In e na ional Jou nal o Nu sing S udies 126 (2022) 104129
Con en s lis s a ailable a ScienceDi ec
In e na ional Jou nal o Nu sing S udies
j o u n a l h o m e p a g e : w w w . e l s e i e . c o m / i j n s
A compa ison be ween midwi e y and obs e ic ca e a bi h in Spain:
Ac oss-sec ional s udy o pe ina al ou comes
Anna Ma in-A ibas
a , b , ∗, Ramon Escu ie
b , c
, Alicia Bo às-San os
d
, Ra ael Vila-Candel
e , , g
,
C is ina González-Blázquez
a
a
Facul y o Medicine, Nu sing Depa men , Uni e sidad Au ónoma de Mad id, Calle A zobispo Mo cillo 4, 28029 Mad id, Spain
b
Ghende s esea ch g oup. School o Heal h Sciences Blanque na, Uni e si a Ramon Lull, Ca e Padilla 326, 08025 Ba celona, Spain
c
Ca alan Heal h Se ice, Go e nmen o Ba celona, T a esse a de les Co s 131, 08028 Ba celona, Spain
d
Gimbe na School o Nu sing, Uni e si a Au ònoma de Ba celona (UAB), San Cuga del Vallès, Spain
e
La Ribe a Hospi al Heal h Depa men , Ca e e a Co be a km 1, 46600 Alzi a, Valencia, Spain
Facul y o Nu sing and Podia y, Uni e si a de València, Jaume Roig, s/n, 46010 Valencia, Spain
g
Founda ion o he P omo ion o Heal h and Biomedical Resea ch in he Valencian Region (FISABIO), Valencia, Spain
a i c l e i n o
A icle his o y:
Recei ed 20 Ma ch 2021
Recei ed in e ised o m 14 Oc obe 2021
Accep ed 29 Oc obe 2021
Keywo ds:
Midwi e y ca e
Obs e ic ca e
Low- isk bi h
Pe ina al ou comes
Mode o bi h
C oss-sec ional s udy
a b s a c
Backg ound: The o ganiza ional s uc u e o ma e ni y se ices de e mines he choice o which p o es-
sionals p o ide ca e du ing p egnancy, bi h, and he pos na al pe iod, and i influences he kind o ca e
hey deli e and he le el o con inui y o ca e o e ed. The e is conside able e idence ha demons a es
a ela ionship be ween how ca e is p o ided and he ma e nal and neona al heal h ou comes. Regis-
e ed midwi es and obs e icians p o ide ma e ni y ca e ac oss Spain. To da e, no s udies ha e assessed
whe he ma e ni y ou comes di e be ween hese wo g oups.
Objec i e: The aim o his s udy was o examine he associa ion be ween he ca e ecei ed (midwi e y
ca e e sus obs e ic ca e) and he ma e nal and neona al ou comes in women wi h no mal, low- and
medium- isk p egnancies in Spain om 2016 o 2019.
Design: A p ospec i e, mul icen e, c oss-sec ional s udy was ca ied ou as pa o COST Ac ion IS1405 a
44 public hospi als in Spain in he yea s 2016–2019. The p o ocol can be accessed h ough he egis y
ISRCTN14062994. The sample size o his s udy was 11,537 women. The p ima y ou come was mode o
bi h. The seconda y ou comes included augmen a ion wi h oxy ocin, use o epidu al analgesia, women’s
posi ion a bi h, pe ineal in eg i y, hi d s age o labou managemen , ma e nal and neona al admission
o in ensi e ca e, Apga sco e, neona al esusci a ion, and ea ly ini ia ion o b eas eeding. Chi-squa e
es s o ca ego ical a iables and independen sample - es o con inuous a iables o assess di e ences
be ween he midwi e y and obs e ic g oups we e calcula ed. Odds a io wi h in e als o confidence a
95% we e calcula ed o obs e ic in e en ions and pe ina al ou comes. A mul i a ia e logis ic eg ession
model was applied in o de o examine he e ec o ype o heal hca e p o ide on pe ina al ou comes.
These models we e adjus ed o ca e p o ide , ype o onse o labou , use o anaes hesia, p egnancy isk,
ma e nal age, pa i y, and ges a ional age a bi h.
Resul s: Midwi e y ca e was associa ed wi h lowe a es o ope a i e bi hs and se e e pe ineal damage
and had no highe ad e se ou comes. No s a is ically significan di e ences we e obse ed in he use o
o he obs e ic in e en ions be ween he wo g oups.
∗Co esponding au ho a : School o Heal h Sciences Blanque na, Uni e si a Ramon Lull, Ca e Padilla 326, 08025 Ba celona, Spain.
E-mail add esses: annama7@blanque na.u l.edu (A. Ma in-A ibas), [email p o ec ed] (R. Escu ie ), [email p o ec ed] (A. Bo às-San os), ila_ a can@g a.es (R. Vila-
Candel), c is ina.gonzalez0[email p o ec ed] (C. González-Blázquez).
h ps://doi.o g/10.1016/j.ijnu s u.2021.104129
0020-7489/© 2021 The Au ho (s). Published by Else ie L d. This is an open access a icle unde he CC BY-NC-ND license
( h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/ )
2 A. Ma in-A ibas, R. Escu ie , A. Bo às-San os e al. / In e na ional Jou nal o Nu sing S udies 126 (2022) 104129
Conclusions: The findings o his s udy should encou age a shi in he cu en ma e ni y ca e sys em
owa ds a g ea e in eg a ion o midwi e y-led se ices in o de o achie e op imal bi h ou comes o
women and newbo ns.
