In e na ional Jou nal o
En i onmen al Resea ch
and Public Heal h
A icle
T ans e s o Ca e be ween Heal hca e P o essionals in
Obs e ic Uni s o Di e en Sizes ac oss Spain and in
a Hospi al in I eland: The MidconBi h S udy
Anna Ma ín-A ibas 1,2 , Ra ael Vila-Candel 3,4,5,* , Rhona O’Connell 6, Ma ina Dillon 7,
Inmaculada Vila-Bellido 8, M. Ángeles Beney o 8, Inmaculada De Molina-Fe nández 9,
Ne ea Rod íguez-Conesa 10, C is ina González-Blázquez 2and Ramón Escu ie 1,11
1
GHende S Resea ch G oup, School o Heal h Sciences Blanque na, Uni e si a Ramon Llull, Ca e Padilla 326,
08025 Ba celona, Spain; [email p o ec ed] (A.M.-A.); [email p o ec ed] (R.E.)
2Facul y o Medicine, Uni e sidad Au ónoma de Mad id, Calle A zobispo Mo cillo 4, 28029 Mad id, Spain;
[email p o ec ed]
3La Ribe a Hospi al Heal h Depa men , Ca e e a Co be a km 1, 46600 Valencia, Spain
4Founda ion o he P omo ion o Heal h and Biomedical Resea ch in he Valencian Region (FISABIO),
46020 Valencia, Spain
5Facul y o Nu sing and Podia y, Uni e si a de València, Jaume Roig, s/n, 46010 Valencia, Spain
6School o Nu sing and Midwi e y, Uni e si y College Co k, T12 YN60 Co k, I eland; [email p o ec ed]
7Co k Uni e si y Ma e ni y Hospi al, Wil on, T12 YE02 Co k, I eland; [email p o ec ed]
8Ve ge dels Lli is Hospi al, Poligon de Ca amanxel s/n, 03804 Alcoi, Spain; [email p o ec ed] (I.V.-B.);
[email p o ec ed] (M.Á.B.)
9Nu sing Depa men , Uni e si a Ro i a i Vi gili, 43003 Ta agona, Spain; inmaculada.demolina@u .ca
10 Rio Ho ega Hospi al, Calle Dulzaina, 2, 47012 Valladolid, Spain; [email p o ec ed]
11 Ca alan Heal h Se ice, Go e nmen o Ba celona, 08028 Ca alonia, Spain
*Co espondence: [email p o ec ed]
Recei ed: 17 Oc obe 2020; Accep ed: 11 No embe 2020; Published: 13 No embe 2020
Abs ac :
Backg ound: In Eu ope, he majo i y o heal hy women gi e bi h a con en ional obs e ic
uni s wi h he assis ance o egis e ed midwi es. This s udy examines he ela ionships be ween he
in apa um ans e o ca e (TOC) om midwi e o obs e ician-led ma e ni y ca e, obs e ic uni size
(OUS) wi h di e en deg ees o midwi e y au onomy, in apa um in e en ions and bi h ou comes.
Me hods: A p ospec i e, mul icen e, c oss-sec ional s udy p omo ed by he COST Ac ion IS1405
was ca ied ou a eigh public hospi als in Spain and I eland be ween 2016–2019. The p ima y
ou come was TOC. The seconda y ou comes included ype o onse o labou , oxy ocin s imula ion,
epidu al analgesia, ype o bi h, episio omy/pe ineal inju y, pos pa um haemo hage, ea ly ini ia ion
o b eas eeding and ea ly skin- o-skin con ac . A logis ic eg ession was pe o med o asce ain
he e ec s o s udied co- a iables on he likelihood ha pa icipan s had a TOC; Resul s: Ou o
a o al o 2,126 low- isk women, hose whose in apa um ca e was ini ia ed by a midwi e (1772)
we e selec ed. The e we e s a is ically signi ican di e ences be ween TOC and OUS (S1 =29.0%,
S2 =44.0%, S3 =52.9%, S4 =30.2%, p<0.001). S a is ically di e ences be ween OUS and onse o
labou , oxy ocin s imula ion, ype o bi h and episio omy o pe ineal inju y we e obse ed (p=0.009,
p<0.001, p<0.001, p<0.001 espec i ely); Conclusions: Findings sugges ha he model o ca e
and OUS ha e a signi ican e ec on he p e alence o in apa um TOC and he bi h ou comes.
Fu u e esea ch should examine how models o ca e di e as a unc ion o he OUS in a hospi al,
as well as he cos -e ec i eness o he heal h ca e sys em.
