settings. The important aspects of t h i s research design are the s e l e c t i o n of i n d i c a t o r c o n d i t i o n s f o r which medical care i s g e n e r a l l y agreed upon and f o r which s p e c i f i c c r i t e r i a can be developed. Prenatal care i s a good example of such an i n d i c a t o r c o n d i t i o n because the b a s i c medical care of pregnant women has become standardized over the l a s t s e v e r a l decades and medical p r a c t i c e b e l i e f s accept a s p e c i f i c common minimal l e v e l of care. The B u r l i n g t o n p r e n a t a l c r i t e r i a m i r r o r these medical p r a c t i c e s and the Updated B u r l i n g t o n P r e n a t a l C r i t e r i a r e f l e c t current terminology and practice. In most studies several indicator conditions are selected i n order to i d e n t i f y a r e p r e s e n t a t i v e study population w i t h a range of c l i n i c a l problems f o r the measurement of q u a l i t y of care. In the present study, prenatal care was the only indicator condition used to assess the quality of c a r e , as the purpose was t o d e t e r m i n e i f a d i f f e r e n t h e a l t h p r o f e s s i o n a l , the nurse-midwife, could provide p r e n a t a l care t h a t was equivalent to the predominant and accepted care g i v e r , the general p r a c t i t i o n e r . Choosing one i n d i c a t o r c o n d i t i o n f o r a p p r a i s a l was a fu n c t i o n of time c o n s t r a i n t s , a v a i l a b l e published c r i t e r i a , l i m i t e d c l i n i c a l areas of overlap between the two practitioner groups and l i m i t e d access to records. /79 A second adaptation of the traditional chart audit was the selection of practitioners for the control group. All of the nurse-midwife patients attending the Low-Risk Clinic were compared to a relatively small sample of general practitioner patients who delivered at the same hospital. Seventy-one general practitioners provided care to the 88 matched controls assessed in this study. Over 600 physicians have priviledges to practice at the hospital where the study took place; the physicians were included in the study only because they had hospital privileges and because their patient was matched to one of the nurse-midwives patients. Thus, this study compares the prenatal care received by 44 nurse-midwife patients to that of 88 general practitioner patients rather than the prenatal care provided by 4 nurse-midwives to that provided by 71 general practitioners. An additional adaptation was the use of a case-control design with the analysis of each matched tripl e t . A retrospective audit of the nurse-midwives records alone, with the established and tested criteria would have indicated the quality of care provided by this group in isolation, apart from comparisons to other published studies which used the same criteria. The introduction of a matched control group enabled comparisons of care to that which was actually provided in the same community, thus permitting broader conclusions. Certain limitations arise with a retrospective chart audit which measures quality of care. A major concern is the r e l i a b i l i t y of the medical record in reflecting the care that actually occurred. In this study several factors contribute to the validity of the prenatal record. First, a large component of routine prenatal care is a systematic screening /80 process that is well established and accepted, and secondly, i t is recorded on a standardized form. While, i t is possible for whole vi s i t s to go unrecorded, or for normal signs and symptoms to be omitted from the record which were mentally noted by the conscientious practitioner, a component of prenatal care is the identification of changes over time, which demands a complete ongoing record for adequate assessment, (eg. B.P., urine tests, fetal growth, weight). Thirdly, the prenatal record is a communication to colleagues both within a practice and in the hospital where i t is sent prior to delivery. Hospitals require the submission of prenatal records, and internal hospital committees u t i l i z e this record for peer review. Moreover, the prenatal record is a legal record of medical care. Consideration of the multiple purposes of the prenatal record and of the nature of prenatal care in general, supports its use as a good indicator of the care that was provided to the prenatal patient. Another common concern with chart audits is the appropriateness of the c r i t e r i a used for assessing the level of care provided. The use of explicit rather than implicit c r i t e r i a , and the development of minimal standards of care rather than optimal standards has improved the reliability of this method in general (Brook and Appel 1973). The original Burlington prenatal criteria listed 10 requirements for an adequate score which were developed by family physicians and pretested, and i t was found that the criteria did measure the quality of care and provided results that were similar to outcome measures of quality of care in the same practice settings (Sibley et al. 1975:51). (see Chapter 4 for further discussion of the Burlington prenatal criteria). For the present study the criteria were /81 reviewed by general practitioners so that their current applicability could be assessed. As discussed in Chapter 4, a l l the p r a c t i t i o n e r s f e l t the basic c r i t e r i a were relevant to their practices and their suggested changes to the c r i t e r i a simply involved updating terminology and a l t e r i n g "appropriate interventions" in a few of the intermediate conditions. An extensive peer review was not performed because of time constraints and because this group produced very similar results. A further comparison of the c r i t e r i a to the published standards of several medical professional organizations supported the Burlington prenatal c r i t e r i a as minimal, but appropriate indicators of prenatal care. In considering the manner in which the Burlington c r i t e r i a were developed and tested, the review by practitioners in the local community, and the comparison with professional standards, i t was concluded that the c r i t e r i a were v a l i d measures of quality of prenatal care. It i s inte r e s t i n g to note that the additional c r i t e r i a included in the Adapted Burlington Prenatal Criteria did not alter the scores appreciably, however they did provide more information on patterns of practice. The present study permits conclusions to be made about the quality of the process of care received by a group of patients attended by nurse-midwives and another group of patients attended by general practitioners. Conclusions can also be made from t h i s study about the prenatal care the nurse-midwives provided in the LowRisk Clinic. Furthermore, these results are applicable to other nurse-midwives with comparable backgrounds practising in similar settings with a similar model. However, this study design does not allow conclusions about the quali t y of care provided to /82 prenatal patients in general by physicians since no attempt was made to establish a representative sample of patients seen by general practitioners. The focus was to establish two similar groups of patients to determine i f there was a difference in the care they received. The sample of general practitioners has wide confidence intervals and i t is possible that a socio-economic confounder influenced the selection of general practitioners through the patient matching process. At the same time, however, there is no reason to conclude that the physicians in this study were different from others who practiced at the same hospital. 6 . 2 . Results Discussion The minimal and explicit Burlington prenatal criteria indicated that the care received by nurse-midwife patients at the Low-Risk Clinic is more comprehensive than the care received by general practitioner patients as measured from the prenatal record. Given the "experimental" nature of the Low-Risk Clinic, the high score achieved by the nurse midwives (84% "superior" or "adequate" with UBPC) is not surprising (i.e. the Hawthorne effect). The low proportion of "adequate" or "superior" scores (40% with UBPC) found in the general practitioner control group was not anticipated as family physicians achieved higher scores in other studies using the Burlington prenatal c r i t e r i a . Sibley et al's, and Sheps and Robertson's studies found "adequate" or "superior" scores of 70% and 48% respectively among general practitioners records. (Table 6.1). A minor adaptation of the scoring process which was also used in the present study, boosted Sheps and Robertson's score to 65%. /83 Table 6.1. Proportions of Adequate and Superior Scores Achieved with the Burlington Randomized C l i n i c a l T r i a l (BRCT) C r i t e r i a for Prenatal Care i n Three Studies Care Giver Group Studies Nurse Prac t i t i o n e r NP + GP General Practioner (NP) (GP) %(Actual No.) %(Actual No.) %(Actual No.) Sibley et a l . 77% (13) 71% (3D (1976) Sheps & Robertson 48% ( 11 ) (1984) 65% (15)3 Buhler 1 84% (37)2 40% (35) 1. Updated Burlington Prenatal C r i t e r i a Results 2. C e r t i f i e d Nurse-Midwives 3. Adjusted ratings by Sheps & Robertson, si m i l a r to UBPC. S i b l e y et al.'s study was prospective and the p r a c t i t i o n e r s i n the three practices they studied were aware of a research program. These three practices achieved s i m i l a r scores. Sheps and Robertson performed a chart audit using the B u r l i n g t o n c r i t e r i a f o r 7 of the p o s s i b l e 10 i n d i c a t o r conditions developed by Sibley et a l . They r e t r o s p e c t i v e l y examined the primary care provided by 2 nurse practitioners and f i v e family physicians i n a community c l i n i c . The scores of the nurse p r a c t i t i o n e r s and the physicians were combined as care g i v e r per se was not an issue i n that study. Both of these s t u d i e s evaluated the care provided i n s p e c i f i c medical s e t t i n g s . The present study d i f f e r s from these two i n that the c o n t r o l group i s composed of many general p r a c t i t i o n e r s f u n c t i o n i n g i n /84 their own private medical practices, thus introducing a range of settings. The numbers of prenatal records reviewed in these two studies were small. Sibley et al. reviewed 13 charts in the randomized nurse practitioner group and 31 charts in the control group; Sheps and Robertson reviewed 23 prenatal records. In the present study records for 44 NM cases and 88 GP controls were reviewed which, in turn, examined 75 practitioners (4 NM, 71 GP). The differences in the scores for the nurse-midwife group and the general practitioner group are emphasized by the findings that 84% of the NM cases had two or more "superior" indications per chart while 51% of the GP controls had at least 2 "inadequate" indications per chart. The nurse-midwives consistently met the superior c r i t e r i a of "evidence of a psychosocial interview" (68%) while the general practitioner met the pap smear criterion (70%) but rarely met the psychosocial criterion (10%). This finding clearly identifies a difference in practice between the two care giver groups as the nurse-midwives recorded psychosocial adaptation throughout the pregnancy cycle. A third superior indication, "interview with husband and wife together", was known to occur with