In Midwifery Care

The winter issue of Birth includes a study that provides proof positive that physiologic care is superior to medical management. The study reports the results of Strong Start, a program providing care at American Association of Birth Centers free-standing birth centers to Medicaid beneficiaries. Let’s look at the numbers.

Overall, 3136 women participated, of whom 2082 were at low medical risk. The remaining 1054 had risk factors such as hypertension, preterm labor, non-reassuring fetal testing, etc. that would exclude them from birth center delivery. The proportion of women with these factors was similar to that in the general U.S. population.

The Strong Start population was much less likely to have cesareans (10% vs. 33%), episiotomies (2% vs. 12%), or labor inductions (13% vs. 23%) compared with the U.S. population at large. Moreover, the difference in induction rates is larger than appears because the Strong Start numbers only include women who labored while the U.S. induction rate includes planned cesareans in the denominator. When limited to women planning labor, the U.S. rate rises to 48%. In addition, 93% of the Strong Start women were exclusively breastfeeding at the time they left the birth center or hospital vs. 42% of women nationally. At admission to prenatal care investigators found racial/ethnic disparities in intent to breastfeed (88% white; 72% black; 64% Hispanic), but they disappeared by the end of the pregnancy. The investigators attributed this shift to interactions during prenatal care. Among women at low medical risk, the cesarean and induction rates were both 4%, the episiotomy rate was 2%, and 94% were exclusively breastfeeding at discharge. The Strong Start numbers are all the more remarkable when you consider that these were low-income women who were likely to be experiencing the ill effects of poverty such as poor nutrition or a high-stress living environment.

This brings us to the acid test. To ensure apples-to-apples comparisons, the U.S. uses cesarean rates in 1st-time mothers who have reached full term (37 weeks or more) and are carrying one, head-down baby as one of its health care standards. The national U.S. rate in this subgroup is 27%, but it was half that number—14%—in Strong Start participants. The logic is inescapable: if you apply differing models of care to similar populations and one results in worse outcomes, then it is proven to be inferior to the other. The Strong Start program has unequivocally demonstrated that medical management should be abandoned in favor of physiologic care.

The Take-Away: Seek out care providers who practice physiologic care. These are more likely to be, but are not necessarily, midwives.

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