Keywo ds:
midwi e-led ca e; obs e ician-led ca e; con inui y o ca e; ans e o ca e; ma e nal
ou comes; neona al ou comes
In . J. En i on. Res. Public Heal h 2020,17, 8394; doi:10.3390/ije ph17228394 www.mdpi.com/jou nal/ije ph
In . J. En i on. Res. Public Heal h 2020,17, 8394 2 o 15
1. Backg ound
The pas ew yea s ha e wi nessed he eme gence o a wo ldwide deba e abou he ca e ha
heal hy women ecei e when gi ing bi h. This deba e includes di e ing opinions as o he use o
a ious echnologies o no mal o low- isk p ocedu es [
1
], he concep o labou as a physiological
p ocess ha is no o be unde s ood in solely medical e ms, and he g owing ole women hemsel es
a e aking in he decision-making p ocesses a ec ing hei ca e [
2
]. Addi ionally, he inc ease in he
equency o in e en ions ca ied ou du ing labou , especially o caesa ean sec ions, is a sou ce o
conce n o a numbe o o ganiza ion and o heal h ca e o icials. In di e en Eu opean coun ies,
he a es a e abou 25% o 35% [3,4].
The o ganiza ional s uc u e o ma e ni y se ices migh ha e an in luence on he heal h ou comes
o women and new-bo ns [
5
]. The way hese medical se ices a e o ganized de e mines he le el o
con inui y o ca e o e ed and he choice o which p o essionals p o ide wha kinds o ca e h oughou
he p ocess o p egnancy, labou and pos pa um ca e. A numbe o s udies ha e shown posi i e
esul s when midwi es a e he p ima y p o ide s o ca e h oughou he p ocess [6].
Ma e ni y ca e in Eu ope is o e ed by o ganiza ions wi h a numbe o di e en kinds o s uc u es,
se ings and loca ions [
7
]. The deg ee o which Eu opean heal h ca e sys ems o e co e age a ies
om coun y o coun y [
8
]. In some places, women a e gua an eed co e age o he whole ange
op ions, whe he women choose home bi hs, bi h cen es, ma e ni y uni s a ended by midwi es o
con en ional obs e ic uni s. The size o ma e ni y uni s also a y as does he deg ee o midwi e y
au onomy [
6
]. The mos common model in Eu opean coun ies is ha o p o iding ca e in con en ional
obs e ics uni s [
9
]. This ansla es in o a si ua ion in which mos heal hy women ecei e ca e in highly
echnological se ings. Addi ionally, he equency o in apa um in e en ions a ies g ea ly om
place o place [10].
The quali y o ca e p o ided o women du ing labou has been ex ensi ely s udied by a numbe o
esea che s [
11
]. None heless, mos o he indica o s used in hese s udies ha e been aimed a assessing
he use o in e en ions and a seeking ou esul s based on pa hology (i.e., pos pa um haemo hages,
pe ineal ea s, e c.). The aim o he MidconBi h s udy is o o e a new pe spec i e on his issue
and o con ibu e o esea ch on he assessmen o he quali y o ca e ha women ecei e when in
labou [
9
]. In mos heal h ca e se ices, midwi es a e he p ima y p o ide s o ca e h oughou he
p ocess, bu his is no always he case [
6
]. The oles o di e en ca e p o ide s a y depending on
how heal h se ices and medical eams a e o ganized [
12
]. Mos women who gi e bi h a e heal hy
o a leas a low- isk du ing hei p egnancies, and hey end o ecei e ca e om midwi es who
exe cise comple e au onomy om he onse o labou [
13
]. The ans e o ca e (TOC) du ing labou
means ha midwi es a e esponsible o de ec ing any isk, p oblem o pa hology equi ing he
in e en ion o ano he p o essional [
11
]. In some cases, howe e , midwi es’ deg ee o au onomy
is a ec ed by he o ganiza ional s uc u e o p o essional eams. In Spain, mos women in labou
ecei e ca e in obs e ic uni s s a ed by bo h obs e icians and midwi es [
14
]. These uni s ha e all
he necessa y echnology o p o ide ca e o women ega dless o he le el o isk p esen in he
p egnancy. Ca e is p o ided by p o essional eams o ganized in o hie a chical s uc u es [
7
]. As a
esul , p ocedu es a e o en de e mined by p o ocols, and p o essionals end o wo k in acco dance
wi h a gi en cen e’s o ganiza ional cul u e. In gene al, midwi es end o be esponsible o women
wi h low- isk p egnancies du ing labou [
6
]. The deg ee o au onomy exe cised by hese midwi es
a ies om cen e o cen e [
6
]. Meanwhile, obs e icians ac as consul an s in hese cases. In I eland,
in apa um ca e o women wi h low- isk p egnancies is p o ided unde he Mo he and In an Ca e
Scheme [
15
], a p og am ha p omo es indi idualized ca e o low isk women in labou by midwi es
and unde which obs e icians ac only upon he eques o hese midwi es.
S udies ha e shown ha midwi e-led models a e associa ed wi h bo h ewe medical in e en ions
and inc eased sa is ac ion wi h he bi hing expe ience [
6
]. Howe e , a ecen s udy on obs e ic
in e en ions in Spain sugges s he need o u he examina ion o ac o s associa ed wi h he
o ganisa ion o childbi h se ices which a e in luencing hese in e en ions [13].
In . J. En i on. Res. Public Heal h 2020,17, 8394 3 o 15
This s udy examines he ela ionships be ween he in apa um ans e o ca e om midwi e o
obs e ician-led ma e ni y ca e and he obs e ic uni size (OUS), in apa um in e en ions and bi h
ou comes wi hin wo di e en coun ies wi h a di e en midwi e y o ganisa ion o ca e.
