Comparison of Midwifery and Obstetric Care in Low-Risk Hospital Births

Abstract

OBJECTIVE: To compare midwife and obstetrician labor practices and birth outcomes in women with low-risk pregnancies delivered in the hospital. METHODS: We conducted a retrospective cohort study of singleton births of 37 0/7–42 6/7 weeks of gestation at 11 hospitals between January 1, 2014, and December 31, 2018. Exclusions included intrapartum transfer from home-birth center, antepartum stillbirth, previous cesarean delivery, practitioner other than midwife or obstetrician, prelabor cesarean, prepregnancy maternal disease, and pregnancy complications or risk factors. Interventions (induction, artificial rupture of membranes, epidural, oxytocin, and episiotomy), mode of delivery, maternal outcomes (third- or fourth-degree laceration, postpartum hemorrhage, blood transfusion, and severe maternal morbidity), and newborn outcomes (shoulder dystocia, 5-minute Apgar score less than 7, resuscitation at delivery, birth trauma, and neonatal intensive care unit admission) were examined by practitioner type. We used modified Poisson regression models adjusted for individual confounders to assess risk ratios, stratified by parity, for health care provider type and perinatal outcomes. RESULTS: The study cohort comprised 23,100 births (3,816 midwife and 19,284 obstetrician). Compared with obstetricians, midwifery patients had significantly lower intervention rates, an approximately 30% lower risk of cesarean delivery in nulliparous patients (adjusted relative risk [aRR] 0.68; 95th% CI 0.57–0.82), and an approximately 40% lower risk of cesarean in multiparous patients (aRR 0.57; 95th% CI 0.36–0.89). Operative vaginal birth was also less common in nulliparous patients (aRR 0.73; 95th% CI 0.57–0.93) and multiparous patients (aRR 0.30; 95th% CI 0.14–0.63). Shoulder dystocia was more common in multiparous patients receiving midwifery care (aRR 1.42; 95th% CI 1.04–1.92). CONCLUSIONS: In low-risk pregnancies, midwifery care in labor was associated with decreased intervention, decreased cesarean and operative vaginal births, and, in multiparous women, an increased risk for shoulder dystocia. Greater integration of midwifery care into maternity services in the United States may reduce intervention in labor and potentially even cesarean delivery, in low-risk pregnancies. Larger research studies are needed to evaluate uncommon but important maternal and newborn outcomes.

The role of midwifery and other international insights for maternity care in the United States: An analysis of four countries

“…75,76 Effective collaboration has been identified as critical to US obstetric/midwifery practice models with improved outcomes. 77,78 Key factors for successful collaboration were integration of care, mutual trust and respect, regulation for the full scope of midwifery practice, and interprofessional education. There is a growing maternity workforce crisis in the United States; over half of US counties do not have a maternity provider.…”

Outcomes of trial of labor after cesarean birth by provider type in low‐risk women

“…Data suggest that CNMs may have lower overall unplanned cesarean rates compared with obstetricians managing low‐risk pregnancies, but the rate of cesarean and the risks by provider type specifically for labor after cesarean are not known. We hypothesized that CNM management of low‐risk TOLAC patients increases vaginal delivery success without additional morbidity.…”

“…13 Despite the small but potentially catastrophic risks of TOLAC, it remains cost-effective and provides improved long-term health outcomes compared with scheduled repeat cesarean. 20 Data suggest that CNMs may have lower overall unplanned cesarean rates compared with obstetricians managing low-risk pregnancies, [21][22][23] but the rate of cesarean and the risks by provider type specifically for labor after cesarean are not known. We hypothesized that CNM management of low-risk TOLAC patients increases vaginal delivery success without additional morbidity.…”

The Effectiveness of Midwifery Care in the World Health Organization Year of the Nurse and the Midwife: Reducing the Cesarean Birth Rate

“…11 More recent work has used statistical methods to control for a priori differences in the population of women served by midwives and the population served by physicians. 12 These techniques can adjust for variables that are known to independently influence an individual's risk for cesarean as long as those variables are present in the data, but they cannot control for variables that are not accounted for or are unknown, a limitation of all observational studies. Systematic reviews are designed to assess the full body of relevant published research in order to identify a consistent theme or effect.…”

“…The independent effect of midwifery care on cesarean birth rates in settings where obstetric interventions such as neuraxial analgesia, intravenous medications, and cesarean are commonly employed has been difficult to parse. Some studies have found that midwifery care is associated with lower cesarean rates, whereas others have found that midwifery care is not associated with a change in cesarean rates . Given all studies that have compared the outcomes of individual women after receipt of midwifery or obstetric care are generally positive but potentially confounded by different types of bias, it is time to look at this issue differently.…”