Regis y numbe : ISRCTN14062994
©2021 The Au ho (s). Published by Else ie L d.
This is an open access a icle unde he CC BY-NC-ND license
( h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/ )
Wha is al eady known
•The e is conside able e idence indica ing a ela ionship be-
ween how ma e ni y ca e is p o ided and ma e nal and neona-
al heal h ou comes.
•Midwi e y-led ca e has been shown o be associa ed wi h ewe
obs e ic in e en ions and inc eased women’s sa is ac ion wi h
hei bi hing expe ience.
•The e is a need o de e mine which o he ac o s associa ed
wi h he o ganiza ion o ma e ni y se ices influence he use o
obs e ic in e en ions and pe ina al ou comes in Spain.
Wha his pape adds
•This is he fi s s udy o analyse he associa ion o he heal h
ca e p o ide g oup and pe ina al ou comes in Spain.
•Heal hy women ecei ing midwi e y ca e we e hal as likely o
ha e an ope a i e bi h and had an app oxima ely 40% lowe
isk o se e e pe ineal damage han hose ecei ing obs e ic
ca e in Spain.
•Midwi e y ca e is sa e and e ec i e and is no associa ed wi h
highe isk o ad e se ou comes o women wi h no mal, low-
and medium- isk p egnancies and hei in an s.
1. Backg ound
The ca e o e ed o heal hy women du ing bi h has been sub-
jec o conside able deba e wo ldwide in ecen yea s. The Wo ld
Heal h O ganiza ion has acknowledged ha in apa um ca e o -
en includes he same le el o in e en ion, ega dless o whe he
he in e en ion is needed ( Wo ld Heal h O ganiza ion, 1997 ). Ob-
s e ic in e en ions a e o en used excessi ely o when hey a e
no clinically indica ed, and bo h he po en ial impac o hese in-
e en ions on women and in an s’ wellbeing and hei economic
cos a e issues o g ea conce n, pa icula ly in high-income coun-
ies ( Caughey e al., 2014 ; Mille e al., 2016 ).
The o ganiza ional s uc u e o ma e ni y se ices de e mines
he choice o which p o essionals p o ide ca e du ing p egnancy,
bi h and he pos na al pe iod, and i influences he kind o ca e
hey deli e and he le el o con inui y o ca e o e ed. The e is
conside able e idence ha demons a es a ela ionship be ween
how ca e is p o ided and he ma e nal and neona al heal h ou -
comes ( B ocklehu s e al., 2012 ; Ma shall e al., 2015 ; Ma ín-
A ibas e al., 2020 ; Sou e e al., 2019 ; Thiessen e al., 2016 ;
Voon e al., 2017 ).
A numbe o s udies ha e shown posi i e esul s when mid-
wi es a e he p ima y ca e p o ide s h oughou his pe iod.
Wo ldwide, midwi e led-ca e has been shown o be associa ed
wi h ewe obs e ic in e en ions and wi h inc eased sa is ac ion
on he pa o women wi h hei bi hing expe ience ( Sandall e al.,
2016 ; Ten Hoope-Bende e al., 2014 ; Wo ld Heal h O ganiza-
ion, 2018 ). In addi ion, o he s udies sugges ha , o low- isk
p egnancies, midwi e y ca e is mo e cos -e ec i e han o he mod-
els o ca e ( Kenny e al., 2015 ; T acy e al., 2013 ). The e o e, many
coun ies ha e made s ong e o s o implemen al e na i e mod-
els o ca e o women wi h low- isk p egnancies.
Rela i e o o he coun ies such as he Uni ed Kingdom and
he Ne he lands, ma e ni y ca e in Spain is s ill significan ly med-
icalized ( Escu ie -Pei ó e al., 2015 ). Mos women gi e bi h in
highly echnological obs e ic uni s s a ed by bo h obs e icians
and midwi es ( Minis y o Heal h and Consume s’ A ai s, 2008 ).
In he Spanish Heal h Sys em, midwi es p o ide ca e o women
wi h no mal, low- isk o medium- isk p egnancies. Howe e , s ud-
ies ha e shown ha midwi es’ deg ee o au onomy is cons ained
by he o ganiza ional s uc u e o p o essional eams ( Ma ín-
A ibas e al., 2020 ). A local s udy highligh ed he need o u -
he examina ion o ac o s associa ed wi h he o ganiza ion o ma-
e ni y se ices ha may influence he use o obs e ic in e en-
ions and pe ina al ou comes ( Escu ie e al., 2014 ). Fu he mo e,
in Spain, o da e, no la ge s udies ha e analysed he associa ion o
he heal h ca e p o ide g oup and pe ina al ou comes.
The aim o his s udy was o examine he associa ion be ween
he ca e ecei ed (midwi e y ca e e sus obs e ic ca e) and he
ma e nal and neona al ou comes in women wi h no mal, low- and
medium- isk p egnancies in Spain om 2016 o 2019.
2. Me hods
2.1. S udy design
This a icle p esen s a pa o he esul s ob ained wi hin
he MidconBi h s udy. This is a p ospec i e, mul icen e , c oss-
sec ional s udy unde he auspices o COST Ac ion IS1405. The
p o ocol can be accessed h ough he egis y ISRCTN14062994
( Escu ie e al., 2017 ).
2.2. Pa ien and public in ol emen
A mul idisciplina y eam and use s’ ep esen a i es we e in-
ol ed in he design and he dissemina ion plans o his esea ch.