2. Me hods
This a icle p esen s 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 p omo ed by he COST Ac ion IS1405 ca ied ou in di e en hospi als
in Spain and I eland. The p o ocol can be accessed h ough he egis y ISRCTN14062994 [
9
]. Fo he
pu poses o his s udy, we selec ed bi hs a ended o in obs e ic uni s in h ee di e en egions ha
a e ep esen a i e o Spain in e ms o sociodemog aphic and economical cha ac e is ics (Ca alonia,
C. Valenciana and Cas illa y Le
ó
n), and ano he in I eland. These include hospi als wi h low olumes
o bi hs (<600 bi hs pe yea ) o Uni Size 1 (S1), medium ( om 601 o 1200 bi hs) and high annual
olumes o bi hs (1201 o 2400 bi hs) o Uni Size (S2) and Uni Size (S3) espec i ely, as well as bi hs
a ended o by a con inui y o ca e eam in I eland (Co k), a hospi al wi h high annual olume o
bi hs (>2400 bi hs) o Uni Size 4 (S4). Da a we e collec ed h ough an online pla o m in 2016–2019.
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 uncomplica ed p egnancy be ween 37 and 42 weeks o ges a ion.
Fo his s udy, women wi h p egnancies classi ied as high o e y high isk we e excluded.
The e e ence popula ion was 5708 women. The sample size is calcula ed on he annual numbe
o bi hs o each pa icipa ing cen e o midwi e. To calcula e he sample size (95% le el o con idence)
i is assumed 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%. A minimum
es ima ed sample size was 365 women o achie e a ep esen a i e sample o each hospi al in Spain
and o he caseload midwi e y eam in I eland. Da a collec ion was conduc ed consecu i ely du ing
he speci ied pe iod un il he minimum numbe o cases needed was eached. The p ima y ou come
was ans e o ca e (TOC). This happens when he p o essional who is looking a e he woman a he
s a o he labou ans e s he esponsibili y o ca e o ano he p o essional. The seconda y ou comes
included ype o onse o labou (spon aneous o induced labou ), oxy ocin s imula ion (use o oxy ocin
du ing he i s o second s age o labou ), epidu al analgesia (use o epidu al analgesia du ing he
second o hi d s age o labou ), ype o bi h (no mal o dys ocic), episio omy/pe ineal inju y ( he use
o episio omy and/o p esence o pe ineal damage), pos pa um haemo hage (mo e han 1000 mL o
blood loss), ea ly ini ia ion o b eas eeding (wi hin one hou om bi h) and ea ly skin- o-skin con ac
(con ac be ween mo he and new-bo n is s a ed immedia ely a e bi h and/o unin e up ed du ing
he i s 30 min).
Desc ip i e s a is ics we e used o summa ize he women’s cha ac e is ics. The s a is ical analysis
was ca ied ou using he SPSS p og am e sion 23.0 (IBM SPSS S a is ics o Windows, Ve sion 25.0,
eleased 2018, IBM Co p., A monk, NY, USA). F equencies 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 iables mean was
calcula ed. The Chi-squa e es was used o analyse he s a is ical signi icance o he di e ences in he
pe cen ages o hospi al g oups be ween he a iable ca ego ies; o isk ac o s o ans e s o ca e,
an odds a io (OR) wi h a 95% CI, was calcula ed. A mul i a ia e logis ic eg ession models we e
pe o med o asce ain he e ec s o s udied co- a iables on he likelihood ha pa icipan s had a TOC.
These models we e adjus ed using a s epwise a iable selec ion p ocess based on a likelihood a io (LR).
Nagelke ke’s R
2
was used o es ima e he coe icien o de e mina ion om 0 o 1. The signi icance
le el was se a p<0.05.
E hics App o al and Consen o Pa icipa e
The MidconBi h s udy was app o ed by he e hics commi ee o he coo dina ing cen e (Clinical
Resea ch E hics Commi ee o Pa c Salu Ma 2016/6785/I) ISRCTN egis y 17,833,269 and la e by
he e hics commi ee o each pa icipa ing cen e (Clinical Resea ch E hics Commi ee o he Ca alan
In . J. En i on. Res. Public Heal h 2020,17, 8394 4 o 15
Hospi als Union Founda ion (CPMP/ICH/135/95), Clinical Resea ch E hics Commi ee o Rio O ega
Hospi al (117/16), Clinical Resea ch E hics Commi ee (CREC) Co k Re ECM4 (09/05/17), Human E hics
Commi ee a Hospi al Uni e si a io de La Ribe a Resea ch E hics Commi ee and Resea ch Commission
and he Spanish Medicines and Medical De ices Agency app o ed he s udy (HULR15/12-01), Resea ch
E hics Commi ee o Complejo Asis encial Uni e si a io de Palencia (CIB-2017005) and Resea ch E hics
Commi ee o Hospi al Ve ge dels Lli is. E hics commi ee app o al was equi ed 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 ca ed o in he pa icipa ing cen es. I a hospi al equi ed consen om he women
unde hei ca e, w i en consen was ob ained. Fu he in o ma ion and documen a ion a e a ailable
on eques .