a l l Low-Risk Clinic patients and was l i k e l y to have occurred with many general practitioners' patients, but neither group noted i t in the record. The high proportion of "inadequate" indications found in the GP controls' records was not entirely limited to one or two criteria, although most omissions were associated with the ongoing care; a smaller proportion of charts (between 5-10%) omitted i n i t i a l assessment criteria. Many of these omissions have practical implications for identifying inadequate care /85 because one purpose of prenatal screening i s i d e n t i f y i n g changes over time. The magnitude of these omissions i s increased when the l e n i e n c y of the s c o r i n g process i s considered. For example, i f a u r i n e t e s t , blood pressure reading, or weight was omitted on a single v i s i t but other ongoing r e c o r d i n g s were present, t h a t v i s i t was s t i l l judged "adequate" i f the omission occurred once in the record. Furthermore, frequency of prenatal v i s i t s was judged adequate even i f "up to 6 weeks" elapsed between v i s i t s on one occasion, prior to 32 weeks gestation. V i s i t s 5 weeks apart p r i o r to 32 weeks gestation, and 3 weeks apart between 32 and 36 weeks gestation were also considered adequate. In addition to these considerations, i f a c h a r t r e c e i v e d an "inadequate" score because of one i n d i c a t i o n but was " s u p e r i o r " i n other r e s p e c t s , the chart was re-assessed as "adequate". T h i s s c o r i n g was c o n s i d e r e d r e a l i s t i c s i n c e i t d i d not p e n a l i z e p r a c t i t i o n e r s f o r o c c a s i o n a l omissions and f o r d i f f i c u l t i e s scheduling appointments. Despite t h i s " l e n i e n c y " , the GP c o n t r o l s s t i l l achieved a remarkably low l e v e l of "adequate" or "superior" scores. These differences support the hypothesis of the study and indicate, that the nurse-midwives' records were more thorough and more consistent than those in the general p r a c t i t i o n e r group. An examination of v a r i a b l e s other than those which were used f o r matching r e v e a l s more s i m i l a r i t i e s and a few d i f f e r e n c e s between the patient groups. The outcomes of labour and delivery, with the exception of the c o n d i t i o n of the perineum were s i m i l a r . The d i f f e r e n c e s i n the frequencies of episiotomies and tears between the two groups indicates the d i f f e r e n t s t y l e of practice during delivery of the nurse-midwives and the /86 general practitioners. The s i m i l a r i t i e s of the matching, and labour and delivery variables supports the conclusion that two low r i s k groups were established. The differences found in the frequency of prenatal v i s i t s i s a result, to some degree, of the GP controls' records being sent to the hospital at 37 weeks gestation while the nurse-midwive's records were maintained u n t i l d e l i v e r y . An a n a l y s i s of the frequency of v i s i t s f o r each group p r i o r to 37 weeks g e s t a t i o n was not done. However, the mean number of v i s i t s recorded for the NM cases was 13.4 and for the GP controls was 9.3. The NM cases had a mean of 2 v i s i t s a f t e r 37 weeks wit h a range from 0 to 5 v i s i t s . Therefore, one can surmise t h a t the NM cases experienced approximately 2 more v i s i t s than GP controls prior to 37 weeks gestation. I t i s not possible to determine from t h i s study whether t h i s difference was c l i e n t or provider i n i t i a t e d , or whether i t simply indicates a difference i n patient compliance i n attending scheduled appointments. I t i s possible that t h i s f i n d i n g i d e n t i f i e s a d i f f e r e n c e i n the two p a t i e n t groups supporting the anecdotal comment that the Low-Risk C l i n i c served a unique c l i e n t e l e of "highly aware health care consumers" (Carty et a l 1984:4). I t was not p o s s i b l e to measure t h i s v a r i a b l e i n the present study as i t was beyond the scope of a r e t r o s p e c t i v e chart audit. The d i f f e r e n c e i n prenatal v i s i t s may also be an indication of a difference i n the styles of practice between nurse-midwives and general practitioners, with the former scheduling more appointments f o r r o u t i n e p r e n a t a l care, and not a d i f f e r e n c e i n p a t i e n t groups. The nurse-midwives reported e x t r a / 8 7 appointments d u r i n g the p r e n a t a l p r o c e s s f o r an i n i t i a l i n t e r v i e w , f o r d e v e l o p i n g a b i r t h p lan, and f o r a labour and d e l i v e r y "dress r e h e a r s a l " . I t i s not known whether routine prenatal screening always occurred at these v i s i t s or even i f they were c o n s i s t e n t l y recorded on the prenatal record. As suggested i n Chapter 4, the i m p l i c a t i o n o f a h i g h e r frequency o f prenatal v i s i t s for the nurse-midwives with respect to the evaluation are two-fold. Since NM cases had more v i s i t s evaluated per patient than the GP controls, they had more opportunities to achieve both an "inadequate" score or meet a "superior" c r i t e r i o n . The actual r e s u l t s of the study ind i c a t e t h a t the a d d i t i o n a l p r e n a t a l v i s i t s e x p e r i enced by the NM cases d i d not cause many "inadequate" scores. As w e l l , the achievement of the superior c r i t e r i a o c c u r r e d e a r l y i n the r e c o r d , as "pap smear or c y t o l o g y r e c o r d " was done i n the f i r s t trimester, and "evidence of a psychosocial interview" was an ongoing aspect of the nurse-midwive's r e c o r d s . Thus d e s p i t e a "harder test", the nurse-midwives performed better. The increased number of v i s i t s evaluated did not a f f e c t the r e s u l t i n g score and further supports the evidence t h a t nurse-midwives are capable o f p r o v i d i n g s u p e r i o r c a r e throughout the prenatal period. Differences found in the quantity of intermediate conditions between the two groups i s a l s o i n t e r e s t i n g . The NM cases had a much hi g h e r proportion of intermediate conditions than did the GP controls. The higher i n c i d e n c e o f Albuminurea was d i s c u s s e d b r i e f l y i n Chapter 5 . T h i s d i f f e r e n c e was probably a r e s u l t of the nurse-midwives o r d e r i n g a u r i n a l y s i s a f t e r one abnormal u r i n e d i p - s t i c k t e s t . Another d i f f e r e n c e , the 2 1/2 times higher incidence of hypertension in the NM cases may have been a f u n c t i o n o f the f a c t t h a t the nurse-midwives' r e c o r d s were /88 maintained through the l a t t e r part of pregnancy. The incidence of hypertension does increase progressively i n the l a s t trimester of pregnancy ( H a l l and Chng 1982:64). The 5 times higher incidence of discharge or p r u r i t i s and the accompanying i n t e r v e n t i o n of p e l v i c examination and c u l t u r e may have a l s o been a f u n c t i o n of the l a t t e r part of pregnancy as the nurse-midwives may have screened patients for candidiasis infections for the purpose of preventing neonatal thrush. The i d e n t i f i c a t i o n of a "Rh t i t r e r i s i n g or anticipated problem" was l i k e l y a result of the extensive antibody screening t e s t t h a t was r o u t i n e l y performed at the Low-Risk C l i n i c . E v i d e n t l y t h i s t e s t i s not r o u t i n e l y performed i n general practitioners* o f f i c e s . The small number of "inappropriate interventions" in the GP controls and the absence of " i n a p p r o p r i a t e i n t e r v e n t i o n s " i n the NM cases f o r the intermediate c o n d i t i o n s i n d i c a t e s that, i n one sense, p r e n a t a l care was g e n e r a l l y good, t h a t i s , p o t e n t i a l l y s e r i o u s c o n d i t i o n s were not misdiagnosed by either group. At the same time, however, the incomplete prenatal records of many GP controls made i d e n t i f i c a t i o n of intermediate conditions less r e l i a b l e than that of the NM cases. In g e n e r a l , the d i f f e r e n c e s i n the i n c i d e n c e o f the v a r i o u s intermediate conditions between the groups can be explained by the longer screening period that the NM cases experienced, p a r t i c u l a r l y at the end of pregnancy, and by a more rigorous attitude toward screening by the nurse-midwives. In r e t r o s p e c t i t i s unfortunate that the c h a r t s were not /89 abstracted i n a way that would have indicated the weeks of gestation at the time that the intermediate c o n d i t i o n was i d e n t i f i e d . This l a c k of i n f o r m a t i o n makes i t impossible to conclude whether i t was a r e a l difference i n practice between the groups, or whether i t was a function of the time period involved i n the screening (ie. the nurse-midwives having the chart l a t e r in pregnancy). 6.3. Limitations Specific l i m i t a t i o n s of t h i s study include (a) the comparability of the two p a t i e n t groups, and (b) the a p p l i c a t i o n of a chart a u d i t f o r reviewing a s m a l l group of p r a c t i t i o n e r s and comparing them to a l a r g e group of p r a c t i t i o n e r s . As noted e a r l i e r , the two p a t i e n t groups were s i m i l a r on many matched as w e l l as unmatched v a r i a b l e s . However, a "membership b i a s " may have i n f l u e n c e d the r e s u l t s of the study. Sackett s t a t e s that "membership i n a group may imply a degree of h e a l t h which d i f f e r s s y s t e m a t i c a l l y from that of the general population" (Sackett 1979:54). This d e f i n i t i o n can be a p p l i c a b l e to the p a t i e n t s who attended the Low-Risk C l i n i c and thus may have systematically influenced the care they received, making i t different than the comparison group. I f true, i t would be d i f f i c u l t to a s c e r t a i n i n a r e t r o s p e c t i v e study, how the care was influenced. One could surmise that an assertive, knowledgeable health care consumer who sought out a nurse-midwife could i n s i s t that discussions or screening practices take place which could influence assessment of scores of t h e i r prenatal records. However, the c r i t e r i a used for the assessment /90 were not designed f o r t h i s type of h e a l t h care consumer, but rather r e f l e c t e d normal i n t e r a c t i o n s i n a general p r a c t i c e s e t t i n g . The Bu r l i n g t o n c r i t e r i a , t h e r e f o r e , would minimize the p o s s i b l e b i a s the NM cases may have introduced. The other major concern with regard to the l i m i t a t i o n s of th i s study focuses on the application of a chart audit which compares a small group of practitioners to a large group of practitioners. Other studies were found which made s i m i l a r comparisons between nurse-midwives and physicians but they almost exclusively examined outcome indicators, rather than process of care i n d i c a t o r s . P u b l i c a t i o n s using the B u r l i n g t o n c r i t e r i a have not evaluated l a r g e groups of p r a c t i t i o n e r s . I t i s p o s s i b l e that the difference found between the NM cases and the GP controls were skewed by one group f u n c t i o n i n g i n a s m a l l cohesive s e t t i n g while the other group functioned i