The p io i y o he esea ch ques ion and choice o ou come mea-
su es we e decided by hese wo g oups. Once he s udy has been
published, pa icipan cen es and women’s associa ions will be in-
o med o he esul s ia email and h ough a dedica ed websi e
( www.lle ado a.eu ). The esul s will also be p esen ed in a sum-
ma y sui able o a non-specialis audience.
2.3. Se ings and pa icipan s
Fo he pu pose o his s udy, we selec ed 44 publicly unded
hospi als om ou di e en egions ha a e ep esen a i e o
Spain as a whole in e ms o sociodemog aphic and economical
cha ac e is ics.
The sample was limi ed o p imipa ous and mul ipa ous
women be ween 18 and 40 yea s o age wi h a single on, cephalic
p esen a ion and low o medium- isk p egnancy be ween 37 and
42 weeks o ges a ion. Women we e classified as “women wi h
no mal, low- o medium- isk p egnancies” i , be o e he onse o
labou , hey we e no known o ha e any o he medical o ob-
s e ic isk ac o s included on he lis desc ibing high o e y
high- isk p egnancies in he an ena al ca e guidelines o Ca alo-
nia (Spain) ( Fe nandez and Escu ie , 2018 ). The p esence o such
ac o s is belie ed o inc ease isk o he woman o baby, and
obs e ic-led ca e would be expec ed unde hese ci cums ances.
A. Ma in-A ibas, R. Escu ie , A. Bo às-San os e al. / In e na ional Jou nal o Nu sing S udies 126 (2022) 104129 3
Fig 1. Flow cha o he eco d selec ion o egis e ed bi hs be ween 2016 and 2019.
The e o e, his s udy did no include women wi h p egnancies
classified as high o e y high isk o hose equi ing an elec i e
caesa ean sec ion.
2.4. Sample size
The e e ence popula ion was 42,141 women. The sample size
was calcula ed based on he annual numbe o bi hs o each pa -
icipa ing cen e. To calcula e he sample size (95% le el o confi-
dence) i was assumed ha an unknown p opo ion o bi hs a -
ended by midwi es o each es ima ed popula ion (50%) in each
se ing, wi h a ( + / −) 5% p ecision and a eposi ion p opo ion o
10%. The minimum es ima ed sample size o achie e a ep esen-
a i e sample o each hospi al in Spain was 11,314 women. The
ini ial sample was 12,190. Then, a e excluding eco ds o women
who we e no eligible o eco ds wi h missing alues, he final
sample size o his s udy was 11,537 women ( Fig 1 ).
2.5. Ou come measu es
The p ima y ou come was he mode o bi h o women who
ga e bi h in publicly unded hospi als du ing he s udy pe iod.
The seconda y ou come was a composi e o a ange o di e en
pe ina al ou comes. This composi e was designed o cap u e he
quali y o in apa um ca e acco ding o he WHO’s s anda ds o
good p ac ise ( Wo ld Heal h O ganiza ion, 2018 ). This composi e
included augmen a ion wi h oxy ocin, use o epidu al analgesia,
women’s posi ion a bi h, pe ineal in eg i y, hi d s age o labou
managemen , ma e nal and neona al admission o in ensi e ca e,
Apga sco e, neona al esusci a ion, and ea ly ini ia ion o b eas -
eeding.
2.6. Da a collec ion
Da a we e collec ed h ough an online pla o m om 2016 o
2019. Each pa icipa ing uni o us had a local coo dina ing mid-
wi e. Da a collec ion o ms o he s udy we e designed o be com-
ple ed by he midwi e p o iding in apa um ca e. All midwi es
pa icipa ing in he s udy ecei ed a aining session on da a col-
lec ion. In addi ion, all midwi es signed a commi men o m s a -
ing ha he da a was collec ed acco ding o he p o ocol. Fu -
he mo e, da a collec ion was conduc ed consecu i ely du ing he
specified pe iod un il he minimum numbe o cases needed was
eached, as pe p o ocol.
The in e en ion examined in his s udy is he ca e p o ided
o women wi h no mal, low- and medium- isk p egnancies du ing
labou and bi h. The da a collec ed included in o ma ion on he
sociodemog aphic cha ac e is ics o he women (age, na ionali y,
le el o educa ion, e hnici y) and on obs e ic ea u es. In o ma-
ion was also ga he ed on he heal h p o essional a ending each
woman, along wi h da a ela ed o p ocedu es pe o med on each
woman who me he inclusion c i e ia, and hei espec i e pe i-
na al ou comes.
2.7. S a is ical analysis
The analysis popula ion included all eligible heal hy women
wi h no mal, low- and medium- isk p egnancies o whom da a
we e collec ed. Women we e included in he midwi e y ca e o
obs e ic ca e g oups a he s a o ca e in labou ega dless o
whe he hey we e la e ans e ed du ing labou . We compa ed
he wo g oups in o de o es ablish whe he ou comes di e ed
be ween hem. In addi ion, women’s eco ds wi h missing alues
we e excluded om he analysis.
4 A. Ma in-A ibas, R. Escu ie , A. Bo às-San os e al. / In e na ional Jou nal o Nu sing S udies 126 (2022) 104129
Table 1
Women’s socio-demog aphic cha ac e is ics and hei obs e ic ea u es.