3. Resul s
3.1. Cha ac e is ics o he Sample
The o al sample analysed was made up o 2126 cases. In e ms o he egional dis ibu ion,
Co k (I eland) collec ed da a on 7.1% (150) o he cases, 44.7% (951) we e in Ca alonia, 48.2% (1025)
in he egions o Valencia and Cas illa y Le
ó
n (Spain). Rega ding he obs e ic uni size dis ibu ion,
S1 ep esen ed 8.8% (187) o he cases, 51% (1086) we e in S2, 33% (703) we e in S3 and 7.1% (150) we e
in S4 (Figu e 1).
In . J. En i on. Res. Public Heal h 2020, 16, x 4 o 16
E hics App o al and Consen o Pa icipa e
The MidconBi h s udy was app o ed by he e hics commi ee o he coo dina ing cen e
(Clinical Resea ch E hics Commi ee o Pa c Salu Ma 2016/6785/I) ISRCTN egis y 17,833,269 and
la e by he e hics commi ee o each pa icipa ing cen e (Clinical Resea ch E hics Commi ee o he
Ca alan Hospi als Union Founda ion (CPMP/ICH/135/95), Clinical Resea ch E hics Commi ee o Rio
O ega Hospi al (117/16), Clinical Resea ch E hics Commi ee (CREC) Co k Re ECM4 (09/05/17),
Human E hics Commi ee a Hospi al Uni e si a io de La Ribe a Resea ch E hics Commi ee and
Resea ch Commission and he Spanish Medicines and Medical De ices Agency app o ed he s udy
(HULR15/12-01), Resea ch E hics Commi ee o Complejo Asis encial Uni e si a io de Palencia (CIB-
2017005) and Resea ch E hics Commi ee o Hospi al Ve ge dels Lli is. E hics commi ee app o al
was equi ed 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 ca ed o in he pa icipa ing cen es. I a
hospi al equi ed consen om he women unde hei ca e, w i en consen was ob ained. Fu he
in o ma ion and documen a ion a e a ailable on eques .
3. Resul s
3.1. Cha ac e is ics o he Sample
The o al sample analysed was made up o 2126 cases. In e ms o he egional dis ibu ion, Co k
(I eland) collec ed da a on 7.1% (150) o he cases, 44.7% (951) we e in Ca alonia, 48.2% (1025) in he
egions o Valencia and Cas illa y León (Spain). Rega ding he obs e ic uni size dis ibu ion, S1
ep esen ed 8.8% (187) o he cases, 51% (1086) we e in S2, 33% (703) we e in S3 and 7.1% (150) we e
in S4 (Figu e 1).
Figu e 1. S udy low cha .
The a e age age o he women in he s udy was 31.7 ± 4.9 yea s. B oken down by coun y o
o igin, 70.2% (1490) o he women we e om Spain, 11.8% (250) we e om elsewhe e in Eu ope, 7.3%
Figu e 1. S udy low cha .
The a e age age o he women in he s udy was 31.7
±
4.9 yea s. B oken down by coun y o o igin,
70.2% (1490) o he women we e om Spain, 11.8% (250) we e om elsewhe e in Eu ope, 7.3% (155)
we e om Sou h o Ame ica, 8.1% (172) we e om A ica, 2.0% (42) we e om Asia, 0.5% (10) we e
om he Middle Eas , 0.2% ( ou ) we e om No h Ame ica and o 0.1% ( h ee) o he women his da a
was missing. 36.3% (772) o he women had a ended uni e si y, 34.3% (729) had high school deg ees,
and 25.2% (535) had only comple ed p ima y school, while o 4.2% (90) o he women he le el o
In . J. En i on. Res. Public Heal h 2020,17, 8394 5 o 15
educa ion was unknown o could no be classi ied. 52.3% (1111/2126) we e p imipa ous, while he
a e age ges a ion pe iod be o e labou was 39.0 ±3.0 weeks ( ange o 37–41).
The clinical cha ac e is ics o women in e e y OUS g oup a e shown in Table 1, which also
displays he s a is ically signi ican di e ences be ween OUS, wi h he excep ion o he use o epidu al
anaes hesia (p=0.632).
Table 1. Cha ac e is ics o he sample, by obs e ic uni size (N=2126).
