Abstract
Background
Data Sources
Study Eligibility Criteria
Methods
Results
Limitations
Conclusion
Introduction
Andrews, R. M. (2008). The national hospital bill: The most expensive conditions by payer, 2006. Available: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb59.pdf. Accessed January 14, 2010.
Sakala, C., & Corry, M. P. (2008). Evidence-based maternity care: What it is and what it can achieve. Available: http://www.milbank.org. Accessed July 8, 2009.
American College of Nurse-Midwives. (2004). Philosophy of the American college of nurse-midwives. Available: http://www.midwife.org/display.cfm?id=480&print=2. Accessed August 4, 2010.
Review Question
Newhouse, R., Stanik-Hutt, J., White, K. M., Johantgen, M., Bass, E., Zangaro, G., et al. (2010). Advanced practice nurse outcomes 1990-2008: A systematic review. Nursing Economic$ 29(5). Available: https://www.nursingeconomics.net/ce/2013/article3001021.pdf. Accessed July 15, 2011
Review Methods
Defining the Question
Searching for Studies

Selecting Studies and Collecting Data

Assessing Risk of Bias/Study Quality
Summarizing Results
Interpreting Findings/Grading of Evidence
- •High: Further research is unlikely to change confidence in the estimate of effect.
- •Moderate: Further research is likely to have an important impact on confidence in estimate of effect and may change the estimate.
- •Low: Further research is very likely to have an important impact on confidence of estimate of effect and is likely to change the estimate.
- •Very low: Any estimate of effect is very uncertain.
Criteria | Decrease from Baseline Level | Definition |
---|---|---|
1: Based on the number of studies and numbers of patients, is this sparse? | −1 | Sparse reflects <3 studies per outcome; <2 RCTs when RCTs are appropriate |
2: As a body of evidence, are the study designs the strongest o answer the question? | −1 | Strong study designs may be dependent on outcome studied; RCTs are not always feasible. |
3: Is the quality of the studies acceptable? | −1 | Refers to the study methods and execution and is reflected in the individual study quality ratings. |
4: Are there important inconsistencies across the studies? | −1 | Refers to similar estimates of the effect. Inconsistency is demonstrated through differences in directions of effect and significance. |
5: Is there concern about the directness of the evidence? | −1 | The extent to which study participants, measures, and outcomes are similar to the population of interest. |
6: Is there a high probability of reporting bias? | −1 | Refers to other publication bias and selective reporting bias that would result in more significant differences in comparison groups. |
Results
Author (Year) | Comparisons | Patient Population | Study Quality |
---|---|---|---|
RCTs (n = 2) | |||
Heins et al., 1990 | Multicomponent prenatal intervention administered by CNM (n = 667) compared with care from obstetricians (n = 679) according to local standards. | Pregnant women attending state-funded prenatal clinics and considered high risk for low birthweight. | 6/High |
Chambliss et al., 1992 | Compared women randomly assigned to unit for normal birth managed by CNM (n = 234) with those managed by senior residents (n = 253) on a separate floor. | Pregnant, low-risk women. | 7/High |
Observational (n = 19) | |||
Baruffi et al., 1990 | Compared women at a women's hospital where care was provided by CNM (n = 788) with women in a teaching hospital where care was by residents and attending physicians (n = 761). | Pregnant women delivering in 1977–1978 at 1 hospital; excluded previous Cesarean. | 6/High |
Blanchette, 1995 | Compared women in a primary care access clinic staffed by CNMs (n = 496) with the same clinic's private patients cared for by the obstetricians (n = 611). | Pregnant women giving birth August 1991–March 1994 at single practice; excluded those with medical problems. | 4/Low |
Butler et al., 1993 | Compared women cared for by CNMs providing personal labor support (n = 1,056) with those cared for physicians (n = 3,551). | Pregnant women delivering January 1981–June 1988; considered low risk for poor outcomes. | 6/High |
Cragin, 2002 | Compared total population of women who enrolled for prenatal care with either CNM (n = 822) or obstetrician (n = 351) at 2 sites. | Pregnant women receiving care at 2 sites and considered moderate risk. | 6/High |