n a v a r i e t y of s e t t i n g s under v a r i a b l e c o n d i t i o n s and with different backgrounds. Penalizing physicians for differences in approaches to care however was reduced by selecting minimimal c r i t e r i a that applied to general practice, by interpreting the c r i t e r i a l e n iently, and by reviewing the c r i t e r i a with general practitioners many of whom were l a t e r (by chance) included i n the study. Further research e v a l u a t i n g s p e c i f i c general p r a c t i t i o n e r s i n the same community w i t h the B u r l i n g t o n c r i t e r i a could indicate whether t h i s bias was introduced by the study design. / 9 1 CHAPTER 7 Implications 7.1. F e a s i b i l i t y and Application of the Research Method Chart a u d i t s which use process c r i t e r i a f o r e v a l u a t i o n of primary p r a c t i c e s e t t i n g s have many a p p l i c a t i o n s because the r e s u l t s describe patterns, as w e l l as, q u a l i t y of care. The r e s u l t s provide s p e c i f i c and c l e a r i n f o r m a t i o n to the p r a c t i t i o n e r ( s ) evaluated by i d e n t i f y i n g the strong and weak areas of t h e i r care. For example, Sheps and Robertson summarized t h e i r r e s u l t s w i t h the B u r l i n g t o n c r i t e r i a i n t o the general areas of (a) h i s t o r y t a k i n g , (b) p h y s i c a l examination, (c) l a b o r a t o r y work, and (d) management. This allowed them to i d e n t i f y trends i n p a r t i c u l a r aspects of medical care and provided u s e f u l feedback to the practitioners evaluated (Sheps and Robertson 1984:883). A process focused, q u a l i t y of care e v a l u a t i o n can also provide b a s e l i n e i n f o r m a t i o n f o r a practice which wants to measure innovations i n care. (e.g. introduction of new personnel, change i n chart format, or a new o r g a n i z a t i o n s t r u c t u r e ) . At the same time, i t can provide the standard for comparing di f f e r e n t types of care g i v e r s , as i n the present study, or i t can be used f o r comparing di f f e r e n t models or settings of care. Process quality of care studies have a p p l i c a t i o n s beyond the p r a c t i c e s e t t i n g . The results may ide n t i f y need f o r change or augmentation i n a p r a c t i t i o n e r ' s primary and con t i n u i n g education, as well as, support further research into primary care practice by providing data which can generate more s p e c i f i c hypotheses. F i n a l l y , process of care s t u d i e s e v a l u a t i n g primary care s e t t i n g s c o n t r i b u t e new information which can be used to affect s o c i a l policy changes, such as the introduction of an alternative health care provider. /92 When con s i d e r i n g the a p p l i c a t i o n s of t h i s study methodology, i t s l i m i t a t i o n s should be kept in mind. Generally, chart audits are indirect measures of care, and the use of one i n d i c a t o r c o n d i t i o n (eg. p r e n a t a l care) severely r e s t r i c t s the g e n e r a l i z a b i l i t y of the conclusions of the study. The use of the prenatal record i n the present study minimized one l i m i t a t i o n of the audit because the record i t s e l f was an important aspect of the care. The other l i m i t a t i o n , that of using one indicator condition, does not apply to t h i s study because the purpose was to examine only that aspect of the p r a c t i t i o n e r ' s a b i l i t y to provide care. Most a p p l i c a t i o n s necessitate the use of several indicators to evaluate the ove r a l l quality of care provided. The use of the Burlington prenatal c r i t e r i a i n t h i s case-control chart audit was a feasible solution to a research si t u a t i o n i n which the quality of prenatal care provided by two health professional groups was evaluated and compared. The c r i t e r i a were found to be straight forward. The current a p p l i c a b i l i t y of c r i t e r i a i n general, i s assured w i t h a review by practitioners i n the study's locale. This review i s an essential aspect of the study's methodology as i t updates the c r i t e r i a to current terminology and p r a c t i c e , and i n t h i s case, supported the i n c l u s i o n of a d d i t i o n a l c r i t e r i a . The o r i g i n a l B u r l i n g t o n a b s t r a c t i o n sheets were not used f o r the present study because more information was required from the charts. The new a b s t r a c t i o n sheets developed for t h i s audit permit s c o r i n g to occur a f t e r a l l the char t s are abstracted. This i s an important c o n s i d e r a t i o n when practitioners from different d i s c i p l i n e s are compared, as different / 9 3 models of practice may be reflected i n the content of the records. The new abstraction sheets f a c i l i t a t e r e l i a b l e scoring by presenting the data in a more consistent format and eliminating p o t e n t i a l l y biasing influences such as, l e g i b i l i t y , a d d i t i o n a l i n f o r m a t i o n , and o v e r a l l appearance of the record. In general, the methods of t h i s study can be applied to other primary care s e t t i n g s , and w i t h the pr e n a t a l record i n p a r t i c u l a r , to h o s p i t a l settings. The most time consuming aspect was the selection of controls. At the time of the study, the "perinatal data base" was not entered into a computer system so the o r i g i n a l data base forms were used: the matching process took approximately 120 hours. The abstractions of the charts were s t r a i g h t forward and took approximately 20 minutes per chart and the s c o r i n g took an a d d i t i o n a l 5 minutes per chart. The data were e a s i l y entered i n t o a computer f o r the i n i t i a l analyses from the a b s t r a c t i o n sheets. As Sheps and Robertson found, "The e v a l u a t i o n method used i s feasible for short-term studies and i s r e l a t i v e l y inexpensive in terms of research time and money: i t thus can r e a l i s t i c a l l y be ap p l i e d to many primary care settings" (Sheps and Robertson 1984:886). 7.2. Implications for Planning This research, which has found nurse-midwives to be safe and "superior" practitioners of prenatal care and able to achieve many s i m i l a r labour and delivery outcomes to those of general practitioners, contributes needed i n f o r m a t i o n to the issue of nurse-midwifery p r a c t i c e i n Canada. H a l l , Land, Parker and Webb (1975) i d e n t i f y general c r i t e r i a and f a c t o r s / 9 4 which influence emerging issues in the realm of innovative social policy changes. They identify information as one of several factors which influences both the legitimacy, f e a s i b i l i t y and support c r i t e r i a of the issue, as well as, the "image" of the issue. The findings of this study alter the placement of the nurse-midwifery issue along each c r i t e r i a continuum in the following way. The l e g a l i z a t i o n of nurse-midwifery is clearly a legitimate responsibility of government. For example, recent court cases and inquiries into homebirths attended by midwives have addressed the implications of their current illegal status. (Hendrickson 1985). In one inquiry the judge noted health consumers' desires for alternative birthing experiences and recommended the legal recognition of midwifery so that the profession could be regulated and controlled. (Globe and Mail 1985). The Ontario Minister of Health responded by stating that his ministry would be looking into research which examines this issue. Hall et al. stated that "The empirical demonstration that certain problems actually exist is regarded as an essential step in securing state action to deal with them" (Hall et al. 1975:502). The combination of the recent court cases and this research, which not only finds the nurse-midwife to be an effective provider of prenatal care but also identifies a problem with the quality of prenatal care that is presently being provided by general practitioners, may be enough evidence to encourage the government to address the issue of nurse-midwifery practice in a concrete manner. Hall et al. state that the f e a s i b i l i t y of an issue is usually not readily apparent. Aside from ideological viewpoints among policy makers /95 and the p o l i t i c a l c l i m a t e , these authors note t h a t the f e a s i b i l i t y of an issue i s influenced by available resources, collaborative f e a s i b i l i t y and administrative f e a s i b i l i t y (Hall et a l . 1975:479-83). At the present time l i t t l e i s known about the f e a s i b i l i t y of including nurse-midwives in the Canadian health care system. However, the Low-Risk Clinic's report (Carty et a l . 1984) and the present study i n d i c a t e that nurse-midwives have an adequate the o r e t i c a l and technical knowledge base and function w e l l i n a hospital based setting. Other factors, outside of the parameters of t h i s study a l s o c o n t r i b u t e t o the f e a s i b i l i t y of t h i s issue. F i r s t , Canadian nursing a s s o c i a t i o n s have c o l l a b o r a t e d w i t h nurse-midwives i n d e f i n i n g standards of practice and they have offered to monitor and register nurse-midwives u n t i l an independent o r g a n i z a t i o n i s e s t a b l i s h e d (eg. Task Committee Report 1979). Secondly, a p o t e n t i a l source of manpower i s an unknown number of Canadian nurses who have been trained and are accredited i n midwifery i n other countries. Thirdly, to meet future manpower tr a i n i n g needs some nursing schools have developed a p o t e n t i a l three year nurse-midwifery curriculum (Carty 1985). Fourthly, the development of delivery of care models, which incorporate nurse-midwives i n t o modern Canadian o b s t e t r i c a l care, can be based on the v a r i e d models found i n the United States and Western European c o u n t r i e s (eg. K e i r s e 1982; Lindheim 1981; Parboosingh and Kerr 1982; Powis 1981; R i s i n g and L i n d e l l 182; Robinson, Golden and Bradley 1982). Moreover, the Federal Task Force on High Risk Pregnancies (1984) suggested expanded r o l e s f o r s e v e r a l groups of practitioners in o b s t e t r i c a l care. However, further studies are necessary at t h i s time to explore the many f e a s i b i l i t y questions that have not been addressed. In p a r t i c u l a r there i s a need to assess the f i n a n c i a l /96 feasibility of a nurse-midwifery component in various models of obstetrical care delivery. Other aspects of the evaluation should include consumer satisfaction and integration within the system, as well as, the nurse-midwife's integration into the system. The present research evaluating the Low-Risk Clinic encourages further exploration into the f e a s i b i l i t y of including nurse-midwives in Canadian obstetrical care. Support is the third criteria which influences social policy issues as identified by Hall et al. As noted earlier, many health consumers, nursing organizations and individual physicians support the development of nurse-midwifery in Canada. However, medical organizations and provincial governments have so far opposed this innovation. Hall et al. state that "when issues are advanced from positions of weakness the deployment of factual evidence w i l l be important in affecting their