Obs e ic Uni Size
S1 n=187 S2 n=1086 S3 n=703 S4 n=150
n%n%N%n% To al p*
Onse o labou
Spon aneous 163 87.2 745 68.6 492 70.0 127 84.6 1527
<0.001
Induced 23 12.3 331 30.5 181 25.7 22 14.7 557
C-sec ion 1 0.5 10 0.9 30 4.3 1 0.7 42
Pha macological s imula ion o labou
No 129 69.0 419 38.6 208 29.6 99 66.0 855 <0.001
Yes 58 31.0 667 61.4 495 70.4 51 34.0 1271
Epidu al analgesia
No 30 16.0 169 15.6 102 14.5 28 18.7 329 0.632
Yes 157 84.0 917 84.4 601 85.5 122 81.3 1797
Type o bi h
No mal 145 77.5 757 69.7 442 62.9 104 69.3 1448 <0.001
Dys ocic 42 22.5 329 30.3 261 37.1 46 30.7 678
Weigh o newbo n (g)
<2500 5 2.7 15 1.4 6 0.9 0 0.0 26
<0.001
2501–3000 34 18.2 227 20.9 142 20.2 10 6.7 413
3001–3500 84 44.9 505 46.5 302 43.0 52 34.7 943
3501–4000 49 26.2 284 26.2 212 30.2 53 35.3 598
>4001 15 8.0 55 5.1 41 5.8 35 23.3 146
Pe ineum
No episio omy o 1s o
2nd deg ee 111 59.4 555 51.1 398 56.6 100 66.7 1164 0.001
P esence o episio omy o
3 d o 4 h deg ee 76 40.6 531 48.9 305 43.4 50 33.3 962
Pos pa um haemo hage
No 182 97.3 1064 98.0 676 96.2 139 92.7 2061 0.002
Yes 5 2.7 22 2.0 27 3.8 11 7.3 65
Ea ly skin- o-skin con ac
Yes 180 96.3 959 88.3 646 91.9 141 94.0 1926 0.001
No 7 3.7 127 11.7 57 8.1 9 6.0 200
Ea ly ini ia ion o b eas eeding
Yes 165 88.2 823 75.8 552 78.6 124 83.2 1664 0.001
No 22 11.8 263 24.2 150 21.4 25 16.8 460
P o essional a ending he onse o labou
Midwi e 181 96.8 901 83.0 546 77.7 149 99.3 1777 <0.001
Obs e ician 6 3.2 185 17.0 157 22.3 1 0.7 349
P o essional a ending he bi h
Midwi e 132 70.6 677 62.3 324 46.1 104 69.3 1237 <0.001
Obs e ician 55 29.4 409 37.7 379 53.9 46 30.7 889
Bi h a ended by midwi e om s a o end
Yes 132 70.6 603 55.5 317 45.1 104 69.3 1156 <0.001
No 55 29.4 483 44.5 386 54.9 46 30.7 970
* Chi-squa e es ; S1 =Obs e ic Uni Size 1 (<600 bi hs pe yea ); S2 =Obs e ic Uni Size 2 ( om 601 o 1200 bi hs
pe yea ); S3 =Obs e ic Uni Size 3 (1201 o 2400 bi hs pe yea ); S4 =Obs e ic Uni Size 4 (>2400 bi hs pe yea ).
O women who had dys ocic bi hs, in S1 we obse ed ha 12.3% (23) o women equi ed
eme gency caesa ean sec ions; in S2 he pe cen age was 12.6% (137); in S3 16.5% (116) and in S4 11.3%
(17). The di e ences he e we e s a is ically signi ican (p<0.001). S1 displayed a lowe pe cen age o
In . J. En i on. Res. Public Heal h 2020,17, 8394 6 o 15
ans e (29.4%), ewe cases o labou s imula ed wi h oxy ocin (31.0%) and ewe cases o induced
labou (12.4%). Meanwhile, S1 displayed he highes pe cen ages o no mal bi hs (77.5%), skin- o-skin
con ac be ween he mo he and he new-bo n (96.3%), and ea ly ini ia ion o b eas eeding (88.2%).
S2 showed he highes pe cen age o induced labou (30.8%), se ious pe ineal inju ies including
episio omies and hi d- and ou h-deg ee pe ineal ea s (48.9%), bu his OUS showed he lowes
pe cen age o pos pa um haemo hages (2.0%).
S3 displayed he g ea es pe cen age o ans e (54.9%), o labou s imula ion wi h oxy ocin
(70.4%), o he use o epidu al analgesics (85.5%) and o dys ocic bi hs (37.1%).
S4 showed he lowes p opo ion o bi hs wi h epidu al analgesia (18.7%), was mos likely o
lack se ious pe ineal inju ies, cha ac e ized as cases whe e he pe ineum was in ac o cases wi h
second and hi d deg ee pe ineal ea s (66.7%), and had he highes pe cen age o he s a o labou
a ended by midwi es (99.3%). Howe e , his OUS also displayed he highes pe cen age o pos pa um
haemo hages (7.3%).
3.2. T ans e Analysis
We we e in e es ed in analysing he ela ionship be ween he TOC be ween he midwi e and he
obs e ician and he es o he ac o s ha in luence a bi h. Fo he pu poses o his analysis, cases o
elec i e caesa ean sec ions (42) we e excluded. Thus, he o al numbe o cases analysed was 2084.
Midwi es a ended he s a o he deli e ies in 85.1% (1773/2084), and hey a ended du ing he
expulsi e phases o he deli e ies in 59.4% (1237/2084) o cases. Meanwhile, obs e icians a ended he
s a o he deli e ies in 14.9% (311/2084) o cases, and hey a ended he end o deli e ies in 40.6%
(847/2084) o cases.
