BC study shows integrated midwifery care safe for moderate- and high-risk pregnancies

Midwives have been regulated primary health care providers in BC since 1998, usually providing medical care in pregnancy, birth and up to 3 months after birth.

To understand the outcomes of childbearing people in BC with a midwife as the most responsible provider (MRP) who provided the most care, researchers looked at outcomes of midwifery clients compared with people cared for by a family physician or obstetrician. Of the 425 056 births in the study, 63 151 (14.9%) had a midwife as their MRP, 189 679 (44.6%) a family physician and 172 226 (40.5%) an obstetrician. The proportion of births that had a midwife listed as MRP increased from 9.2% to 19.8% over the study period.

Clients whose MRP was a midwife were less likely to have preterm births and low-birth-weight babies whether at low, moderate or high risk of complications, compared with those with a physician MRP. Cesarean delivery rates increased for midwife clients as medical risk increased but were lower than rates for people with physician MRPs.

“As medical risk increases, both midwives and family physicians collaborate increasingly and appropriately with obstetrician specialists,” writes Dr. Kathrin Stoll, Department of Family Practice, University of British Columbia, with coauthors. “The study provides evidence for the safety and efficacy of midwife-led care across medical risk strata in BC.”

Over the study period (2008–2018), the proportion of people with midwives as their MPR increased for all low-risk, moderate-risk and high-risk births.

Despite increases in midwifery care during the study period, Canada has some of the lowest rates of midwifery access in the world and increasing rates of cesarean delivery.

“[T]he study provides population-level evidence that midwives provide safe primary care for clients with varied levels of medical risk. If scaled up, the expansion of midwifery in BC holds potential for meeting national mandates to lower obstetric intervention rates and to increase access to midwifery care to under-served communities,” the authors write.

They recommend that expansion of midwifery should be supported by policies and payment structures that enable retention of midwives, health system integration and collaboration with physician colleagues.

In a related editorial, Dr. Shannon Charlebois, a family physician and editor, CMAJ, writes “Midwives can provide continuity of maternal care and spend an amount of dedicated time with their patients that cannot be matched by physicians” but notes that as other parts of Canada are less advanced in midwifery care, the study findings may not be widely applicable.

“For many people who give birth, midwifery is a safe, evidence-based, appropriate option that they should be able to choose to access,” Dr. Charlebois writes. “For others, obstetric care from a physician may be preferred or more appropriate. Therefore, trust and willingness to collaborate must continue to develop between physicians and their midwife colleagues; this will be enhanced by careful planning of services that can ensure safe systems of integrated obstetric care in all Canadian jurisdictions.”

“Perinatal outcomes of midwife-led care, stratified by medical risk: a retrospective cohort study from British Columbia (2008–2018)” was published February 27, 2023. n H

Nirmatrelvir–ritonavir (Paxlovid) significantly reduced the likelihood of hospitalization or death from COVID-19 in people at risk of severe illness, according to new research in CMAJ (Canadian Medical Association Journal).

The study, conducted by Ontario researchers, aimed to evaluate the effectiveness of nirmatrelvir–ritonavir in preventing severe illness during the emergence of the Omicron variant. They looked at data on adults with mild disease who tested positive for SARS-CoV-2 by polymerase chain reaction (PCR) test between April 4 and August 31, 2022, and compared 8,876 patients treated with nirmatrelvir–ritonavir with 168,669 who were not treated. Most patients were older than 70 years, were vaccinated and had potential drug–drug interactions.

A previous randomized controlled trial, Evaluation of Protease Inhibition for COVID-19 in High-Risk Patients (EPIC-HR), conducted before the emergence of the Omicron variant had found nirmatrelvir–ritonavir to be effective at treating patients. That trial, however, did not include people who had been vacci- nated or who had potential drug-drug interactions.

“Our study, in conjunction with previous clinical trials and observational research, supports the effectiveness of nirmatrelvir–ritonavir at reducing hospital admission from COVID-19 and allcause death,” writes lead author Dr. Kevin Schwartz, Public Health Ontario and ICES, Toronto, Ontario, with coauthors.

They found that for every 62 people treated with nirmatrelvir–ritonavir, the medication prevented one case of severe COVID-19.

According to Dr. Schwartz, “This study highlights the importance of testing for SARS-CoV-2 if you have symptoms, and access to Paxlovid for those at risk for severe COVID-19. If you test positive for COVID-19, are over 60 years of age, or if you have other risk factors for severe infection, such as chronic medical conditions or are undervaccinated, contact your health care provider or pharmacy within 5 days of symptoms starting and ask about Paxlovid.”

“Population-based evaluation of the effectiveness of nirmatrelvir–ritonavir for reducing hospital admissions and mortality from COVID-19” was published February 13, 2023. n H