progress..." (1975:506), and "the actual magnitude of issues indicated by the fact is also likely to affect their impact" (1975:505). The results of this study may have two effects on reducing the opposition to nurse-midwifery. First, since nurse-midwives were found to be effective providers of prenatal care, governments may reconsider nurse-midwives as "substitute" care givers for physicians, rather than "add-on" care givers. Substitute care givers implies that they would decrease or maintain health care expenditures. This finding, coupled with increasing consumer demand, may encourage governments to explore, more realistically, the nurse-midwife alternative. The second result, which found "inadequate" prenatal care among the majority of general practitioner patients in the /97 study, undermines a common physician argument that inclusion of other non-physician personnel in primary care w i l l reduce the quality of care. For example, in a recent policy paper addressing midwifery, the B.C. College of Physicians and Surgeons state that inclusion of a midwife as an independent practitioner in the Canadian health care system would increase home births as well as maternal/infant morbidity and mortality rates. They also note that this change would alter the health care structure in a counter productive manner and that "It would be an unjustified and regressive measure to authorize any group with different training and background to practice obstetrical and newborn care". ("Position on Midwifery" 1984:6). Interestingly, the position paper only implies that nurse-midwives would provide lower quality obstetrical care, i t is never explicitly stated. In contrast to this position, the present study indicates that a different health professional (i.e. the nurse-midwife) would improve obstetrical care. This finding may cl a r i f y the issue and alter some opponent's positions, thus increasing support for exploration of a nurse-midwifery model in Canada. In summary, this study's results present new information which influences the criteria of legitimacy, feasibility and support of the issue of nurse-midwifery. First, i t s legitimacy has been increased with the identification of "inadequate" prenatal care scores among the general practitioner patients in the study. Secondly, its f e a s i b i l i t y has been supported by the finding that nurse-midwives have adequate theoretical and technical knowledge as indicated by their "superior" prenatal care scores. And thirdly, increased support for nurse-midwives w i l l develop among /98 various constituences from the presentation of this data. If the issue moves from the realm of a potential innovation to the realm of an actual innovation in health care delivery, this study w i l l provide background information which health care planners can utilize in the data gathering phrase of the planning process (Taylor 1972:22). 7.3- Conclusion In conclusion, this study found nurse-midwives to be safe effective primary practitioners in a hospital based setting with low risk patients. A comparison to another group of practitioners with established criteria found that nurse-midwives provided "superior" prenatal care and that general practitioners provided "inadequate" prenatal care. Both groups tended to meet the in i t i a l prenatal criteria, but the general practitioners frequently omitted ongoing recordings such as blood pressure and urine tests, and they recorded an inadequate number of vis i t s . These findings suggest that the inclusion of the nurse-midwife on the modern obstetrical team would improve the qualty of maternal/infant care in Canada. Their inclusion would also provide an opportunity to more ful l y evaluate the effectiveness of this innovative health care professional. Information gathered in this study has contributed to the legitimacy, feasibility and support of the legalization of nurse-midwifery and at the same time, has demonstrated an economical and feasible methodology for examining quality of care in primary practice. /99 BIBLIOGRAPHY Antenatal Care. (1983). Acta Obstetrica and Gynecologia Scandinavia, 117, 6-10, 32-39. Bachman, J.W. (1983). Prenatal Care of the Normal Pregnant Woman. Primary Care, 10(2), 145-160. Benard, A. and van Elteren, P. (1953). A Generalization of the Method of m Rankings. Indagationes Math., 15, 358-369. Brook, R.H. and Appel, F.A. (1973). Quality of Care Assessment: Choosing a Method for Peer Review. New England Journal of Medicine, 288 (25), 1323 - 1329. Burnett, J.E. (1972). A Physician-Sponsored Community Nurse-Midwife Program. Obstetrics and Gynecology, 40 (5), 719-723. Caplan, R.M. (1982). Antenatal Care. In R.M. Caplan (Ed.), Principles  of Obstetrics (pp. 104-105). Baltimore: Williams & Wilkins. Carty, E. (1985). Personal communication. Carty, E., Effer, S., Farquharson, D., King, J., Rice, A., Tier, D., Weatherston, L., and Wittman, B. (1984). The Low Risk Clinic:  Family Care Based on the Midwifery Model, 1981-1984. Vancouver: Shaughnessy Hospital Education Services. Carty, E., Gordon, I., and Rice, A. (1981). An Alternative Birth Centre Proposal. Canadian Nurse, December, 34-35, 37. Casson, R.I. and Sennett, E.S. (1984). Prenatal Risk Assessment and Obstetric Care in a Small Rural Hospital: Comparison with Guidelines. Canadian Medical Association, 130, 1311-1315. Chalmers, I. and Enkin M. (1982). Miscellaneous Interventions in Pregnancy: RH Immunization; Preparation for Breast Feeding; External Cephalic Version. In M. Enkin & I. Chalmers (Eds.), Effectiveness and  Satisfaction in Antenatal Care, (pp. 209-221). Philadelphia:Lippincott, Danforth, D.N. (1982). Obstetrics and Gynecology (4th ed.). New York: Harper & Row. Diers, D. (1980). Nurse-Midwifery as a System of Care: Provider Process and Patient Outcome. In L.H. Aiken (Ed.), Health Policy and Nursing  Practice, (pp. 73-89). New York: McGraw-Hill. Diers, D. (1982). Future of Nurse-Midwives in American Health Care. In L.H. Aiken (Ed.), Nursing in the 1980's: Crises, Opportunities,  Challenges, (pp. 267-294). Philadelphia:Lippincott. /100 BIBLIOGRAPHY (Continued) Diers, D. and Burst, H. (1983). Effectiveness of Policy Related Research: Nurse-Midwifery as Case Study. Image, 15 (3), 68-74. Dillon, T.F., Brennan, B.A., Dwyer, J.F., Risk, A., Sear, A,. Dawson, L. and Wiele, R.V. (1978). Midwifery, 1977. American Journal of Obstetrics  and Gynecology, 130 (8), 917-926. Donabedian, A. (1967). Evaluating the Quality of Medical Care. In D. Mainland (Ed.), Health Services Research (pp. 166-205). New York: Milbank Memorial Fund. Enkin, M. and Chalmers, I. (Eds.) (1982a). Effectiveness and Satisfaction  in Antenatal Care. Philadelphia:Lippiincott. Enkin, M. and Chalmers, I. (1982b). Effectiveness and Satisfaction in Antenatal Care. In M. Enkin and I. Chalmers (Ed.), Effectiveness and  Satisfaction in Antenatal Care (pp. 266-290). Philadelphia:Lippincott. Enkin, M. and Chalmers, I. (1982c). Symptomatic Treatment in Pregnancy: Antiemetics, Antacids, Laxatives, Calcium Supplements. In M. Enkin & I. Chalmers (Eds.), Effectiveness and Satisfaction in Antenatal Care (pp. 122-13D. Philadelphia:LippincbTt. Federal Task Force Report. (1984). High Risk Pregnancies and Prenatal  Record Systems. Health and Welfare, Canada. Ford, P.A., Seacat, M.A. & Silver, G.A. (1966). The Relative Roles of the Public Health Nurse and the Physician in Prenatal and Infant Supervision. American Journal of Public Health, 56 (7) 1097-2003. Gatewood, T.S. and Stewart, R.B. (1975). Obstetricians and Nurse-Midwives: The Team Approach in Private Practice. American Journal of  Obstetrics and Gynecology, 123 (1), 35-40. Gillespie, S. (1981). Childbirth in the 1980's: What Are the Options? Issues in Health Care of Women, 3, 101-128. Globe and Mail. (1985, July 19). Page 1, Column 4. Gortmaker, S.L. (1979). The Effects of Prenatal Care Upon the Health of The Newborn. American Journal of Public Health, 69, (7), 653-660. Grant, A. & Mohide P. (1982). Screening and Diagnostic Tests in Antenatal Care. In M. Enkin & I. Chalmers (Eds.), Effectiveness and Satisfaction in  Antenatal Care (pp. 22-59). Philadelphia:Lippincott. Greenberg, R.S. (1983). The Impact of Prenatal Care in Different Social Groups. American Journal of Obstetrics and Gynecology, 145 (7), 797-801. Guidelines for Perinatal Care. (1983). Evanston, 111. :American Academy of Pediatrics. /101 BIBLIOGRAPHY (Continued) Guidelines for Prenatal Care in Canada (1984). Society of Obstetrics and Gynecologists of Canada. Haire, D. (1981). Improving the Outcome of Pregnancy Through Increased Utilization of Midwives. Journal of Nurse-Midwifery, 26 (1), 5-8. Hall, M.H. & Chng, P.K. (1982). Antenatal Care in Practice. In M. Enkins & I. Chalmers (Eds.), Effectiveness and Satisfaction in Antenatal  Care (pp. 60-68). PhiladelpiarLippincott. Hall, M.J., Chng, P.K. & MacGillivray, I. (1980). Is Routine Antenatal Care Worth While? The Lancet, July 12, 78-80. Hall, P., Land, H., Parker, R,. and Webb, A. (1975). Change, Choice  and Conflict in Social Policy. London:Atheneum. Harris, J.E. (1982). Prenatal Medical Care and Infant Mortality. In V.R. Fuchs (Ed.), Economic Aspects of Health, (pp. 15-52). Chicago:University of Chicago Press. Hendrickson, B. (1985, July 14). Midwives on Trial in Death, The  Province, 16. Hulka, B.S., Kupper, L.L. & Cassel, J.C. (1976). Physician Management Primary Care. American Journal of Public Health, 66 (12), 1173-1179. Hurlburt, J. (1981). Midwifery in Canada: A Capsule History. Canadian  Nurse, February, 30-31. Keirse, M.J. (1982). Interaction Between Primary and Secondary Antenatal Care, With Particular Reference to the Netherlands. In M. Enkin and I. Chalmers (Eds.) Effectiveness and Satisfaction in Antenatal Care (pp. 222-233). Philadelphia:Lippincott. Kessner, D.M., Kalk, C.E., and Singer, J. (1973). Assessing Health Quality - The Case For Tracers. New England Journal of Medicine, 288 (4), 189-194. Korn, G. (1980). Board's midwifery policy out of line with proposals. B.C. Medical Journal, 22 (8), 359-360. Kotelchuck, M., Schwartz, J.B., Anderka, M.T. and Finison K.S. (1984). WIC Participation and Pregnancy Outcomes: Massachusetts Statewide Evaluation Project. American Journal of Public Health, 74 (10), 1086-1149. Laudis, J.R. and Koch, G.G. (1977). The measurement of observer agreement for categorical data. Biometrics, 33, 159-174. Levy, B.S., Wilkinson, F.S. & Marine, W.M. (1971). Reducing Neonatal Mortality Rate with Nurse-Midwives. American Journal of Obstetrics  and Gynecology, 109 (50). / 1 0 2 BIBLIOGRAPHY (Cont inued) L indhe im, R. (1981) . B i r t h i n g Centers and H o s p i c e s : ' R e c l a i m i n g B i r t h and Death. Annual Reviews o f P u b l i c H e a l t h , 2 , 1-29. Lumley, J . & As tbu ry , J . (1982). Adv ice i n Pregnancy: P e r f e c t Remedies, Imper fect S c i e n c e . In M. Enk in and I. Chalmers ( E d s . ) , E f f e c t i v e n e s s  and S a t i s f a c t i o n i n An tena ta l Care (pp. 132-150). P h i l a d e l p h i a : L i p p i n c o t t . M a n t e l , N. (1963) . Ch i -square Tes ts w i th One Degree o f Freedom: Ex tens ions o f the Mante l -Haensze l Procedure . J o u r n a l o f the American S t a t i s t i c a l  A s s o c i a t i o n , 58, 690-700. M idw i fe ry Fac t Shee t . (1981). Vancouver :Midwi fery Task F o r c e . M i e t t i n e n , 0 . (1968) . The Matched P a i r s Design i n the Case of A l l - o r -None Responses. B i o m e t r i c s , 24 (2 ) , 339-355. M