In 55.5% (1156/2084) o he deli e ies, he e was no TOC om he midwi e o he obs e ician.
In o he wo ds, in hese cases midwi es a ended he whole labou and bi h p ocess. In e ms o he
dis ibu ion by OUS, he midwi es in S1 we e he leas likely o ans e ca e (wi h 71.0% [132/186]
a ending o he labou and bi h in i s en i e y), ollowed by hose in S4 (69.8% [104/149]), S2 (56.0%
[1076/673]) and, inally, S3 (47.1% [317/773]).
We conduc ed an analysis o he di e ences in he labou and bi h p ocesses and he associa ed
pe ina al esul s in each OUS, examining hem in e ms o whe he o no he e was a TOC du ing he
p ocess. Fo he a iables analysed, ( ype o s a o labou , pha macological s imula ion o labou ,
use o epidu al analgesics, ype o bi h and s a us o he pe ineum), s a is ically signi ican di e ences
we e ound, bo h wi hin each obs e ic uni size and o he sample as a whole.
I is ue ha he midwi e migh no be di ec ly esponsible o he decision o induce labou ,
as his ep esen s a depa u e om a no mal bi h because he onse is no spon aneous. Howe e ,
his p ocess is o en de e mined by p o ocol and cha ac e ized by a sha ed esponsibili y o he midwi e
and he eam o obs e icians [7].
Ou analysis o he ac o s associa ed wi h a g ea e likelihood o TOC and he isks associa ed
wi h his p ac ice is displayed in he 2 ×2 ables and he odds a io calcula ions (Table 2).
When he e was no TOC, S4 eco ded he highes p opo ion o spon aneous onse o labou
[S4 93.3% (97/104), compa ed wi h S1 a 90.9% (120/132), S2 a 83.3% (502/603), and S3 a 83.0% (263/317)],
and he di e ences ound he e we e s a is ically signi ican (p<0.001). S3 showed he highes a e o
induced bi hs a ended by midwi es in which no TOC occu ed [17.0% (54/317), while o S2 he igu e
was 16.7% (101/603), o S1 i was 9.1% (12/132), and o S4 i was 6.7% (7/104)]. The di e ences ound
we e s a is ically signi ican (p<0.001). S4 displayed he lowes equency o oxy ocin use in deli e ies
when no TOC occu ed [13.5% (14/104)]. Meanwhile, S3 egis e ed he highes a e o pha macological
s imula ion (55.5% [176/317]). Addi ionally, in S4 TOC was mo e likely when oxy ocin was used, o
labou was s imula ed, inc easing wi h espec o when labou was no s imula ed (p<0.001).
In . J. En i on. Res. Public Heal h 2020,17, 8394 7 o 15
Table 2. T ans e o ca e dis ibu ion be ween di e en s udied a iables, and Odds Ra io and 95% con idence in e als (N=2084).
Obs e ic Uni Size
S1 S2 S3 S4 To al
Midwi e S a o End
p *
Midwi e S a o End
p *
Midwi e S a o End
p *
Midwi e S a o End
p *
Midwi e S a o End
p *
Yes (132) No (54) Yes (603) No (473) Yes (317) No (356) Yes (104) No (45) Yes (1156) No (928)
n%
col n%
col n%
col n%
col n%
col n%
col n%
col n%
col n%
col n%
col
Onse o labou
Spon aneous 120 90.9 43 79.6 0.048 502 83.3 243 51.4
<0.001
263 83 229 64.3
<0.001
97 93.3 30 66.7
<0.001
982 47.1 545 26.2
<0.001
Induced 12 9.1 11 20.4 101 16.7 230 48.6 54 17 127 35.7 7 6.7 15 33.3 174 8.3 383 18.4
Pha macological s imula ion
None 107 81.1 21 38.9
<0.001
288 47.8 121 25.6
<0.001
141 44.5 65 18.3
<0.001
90 86.5 8 17.8
<0.001
626 0.3 215 10.3
<0.001
Yes 25 18.9 33 61.1 315 52.2 352 74.4 176 55.5 291 81.7 14 13.5 37 82.2 530 25.4 713 34.2
Epidu al analgesia
None 28 21.2 2 3.7 0.003 128 21.2 41 8.7
<0.001
79 24.9 23 6.5
<0.001
25 0.24 3 6.7 0.013 260 12.5 69 3.3
<0.001
Yes 104 78.8 52 96.3 475 78.8 432 91.3 238 75.1 333 93.5 79 0.76 42 93.3 896 0.43 859 41.2
Type o bi h
No mal 132 100.0 13 24.1
<0.001
603 1 154 32.6
<0.001
317 1 125 35.1
<0.001
104 1 0 0
<0.001
1156 55.5 292 0.14
<0.001
Dys ocic 0 0.0 41 75.9 0 0 319 67.4 0 0 231 64.9 0 0 45 1 0 0 636 30.5
Episio omy
None s. I-II g ade 100 75.8 10 18.5
<0.001
436 72.3 118 24.9
<0.001
236 74.4 160 44.9
<0.001
98 94.2 2 4.4
<0.001
870 41.7 290 13.9
<0.001
Yes s. III-IV g ade 32 24.2 44 81.5 167 27.7 355 75.1 81 25.6 196 55.1 6 5.8 43 95.6 286 13.7 638 30.6