Cha ac e is ics Midwi e-led ca e n = 10,844 (94.0) N (%) Obs e ician-led ca e n = 693 (6.0) N (%) To al n = 11,537 (100) N (%) P- alue
Demog aphics
Age in yea s
Mean [SD] 31.3 (5.1) 31.8 (4.9) 31.3 (5.1) 0.0045
< 20 192 (1.8) 12 (1.7) 204 (1.7)
≥20 o < 35 7410 (68.3) 453 (65.4) 7863 (68.2)
≥35 3242 (29.9) 228 (32.9) 3242 (30.1)
Educa ional le el
Low 2437 (22.5) 174 (25.1) 2611 (22.6) < 0.001
Middle 3469 (32.0) 218 (31.5) 3687 (32.0)
High 2970 (27.4) 217 (31.3) 3187 (27.6)
Unknown 1968 (18.2) 84 (12.1) 2052 (17.8)
E hnici y
Spanish 7380 (68.1) 506 (73.0) 7886 (68.4) 0.0159
Eu opean (O he han Spanish) 647 (6.0) 27 (3.9) 674 (5.8)
Sou h and cen al-Ame ican 1000 (9.2) 66 (9.5) 1066 (9.2)
No h-Ame ican 16
(0.2) 2 (0.3) 18 (0.2)
A ican 1379 (12.7) 71 (10.2) 1450 (12.6)
Asian 275 (2.5) 18 (2.6) 293 (2.5)
O he 147 (1.3) 3 (0.4) 150 (1.7)
Residence
Ca aluña 6905 (63.7) 349 (50.4) 7254 (62.9) < 0.001
Galicia 2219 (20.5) 59 (8.5) 2278 (19.8)
Comunidad Valenciana 902 (8.3) 99 (14.3) 1001 (8.7)
Cas illa y León 818 (7.5) 186 (26.8) 1004 (8.7)
Obs e ic ea u es
Pa i y
P imipa ous 5164 (47.6) 401 (57.9) 5565 (48.2) < 0.001
Pa ous 5680 (52.4) 292 (42.1) 5972 (51.8)
Ges a ional age
Mean [SD] 39.5 (1.1) 39.6 (1.2) 39.5 (1.1) < 0.001
⩽ 40 8654 (79.8) 502 (72.4) 9156 (79.4)
> 40
o ⩽ 41 + 6 2190 (20.2) 191 (27.6) 2381 (20.6)
P egnancy isk
No mal p egnancy 3746 (34.5) 166 (24.0) 3912 (33.9) < 0.001
Low- isk 2792 (25.8) 172 (24.8) 2964 (25.7)
Medium isk 4306 (39.7) 355 (51.2) 4661 (40.4))
Type o onse o labou
Spon aneous 7996 (74.4) 264 (44.5) 8260 (72.9) <
0.001
Induc ion 2745 (25.6) 329 (55.5) 3074 (27.1)
Desc ip i e s a is ics we e used o summa ize he women’s
socio-demog aphic cha ac e is ics and hei obs e ic ea u es. The
s a is ical analysis was ca ied ou using he STATA e sion 16. F e-
quencies and pe cen ages o he ca ego ies we e calcula ed o all
he a iables. The s anda d de ia ion (SD) o he quan i a i e a i-
ables’ means was calcula ed. Chi-squa e es s we e conduc ed o
ca ego ical a iables, and an independen sample - es was done
o con inuous a iables in o de o assess any di e ences be ween
he midwi e y ca e and obs e ic ca e g oups. Odds a ios (OR)
wi h confidence in e als (CI) a 95% we e calcula ed o obs e ic
in e en ions and pe ina al ou comes. P- alues < 0.05 we e con-
side ed s a is ically significan . A mul i a ia e logis ic eg ession
model was pe o med in o de o examine he di e ing e ec s o
midwi e y ca e and obs e ic ca e on pe ina al ou comes and o as-
ce ain he e ec s o he s udied co- a iables. These models we e
adjus ed using a s epwise a iable selec ion p ocess based on he
le el o significance o he uni a ia e analysis. We adjus ed o ca e
p o ide , ype o onse o labou , use o anaes hesia, p egnancy
isk, ma e nal age, pa i y, and ges a ional age a bi h.
2.8. E hics
This s udy was app o ed by he e hics commi ee o he coo di-
na ing cen e (Clinical Resea ch E hics Commi ee o Pa c de Salu
Ma 2016/6785/I) and by he e hics commi ee o each pa icipa -
ing hospi al. Since his is an obse a ional s udy in which da a was
anonymized, no consen was equi ed om he women who had
ecei ed ca e in he pa icipa ing cen es. I a gi en hospi al e-
qui ed consen om he women unde i s ca e, w i en consen
was ob ained.
3. Resul s
The o al sample included in he analysis consis ed o 11,537
eco ds de ailing cases in which 10,844 (94%) women ecei ed in-
apa um ca e om midwi es and 693 (6%) ecei ed his ca e
om obs e icians. The women’s socio-demog aphic cha ac e is ics
and hei obs e ic ea u es a e p esen ed in Table 1 .
The uni a ia e analysis o obs e ic in e en ions and pe ina-
al ou comes o bo h g oups a e p esen ed in Table 2 . Women in
he midwi e y ca e g oup we e less likely o ha e ecei ed epidu-
al analgesia (80.8% e sus 88.9%; p ≤0.001) and augmen a ions o
labou (58.6% e sus 72.7%; p ≤0.001) han women in he obs e -
ic ca e g oup. The majo i y o women in bo h g oups ga e bi h in
li ho omy posi ion. None heless, women gi ing bi h in posi ions
o he han he li ho omy posi ion we e also significan ly highe in
he midwi e y ca e g oup (41.9% e sus 32.7%; p ≤0.001). The p o-
po ion o women in he midwi e y ca e g oup gi ing bi h spon-
aneously was highe han in he obs e ic ca e g oup, and his di -
e ence was s a is ically significan (74% e sus 44.3%; p ≤0.001).