i e t t i n e n , 0 . (1969) . I n d i v i d u a l matching w i t h m u l t i p l e c o n t r o l s i n the case o f a l l - o r - n o n e responses . B i o m e t r i c s , 25, 339-354. NAPS document #02421. ASIS/NAPS M i c r o f i c h e P u b l i c a t i o n s : New York . Neeson, J . D . , P a t t e r s o n , K . A . , Mercer , R.T. & May, K . A . (1983). Pregnancy Outcome For Ado lescen ts Rece iv ing P r e n a t a l Care by Nurse P r a c t i t i o n e r s i n Extended R o l e s . Jou rna l o f Ado lescen t  Hea l t h Care , _4 ( 2 ) , 94 -99 . N u t t i n g , P .A . B a r r i c k , J . E . , and Logue, S . C . (1979). The Impact o f a Mate rna l and C h i l d Hea l t h Care Program on the Q u a l i t y of P r e n a t a l Care : An A n a l y s i s by R isk Group. J o u r n a l o f Community H e a l t h , 4 (4 ) , 267-279. Oak ley , A. (1982a). The O r i g i n s and Development o f An tena ta l Care . In M. Enk in and I. Chalmers ( E d s . ) , E f f e c t i v e n e s s and S a t i s f a c t i o n  i n An tena ta l Care (pp. 1-21) . P h i l a d e l p h i a : L i p p i n c o t t . Oak ley , A. (1982b). The Relevance of the H i s t o r y o f Med ic ine to an Understanding o f Cur renty Change: Some Comments from the Domain o f An tena ta l Ca re . S o c i a l Sc ience and Med ic ine , 16, 667-674. Parboos ingh , J . and K e r r , M. (1982). Innovat ions i n the Role o f O b s t e t r i c H o s p i t a l s i n P r e n a t a l Care . In M. Enk in and I. Chalmers ( E d s . ) , E f f e c t i v e n e s s and S a t i s f a c t i o n i n An tena ta l Ca re , (pp. 254-265) . P h i l d e l p h i a : L i p p i n c o t t . Peop les , M.D. & S i e g e l , E. (1983) . Measuring the Impact o f Programs fo r Mothers and I n f a n t s on P r e n a t a l Care and Low B i r t h Weight : The Value o f Ref ined A n a l y s e s . Med ica l Ca re , 21_ (6 ) , 586-605. P e o p l e s , M .D . , Gr imson, R .C . & Daughtry, G . L . (1984) . E v a l u a t i o n o f the E f f e c t s o f the Nor th C a r o l i n a Improved Pregnancy Outcome P r o j e c t : I m p l i c a t i o n s f o r S t a t e - L e v e l D e c i s i o n Making. American J o u r n a l o f P u b l i c H e a l t h , 74 ( 6 ) , 549-554. /103 BIBLIOGRAPHY (Continued) Pike, M.C. and Morrow, R.H. (1970). Statistical Analysis of Patient-Control Studies in Epidemiology. British Journal of Preventative  Society of Medicine, 24, 42-44. Position on Midwifery. College of Physicians and Surgeons of B.C. (1984). College Bulletin, J_ (1), 1-6. Powis, J. (1981). The Quiet Revolution. Canadian Nurse, February, 26-29. Record, J.C. & Greenlick, M.R. (1975). New Health Professionals and the Physician Role: An Hypothesis from Kaiser Experience. Public Health  Reports, 90 (3), 241-246. Redman, C. (1982a). Management of Pre-eclampsia. In M. Enkin & I. Chalmers (Eds.), Effectiveness and Satisfaction in Antenatal Care (pp. 182-197). Philadelphia:Lippincott. Redman, C. (1982b). Screening for Pre-eclampsia. In M. Enkin & I. Chalmers (Eds.), Effectiveness and Satisfaction in Antenatal Care (pp. 69-80). Phildelphia:Lippincott. Reid, M.L. & Morris, J.B. (1979). Perinatal Care and Cost Effectiveness. Medical Care, V7_ (5), 491-500. Rising, S. and Lindell, S. (1982). The Childbearing Childrearing Centre. Nursing Clinics of North America, 17 (1), 11-21. Robinson, S., Golden J. and Bradley S. (1982). The Role of the Midwife in the Provision of Antenatal Care. In M. Enkin and I. Chalmers (Eds.) Effectiveness and Satisfaction in Antenatal Care, (pp. 234-246). Philadelphia:Lippincott. Romm, F.J. and Putman, S.M. (1981). The Validity of the Medical Record. Medical Care, _19 (3), 310-315. Ross, M.G. (1981). Health Impact of a Nurse-Midwife Program. Nursing Research, 30 (6), 353-355. Runnerstrom, L. (1969). The Effectiveness of Nurse-Midwifery in a Supervised Hospital Environment. Journal of the American College of Nurse-Midwives, 14, 40-52. Ryan, G.M., Sweeney, P.J. & Solola, A.S. (1980). Prenatal Care and Pregnancy Outcome. American Journal of Obstetrics and Gynecology, 137 (8), 876-881. Sackett, D., Spitzer, W., Gent, M., and Roberts, R. (1974). The Burlington Randomized Trial of the Nurse Practitioner: Health Outcomes of Patients. Annals of Internal Medicine, 80 (2), 137-142. /104 BIBLIOGRAPHY (Continued) Sackett, D.L. (1979). Bias in Analytic Research. Journal of  Chronic Diseases 32, 51-63. Sanazaro, P.J. (1980). Quality Assessment and Quality Assurance in Medical Care. Annual Reviews of.Public Health, J_, 37-68. Schlesselman, J.J. (1982). Case Control Studies. New York: Oxford University Press. Sheps, M.C. (1953). Approaches to the Quality of Hospital Care. Public Health Reports, 70, 877-886. Sheps, S. & Robertson, A. (1984). Evaluation of Primary Care in a Community Clinic by Means of Explicit Process Criteria. Canadian Medical Association Journal, 131, 881-886. Sibley, J.C, Spitzer, W.O., Rudnick, K.V., Bell, J.D., Bethune, R.D., Sackett, D.L. and Wright, K. (1975). Quality of Care Appraisal in Primary Care: A Quantitative Method. Annals of Internal Medicine, 83, 46-52. Slome, C, Wetherbee, H., Daly, M., Christensen, K., Meglen, M., and Thiede, H. (1976). Effectiveness of Certified Nurse-Midwives. American Journal of Obstetrics and Gynecology, 124 (2), 177-182. Standards for Obstetric-Gynecologic Services (5th ed.). (1982). Washington, D.C: The American College of Obstetricians and Gynecologists. Statistics Canada. (1983). Census Tracts, Selected Social and Economic  Characteristics, Vancouver, 1981. Ottawa: Minister of Supply and Services. Task Committee Report. (1979). The Future of Nurse Midwifery in British  Columbia. Vancouver:Registered Nurses Association of B.C. Taylor, C. (1972). Stages in the Planning Process. In W. Reinke (Ed.), Health Planning, 20-33. Baltimore:Waverly Press. Thiede, H.A. (1971). A Presumptuous Experiment in Rural Maternal and Child Health Care. American Journal of Obstetrics and Gynecology, H i (5), 736-742. Ury, H.K. .09.75). Efficiency of Case-Control Studies with Multiple Controls per Case: Continuous or Dichotomous Data. Biometrics, 31,643-649. Yankauer, A. and Sullivan, J. (1982). The New Health Professionals: Three Examples. Annual Reviews of Public Health, 3, 249-276. Weatherston, L., Carty, E., Rice, A., and Tier, D. (1985). Hospital-Based Midwifery: Meeting the Needs of Childbearing Women. Canadian  Nurse, January, 35-37. APPENDIX A Low Risk C r i t e r i a /105 Source; Carty, E., Effer, S., Farquharson, D., King, J. , Rice, A., Tier, D., Weatherston, L., and Wittmann, B. (1984). The Low-Risk C l i n i c ; Family Care Based on the Midwifery  Model, 1981-1984. Vancouver:Shaughnessy Hospital Education Services. POLICIES FOR MIDWIFE MANAGEMENT OF CLIENT CARE I. S e l e c t i o n of C l i e n t s The midwives may take r e s p o n s i b i l i t y for s p e c i f i c delegated aspects of o b s t e t r i c a l care of the following women: A. Those whose past medical, s u r g i c a l and o b s t e t r i c a l h i s t o r y reveals no c o n d i t i o n which would adversely influence the course of the pregnancy or be unfavourably affected by i t , thus requiring s p e c i a l medical management. B. Those who present no i n d i c a t i o n of pathology. C. Those who are o b s t e t r i c a l l y and medically normal with the p o t e n t i a l for continued normal progress without s p e c i a l medical management. Conditions which exclude women from the program: A . Diabetes B. Cardiac disease C. Epilepsy D. Tuberculosis or other pulmonary complication E. Severe anemia F. Blood dyscrasias G. E s s e n t i a l hypertension H. Previous p e r i n a t a l death I . Previous caesarean J . Grand multipara 4 K. E l d e r l y primipara 40 years L. Obesity 200 l b s M. Poor o b s t e t r i c a l h i s t o r y /106 Conditions which require immediate o b s t e t r i c a l c onsultation during the antepartum period include: A. Hyperemesis gravidarum B. M u l t i p l e pregnancy C. Vaginal bleeding D. Sens i t i z e d Rh-negative women E. Polyhydramnios F. Preterm labour G. Pregnancy-induced hypertension H. Intra-uterine growth retardation I. Temperature el e v a t i o n over 38°C J . Malpresentation or malposition a f t e r 36 weeks' gestation K. Premature rupture of membranes L. Suspected g e s t a t i o n a l diabetes M. F e t a l cardiac arrhythmias N. Cholestasis 0. Decreased f e t a l movements P. Postdatisrn Q. Primigravida with unengaged head at term The midwives may continue to give nursing support to women who develop complications during the course of pregnancy, i f appropriate, even though they are no longer under t h e i r d i r e c t care. APPENDIX B.l Burlington Prenatal C r i t e r i a Source: NAPS document #02421, Order from ASIS/NAPS /107 I N P 1 C A T 0 R C 0 : i 0 1 T 1 0 » l « 3 - P R E N A T A L C A R E I f f P H T S I C I A H ' 5 O F F I C E DEFINITION or AN EPISODE - PRT?IATAL CAW; Assessment of prenatal care will be of a period not less than fiv* months of the gestation period, provided the five-month episode falls within particular definite dates that identify the Interval of interest in the study. A patient that was seen f o u r months prior to beginning date of study could be Included, a n d the last five months of the pregnancy a s s e s s e d . A patient w h o s e date of gestation fell four months past closing d a t e of t h e s t u d y , could be a s s e s s e d for the first five months.. The period under s t u d y in the Burlington practices will bo June 28. 1971 to J u n e 30, 1972. CATEGORIES OP INTCRVEN'TICN • 1. Pelvic assessment - if no previous successful delivery 2. Past obstetrical history 3. Conplctc physical assessment - within two year period 4. A t least one h a e m o g l o b i n during prenatal period 5. Urinalysis on each visit 6. Frequency of subsequent visits M o n t h l y or f o u r w e e k l y - 1st to 7th month t w o w e e k l y - 8th m o n t h w e e k l y - 9th m o n t h to term 7. Must be record o f weight 8. Must be record o f . b l o o d pressure 9. Must be record of R h a n d S.T.S. 10. M u s t b e s t a t e m e n t o f gestation 11. Evidence o f a psycho-social interview (expressed fear ox anxiety) 12. A m e e t i n g of t . i e husband and w i f e together during the pregnancy 13. Pap srear 14. A t w o - h o u r P.C. sugar if there is a strong family history OR If there is glucosuria found, OR If there is a history of large babies. S C O R I N G A D E Q U A T E 1. Pelvic assessment - if no previous successful delivery 2. Past obstetrical history 3. Complete physical assessment - within two year period 4. At least one haemoglobin during prenatal period 5. Urinalysis on each visit 6. Frequency of subsequent visits Monthly or four weekly - 1st to 7th month two weekly - 8th month weekly - 9th month to tern /108 " 7. Must be record of weight fe. Must b« record of blood pressure 9. Must bo record of Rh and S.T.S. 1 0 . Must bo statestont of gestation INADEQUATE Absence of any one of the above SUPERIOR Adoquate - PLUS CAE 0T THE rOLLOWIHGi 1 1 . Evidence of a psycho-social interview (expressed fear or anxiety) 1 2 . A aweting of tho husband and wife together during the pregnancy 13. Pap smear 14 . A two hour P.C. sugar if there is a strong fanlly history INTERMEDIATE STATE SCO RING ADEQUATE for the following specific conditions, the stated intervention ttnnt have been carried out in addition to the appropriate Inter-ventions itemized above (1 - 10) INADEQUATE Absence of any one of the above OR If there is glucosurla found. OR If there is a history of large babies. 