Preventing Cesarean Birth in Women with Obesity: Influence of Unit‐Level Midwifery Presence on Use of Cesarean among Women in the Consortium on Safe Labor Data Set

Abstract

Introduction: Maternal obesity is associated with slow labor progression and unplanned cesarean birth. Midwives use fewer medical interventions during labor, and the women they care for have lower cesarean birth rates, compared with low-risk, matched groups of women cared for by physicians. The primary aim of this study was to examine associations between midwifery unit-level presence and unplanned cesarean birth in women with different body mass index (BMI) ranges. Unit-level presence of midwives was analyzed as a representation of a unique set of care practices that exist in settings where midwives work. Methods: A retrospective cohort study was conducted using Consortium on Safe Labor data from low-risk, healthy women who labored and gave birth in medical centers with (n = 9795) or without (n = 13,398) the unit-level presence of midwives. Regression models were used to evaluate for associations between unit-level midwifery presence and 1) the incidence of unplanned cesarean birth and 2) in-hospital labor durations with stratification by maternal BMI and adjustment for maternal demographic and pregnancy factors. Results: The odds of unplanned cesarean birth among women who gave birth in centers with midwives were 16% lower than the odds of cesarean birth among similar women at who gave birth at centers without midwives (adjusted odds ratio, 0.84; 95% CI, 0.77-0.93). However, women whose BMI was above 35.00 kg/m 2 at labor admission had similar odds of cesarean birth, regardless of unit-level midwifery presence. In-hospital labor duration prior to unplanned cesarean was no different by unit-level midwifery presence in nulliparous women whose BMI was above 35.00 kg/m 2. Discussion: Although integration of midwives into the caregiving environment of medical centers in the United States was associated with overall decrease in the incidence of cesarean birth, increased maternal BMI nevertheless remained positively associated with these outcomes.

Birth Outcomes of Women with Obesity Enrolled for Care at Freestanding Birth Centers in the United States

“…In contrast, women with obese BMIs in the UK Birthplace Study had a 13.6% cesarean birth rate, 12 and women with BMIs of at least 35 admitted to alongside birth centers in England had a 4.7% cesarean birth rate 29 . Lower cesarean birth rates in these studies may be attributable to evidence‐based midwifery techniques including delaying admission until labor is active, using upright positions and mobility during the first stage of labor, using relaxation techniques for labor pain relief, continuous support in labor, and using water immersion during labor 27–31 …”

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

“…They found the odds of unplanned cesarean birth were 16% lower (aOR, 0.84; 95% CI, 0.77‐0.93) in settings that had midwives compared with settings that did not have midwives. However, women whose body mass index was greater than 35 kg/m 2 at labor admission had similar odds of cesarean birth when units that had midwives were compared with units that did not have midwives …”

“…Two articles in this issue conducted studies using the Consortium on Safe Labor (CSL) database to identify the effect of midwifery care. 16,17 This database categorizes hospitals by those that offer midwifery and obstetric intrapartum care and those that offer obstetric services only. Thus, analyses using the CSL data do not assess the effect of midwifery care directly; rather they compare outcomes of women who give birth in settings where midwives practice versus settings where midwives do not practice.…”

“…However, women whose body mass index was greater than 35 kg/m 2 at labor admission had similar odds of cesarean birth when units that had midwives were compared with units that did not have midwives. 17 Two other studies in this issue evaluated outcomes from large data sets collected in California and provide additional insights. 18,19 Lundsberg et al divided 185 hospitals in California into 2 groups based on their use of interventions such as intermittent auscultation, admission in latent-phase labor, and use of nonpharmacologic methods of pain relief.…”

“…Two articles in this issue conducted studies using the Consortium on Safe Labor (CSL) database to identify the effect of midwifery care . This database categorizes hospitals by those that offer midwifery and obstetric intrapartum care and those that offer obstetric services only.…”