以助产士为基础的城市正常孕产妇保健模式构建与实证研究

Child policy transition highlighted the tendency of over-medicalization and the weakening function of prevention and health management in midwifery services in urban cities, China. There is an urgent need to develop the midwife-based care model for urban women with uncomplicated pregnancies, as a useful supplement to the current obstetrician-led model which mainly focuses on high-risk pregnant women. Oriented by the needs of women with uncomplicated pregnancies, the working scope for caring them and the core service items will be ascertained through multiple research approaches on basis of our previous studies. Informed by "midwife-led care model " that is popular in Northern Europe, mainly focusing on the service items that midwives can provide, organization of all the service items, continuity of midwifery services, and multidisciplinary collaboration, we will employ grounded theory study to establish the midwife-based care model for uncomplicated pregnant women. The model will be revised and confirmed through key informant interviews and intention survey in midwifery institutions nationwide. Then the evidence-based methods will be applied to translate the care model to practical protocol. Guided by the theory of diffusion of innovation, we will select midwifery institutions with good foundation and strong intention to implement the protocol. Quasi-experimental study will be carried out to evaluate the effectiveness of the model. This project is supposed to explore the rational use of healthcare human resources to improve the efficiency of midwifery services and manage the effect of child policy change. It can also provide decision-making information for the government to rationally allocate the proportion of midwives and obstetricians.

生育政策调整使中国城市助产服务过度医疗化、预防保健功能弱化问题更加凸显。需构建以助产士为基础的城市正常孕产妇保健模式，作为现行高危诊疗模式的有益补充，以夯实预防保健基础、推进防治结合服务模式。将基于前期研究基础，以正常孕产妇需求为导向，综合多种研究方法确定所需提供给城市正常孕产妇的服务范畴和核心项目。在此基础上借鉴北欧国家助产士服务模式，采用扎根理论研究，聚焦助产士可提供的服务项目、服务项目的组织管理、服务的连续性和多学科协作性，构建“以助产士为基础的城市正常孕产妇保健模式”，并通过关键知情人访谈和助产机构意向调查进行调整、确认。然后采用循证方法对模式进行具化形成实践方案，在创新扩散理论指导下选择基础好、意向强的助产机构模拟运作，最后采用类试验研究评价效果。此项目在合理使用人力资源、提高助产服务效率、应对生育政策调整效应方面进行探索，可为政府合理配置助产士和产科医生比例提供决策依据。

生育政策调整使中国城市助产服务过度医疗化、预防保健功能弱势化、助产士服务边缘化等问题更加凸显，亟需优化助产士服务职能，构建以助产士为基础的正常孕产妇保健模式，作为现行高危诊疗模式的有益补充，以夯实预防保健基础、推进防治结合服务模式，满足孕产妇多层次健康需求。.本项目以Renfrew循证助产服务框架为指导，在分析国内外相关政策文件和文献基础上，从供需方双角度开展助产服务的需求评估，并进行差距分析，最后通过两轮Delphi专家咨询，确定了所需提供给中国城市正常孕产妇的助产服务范畴和任务清单，包括3项一级指标（服务阶段）、13项二级指标（任务要素）、58项三级指标（服务项目），并从任务清单二级和三级指标中进一步提取我国助产士服务的常规任务要素和拓展任务要素各3项，形成了以助产士为基础的正常孕产妇保健服务模式，即中国城市助产士服务优化模式，信息、教育和咨询（Information, Education, Counselling, IEC）、评估、筛查和转介（Assessment, Screening, Referral, ASR）、以及健康管理和正常分娩促进（Health management, Promotion of normal childbirth, HP）这三大要素是此模式下需要拓展的助产士工作任务。以此为基础，在Stetler证据应用模式指导下，综合了24篇由国际权威机构发布的临床实践指南，吸收了本地多学科专家团队以及试点机构利益相关群体的意见和建议，形成了由233条证据集成的适用于我国本土的实践内容推荐意见，其中165条证据属于拓展任务。然后以结构-过程-结果三维质量模型为指导，选择上海市某医院进行试点，开展实证研究。共招募22名高年资助产士进行实践方案培训和模拟运作。最后采用随机对照试验，对干预方案的实施进行效果评价。共招募984例符合纳入和排除标准的孕妇进行随机分组，干预组予以新的实践方案，对照组予以常规服务。813例纳入分析，749例完成全部随访。实证研究验证了此服务模式的可操作性、安全性和有效性，降低了剖宫产率等医疗干预指标，并改善了孕产妇的服务体验及部分健康结局。.本项目在优化助产士服务职能、应对生育政策调整效应方面进行了有益探索，为政府合理配置助产人力资源、提升助产服务内涵提供决策依据。