6 U P E M O R Adequate aa defined - PLUS ONE QT THE POLOWINGi 11. 12. 13. 14, listed above. CONDITION nflTEVEMTIOH Albuminuria 1. Must have further urinary investigation or an adequate explanation. Hypertension - a diastolic over 90 or 15 s c i . over the previous baseline. 2 . A statement of concurrent urinary findings. Zxcovqive weight gain (ovei 5 lbs. per 4 weeks) 3. Patient cautioned and/or dietary /109 CONDITION Hypertension and weight gain 4.1. Hypertension and albuminuria 4 . 2 . Hypertension plus albuminuria 4.3. plus weight gain Weight gain plus albuminuria 4 . 4 . Glucosuria 4.S. Discharge and/or pruritic - S. persistent or distressing Pyuria 6. Diagnosis of diabetes, either 7. previously established or currently established Possible German Measles contacts. Established German Measles contact 9. Last trimester bleeding 10. First trimester bleeding -not in the scope of this evaluation Premature rupture of membranes 11 Inadequacy of pelvis in 1 2 . primipara Rising Rh Titre or 13. anticipated Rh problem I N A D E Q U A T E The appropriate intervention for not carried out. nnrnvomow Meat He-visit within 72 hours Salt restriction and/or diuretics Sedation (Phcnobarb) - optional Either a blood sugar recorded or an adequate explanation for the glucosuria Culture and smear of the discharge Urine, culture and sensitivity Consultation during pregnancy K« Ha I • Ae Consultation Admission to hospital and consultation Hospitalisation immediately Zn labour within 12 hours, or Consultation Subsequent notation re dis-proportion Subsequent laboratory follow-up, or Consultation the apeclfio condition was A P P E N D I X B.2 I UPDATED BURLINGTON PRENATAL CRITERIA (UBPC) A. ADEQUATE 1. Pe lv ic Assessment, i f no previously successful del ivery 2. Past obste t r ical history. 3. Complete physical assessment within 2 year period. 4. A t lease one hemoglobin during the prenatal period. 5. Urinalysis on each v is i t . 6. Frequency of subsequent vis i ts : monthly to four week intervals from 6 weeks to 32 weeks two week intervals from 32 weeks to 36 weeks weekly intervals from 36 weeks to term 7. Must be a record of weight. 8. Must be a record of B . P . 9. Must be a record of Rh and A . R . T . 10. Must be a statement of gestation. B. INADEQUATE Absence of any categories above, 1-10. C . SUPERIOR Adequate score plus one of the fol lowing: 11. Evidence of a psychosocial in terview. 12. A meeting of the husband & wife together, during the pregnancy. 13. Pap Smear. 14. A two hour p.c. sugar i f there is a strong family history, i f there is glucosuria found, or i f there is a history of large babies. INTEKMEOI&TE CONDITIONS (Condition & Intervention) Albuminuria - > + 1 (30 mg.) over a period of two tests further urinary investigation or an adequate explanation Hypertension - a diastolic over 90 or, 15mm, over previous baseline statement of concurrent urinary findings Excessive Weight Gain (over 2.3 kg or 5 lbs. in 4 weeks) > 2.3 k/4 wk. (5 lbs.) but < 3.6/8 wk. (8 lbs.) cautioned (patient and/or dietary enforcement and/or more frequent visits > 2.3 k/4 wk. but not over 3 wk. cautioned (patient cautioned and/or dietary enforcement and/or more frequent visits) > 7.2 k/8 wk. cautioned (patient cautioned and/or dietary enforcement and/or more frequent visits) Hypertension and weight gain - comment to rest Hypertension and Albuminuria - re-visit within 72 hours Hypertension plus Albuminuria plus weight gain - salt restriction or other intervention Weight gain plus Albuminuria - rest /112 Glucosuria - blood sugar recorded or adequate explanation for glucosuria Discharge and/or p r u r i t i s — persistent and di s t r e s s i n g - culture and smear of discharge Pyuria - urine culture and s e n s i t i v i t y Diagnosis of Diabetes, either previously established or currently established - consultation during pregnancy Possible Rubella Contact - R.H.I.A. Test Established Rubella Contact - consultation Last Trimester bleeding - admission to hospital and consultation F i r s t Trimester bleeding - not in the scope of t h i s study Premature Rupture of Membranes - present - h o s p i t a l i z a t i o n immediately and in labour within 12 hours Rising Rh t i t r e or anticipated Rh problem - subsequent laboratory follow-up - consultation - Rho Gam given APPENDIX B.3 /113 ADAPTED BURLINGTON PRENATAL CRITERIA (ABPC) A. ADEQUATE Same as above except omit No. 1, pelvic assessment and add; 15. Evidence of a dietary interview. 16. Must be a record of fundal height measurements in centimeters after 20 weeks. B. INADEQUATE Same as UBPC. C. SUPERIOR Same as UBPC. A P P E N D I X C Q u e s t i o n n a i r e /114 THE UNIVERSITY OF BRITISH COLUMBIA Faculty of Medicine Department of Health Care and Epidemiology Mather Building 5 8 0 4 Fairview Avenue Vancouver, B.C. V6T 1W5 ( 6 0 4 ) 2 2 8 - 2 7 7 2 REVIEW OF BURLINGTON C R I T E R I A P. Lynn Buhler, B.S.N. June, 1984 I am a graduate student i n the He a l t h S e r v i c e s P l a n n i n g program i n the Department o f H e a l t h Care and Epidemiology i n the F a c u l t y of Medicine at U.B.C.. In my t h e s i s I am e v a l u a t i n g p r e n a t a l care. A standard r e f e r r e d to as the " B u r l i n g t o n C r i t e r i a " was developed t en years ago to measure the q u a l i t y of p r e n a t a l care i n gene r a l p r a c t i c e . The c a t e g o r i e s o f i n t e r v e n t i o n are b r i e f and g e n e r a l , as they were used f o r measuring q u a l i t y of care by rev i e w i n g p a t i e n t ' s c h a r t s . The B u r l i n g t o n group decided t h a t adequate care was pro v i d e d when the p a t i e n t ' s c h a r t i n c l u d e d i n f o r -mation r e g a r d i n g i n t e r v e n t i o n s one through ten; s u p e r i o r care was p r o v i d e d when the chart a l s o i n c l u d e d e i t h e r i n t e r v e n t i o n 11,12.13 or 14; and inadequate care o c c u r r e d when one of the f i r s t ten i n t e r v e n t i o n s was omitted. I would l i k e you to b r i e f l y review these c r i t e r i a and to comment on t h e i r a p p r o p r i a t e n e s s i n gene r a l p r a c t i c e i n 1984. Your a s s i s t a n c e w i l l be most h e l p f u l . C a t e g o r i e s of I n t e r v e n t i o n P r e n a t a l Care i n a Family P r a c t i c e O f f i c e The f o l l o w i n g are the c a t e g o r i e s of care t h a t the B u r l i n g t o n group found r e l e v a n t to g e n e r a l p r a c t i c e p r e n a t a l care. Is t h i s i n t e r v e n t i o n a p p l i c a b l e to your p r a c t i c e ? Would you d e f i n e t h i s i n t e r v e n t i o n d i f f e r e n t l y ? I f yes, how would you d e s c r i b e t h i s i n t e r v e n t i o n ? 1. PELVIC ASSESSMENT - i f no p r e v i o u s s u c c e s s f u l d e l i v e r y Is t h i s Intervention applicable to your practice? Yes Would you define thla intervention d i f f e r e n t l y ? Yea I f yes, how would you define t h i s Intervention? Coiments: PAST OBSTETRICAL HISTORY / 1 1 S Is t h i s intervention applicable to your practice? Yes No | Comment3; Would you define/ this Intervention d i f f e r e n t l y ? Yes No If yes, how would you define this intervention? COMPLETE PHYSICAL ASSESSMENT - w i t h i n two year p e r i o d Is t h i s Intervention applicable to your practice? Yes No Comments: Would you define this Intervention d i f f e r e n t l y ? Yes No If yee, how would you" define -hie Intervention? — — — — AT LEAST ONE HAEMOGLOBIN DURING PRENATAL PERIOD Is t h i s Intervention applicable to your practice? Yea No ____ Comments: Would you define this intervention d i f f e r e n t l y ? Yes No If yes, how would you define this intervention? URINALYSIS ON EACH VISIT Is t h i s i n t e r v e n t i o n applicable to your practice? Yes No Would you define t h i s intervention d i f f e r e n t l y ? Yes No If yes, how would you define this Intervention? MUST BE RECORD OF WEIGHT ON EACH VISIT Is t h i s i n t e r v e n t i o n applicable to your practice? Yea No Would you define t h i s intervention d i f f e r e n t l y ? Yes No If yes, hov would you define this intervention? FREQUENCY OF SUBSEQUENT VISITS - monthly o r f o u r weekly - 1st to 7 t h month two weekly - 8 t h month weekly - 9t h month to term Is t h i s Intervention applicable to your practice? Yes Would you define t h i s intervention d i f f e r e n t l y ? Yes If yes, how would you define this intervention? No Comments: No 8 . MUST BE A RECORD OF BLOOD PRESSURE ON EACH VISIT / 1 1 6 Is this intervention applicable to your practice? Yes NO Consents: Would you define this intervention d i f f e r e n t l y ! • Yes No If yes, how would you define this intervention? MUST BE RECORD OF Rh AND S.T.S. Is this Intervention applicable to your practice? Yes NO "ould you define this intervention diff e r e n t l y ? Yes No If yes, how would you define this intervention? 10. MUST BE A STATEMENT OF GESTATION Is this intervention applicable to your practice? Yes NO Contents: Would you define this intervention differently? Yes No I f yes, how would you define this Intervention? 11. EVIDENCE OF A PSYCHO-SOCIAL INTERVIEW (expressed f e a r or anxiety) Is this intervention applicable to your practice? Yes NO Comments: Would you define this intervention differently? Yes No If yes, how would you define this Intervention? 12. A MEETING OF THE HUSBAND AND WIFE TOGETHER DURING THE PREGNANCY Is this intervention applicable to your practice? Yes NO Consents: Would you define this intervention differently? Yes No I f yes, how would you define this Intervention? 13. PAP SMEAR Is t h i s intervention applicable to your practice? Yes No Comments^ Would you define this intervention diff e r e n t l y ? Yea No If yes, how would you define this intervention? / 1 1 7 14. A TWO-HOUR P.C. SUGAR IF THERE IS A STRONG FAMILY HISTORY OR IF THERE IS GLUCOSURIA FOUND OR IF THERE IS A HISTORY OF LARGE BABIES Is t h i s intervention applicable to your practice! Yea No Conoaenta:_ Would you define this intervention differently? "Yea No If yea, how would you define thia intervention? In my ch a r t e v a l u a t i o n I i n t e n d to a b s t r a c t the i n f o r m a t i o n about the i n t e r v e n t i o n s from the p r o v i n c i a l p r e n a t a l record form contained i n the h o s p i t a l records. The r e -cord w i l l be scored as e i t h e r ADEQUATE, INADEQUATE, or SUPERIOR according to the arrangement of the f o l l o w i n g c a t e g o r i e s ( an adequate chart must i n c l u d e a l l of the items 1-10) : 1. P e l v i c a s s e s s m e n t - i f no p r e v i o u s s u c c e s s -f u l d e l i v e r y 2. P a s t o b s t e t r i c a l h i s t o r y 3. C o m p l e t e p h y s i c a l a s s e s s m e n t - w i t h i n a two y e a r p e r i o d 4. At l e a s t one h a e m o g l o b i n d u r i n g p r e n a t a l p e r i o d 5. U r i n a l y s i s on e a c h v i s i t 6. F r e q u a n c y o f s u b s e q u e n t v i s i t s m o n t h l y to 4 w e e k l y - 1 s t to 7 t h mo. 2 w e e k l y - 8 t h mo. w e e k l y - 9 t h mo. t o t e r m 7. Must be r e c o r d o f w e i g h t 8. Must be r e c o r d o f b l o o d p r e s s u r e 9. Must be r e c o r d o f Rh and S.T.S. 10. Must be s t a t e m e n t o f g e s t a t i o n Absence o f any o f c a t -e g o r i e s I - 10 A d e q u a t e s c o r e p l u s one o f t h e f o l l o w i n g : 11. E v i d e n c e