title: Impact of collaborative management and early admission in labor on method of delivery.
abstract: OBJECTIVE
  This study compared the effects of early admission in labor and perinatal care provider on delivery method. Higher spontaneous vaginal delivery rates for certified nurse midwives as compared with physicians have been reported in observational studies and randomized clinical trials. Certified nurse midwives, with their more expectant approach to labor management, would be expected to admit women later in labor than obstetricians.
  
  
  METHODS
  Prospective cohort study of 2,196 low-risk pregnancies, with singleton, vertex infants admitted in spontaneous labor. Independent and joint effects of perinatal care provider and cervical dilation at admission on delivery method were evaluated. Confounding was addressed using restriction and multiple regression.
  
  
  RESULTS
  Fewer (23.4%) women in collaborative care were admitted in early labor (< 4 cm cervical dilation) than women managed by obstetricians (95% CI = -27.6 to -19.2). Obstetrician care had 9% to 30% fewer spontaneous vaginal deliveries. Women admitted early in labor also had 6% to 34% fewer spontaneous vaginal deliveries. Evaluation of joint effects suggested that interaction between obstetrician provider and earlier admission increased the risk of operative delivery.
  
  
  CONCLUSIONS
  Later admission in labor (at 4 cm or greater cervical dilation) and management of perinatal care by certified nurse midwives in collaboration with obstetricians increased the rate of spontaneous vaginal delivery in low-risk women.
authors.affiliation: University of the Western Cape, School of Public Health, Cape Town, South Africa. bessrfam@iafrica.com
authors.forename: Debra J
authors.initials: DJ
authors.lastname: Jackson
authors.forename: Janet M
authors.initials: JM
authors.lastname: Lang
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Ecker
authors.forename: William H
authors.initials: WH
authors.lastname: Swartz
authors.forename: Tim
authors.initials: T
authors.lastname: Heeren
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000451:nursing / Q000706:statistics & numerical data; D015331:Cohort Studies; D036861:Delivery, Obstetric / Q000451:nursing* / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D007745:Labor Onset; D007743:Labor, Obstetric; D009321:Natural Childbirth / Q000451:nursing* / Q000706:statistics & numerical data; D009721:Nurse Midwives / Q000592:standards*; D024802:Nurse's Role; D018743:Perinatal Care / Q000379:methods; D010818:Practice Patterns, Physicians' / Q000592:standards; D011247:Pregnancy; D011446:Prospective Studies; D012306:Risk; D014481:United States / Q000453:epidemiology