Ope a i e bi hs included acuum, o ceps, spa ula, and caesa ean
deli e ies. Those we e significan ly less equen o women in he
midwi e y ca e g oup han o hose in he obs e ic ca e g oup
( acuum: 8.8% e sus 9.0%; o ceps: 4.5% e sus 8.4%; spa ula: 2.2%
e sus 5.9%; caesa ean sec ion: 10.4% e sus 32.2%; all p- alues
we e ≤0.001). Women unde midwi e y ca e had lowe a es o
A. Ma in-A ibas, R. Escu ie , A. Bo às-San os e al. / In e na ional Jou nal o Nu sing S udies 126 (2022) 104129 5
Table 2
Desc ip i e and uni a ia e analysis o obs e ic in e en ions and pe ina al ou comes.
Midwi e y ca e n = 10,844 (94.0) N (%) Obs e ic ca e n = 693 (6.0) N (%) P- alue OR (CI 95%)
Use o epidu al/gene al anaes hesia du ing labou < 0.001
No d ugs 2080 (19.2) 77 (11.1) 1
Use o epidu al/gene al anaes hesia du ing labou 8764 (80.8) 616 (88.9) 0.5 (0.4–0.7)
Augmen a ion wi h oxy ocin < 0.001
Yes 6357 (58.6) 504 (72.7) 1
No 4487 (41.4) 189 (27.3) 1.9 (1.6–2.2)
Mode o bi h < 0.001
Spon aneous aginal bi h 8029 (74.0) 307 (44.3) 1
Ope a i e bi h 2815 (26.0) 386 (55.7) 0.3 (0.2–0.3)
Posi ion a bi h < 0.001
Li ho omy 6265 (58.1) 419 (67.3) 0.7 (0.6–0.8)
O he s 4523 (41.9) 204 (32.7) 1
Thi d s age o labou managemen < 0.001
Ac i e 5789 (53.7) 428 (68.7) 1
Physiological 4999 (46.3) 195
(31.3) 1.9 (1.6–2.3)
Pe ineal in eg i y < 0.001
In ac pe ineum/ I-II deg ee 9549 (98.3) 159 (29.4) 1
Episio omy, III-IV deg ee 170 (1.7) 127 (23.5) 1.1 (0.8–1.4)
Ma e nal admission o in ensi e ca e 0.0196
Yes 65 (0.6) 10 (1.4) 1
No 10,779 (99.4) 683 (98.6) 2.4 (1.2–4.7)
Apga sco e 0.012
5-minu e Apga ≥7 10,765 (99.3) 681 (98.3) 1
5-minu e Apga < 7 79 (0.7) 12 (1.7) 0.4 (0.2–0.8)
Neona al esusci a ion < 0.001
Yes 510 (4.7) 63 (9.1) 1
No 10,334 (95.3) 630 (90.9) 2.0 (1.5–2.7)
Ea ly ini ia ion o b eas eeding < 0.001
Yes 8830 (81.4) 490 (70.7) 1
No 2014 (18.6) 203 (29.3) 0.6 (0.5–0.7)
OR: Odds Ra io (Obs e ic ca e s. Midwi e y ca e); CI: Confidence In e al.
Table 3
C ude and adjus ed associa ions be ween di e en a iables and ope a i e mode o bi h .
C ude OR (CI 95%) Adjus ed OR (CI 95%) P- alue (adjus ed)
Ca e p o ide
Obs e ic ca e 1 1 < 0.001
Midwi e y ca e 0.28 (0.24 - 0.33) 0.5 (0.4–0.6)
Type o onse o labou
Spon aneous 1 1 < 0.001
Induc ion 2.48 (2.26–2.71) 1.7 (1.4–1.8)
P egnancy isk
No mal p egnancy 1 1
Low isk 1.05 (0.94 - 1.17) 1.1 (0.97–1.2) 0.127
Medium 1.4 (1.27–1.54) 1.6 (1.43–1.78) < 0.001
Ges a ional age
⩽ 40 1 1 < 0.001
> 40 o ⩽ 41 + 6 1.47 (1.35–1.59) 1.50 (1.33- 1.61)
Ma e nal age 1.02 (1.01–1.03) 1.04 (1.03–1.05) < 0.001
Pa i y
Nullipa ous 1 1 < 0.001
Pa ous 0.25(0.23–0.28) 0.2 (0.2–0.3)
OR: Odds Ra io; CI: Confidence In e al.
se e e pe ineal damage (III- and IV-deg ee ea s and episio omy)
(1.7% s. 23.5%; p ≤0.001). Fu he mo e, women in he midwi e y
ca e had significan ly lowe a es o ac i e hi d s age managemen
(53.7% e sus 68.7%; p ≤0.001). S a is ical di e ences be ween he
wo g oups we e also ound in he pe cen age o women admi ed
o in ensi e ca e (0.6% e sus 1.4%; p = 0.02).
Compa ed wi h he in an s in he obs e ic ca e g oup, mid-
wi e y newbo ns had significan ly lowe a es o 5-minu es Ap-
ga sco e < 7 (0.7% e sus 1.7%; p = 0.012), neona al esusci a ion
(4.7% e sus 9.1%; p ≤0.001) and highe a es o ea ly ini ia ion o
b eas eeding (81.4% e sus 70.7%; p ≤0.001).