o f a p s y c h o - s o c i a l i n t e r v i e w ( e x p r e s s e d f e a r o r a n x i e t y ) 12. A m e e t i n g o f the husband and t h e w i f e t o g e t h e r d u r i n g t h e p r e g n a n c y 13. Pap smear 14. A two h o u r P.C. s u g a r i f t h e r e i s a s t r o n g f a m i l y h i s t o r y o_r i f t h e r e i s g l u c o s u r i a found or_ i f t h e r e i s a h i s t o r y o f l a r g e b a b i e s DO you t h i n k t h i s arrangement i s ap p r o p r i a t e f o r general- p r a c t i t i o n e r s ? yes no I f no, WHY? WHAT WOULD YOU SUGGEST? /118 Two c a t e g o r i e s t h a t I think, should be added to the l i s t of inte r v e n t i o n } are: 15. EVIDENCE OF DIETARY INTERVIEW l a t h i s intervention applicable to your practice? Yes Would you define this intervention differently? Yes If yes, how would you define this Intervention? No Comments:, No In which category should t h i s i n t e r v e n t i o n be coasidered? ADEQUATE SUPERIOR not a p p l i c a b l e 16. FUNDAL HEIGHT MEASURES Is t h i s intervention applicable to your practice? Yee Would you define this intervention differently? Yes If yea, how woutd you define thla intervention? No Comments: I n which category should t h i s i n t e r v e n t i o n be considered? ADEQUATE SUPERIOR not a p p l i c a b l e Are there any i n t e r v e n t i o n s t h a t you c o u l d add th a t have not been considered? yes IF YES: The B u r l i n g t o n c r i t e r i a s t a t e s that under the f o l l o w i n g c o n d i t i o n s , a s p e c i f i c i n t e r v e n t i o n must take place i n order to maintain an adequate or s u p e r i o r score. Is the c o n d i t i o n and/or i n t e r v e n t i o n s t i l l appropriate? I f i t i s ina p p r o p r i a t e , ' /119 please comment a t the end of the l i s t . CONDITION INTERVENTION APPROPRIAT YES NO A. Albuminuria I. Must have f u r t h e r u r i n a r y i n v e s t -i g a t i o n or an adequate e x p l a i n a t i o n . . . . Y N_ B. Hypertension-a-uiastolic over 2. A statement of concurrent u r i n a r y 90 o r , 15 mm.; over the prev- f i n d i n g s Y N_ ious b a s e l i n e . C. Excess i v e weight gain (over 3. P a t i e n t cautioned and/or d i e t a r y 2.3 kg. (51bs.) per 4 weeks) enforcement and/or more frequent Y N_ v i s i t s and/or d i u r e t i c s . DI. Hypertension and weight gain 4.1 Rest Y N_ D2. Hypertension and Albuminuria 4.2 R e - v i s i t w i t h i n 72 hrs Y N_ D3. Hypertension plus Albuminuria 4.3 S a l t r e s t r i c t i o n and/or d i u r e t i c s Y N_ p l u s weight gain. D4. Weight gain p l u s Albuminuria 4.4 Sedation (Phenobarb)- o p t i o n a l Y N_ D5. G l u c o s u r i a 4.5 E i t h e r a blood sugar recorded or an adequate explanation f o r the Y N_ g l u c o s u r i a . E. Discharge and/or p r u r i t i s — 5. C u l t u r e and smear of the discharge Y N_ p e r s i s t e n t and d i s t r e s s i n g F. P y u r i a 6. Urine c u l t u r e and s e n s i t i v i t y Y N_ G. Diagnosis of Diabetes, e i t h e r 7. C o n s u l t a t i o n during pregnancy Y N_ p r e v i o u s l y e s t a b l i s h e d or c u r r e n t l y e s t a b l i s h e d H. P o s s i b l e German Measles c o n t a c t s . R.H.I.A Y N_ I . E s t a b l i s h e d German Measles 9. C o n s u l t a t i o n Y N_ contac t J . Last t r i m e s t e r b l e e d i n g 10.Admission to h o s p i t a l and c o n s u l t -a t i o n Y N_ K. F i r s t t r i m e s t e r b l e e d i n g — not i n the scope of t h i s e v a l u a t i o n L. Premature rupture of membranes 1 1 . H o s p i t a l i z a t i o n immediately, i n la b o r w i t h i n 12 hrs. or consult Y N_ M. Inadequacy of p e l v i s i n prim- 12.Subsequent n o t a t i o n re d i s -i p e r a p r o p o t i o n Y N_ N. R i s i n g Rh t i t r e of a n t i c i - 13.Subsequent l a b o r a t o r y f o l l o w -pated Rh problem up, or c o n s u l t a t i o n Y N_ CONDITION ( l e t t e r s ) +/or INTERVENTION ( numbers ) COMMENTS /120 Can you suggest any c o n d i t i o n s or i n t e r v e n t i o n s that have been omitted? THANK YOU f o r t a k i n g the time to review the " B u r l i n g t o n P r e n a t a l C r i t e r i a " . To give me an idea of who reviewed the c r i t e r i a , could you please i n d i c a t e whether you are a general p r a c t i t i o n e r or an o b s t e t r i c i a n , and approximately, the number of b i r t h s you a t t e n d per month. Thank you. General P r a c t i t i o n e r O b s t e t r i c i a n Other: Approximate Number of B i r t h s Attended per Month: . PRENATAL RECORD PARTI 1. NAME MOTHER'S AGE FATHER'S NAME TELEPHONE NUMBER MARITAL STATUS - APPENDIX -D - - ... B.C. Prenatal Record Form (Permission to use follows) . / 1 2 I OOCTOR'S NAME FATHER'S AGE FATHER'S OCCUPATION M.S.P. NUMBER DOCTOR'S PHONE NUMBER 2. OBSTETRICAL HISTORY INCLUDING ABORTIONS TYPE OF DELIVERY COMPLICATIONS MOTHER AND/OR INFANT 3. RISK ASSESSMENT Reproductive History Q Age - less Ulan 15, greater man 35. Q Parity 5 +• I—| Weignl - less than 45 greaiet tnan I—J 90kg. | < 1 0 0 : > ? O O I D S . ) I j Habitual Abortion Q Stillbinn/Neonatat Dealti [~] Fetal Anomalies I | Labour Premature I | Labour Prolonged I 1 Labour precioitous { < 3 Hours) Q Difficult Delivery Q Post p Hemormage. Manual Removal I | Preeclamcsia/Hypertension Associated Hi Risk Conditions Uterine Surgery or Malformations I—, C-section Cone Biopsy. L i Cervical Suture, eic. I | Chronic Renal Disease • Diabetes f i n d . Gest.j | | Cardiac Disease & Hypertension l — , Serious Mecical. Surgical or I I Psychialric Disorders HISTORY OF PRESENT PREGNANCY (Specify) YES • • ' • • • '  • • 4 . NO 8LEEOING: U (Date) ,—, PYREXIA: U (Date) RADIATION: U (Date) • NAUSEA: r—. SMOKING: I I (Query pattern of usage) r - , ALCOHOL. DRUGS: L_l {Query pattern of usage) • OCCUPATIONAL NUTRITION: (24 nour recall) GOOD • FAIR • POOR • 5. PAST ILLNESS ISoeciiy) NO YES • RENAL • • CARDIAC • • INFECTIONS • • RUBELLA • • VENEREAL • • ALLERGIES • • OPERATIONS Q • TRANSFUSIONS Q • OTHERS • DATE OF DISCONTIN-UANCE 6. FAMILY HISTORY (Specify) NO YES • DIABETES • • CARDIAC • Q HYPERTENSION Q • TUBERCULOSIS • • TWINS • • MALFORMATIONS • • OTHERS • 10. EXAMINATION UAIt GENERAL CONDITION HEART & LUNGS VARICES & SKIN: VELVIS NORMAL. /ABNORMAL (Describe) _ CERVIX CYTOLOGY (Class No.) OTHER OBSERVATIONS: 7. MENSTRUAL HISTORY l . M . P . (Date) IF UNSURE. CONSIDER EARLY ULTRASOUND MENSTRUAL CYCLE 8. METHOD OF CONTRACEPTION 9. CURRENT MEDICATIONS 11. TOPICS FOR DISCUSSION HLTH 1582 Prepared by T H E P E R I N A T A L P R O G R A M O F B R I T I S H C O L U M B I A W H I T E C O P Y - M O T H E R ' S C H A R T AND ADVICE Alternate Physician(s) Bowels • Genetic Counselling Baths Prenatal Course Clothes & Classes Books Nutrition Breast Care - Supplements Breast Feeding Wt. Control Baby Cafe Exercise Labour Stages - Hosp. Adm. Procedures Rest Arrival at Hospital Smoking Anaes. & Analg. Alcohol - Coitus Medications Q.P. 30472/1 V a n c o u v e r . 8.C Y E L L O W C O P Y • I N F A N T ' S C H A R T P I N K C O P Y - P H Y S I C I A N ' S PRENATAL RECORD PART II 1 2 . L A B O R A T O R Y Blood Group Haemc Initial gtobin 36-38 Weeks A.R.T. Test Rubella HI Titre Hepatitis Garner? Rh AntiDody T Dates ire Results Hn h-actor 1 3 . R I S K F A C T O R S T O B E A N T I C I P A T E D ( P A R T 1) NO YES PREGNANCY f~] f~] ._/122 DOCTOR'S NAME R i s k F a c t o r s i n P r e s e n t P r e g n a n c y ? DELIVERY NEWBORN • • • • ,—| Uncertain Dates U (atter 20 weeks) •—| Poor Weight Gam. I I Weight Loss • Bleeding | | Anemia < 10 gm. • Suspected IUGR Q Multiple Pregnancy Q Hydramnios ,—j Malpresentation U (>3* weeks! | | Isoimmunization | | Hypertension •—, Prolonged Pregnancy U {>42 weeksi Q Pruritus AGE GRAV. PARA. ABORTIONS LIVING L.M.P. EDC. DATE OF QUICKENING CHILDREN. GEST. AGE IN WEEKS HT. OF FUNDUS CMS F.H. 4 ACTIVITY PRESENT 4 POSITION RISK ASSESSMENT (Low, Merj.. High) MEDICATION - REMARKS NOTE: SEND HOSPITAL COPIES AT 37 WEEKS SYMPHYSIS—FUNDUS HEIGHT (cm) 16 18 20 22 24 26 28 30 32 34 36 38 40 G E S T A T I O N A L A G E (WEEKS) 1 4 . P H Y S I C I A N T O C A R E F O R I N F A N T : 15. S P E C I A L I N V E S T I G A T I O N S ( U L T R A S O U N D L A B O R A T O R Y E T C . ) OTHER COMMENTS PHYSICIAN IN CHARGE OF PATIENT HLTH 1582 Prepared by THE PERINATAL PROGRAM OF BRITISH COLUMBIA WHITE COPY • MOTHER'S CHART YELLOW COPY - INFANT'S CHART Vancouver, B.C. PINK COPY • PHYSICIAN'S PATIENTS NAME /124 CHART NUMBER (3.1 APPENDIX E . l A b s t r a c t i o n Form 1— — SECTION I  STUDY NUMBER Please record a c t u a l numbers: (1) AGE I (13) PARITY GRAVIDA \~\ > PREVIOUS PREGNANCY LOSSES "^7 & (13) Number of weeks pregnant at f i r s t v i s i t j | j (13) Number of weeks pregnant at l a s t v i s i t SECTION I I I SECTION I I For the f o l l o w i n g seven items mark 1 i f present, 2 i f absent, & 9 i f "not a p p l i c a b l e " (10) P e l v i c Assessment (or previous s u c c e s s f u l d e l i v e r y ) (2) O b s t e t r i c a l H i s t o r y (10) Complete P h y s i c a l ( w i t h i n two years) (12) Haemoglobin - i n i t i a l -36-38 weeks (12) Rh s t a t u s (12) A.R.T. st a t u s -(7) Statement of Gestation-In the f o l l o w i n g s e c t i o n , i n d i c a t e i f the weight, B.P., u r i n e and f u n d a l h e i g h t were recorded at ejlcj] p r e n a t a l v i s i t by marking 1 i f p r e s e n t , 2 I f absent, & 9 i f not a p p l i -c a b l e . Record the ACTUAL, number of weeks g e s t a c i o n at each v i s i t . WEIGHT B.P. URINE GESTATION WEEKS HEIGHT of FUNDUS 1 1 • •0 • p • P • D T l 23 IT /125 CHART NUMBER P-2.. SECTION IV For the f o l l o w i n g f i v e items, mark 1 i f present, 2 i f absent, and 9 i f not a p p l i c a b l e : (13 & 15) Evidence of a psych o s o c i a l i n t e r v i e w (13 & 15) Meeting of the husband and w i f e together during the pregnancy T5" (10 & 15) Pap smear or record of cytology (6,13&2) A two hour P.C. sugar i f there i s a strong f a m i l y h i s t o r y or • i f there i s g l u c o s u r i a found 0 £ i f there i s a h i s t o r y of large babies ( 4 & 15) N u t r i t i o n a l or Dietary Interview SECTION V Record the f o l l o w i n g i n f o r m a t i o n noted i n s e c t i o n (15) S p e c i a l I n v e s t i g a t i o n s : # weeks g e s t a t i o n T e s t / I n t e r v e n t i o n I n d i c a t i o n P P SECTION XL Were any of the f o l l o w i n g c o n d i t i o n s present during the p r e n a t a l period? I f they were not present i n d i c a t e w i t h a 0, i f they were present see coding guide. Albuminuria (A) Hypertension (H) j [—Excessive wt. gain ( 2.3 kg./ 4wks) [ ^  |—H & wt. gain 1"~T~H & A I |—H & A & wt. gain 1 Wt. gain & A | ~^~|—Glucosuria I I—Discharge &/or p r u r i t i s Hi E^ J— P y u r i a | I—Diagnosis of Diabetes I *iw | ^  [— Rubella contact ( p o s s i b l e ) [ ^  | — R u b e l l a contact ( e s t a b l i s h e d I I—Last Trimester Bleeding | | — F i r s t Trimester Bleeding/ not reviewed 1 \— Premature Rupture of Membranes [ | Inadequate P e l v i s / Primipera (_'r-Rh t i ^ r p r o b l t r e r i s i n g or a n t i c i p a t e d Rh problem SCORE OF CHART USING STRICT CRITERIA [ I SCORE OF CHART USING ADAPTED CRITERIA j 1 ST Number of weeks seen CHART NUMBER /126 r?3. SECTION V I I The f o l l o w i n g i n f o r m a t i o n i s found i n the LABOUR SUMMARY AND DELIVERY RECORD Mark the appropriate number i n d i c a t e i n each category: (4) LABOUR | I 1 None 2 Spontaneous 3 Induced 