Cragin and Kennedy, 2006 | Compared sample of women who chose CNM (n = 196) with those who chose physician (n = 179) care. | Pregnant women giving birth at single urban hospital and considered low or moderate risk. | 5/High |
Davis et al., 1994 | Compared medical interventions and outcomes for women managed by CNM (n = 529) with those managed by obstetricians (n = 8,266). | Pregnant, low-risk women delivered between January 1, 1987 and December 31, 1990. Low-risk women given the option of CNM service or traditional care by MDs. | 6/High |
DeLano et al., 1997 | Compared 20-year trends in births in CNM service (n = 3,123) with births by physicians (n = 4,597) in the same hospital. | Pregnant women; excluded cesarean, multiple birth, and <35 weeks gestation. | 5/High |
Fischler and Harvey, 1995 | Compared 3 different models of prenatal care delivery in relation to pregnancy outcomes (CNM–clinic, n = 309; CNM–private, n = 111; physician–private, n = 297). | Pregnant, low-income, women giving birth between January 1, 1989 and June 30, 1990. Groups varied at baseline in demographic and risk factors. | 3/Low |
Hueston and Rudy, 1993 | Compared labor and delivery management of patients admitted in labor to either a CNM (n = 400) or family physician practice (n = 450). | Random sample of pregnant women receiving care at medical center primary care group between January 1990 and December 1991. | 7/High |
Jackson et al., 2003a | Compared outcomes for women in collaborative care (CNM-MD, n = 1413) with women in traditional MD-only (n = 783) model. | Pregnant, low-income women enrolling for prenatal care at study site from February 1994–November 1996; judged to be at low risk at first prenatal visit, and spontaneous delivery of singleton fetus in vertex position. | 6/High |
Jackson et al., 2003b | Compared outcomes for women in collaborative care (CNM-MD, n = 1,808) with traditional MD-only (n = 1,149) model. | Pregnant, low-income women enrolling for prenatal care at study site from February 1994–November 1996; judged to be at low risk at first prenatal visit, and spontaneous delivery or singleton fetus in vertex position. | 6/High |
Lenaway et al., 1998 | Compared the outcomes of women in a public–private, CNM-led program (n = 692) with women in 2 nonintervention counties cared for by physicians (n = 1,399). | Pregnant, low-income women presenting to single county health department September 1989–December 1990; comparison group drawn from 2 other counties. | 5/High |
Low et al., 2000 | Compared outcomes for women who chose care by CNM group to women who chose care by one of faculty obstetricians (total n = 865). Secondary analysis of larger study. | Pregnant women receiving care from 1987 to 1992 at a tertiary medical center; eligible for midwifery care; had normal spontaneous vaginal birth of single, liveborn infant in the vertex position. | 6/High |
MacDorman and Singh, 1998 | Compared differences in birth outcomes for women delivered by CNMs (n = 153,194) versus MDs/doctors of osteopathy (n = 2,634,550). | Pregnant women with vertex, vaginal, ≥35–43 weeks, singleton, liveborn from 1991 national linked birth/death data. | 6/High |
Oakley et al., 1995 | Compared care processes of women who chose care by CNM (n = 471) with those who chose care by obstetricians (n = 710). | Pregnant women receiving care from 1988 to 1992 at a tertiary medical center; eligible for midwifery care. | 6/High |
Oakley et al., 1996 | Compared care processes of women who choose care by CNM (n = 471) with those who chose care by obstetricians (n = 710). | Pregnant women receiving care from 1988 to 1992 at a tertiary medical center; eligible for midwifery care. | 6/High |
Robinson et al., 2000 | Compared women delivered by CNM (n = 565) with those delivered by faculty obstetricians (n = 192) and those delivered by private obstetricians (n = 819). | Pregnant women entering care between December 1994 and July 1995; nulliparas, singleton, spontaneous vaginal delivery after 36 weeks, and nondiabetic. | 6/High |
Rosenblatt et al., 1997 | Compared differences in patterns of care from a random sample of obstetricians (n = 54), family physicians (n = 54), and CNMs (n = 43), using a random sample of their low-risk patients. | Pregnant women who initiated care with one of the randomly selected providers between September 1988 and August 1989; considered low risk. | 7/High |