Fu he analysis was conduc ed ia mul iple logis ic eg essions
o examine he associa ion be ween he ma e ni y ca e and ob-
s e ic in e en ions and ma e nal and neona al ou comes. Clinical
a iables ha we e s a is ically significan in he uni a ia e analy-
sis we e used as con ounding a iables in he mul i a ia e analy-
sis. S a is ically significan di e ences we e ound be ween he wo
g oups in e ms o he mode o bi h and pe ineal in eg i y a -
e adjus ing o pa i y, ma e nal age, p egnancy isk, ges a ional
age, ype o onse o labou and use o epidu al/gene al anaes hesia
as con ounding a iables. These esul s a e shown in Table 3 and
Table 4 , espec i ely. Women in he midwi e y ca e g oup we e
50% less likely o ha e an ope a i e bi h (aOR: 0.5; 95% CI 0.4–0.6)
han women in he obs e ic ca e g oup. In addi ion, women unde
midwi e y ca e also had significan ly lowe a es o se e e pe ineal
damage (aOR: 0.62; 95% CI (0.49–0.78). Meanwhile, all he o he
6 A. Ma in-A ibas, R. Escu ie , A. Bo às-San os e al. / In e na ional Jou nal o Nu sing S udies 126 (2022) 104129
Table 4
C ude and adjus ed associa ions be ween di e en a iables and se e e pe ineal damage .
C ude OR (CI 95%) Adjus ed OR (CI 95%) P alue (adjus ed)
Ca e p o ide
Obs e ic ca e 1 1 < 0.001
Midwi e y ca e 0.44 (0.37–0.54) 0.62 (0.49–0.78)
Type o onse o labou
Spon aneous 1 1 0.590
Induc ion 1.49 (1.35–1.63) 1.03 (0.92–1.56)
P egnancy isk
No mal p egnancy 1 1
Low isk 0.94 (0.85–1.04) 0.90 (0.79–1.02) 0.107
Medium 0.90 (0.82–0.99) 0.99 (0.89–1.12) 0.975
Ges a ional age
⩽ 40 1 1 0.729
> 40 o ⩽ 41 + 6 1.17(1.08–1.27) 1.02 (0.92–1.12)
Ma e nal age 0.99 (0.98–1) 1.01 (1.0–1.02) 0.040
Pa i y
Nullipa ous 1 1 < 0.001
Pa ous 0.22 (0.20–0.24) 0.3 (0.28–0.35)
OR: Odds Ra io; CI: Confidence In e al.
con ounding a iables we e ound o ha e a s a is ically significan
influence on he mode o bi h. Ma e nal age and pa i y had also a
significan influence on he p e alence o pe ineal damage. No s a-
is ically significan di e ences we e obse ed in any o he o he
heal h ou comes ha we e ound o be s a is ically significan in
he uni a ia e analysis.
4. DISCUSSION
To he bes o ou knowledge, he p esen s udy is he
la ges analysis conduc ed o da e in Spain compa ing ma e nal
and neona al bi h ou comes o women wi h no mal, low, and
medium- isk p egnancies ecei ing midwi e y ca e wi h hose o
women wi h no mal, low, and medium- isk p egnancies ecei ing
obs e ic ca e.
The main finding o ou s udy was ha , e en in a highly med-
icalized ma e ni y sys em whe e 99.8% o women gi e bi h in
con en ional obs e ic uni s, midwi e y ca e had significan pos-
i i e e ec s on ma e nal heal h ou comes. Women in he mid-
wi e y ca e g oup we e hal as likely o ha e an ope a i e bi h
han women in he obs e ic ca e g oup. This finding is consis-
en wi h hose om mos p e ious esea ch ( Ba use iciene e al.,
2018 ; Janssen e al., 2007 ; Sandall e al., 2016 ; Sou e e al., 2019 ;
Su cli e e al., 2012 ). In addi ion, he caesa ean sec ion a e o
women in he midwi e y ca e g oup was 10.4%. This ema kable
caesa ean sec ion a e is a below bo h he caesa ean a e o
women in he obs e ic ca e g oup and he na ional CS a e in pub-
licly unded hospi als, which a e 33.2% and 22.2% espec i ely. Fu -
he mo e, in acco dance wi h findings in he li e a u e, compa ed
wi h obs e icians, his s udy ound ha midwi e y use s had an
app oxima ely 40% lowe isk o se e e pe ineal damage ( Bodne -
adle e al., 2017 ; Dencke e al., 2017 ; Sandall e al., 2016 ). Mo e-
o e , he findings sugges ha midwi e y ca e is sa e and e ec i e,
and ha is no associa ed wi h a highe isk o ad e se ou comes
o women wi h no mal, low- and medium- isk p egnancies and
hei in an s. This suppo s he ecen Coch ane e iew and o he
con empo a y s udies ( Ba use iciene e al., 2018 ; Sandall e al.,
2016 ).
Many may iew hese findings as expec ed. These posi i e ou -
comes may be explained by he cha ac e is ics o ca e midwi es
p o ide. Midwi e y educa ion and midwi es’ scope o p ac ice a e
cha ac e ized by an e hos o no mali y ha includes he concep-
ion o bi h as a na u al p ocess ( In e na ional Con ede a ion o
Midwi es, 2020 ; Kennedy e al., 2010 ; Minis e io de Educación y
Ciencia, 2005 ). In addi ion, midwi es in Spain end o iew ad-
ocacy o women and he sa egua ding and p omo ion o no -
mal bi h as essen ial elemen s o hei ole ( Ma in-A ibas e al.,
2020 ). The e o e, midwi e y ca e, wi h i s ocus on he p omo ion
o no mal bi h, could ha e con ibu ed o op imal bi h ou comes
( Iida e al., 2014 ; In e na ional Con ede a ion o Midwi es, 2020 ;
Sandall e al., 2016 ; Ten Hoope-Bende e al., 2014 ).