Pos pa um haemo hage
None 129 97.7 52 96.3 0.584 595 98.7 459 0.97 0.06 308 97.2 341 95.8 0.337 98 94.2 40 88.9 0.252 1130 54.2 892 42.8 0.01
Yes 3 2.3 2 3.7 8 1.3 14 0.03 9 2.8 15 4.2 6 5.8 5 11.1 26 1.2 36 1.7
Ea ly skin- o-skin con ac
Yes 128 97.0 51 94.4 0.411 528 87.6 424 89.6 0.289 297 93.7 322 90.4 0.122 98 94.2 42 93.3 0.833 1051 50.4 839 40.3 0.239
None 4 3.0 3 5.6 75 12.4 49 10.4 20 6.3 34 9.6 6 5.8 3 6.7 105 0.05 89 4.3
Ea ly ini ia ion o b eas eeding
Yes 118 89.4 46 85.2 0.42 449 74.5 367 77.6 0.234 242 76.6 289 81.2 0.144 85 82.5 39 86.7 0.529 894 42.9 741 35.6 0.047
None 14 10.6 8 14.8 154 25.5 106 22.4 74 23.4 67 18.8 18 17.5 6 13.3 260 12.5 187 0.09
p*: Chi-squa ed es ; S1 =Obs e ic Uni Size 1 (<600 bi hs pe yea ); S2 =Obs e ic Uni Size 2 ( om 601 o 1200 bi hs pe yea ); S3 =Obs e ic Uni Size 3 (1201 o 2400 bi hs pe yea );
S4 =Obs e ic Uni Size 4 (>2400 bi hs pe yea ); CI, Con idence In e al; ns, non-signi ican alue >0.05.
In . J. En i on. Res. Public Heal h 2020,17, 8394 8 o 15
In cases whe e he e was no TOC, S3 egis e ed he lowes a e o use o epidu al analgesics
[75.1% (238/317)], while S1 and S2 displayed he g ea es endency o adminis e hem (78.8% ([104/132]
and 78.8% [475/603], espec i ely). In S1, he isk o TOC was se en imes highe when epidu al
analgesics we e adminis e ed han when hey we e no (p=0.003), wi h he a e eaching 96.3% (52/54)
in hese cases. The lowes p e alence o TOC associa ed wi h he use o epidu al analgesics was ound
in S2 (p<0.001), whe e he igu e was 91.3% (432/473).
In e ms o he ype o bi h, all he spon aneous aginal deli e ies (SVD) in S4 (104/104) we e
a ended by midwi es, and he e o e, he e was no TOC. In con as , none o he S4 bi hs in which
TOC occu ed we e SVD (0/45). Meanwhile, in S3, 35.1% (125/356) o he deli e ies ha ea u ed
ans e s o esponsibili ies we e SVD and a ended by obs e icians. The isk o TOC associa ed wi h
labou ending in dys ocia was he highes in S1 (S1, p<0.001; S2, p<0.001; S3, p<0.001).
Wi h espec o he condi ion o he pe ineum when no TOC occu ed, he S4 egis e ed he
highes numbe o cases wi h in ac pe ineum o 1s o 2nd deg ee pe ineal ea s [94.2% (98/104)],
compa ed wi h he igu e o 72.3% (436/603) o S2. In con as , when TOC occu ed, he highes a e
o in ac pe ineum o 1s o 2nd deg ee pe ineal ea s was ound in S3 [44.9% (160/356)], while S4
displayed he lowes a e [4.4% (2/45)]. Meanwhile, hese episio omies o hi d- o ou h-deg ee ea s
we e p esen in 95.6% (43/45) o he cases in S4 when TOC was pe o med. The lowes a e in his
ega d was ound in S3 [55.1% (196/356]. Thus, when TOC occu s, he isk o episio omy o hi d-
o ou h-deg ee pe ineal ea ( a he han an in ac pe ineum o a i s - o second-deg ee ea ) was
ound in S4 o inc ease by a ac o o 350 (p<0.001). The isk o TOC and o episio omy o hi d- and
ou h-deg ee pe ineal ea s was he lowes in S3 (p<0.001).
In addi ion, signi ican di e ences we e ound wi h ega d o he p esence o pos pa um
haemo hages and ea ly ini ia ion o b eas eeding ini ia ion only in he sample as a whole. This e ec
could be explained by he cons uc ion o a mul i a ia e logis ic eg ession model (Wald es ) be ween
hese a iables and he es o he co a iables s udied, obse ing ha he obs e ic uni size, he induced
onse o labou and ha ing an episio omy o g ade III-IV inju y we e associa ed wi h an inc easing isk
o ha ing pos pa um haemo hage. Women who had an episio omy o a g ade III-IV inju y we e wice
as likely o ha e a pos pa um haemo hage compa ed wi h women who had an in ac pe ineum o a
I-II deg ee ea [OR =2.5; CI95%:1.4–4.4]; induc ion o labou is also a isk o pos pa um haemo hage
[OR =1.8; CI95%:1.1–3.1]. Mo eo e , doing skin- o-skin was associa ed wi h an inc eased p obabili y
o ea ly ini ia ion o b eas eeding onse [OR =45.9; 95%CI: 28.89–72.77] (Table 3).