4 Augmented (5) FETAL MONITORING 1 None 2 A u s c u l t a t i o n Only 3 E x t e r n a l Monitor & A u s c u l t a t i o n 4 Scalp Electrode & A u s c u l t a t i o n 5 I n t e r n a l Uterine Pressure Catheter & A u s c u l t a t i o n 6 Both 3 & 4 7 Both 4 & 5 8 Both 3,4 &5 (10) DELIVERY j j 1 Va g i n a l £o 2 C-section (11) Forceps Use | 1 1 None 6 / 2 Low/Outlet Forceps 3 Mid Forceps or r o t a t i o n forceps 4 Both 2 & 3 (13) Perineum ir 1 I n t a c t (Vaginal B i r t h ) 2 Episiotomy 3 L a c e r a t i o n 1st 4 L a c e r a t i o n 3rd or 4th degree or 2nd degree 5 Not a p p l i c a b l e due to C-section APPENDIX E.2 CODING GUIDE /127 BOX Section 1 Study numbers all N.Midwife patients have a 0 in Box 1 all G.P. patients have 1 or 2 in Box 1 Box 2 and 3 indicates the N.M. patient and the GP patients that were matched to that individual, i.e. pt No. 107 and 207 are GP patients matched to N.M. pt No.007. actual age (matched to within 5 years) one patient is 6 years, it was the best I could match. parity (actual No.) - parity matched exactly gravida (actual No.) gravida matched to same No. + up to two pregnancy losses, or two pregnancy losses. previous pregnancy loss two previous pregnancy losses or two previous pregnancy losses 10 actual number of weeks pregnant at first prenatal visit 11 12 actual number of weeks pregnant at last prenatal visit. /128 Section II 13 pelvic assessment 1 if present; 2 if absent; 9 if N/A 14 obstetrical history 1 if present; 2 if absent; 9 if N/A 15 complete physical 1 if present; 2 if absent; 9 if N/A 16 Initial hemoglobin 1 if present; 2 if absent; 9 if N/A 17 36-38 wk. hemoglobin 1 if present; 2 if absent; 9 if N/A 18 Rh status 1 if present; 2 if absent; 9 if N/A 19 A.R.T. status 1 if present; 2 if absent; 9 if N/A 20 Statement of 1 if present; 2 if absent; 9 if N/A gestation (EDC.) /129 Section III 21 weight 22 blood pressure 23 urine boxes marked as 1 if the column above contained l's for each prenatal visit; if the item is not recorded for a visit but is present for another prenatal visit occuring within the same time period of the schedule, the the box was marked 1. Box was marked 2 if the item was actually marked 2 for the minimum number of prenatal visits. (If 2 prenatal visits occurred in the first 13 sweeks, their data was summarized to make one visit if data was missing.) 24 frequency of visits up to 32 weeks after 32 weeks up to & including 36th week after 36 weeks to delivery marked 1 if adequate; 2 if inadequate, adequate is as follows: ideally wanted "k weekly" visits but accepted 5 week intervals and one 6 or 7 week interval - any less frequent than that was inadequate ideally wanted 2 week intervals, accepted one three week interval if it was followed by weekly visits, (eg. 32, 35, 36 etc.) ideally wanted weekly visits, accepted one two week interval if it was from the 35th to 37th week. 25 fundal heights marked 1 if adequate; 2 if inadequate adequate: if fundal height was recorded for the actual minimum of prenatal visits after 20 weeks. /130 Section IV (Superior indications) 26 psychosocial interview 27 28 husband & wife visit pap smear or record of cytology marked: 1 if present 2 if absent 9 if N/A (only 29 received any 9's) 29 2 hr. p.c. sugar if... 30 nutritional or dietary interview (just adequate on adapted criteria) Section V 31 32 common medical practices mark: 0 if none 1 ultrasound for dates 2 ultrasound - other 3 amniocentisis or genetic counselling k fetal monitoring -non stress testing /131 Section VI 35 53 See typed guide for intermediate conditions. Box Box 54 55 UBPC Score 1 if superior 2 if adequate 3 if inadequate Adequate is indicated by: 1 in boxes 13, 14, 15, 16 or 17, 18, 19, 20, 21, 22, 23, and 24. Inadequate is indicated by a 2 in any of these boxes. Superior is indicated by an adequate score plus a 1 in box 26, 27, 28 or 29. If an adequate or superior score is achieved but an 8 is marked in any of the boxes 35 - 53, the score becomes inadequate. If on one prenatal visit 1 or 2 of the following items: weight 21 , BP 22 , urine 23 , were not recorded but in all other respects the chart was Superior, the chart was rescored adequate. ABPC Score 1 if superior 2 if adequate 3 if inadequate Adequate is indicated by: 1 in boxes 14, 15, 16 or 17, 18, 19, 20, 21, 22, 23, 24, 25 and 30. Inadequate is indicated by a 2 in any of these boxes. Superior is indicated by an adequate score plus a 1 in box 26, 27, 28 or 29. If an adequate or superior score is achieved but an 8 is marked in any of the boxes 35 - 53, the score becomes inadequate. If on one prenatal visit 1 or 2 of the following items: weight 21 , BP 22 , urine 23 , were not recorded but in all other respects the chart was Superior, the chart was rescored adequate. 56 57 actual total number of weeks seen for prenatal care i.e. The range. /132 Section VII 58 Labour 1 none 2 spontaneous 3 induced 4 augmented 9 not marked 59 Fe t a l Moni tor ing during labour and del ivery 60 Del ivery 61 Forceps Use 1 none 6 Both 3 & 4 2 ausculatation only 7 Both 4 & 5 3 ext . monitoring and 8 Both 3, 4, & 5 auscultat ion 9 not marked 4 scalp electrode and ausculatation 5 internal uterine press catheter and auscultation 1 vaginal 2 C . Section 9 not marked 1 none 2 low/out le t forceps 3 mid/rota t ion forceps both 2 & 3 9 not marked 62 Perineum 1 intact (vaginal birth) 2 episiotomy 3 lacerat ion 1st degree 4 lacerat ion 2nd, 3rd or 4th degree 5 not applicable - C . section 6 episiotomy & lacerat ion 63 Tota l number of inadequacies maximum of 1 inadequacy for each prenatal v is i t , if pelvic assessment was absent, counted as inadequate, used s t r ic t c r i t e r i a , did not count-dietary review or fundal height measures. 64 Tota l number of superior indications 65 66 To ta l number of prenatal visi ts recorded /133 C O D I N G G U I D E F O R I N T E R M E D I A T E C O N D I T I O N S For the fol lowing conditions, mark 0 i f they are not present, and as indicated depending upon the intervention as l is ted; Box 35 36 37 Albuminur ia - + 1 (30 mg.) over a period of two tests 0 not present 1 present wi th a further urinary invest igat ion or an adequate explanation 8 present wi th inadequate or no intervention Hypertension - a diastol ic over 90 or, 15mm, over previous baseline 0 not present 1 present wi th a statement of concurrent urinary findings 8 present without appropriate intervention or comment Excessive weight gain (over 2.3 kg or 5 lbs. in 4 weeks) & 00 not present 10 2.3 k/4 wk. (5 lbs.) but 3.6 k/8 wk. (8 lbs.) 38 11 cautioned (patient cautioned and/or dietary enforcement and/or more frequent visits) 20 2.3 k/4 wk. but not over 8 wk. 21 cautioned (patient cautioned and/or dietary enforcement and/or more frequent visits) 30 7.2 k/8 wk. no intervention 31 7.2 k/8 wk cautioned (patient cautioned and/or dietary enforcement and/or more frequent visits) 39 Hypertension and weight gain 0 not present 1 present with comment to rest 8 present without intervention 40 Hypertension and Albuminur ia 0 not present 1 present - re-vis i t within 72 hours 8 present without intervention /134 Hypertension plus Albuminuria plus weight gain 0 not present 1 present - salt restriction 2 present - diuretics (omitted) 3 present - salt restriction and diuretics 4 present - other intervention 8 present without intervention Weight gain plus Albuminuria 0 not present 1 present - sedation (Phenobarb?) optional (omitted) 8 present without intervention Glucosuria 0 not present 1 present - blood sugar recorded 2 present - adequate explanation for glucosuria 3 present - both 1 & 2 8 present - with appropriate intervention Discharge and/or pruritis — persistent and distressing 0 not present 1 present - culture and smear of discharge 8 present - without appropriate intervention Pyuria 0 not present 1 present - urine culture and sensitivity 8 present - without appropriate intervention Diagnosis of Diabetes, either previously established or currently established 0 not present 1 present - consultation during pregnancy 8 present - without appropriate intervention / 1 3 5 Box 47 Possible Rubel la Contac t 0 not present 1 present - R . H . I . A . test 8 present - without appropriate intervention 48 Established Rubel la Contac t 0 not present 1 present - consultat ion 8 present - without appropriate intervention 49 Last t r imester bleeding 0 not present 1 present - admission to hospital and consultat ion 8 present - without appropriate intervention 50 F i r s t t r imester bleeding 0 not in the scope of this study 51 Premature Rupture of Membranes 0 not present 1 present - hospi ta l izat ion immediately and in labour within 12 hours 2 present - consultation 8 present - without appropriate intervention 52 Inadequacy of Pelvis in primipera (omitted) 0 not present 1 present - subsequent notation re disproportion 8 present - wi th no comment re disproportion 53 Ris ing Rh t i t re or anticipated Rh problem 0 not present 1 present - subsequent laboratory follow-up 2 present - consultation 3 present - Rho Gam given 8 present - without appropriate intervention /136 APPENDIX F . 1 Determination of Sample Size (for 90% power) in a Matched Pair Study For a specified a and 3 , the number of discordant pairs required to detect an odds ratio y is given by: m = CZa/2 + Z /P(1 - P)] 2/(P - 1/2)2 (Schlessman 1982:161) 6 where P = y/(1 + y ) If a = 0.5 (one-sided) 3 = - 1 0 V = 2 and P = 2/1 + 2= 2/3 then m * [ 1.645/2 + 1.28 ^ (2/3)(1/3)J2/(2/3 - 1/2)2 m - [.82 + 1.28 (.47)]2/(.17)2 = 2.02/0.29 m =69.7 2 70 discordant pairs A t r i p l e matched design increases efficiency by 4/3, (Ury 1975) thus approximately reducing the number of discordant pairs to 52. /137 APPENDIX F-2 Calculation of Power Estimate of Matched Study Based on m Discordant Pairs For specified a and number of discordant pairs, with a specific odds ratio ¥ , the power estimate is given by: Z = [-Za/2 + /m(P - 1 / 2 ) 2 / /P (1 - P) (Schlesselman 1982:162) If a = 0 .5 (one-sided m = 36~ approximates 36 (4 /3 ) = 48 pairs, when triple-matched V - 2 and P = v / 1 + 2 / 3 . Then: Z g = [ - 1 .645 /2 + ^ 4 8 ( 2 / 3 - 1 / 2 ) 2 ] / ^ 2 / 3 ( 1 / 3 ) = [ - .8225 + 6 . 9 2 8 / 6 ] / . 4 7 1 = .3322/ .471 Z g = .705 8 = 1 - .75 Power - 7 5 % g Y = 2 . / 1 3 8 APPENDIX F.3 Mantel-Haenszel Estimate of the Odds Ratio mh = ^n1 + n2 + 2n3)/(2n4 + n 5 + n^) (Schlessman 1982:215) For UBPC: ¥ mh = 8 + 13 + 2(12)/2(0) + 2 + 4 % h = 7.5 Power Estimate Z = [-Z-/2 + /m(P - 1/2)2] / /P(1 - P) (Schlessman 1982:162) p a If: a = 0.5 (one sided) m = (4/3) 39 = 52 discordant pairs m^h = 7-5 P = Y/1 + T = 7.5/8.5 = .88 Then: A Z 6 = [-1.645/2 +/52(.88 - .5) 2]/ /.88(1 - .88) = [-.822 +/52(.144)]/ /. 106 = -.822 + 2.740/.325 = 1.918/.325 8 = 1 - .9990 Power = >99% § ¥mh = 7.5 /139 APPENDIX G Kappa Calculations 1. Updated Burlington Prenatal C r i t e r i a (UBPC) researcher physician (+) (-) (+) 9 1 (-) 2 28 11 29 K = pob " pex 1 - Pexpected .93 - .61 .32 K 1 - .61 .39 K = .82 UBPC 10 30 40 (+) superior + adequate scores (-) inadequate score pob = 37/40 = .93 (10)(11) ex1 ex4 = 2.75 40 (290(30) 40 21.75 ex D 1 ex 2.75 + 21.75 24.5 40 = ~40~ .61 2. Adapted Burlington Prenatal C r i t e r i a (ABPC) researcher (+) (-) (+) 10 1 physician (-) 1 28 11 29 po ~ pex 1 - P K ex .95 - .60 .35 1 - .60 .40 .875 ABPC 11 P Q = 38/40 = .95 (11X11) 29 P e x 1 = = 3.02 40 40 (29M29) ex4 21.02 40 (3.02)+(21.02) 24.04 ex 40 40 Pex = -60 

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