On he o he hand, i is impo an o no e ha e en hough
women wi h p egnancies classified as high- o e y high- isk p eg-
nancies we e excluded om his s udy, he a e o ins umen-
al bi hs documen ed he e was conce ningly high, a finding in
line wi h he la es Spanish da a epo ed on Eu ope is a ( Eu o-
Pe is a P ojec , 2018 ). Al hough he a e o ins umen al bi hs
was lowe amongs women unde he ca e o he midwi es, he
figu e was high o bo h g oups (15.5% o he midwi e y ca e and
23.3% o he obs e ic ca e) ela i e o he numbe s in o he Eu-
opean coun ies. Fu he mo e, and in con as wi h mos p e i-
ous esea ch, no s a is ical di e ences be ween he midwi e y ca e
and obs e ic ca e g oups we e ound in he equency o obs e -
ic in e en ions such as he use o epidu al, oxy ocin s imula ion,
he use o li ho omy posi ion a bi h o he ac i e managemen
o he hi d s age o labou ( Dencke e al., 2017 ; Iida e al., 2014 ;
Sandall e al., 2016 ; Sou e e al., 2019 ; Voon e al., 2017 ).
When midwi e y-led ca e is p o ided, he use o obs e ic in e -
en ions is expec ed o be lowe in compa ison wi h o he models
o ca e. Ne e heless, his was no he case in he p esen s udy.
This finding may be explained by he in e en ionis app oach
o bi h ca e in ou coun y ( Escu ie -Pei ó e al., 2015 ; Ma ín-
A ibas e al., 2020 ). Despi e inc easing e idence o he influence
o he ma e ni y ca e p o ide and he bi h se ing on pe ina al
ou comes, mos women in Spain con inue o gi e bi h in con en-
ional obs e ic uni s s a ed by eams o midwi es and obs e i-
cians, and al e na i es o his model o ca e a e a ely p esen in
Spain ( Begley e al., 2011 ; Bol en e al., 2016 ; B ocklehu s e al.,
2012 ; Ma ín-A ibas e al., 2020 ; Rei sma e al., 2020 ). This aises
conce ns as o he dubious benefi s o gi ing bi h in mixed en i-
onmen s, as ecen s udies ha e shown posi i e heal h ou comes
when heal hy women a e p o ided ca e in midwi e-led uni s ha
a e sepa a ed om con en ional obs e ic uni s ( Rowe e al., 2014 ;
Sandall e al., 2016 ). A ecen s udy ha explo ed he acili a-
o s and ba ie s o he p omo ion o no mal bi h in he Span-
ish con ex concluded ha he main challenges s anding in he
way o e o s o acili a e no mal bi h in he coun y we e he
hie a chical ela ionship be ween obs e icians and midwi es and
he lack o ins i u ional suppo o p o iding sufficien midwi e y
s affing. Midwi es el unable o u ilize hei midwi e y skills, and
A. Ma in-A ibas, R. Escu ie , A. Bo às-San os e al. / In e na ional Jou nal o Nu sing S udies 126 (2022) 104129 7
hey o en epo ed eeling disempowe ed and us a ed, lead-
ing o an inc ease in obs e ic in e en ions du ing bi h, as seen
in p e ious s udies ( Ca olan-Olah e al., 2015 ; Hadjigeo giou and
Coxon, 2014 ; Ma in-A ibas e al., 2020 ; Thompson e al., 2016 ).
The li e a u e has shown ha con inui y models o ca e and ad-
equa e numbe s o midwi e y s a a e majo solu ions ha can
help a oid unnecessa y in e en ions and imp o e women’s sa -
is ac ion ( Wo ld Heal h O ganiza ion, 2018 ). In o de o inc ease
he p o ision o midwi es in Spain, he access o he midwi e y
aining equi es o be e iewed as he numbe o places is e y
limi ed and does no mee he numbe o midwi es ha a e on
he p ocess o e i emen ( Fede ación de Asociación de Ma onas
de España, 2014 ). These wo key elemen s a e o g ea impo ance
as a po en ial co ec i e o a con ex whe e ac i e managemen o
labou is emb aced o he de imen o women-cen ed ca e and
e idence-based p ac ice. In addi ion, esea ch has shown ha high
a es o in e en ion may be ha m ul o bo h women and babies
( Bu le , 2017 ; Mille e al., 2016 ).
4.1. Implica ions o p ac ice
These findings highligh he impo ance o he selec ion o he
ca e p o ide du ing bi h on he basis o p e ious isk assessmen ,
and hey poin o an u gen need o s eng hen midwi e y ca e in
Spain. In iew o he posi i e bi h ou comes o women unde
he ca e o midwi es desc ibed in ou s udy and he s ong in e -
na ional e idence ha suppo s he many benefi s o midwi e y-
led ca e, i is clea ha policy-make s should conside a shi in
he cu en ly p e ailing ma e ni y ca e p o ision in o de o en-
su e women’s sa e y du ing he en i e bi h p ocess. This change
should include an inc ease in he le el o midwi e y s affing in
bi h se ings, and e o s should be made o p omo e midwi es’
au onomy o hei ull scope o p ac ice in mixed en i onmen s
and o con inue o expand access o ex end midwi e-led ma e ni y
se ices o eligible women. In addi ion, s akeholde s may wish
o conside ways o p o iding con inuous ca e h oughou p eg-
nancy, bi h and he pos na al pe iod, in ligh o s udies showing
he alue women place on con inui y o ca e( Bodne -adle e al.,
2017 ; Iida e al., 2014 ; Ren ew e al., 2014 ; Sandall e al., 2016 ).
