Delivery Outcomes Similar With Family Doctors, Obstetricians

Laurie Barclay, MD

August 25, 2015

For pregnant women who are at low risk for delivery complications, newborn and maternal outcomes are similar for obstetric deliveries by family physicians and obstetricians, according to a retrospective, population-based cohort study published online August 24 in the Canadian Medical Association Journal.

"Over the past several decades in Canada, obstetric deliveries have increasingly been attended by specialist obstetricians rather than family physicians," write Kris Aubrey-Bassler, MD, from the Primary Healthcare Research Unit, Discipline of Family Medicine, Memorial University of Newfoundland in St. John's, and colleagues. "Although specialized care is beneficial for high-risk mothers and their infants, there are concerns that it might increase risk for women whose deliveries could be safely managed without a specialized approach."

Although previous studies suggest that obstetric outcomes are similar for deliveries by family physicians and obstetricians, many of these studies were small and did not adjust for selection bias. To overcome these limitations, investigators in this study used an econometric method to adjust for unobserved confounding.

The cohort for this study consisted of all Canadian (except Quebec) hospital births with delivery by family physicians and obstetricians at 390 hospitals between April 1, 2006, and March 31, 2009. Included deliveries were at greater than 20 weeks' gestational age, with birth weight greater than 500 g.

Among 799,823 infants and 793,053 mothers, there were 3600 perinatal deaths and 14,394 cases of maternal morbidity. Relative risk for perinatal mortality for deliveries by family physicians vs obstetricians was 0.98 (95% confidence interval [CI], 0.85 - 1.14), and of maternal morbidity was 0.81 (95% CI, 0.70 - 0.94), based on logistic regression.

Using instrumental variable methods, relative risks were 0.97 (95% CI, 0.58 - 1.64) for perinatal deaths and 1.13 (95% CI, 0.65 - 1.95) for maternal morbidity.

On the basis of their findings, the study authors conclude that risks for perinatal mortality and adverse maternal outcomes were similar for obstetric deliveries by family physicians and obstetricians after adjustment for observed and unobserved confounders. It is still unknown whether deliveries by these two groups differ in other outcomes and whether use of procedures such as cesarean section affects outcomes. The study authors recommend that pregnant women at high risk should continue to be cared for and delivered by specialists.

Limitations of this study were the exclusion of midwife deliveries, lack of data on at-home deliveries or on infant outcomes other than death, and use of data that may now be somewhat out of date.

"Because of the analytical approach used, these findings apply only to mothers and infants who would be eligible for delivery by either family physicians or specialists in at least some jurisdictions of the country," the authors write. "These results do not apply to mothers who are consistently referred for delivery by obstetricians in all jurisdictions. Future research should explore the effect of different delivery providers on other outcomes and on health resource utilization."

The Dr. A.R. Cox Research Grant via the Medical Research Endowment Fund at Memorial University of Newfoundland funded this study. The authors have disclosed no relevant financial relationships.

CMAJ. Published online August 24, 2015. Full text

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