Table 3.
Mul i a ia e logis ic eg ession be ween haemo hage, b eas eeding and ela ed co a iables
(N=2084).
p-Value OR
CI 95% o EXP (B)
Lowe Uppe
Haemo hage
S4 (Re ) 0.001
S1 0.045 0.3 0.1 0.9
S2 0.000 0.2 0.9 0.4
S3 0.014 0.4 0.9 0.8
Induced 0.028 1.8 1.1 3.1
Episio omy 0.001 2.6 1.5 4.4
Cons an 0.001 0.1
B eas eeding Skin- o-skin con ac 0.001 45.9 28.9 72.8
Cons an 0.001 0.2
Fu he mo e, a mul i a ia e logis ic eg ession model was used in o de o p edic he a iables
ha in luenced he TOC. The ela ed a iables we e OUS, pa i y, onse o labou , pha macological
s imula ion o labou and episio omy, wi h he OUS being he mos in luen ial a iable (Table 4).
Women in S3 ha e wice he p obabili y [OR =2.3; 95% CI: 1.4–3.6] o ha ing a TOC compa ed o hose
In . J. En i on. Res. Public Heal h 2020,17, 8394 9 o 15
in S4; being p imipa ous inc eases he p obabili y o TOC by almos wice [OR =1.9; 95% CI: 1.5–2.4];
inducing labou ises his isk by almos h ee imes [OR =2.9; 95% CI: 2.3–3.8] in compa ison wi h
spon aneous onse o labou ; he use o pha macological s imula ion and epidu al analgesia a e also
isk ac o s o pe o ming TOC [OR =1.3; 95% CI: 1.0–1.7, OR =1.7; 95% CI: 1.2–2.4, espec i ely]
and pe o ming an episio omy inc eases he isk o TOC by i e imes [OR =5.3; 95% CI: 4.3–6.6].
The model ob ained a pe cen age p edic ion o 73.4%.
Table 4. Mul i a ia e logis ic eg ession o a iables ela ed o TOC (N=2084).
p-Value OR
95% CI OR
Lowe Uppe
Uni Size
S4 (Re ) 0.001
S1 0.498 0.8 0.5 1.4
S2 0.273 1.3 0.8 2.0
S3 0.001 2.3 1.5 3.6
Pa i y
Mul ipa ous (Re )
Nullipa ous 0.001 2 1.6 2.4
Beginning o deli e y
Spon aneous (Re )
Induc ion 0.001 3 2.3 3.8
Pha macologic s imula ion
None (Re )
Yes 0.011 1.4 1.1 1.8
Epidu al analgesia
None (Re )
Yes 0.001 1.7 1.2 2.4
Episio omy
None (Re )
Yes 0.001 5.3 4.3 6.6
Cons an 0.001 0.1
Nagelke ke R2=0.379; pe cen age p edic ion =73.4%.
4. Discussion
This c oss-sec ional s udy is pa o a b oade e alua ion o ma e ni y se ices in Spain and a
cen e in I eland. This pape ocuses speci ically on he in apa um TOC o low- isk women be ween
heal h ca e p o essionals in obs e ic uni s and he associa ed clinical and o ganiza ional ac o s.
The majo i y o women whose labou ca e was ini ia ed by a midwi e emained in midwi e y
ca e h oughou hei labou and bi h. Howe e , he e we e s a is ical di e ences in he p opo ion
o women ans e ed om midwi e y ca e o obs e ician ca e acco ding o he OUS (numbe o
bi hs). The hospi als wi h he lowes pe cen ages o TOC we e hose in S1 and S4. These OUS g oups
had a ans e pe cen age o 29.4% and 31.2% espec i ely. Meanwhile, S3 had he highes ans e
pe cen age (47.1%). These ans e a es b ough sha ply in o ocus he di e ences be ween midwi e y
and medical models o ca e.
Ou o all women, hose in S4 ( he highes numbe o bi hs pe yea ) we e mos likely o be p o ided
one o one indi idualized ca e by a caseload midwi e y eam. These cases had he lowes equency
o oxy ocin s imula ion, epidu al analgesia, episio omy o se e e pe ineal damage, and eme gency
caesa ean sec ion, and also egis e ed among he lowes ans e pe cen ages. Midwi e y models
ecognize childbi h as a physiological p ocess which has inhe en sociocul u al and psychological
dimensions [
16
]. Ou indings echo he s ong exis ing e idence ha sugges s ha con inui y o
ca e models achie e he bes ou comes. Fo example, women who a e a ended in midwi e y-led
con inui y models o ca e we e ound o be less likely o expe ience egional analgesia and se e e
pe ineal auma [6,17].