Sze et al., 2008 | Compared outcomes for women delivered by CNMs (n = 3,219), residents (n = 2,001), or obstetricians (n = 3,703). | Pregnant women with singleton, cephalic vaginal delivery that occurred between 2000 and 2004 at tertiary medical center; ≤37 weeks gestation; using forceps or vacuum were excluded. | 6/High |
Author (Year) | Study Quality Rating | Outcomes (Number of Studies) | |||
---|---|---|---|---|---|
Process of Labor | Epidural (10) | Labor augmentation (9) | Labor Induction (9) | Labor analgesia (6) | |
Blanchette, 1995 | 4 | Favors CNM | Favors CNM | Favors CNM | NS |
Butler et al., 1993 | 6 | NS | – | – | – |
Chambliss et al., 1992 | 7 | – | Favors CNM | – | Favors CNM |
Cragin and Kennedy, 2006 | 5 | Favors CNM | – | – | – |
Davis et al., 1994 | 6 | Favors CNM | Favors CNM | Favors CNM | Favors CNM |
Hueston and Rudy, 1993 | 7 | NS | Favors CNM | Favors CNM | NS |
Jackson et al., 2003b | 7 | Favors CNM | – | Favors CNM | Favors CNM |
Lenaway et al., 1998 | 5 | – | Favors MD | Favors MD | – |
Oakley et al., 1995 | 6 | Favors CNM | NS | NS | Favors CNM |
Robinson et al., 2000 | 6 | Favors CNM | Favors CNM | Favors CNM | – |
Rosenblatt et al., 1997 | 7 | Favors CNM | Favors CNM | Favors CNM | – |
Sze et al., 2008 | 6 | Favors CNM | NS | NS | – |
Evidence grade | Moderate | High | Moderate | High | |
Process of Birth | Cesarean (15) | Vaginal operative (8) | Episiotomy (8) | VBAC (5) | |
Baruffi et al., 1990 | 6 | Favors CNM | – | – | – |
Blanchette, 1995 | 4 | Favors CNM | NS | Favors CNM | Favors CNM |
Butler et al., 1993 | 6 | Favors CNM | Favors CNM | – | – |
Chambliss et al., 1992 | 7 | NS | Favors CNM | Favors CNM | – |
Cragin, 2002 | 6 | Favors CNM | Favors CNM | – | Favors CNM |
Cragin and Kennedy, 2006 | 5 | Favors CNM | – | – | – |
Davis et al., 1994 | 6 | Favors CNM | Favors CNM | – | Favors CNM |
DeLano et al., 1997 | 5 | Favors CNM | NS | – | Favors CNM |
Fischler and Harvey, 1995 | 3 | Favors CNM | – | – | – |
Hueston and Rudy, 1993 | 7 | Favors CNM | – | Favors CNM | – |
Jackson et al., 2003b | 5 | Favors CNM | – | Favors CNM | – |
Jackson et al., 2003a | 5 | Favors CNM | – | – | – |
Lenaway et al., 1998 | 5 | – | – | – | NS |
Low et al., 2000 | 6 | NS | – | Favors CNM | – |
Oakley et al., 1995 | 6 | Favors CNM | Favors CNM | Favors CNM | – |
Robinson et al., 2000 | 6 | – | – | Favors CNM | – |
Rosenblatt et al., 1997 | 7 | NS | Favors CNM | Favors CNM | – |
Evidence grade | High | High | High | Moderate | |
Infant outcome | Low Apgar (11) | Low Birthweight (8) | NICU admission (5) | Breastfeeding (3) | |
Blanchette, 1995 | 4 | NS | NS | – | – |
Butler et al., 1993 | 6 | NS | – | Favors CNM | – |
Chambliss et al., 1992 | 7 | NS | – | – | – |
Cragin, 2002 | 6 | – | – | – | Favors CNM |
Davis et al., 1994 | 6 | NS | – | – | – |
Fischler and Harvey, 1995 | 3 | NS | NS | NS | – |
Heins et al., 1990 | 6 | – | NS | – | – |
Hueston and Rudy, 1993 | 7 | NS | – | – | – |
Jackson et al., 2003b | 7 | NS | NS | NS | Favors CNM |
Jackson et al., 2003a | 5 | NS | – | – | – |
Lenaway et al., 1998 | 5 | Favors CNM | NS | – | – |
MacDorman and Singh, 1998 | 6 | – | Favors CNM | – | – |
Oakley et al., 1996 | 6 | NS | NS | Favors CNM | Favors CNM |
Rosenblatt et al., 1997 | 7 | NS | – | – | – |
Sze et al., 2008 | 6 | – | Favors CNM | – | – |
Evidence grade | High | High | Moderate | Moderate | |
Maternal outcome | Perineal lacerations (5) | ||||
Chambliss et al., 1992 | 7 | Favors CNM | |||
Hueston and Rudy, 1993 | 7 | Favors CNM | |||
Low et al., 2000 | 6 | Favors CNM | |||
Oakley et al., 1996 | 6 | Favors CNM | |||
Robinson et al., 2000 | 6 | Favors CNM | |||
Evidence grade | High |
Discussion
References
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American College of Nurse-Midwives. (2004). Philosophy of the American college of nurse-midwives. Available: http://www.midwife.org/display.cfm?id=480&print=2. Accessed August 4, 2010.
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Biography
Article info
Publication history
Footnotes
Supported by Tri-Council for Nursing and the Advanced Practice Registered Nurse Alliance (PI: Newhouse, Robin).