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Primaljska skrb u odnosu na druge modele skrbi za trudnice

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Abstract

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Background

Midwives are primary providers of care for childbearing women around the world. However, there is a lack of synthesised information to establish whether there are differences in morbidity and mortality, effectiveness and psychosocial outcomes between midwife‐led and other models of care.

Objectives

To compare midwife‐led models of care with other models of care for childbearing women and their infants.

Search methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2008), Cochrane Effective Practice and Organisation of Care Group's Trials Register (January 2008), Current Contents (1994 to January 2008), CINAHL (1982 to August 2006), Web of Science, BIOSIS Previews, ISI Proceedings, (1990 to 2008), and the WHO Reproductive Health Library, No. 9.

Selection criteria

All published and unpublished trials in which pregnant women are randomly allocated to midwife‐led or other models of care during pregnancy, and where care is provided during the ante and intrapartum period in the midwife‐led model.

Data collection and analysis

All authors evaluated methodological quality. Two authors checked data extraction.

Main results

We included 11 trials (12,276 women). Women who had midwife‐led models of care were less likely to experience antenatal hospitalisation, risk ratio (RR) 0.90, 95% confidence interval (CI) 0.81 to 0.99), regional analgesia (RR 0.81, 95% CI 0.73 to 0.91), episiotomy (RR 0.82, 95% CI 0.77 to 0.88), and instrumental delivery (RR 0.86, 95% CI 0.78 to 0.96), and were more likely to experience no intrapartum analgesia/anaesthesia (RR 1.16, 95% CI 1.05 to 1.29), spontaneous vaginal birth (RR 1.04, 95% CI 1.02 to 1.06), feeling in control during childbirth (RR 1.74, 95% CI 1.32 to 2.30), attendance at birth by a known midwife (RR 7.84, 95% CI 4.15 to 14.81) and initiate breastfeeding (RR 1.35, 95% CI 1.03 to 1.76), although there were no statistically significant differences between groups for caesarean births (RR 0.96, 95% CI 0.87 to 1.06). Women who were randomised to receive midwife‐led care were less likely to experience fetal loss before 24 weeks' gestation (RR 0.79, 95% CI 0.65 to 0.97), although there were no statistically significant differences in fetal loss/neonatal death of at least 24 weeks (RR 1.01, 95% CI 0.67 to 1.53) or in fetal/neonatal death overall (RR 0.83, 95% CI 0.70 to 1.00). In addition, their babies were more likely to have a shorter length of hospital stay (mean difference ‐2.00, 95% CI ‐2.15 to ‐1.85).

Authors' conclusions

Most women should be offered midwife‐led models of care and women should be encouraged to ask for this option although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Laički sažetak

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Primaljska skrb u odnosu na druge modele skrbi za trudnice

Primaljska skrb nudi prednosti za trudnice i njihovu djecu te se kao takva preporuča.

U mnogim dijelovima svijeta primalje su primarni pružatelji zdravstvene skrbi za trudnice. U drugim pak mjestima tu odgovornost preuzimaju liječnici specijalisti ili liječnici obiteljske medicine, ili je skrb podijeljena. Niti vodilje primaljske skrbi su normalnost, kontinuitet skrbi i prisutnost poznate i pouzdane primalje tijekom porođaja. Naglasak se stavlja na prirodnu mogućnost žene da prođe porođaj uz minimum intervencija. Neki modeli primaljske skrbi obuhvaćaju tim primalja koje dijele određeni broj trudnica, što se naziva „timsko“ primaljstvo. Drugi model je tzv.„primaljstvo jedan na jedan“ gdje je cilj ponuditi veći kontinuitet skrbi uz jednu primalju i njenu suradnicu u primaljskoj praksi. Svi modeli primaljske skrbi nude mrežu koja se sastoji od nekoliko medicinskih stručnjaka koji su dostupni za konzultacije. U liječničkom modelu skrbi, s druge strane, nositelji skrbi su ili specijalist porodničar ili liječnik obiteljske medicine. U modelima sa podijeljenom skrbi, odgovornost se dijeli između nekoliko zdravstvenih djelatnika.

Ovaj pregled literature o primaljskoj skrbi odnosi se na primalje koje pružaju skrb u trudnoći, porođaju i babinju. Opisani se model usporedilo s modelima liječničke skrbi i podijeljene skrbi, za što smo identificirali 11 istraživanja sa ukupno 12 276 žena. Primaljska je skrb imala nekoliko prednosti za majke i djecu, i nije imala negativnih nuspojava.

Glavna prednost je smanjenje učestalosti korištenja lokalnih analgezija, smanjen broj epiziotomija ili porođaja na vakuum ili porodničarskim kliještima. Primaljska je skrb također povećala šanse da uz ženu na porođaju bude primalja koju ona poznaje te je povećala šanse da se žena osjeća kao da donosi vlastite odluke u porođaju, šanse za spontani vaginalni porođaj i uspostavu dojenja. No, nije bilo razlike u postotku carskih rezova.

Žene, koje su nasumično odabrane za primaljsku skrb, rjeđe su prolazile spontani pobačaj prije 24. tjedna trudnoće, dok je rizik od spontanog pobačaja nakon 24. tjedna bio jednak kroz sve modele skrbi. Uz to, djeca čije su majke koristile primaljsku skrb kraće su vrijeme provodila u bolnici.

Ovaj pregled literature je ustanovio da bi sve žene trebale imati mogućnost odabira primaljske skrbi, iako se treba voditi računa o ženama koje su pod povećanim medicinskim ili porodničarskim rizicima.