Routine examination of the newborn: The EMREN study. Evaluation of an extension of the midwife role including a randomized controlled trial of appropriately trained midwives and pediatric senior house officers

Abstract

Objectives: This study assesses the implications and cost-effectiveness of extending the role of midwives to include the routine (24-hour) examination of the healthy newborn usually carried out by junior doctors.

Objectives: This study assesses the implications and cost-effectiveness of extending the role of midwives to include the routine (24-hour) examination of the healthy newborn usually carried out by junior doctors.

Design: The study included a prospective randomized controlled trial (RCT) with mother and baby dyads randomized to either senior house officer (SHO) or midwife for the routine examination of the newborn. Midwives and SHOs were also video taped while performing the examinations, and the videos were rated by an independent consultant and senior midwife. In addition, extensive interviews, surveys, consultations, and assessments were carried out.

Setting: Several settings were involved, including a district general hospital (for the RCT), a London teaching hospital, general practices, and mothers' homes (for interviews). Questionnaires were sent to all maternity units in England (for the National Survey).

Participants: A total of 826 mother and baby dyads in a District General Hospital in southeast England participated. Midwives and SHOs, as well as midwifery managers, pediatric consultants; general practitioners (GPs) and representatives of key organizations also participated.

Interventions: A routine examination of a newborn baby was carried out at approximately 24 hours from birth, and another examination for half the babies in each group was carried out at 10 days at home by the community midwife.

Main outcome measures: Referrals were assessed as appropriate and as major or minor by three independent consultants. Problems identified during the first year of life were assessed as identifiable at 24 hours. Other measures included quality assessment by video against an agreed written proforma, maternal satisfaction, and opinion of professionals and mothers about aspects of the examination.

Results: There was no statistical difference between SHO and midwife examinations in appropriate referral rates to hospital or community or in inappropriate referral rates to hospital. Video taped assessments were assessed to be carried out more appropriately by the midwives than by the SHOs. Overall, maternal satisfaction was high and higher when a midwife rather than an SHO was involved. Few new health problems were identified at the 10-day examination. From the National Survey, it was estimated that approximately 2 percent of babies in England are examined by a midwife. If midwives were to examine all babies where there were no complications of birth or antenatal history, there would be savings of approximately £2 per baby born, equivalent to savings of £1.2 million nationally. Were midwives to examine all babies on normal wards, savings would increase to approximately £4.30 per baby born or £2.5 million nationally. Representatives of the professional bodies were of the opinion that having trained midwives carrying out the examination would be valuable.

Conclusions: All component aspects of the study were consistent in showing benefits or at least no significant barriers to suitably qualified, trained midwives carrying out the examinations. Developing the role of the midwife to include examination of the newborn is likely to result in improved quality of examinations and higher satisfaction from mothers. It would slightly reduce overall health service costs, with some increased resources needed by midwifery departments and some decrease in resource needs of pediatric departments. There is a need for further research into the value of the examination being carried out at home rather than in a hospital, the overall unsatisfactory quality of the examination of the hips, and appropriate inclusion criteria for which babies the midwives should examine.