Fu he mo e, we belie e ha a edis ibu ion o heal h budge s
should be con empla ed. Taking in o conside a ion ha he majo -
i y o p egnan women a e heal hy, i would be ad isable o e-
sou ces o be alloca ed p opo iona ely o p omo e women-cen ed
ca e in spaces wi hou excessi e medicaliza ion. This means ha
highly echnological se ings should be a oided when in apa um
ca e o heal hy women is p o ided. In addi ion, his may also con-
ibu e o he op imal use o esou ces and he sus ainabili y o
he heal h sys em ( F iedman e al., 2015 ; Hollowell e al., 2012 ;
Ryan e al., 2013 ; T acy e al., 2013 ). This is an especially ele an
issue especially in hese imes o global economic c isis and lim-
i ed heal h ca e budge s.
4.2. Implica ions o esea ch
Ques ions emain abou he bes way o implemen midwi e-led
con inui y o ca e models in Spain. Fu u e esea ch should e alua e
he use o obs e ic in e en ions, women’s expe ience and sa is-
ac ion as well as pe ina al ou comes o hose women and new-
bo ns ha ecei e ca e a he newly o med midwi e y-led se ices
wi h i s di e en a ia ions. In addi ion, u he esea ch should
assess he cos -e ec i eness o hese ma e ni y ca e se ices.
4.3. S eng hs and limi a ions
This s udy has se e al s eng hs. This s udy is he fi s o p o-
ide insigh on ma e nal and neona al ou comes in midwi e y ca e
in Spain. This highligh s he impo ance o he selec ion o ca e
p o ide du ing bi h based on p e ious isk assessmen . I also
suppo s he p o ision o midwi e y-led uni s as an addi ional
choice in ma e ni y ca e o women wi h low- isk p egnancies.
O he s eng hs include he sample size o he s udy, he numbe
o cen es pa icipa ing, he ange o ma e nal and neona al ou -
comes and he adjus men o mul iple po en ial con ounding ac-
o s in he analyses. Ne e heless, his s udy has limi a ions which
should be no ed. The fi s s ems om he s udy’s obse a ional de-
sign, which means ha causa ion canno be de e mined ( Poli and
Beck, 2014 ). Howe e , he esul s a e consis en wi h he findings
om p e ious s udies ha showed be e ma e nal ou comes when
midwi e y models o ca e a e implemen ed. This finding dese es
he u he a en ion o policy make s and heal h ca e p o ide s
( Sandall e al., 2016 ). Addi ionally, as an obse a ional s udy, he e
is a p obabili y ha da a collec ion migh p esen some discon-
inui y. None heless, all in es iga o s we e encou aged o collec
he da a consecu i ely and signed a commi men o m in o de
o elimina e he isk o sampling bias, as all eligible pa icipan s
we e ec ui ed. In addi ion, women’s eco ds wi h missing al-
ues we e excluded om he analysis o a oid misin e p e a ions
( Oli ei a, 2020 ). Las ly, his s udy does no include da a om he
ecen ly opened midwi e-led uni s in Spain. Howe e , he au ho s
belie e ha hese findings con ibu e o s eng hening he knowl-
edge o midwi e y ca e in his coun y and i s di e ences wi h
obs e ician-led ca e in low- isk bi hs.
5. Conclusion
In women wi h no mal, low- and medium- isk p egnancies,
midwi e y ca e was associa ed wi h significan ly lowe a es o op-
e a i e bi hs and a lowe equency o se e e pe ineal damage and
had no highe ad e se ou comes. The findings o his s udy should
encou age a shi in he cu en ma e ni y ca e sys em owa ds a
g ea e in eg a ion o midwi e y-led se ices in o de o achie e
op imal bi h ou comes o mo he s and newbo ns.
Decla a ion o Compe ing In e es
The au ho s decla e no conflic s o in e es .
Funding Sou ces
The MidconBi h S udy was unded by he Ca alan Council o
Nu ses - Midwi es Commission. This unding con ibu ed o he
c ea ion o a web-based pla o m o da a collec ion. This s udy
was g an ed wi h he Midwi es Awa d by he Spanish Fede a ion
o Midwi e y Associa ions and he Mus ela Founda ion in 2021. The
ounde o he awa d was no in ol ed in he s udy concep ualisa-
ion, da a collec ion and analysis, decision o publish o p epa a-
ion o he manusc ip .
Acknowledgemen s
This s udy con ibu es o COST Ac ion 1405 Building In a-
pa um Resea ch h ough Heal h –an in e disciplina y whole sys-
em app oach o unde s anding and con ex ualizing physiological
labou and bi h. We a e g a e ul o all women and hei ami-
lies who pa icipa ed in his s udy. We would also like o hank
all hospi als ha pa icipa ed in he MidconBi h s udy, especially,
o hose midwi es ha collec ed all he da a o hei suppo wi h
his esea ch. These a e a ailable on: h ps://lle ado a.eu/ca ego y/
pa icipan es/
8 A. Ma in-A ibas, R. Escu ie , A. Bo às-San os e al. / In e na ional Jou nal o Nu sing S udies 126 (2022) 104129
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