Advanced Practice Nurse Outcomes 1990–2008

A Systematic Review

Robin P. Newhouse, PhD, RN, NEA-BC; Julie Stanik-Hutt, PhD, ACNP, CCNS, FAAN; Kathleen M. White, PhD, RN, NEA-BC, FAAN; Meg Johantgen, PhD, RN; Eric B. Bass, MD, MPH; George Zangaro, PhD, RN; Renee F. Wilson, MS; Lily Fountain, MS, CNM, RN; Donald M. Steinwachs, PhD; Lou Heindel, DNP, CRNA; Jonathan P. Weiner, PhD

Disclosures

Nurs Econ. 2011;29(5):230-250. 

In This Article

Certified Nurse-midwife Outcomes

Outcomes from 21 studies (two RCTs and 19 observational studies) were aggregated for 13 outcomes of care managed by CNMs compared to outcomes of care managed exclusively by physicians. Infant outcomes reported in the studies included Apgar score, birthweight less than 2,500 grams, admission to neonatal intensive care, and breastfeeding. Maternal outcomes reflected both invasive interventions (cesarean section, epidural anesthesia, labor induction/augmentation, epsiotomy, forceps, vacuum use, perineal lacerations) and less-invasive interventions thought to be underused (non-pharmacologic pain relief, vaginal birth after cesarean [VBAC]. The number and type of studies for each outcome will be further described.

Cesarean. Fifteen studies (one RCT) reported differences in cesarean rates between the CNMs and MD patients. When comparing CNM and MD care, there is a high level of evidence CNM groups have lower rates of cesarean sections.

Low APGAR score. Eleven studies (one RCT) reported low infant APGAR scores. When comparing CNM and MD care, CNM have similar infant APGAR scores.

Epidural. Ten studies (0 RCTs) report epidural use. When comparing CNM and MD care, there is a moderate level of evidence CNM groups have lower rates of epidural use.

Labor augmentation. Nine studies (one RCT) reported labor augmentation. When comparing CNM and MD care, there is a high level of evidence to support equivalent levels of labor augmentation.

Labor induction. Nine studies (0 RCTs) reported labor augmentation. When comparing CNM and MD care, there is a moderate level of evidence to support equivalent or lower levels of labor induction of CNM the group.

Episiotomy. Eight studies (one RCT) reported episiotomy rates. When comparing CNM and MD care, there is a high level of evidence to support lower rates of episiotomy for the CNM group.

Low birthweight (<2500 g). Eight studies (one RCT) reported low birthweight infants. When comparing CNM and MD care, there is a high level of evidence to support equivalent levels of low birthweight infants.

Vaginal operative delivery (forceps, vacuum, or both). Eight studies (one RCT) reported vaginal operative delivery. When comparing CNM and MD care, there is a high level of evidence to support comparable levels or lower levels in the CNM group of vaginal operative delivery.

Labor analgesia. Six studies (one RCT) reported labor analgesia. When comparing CNM and MD care, there is a high level of evidence to support lower levels of labor analgesia in the CNM group.

Perineal lacerations. Five studies (one RCT) reported perineal laceration outcomes. When comparing CNM and MD care, there is a high level of evidence to support lower levels of third and fourth-degree perineal laceration rates for the CNM group.

Vaginal birth after cesarean section. Five studies (0 RCTs) reported rates of vaginal birth after cesarean sections. When comparing CNM and MD care, there is a moderate level of evidence to support comparable levels or higher rates of vaginal births after cesarean sections in the CNM group.

Neonatal intensive care unit (NICU) admission. Five studies (0 RCTs) reported NICU admission. When comparing CNM and MD care, there is a moderate level of evidence to support comparable levels or lower rates of infant NICU admission in the CNM group.

Breastfeeding. Three studies (0 RCTs) reported maternal breastfeeding post delivery. When comparing CNM and MD care, there is a moderate level of evidence to support higher rates of breastfeeding in the CNM group.

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