In Midwifery Care

When it comes to comparing outcomes with a midwife vs. a doctor, research shows that in women with uncomplicated pregnancies, midwives are the better bet. Let’s look at the details of a recent study. Once we do that, I’ll explain why midwives do better than obstetricians when caring for healthy women and end, as I usually do, with the “Take-Away”: my tips and ideas for using your knowledge to obtain the best care for you and your baby. Finally, this study isn’t a one-off. If you’d like to read a summary of the body of research comparing midwifery care with obstetric management, scroll down to “Taking a Deeper Dive.”

What Did the Study Find?

Investigators analyzed data from 11 U.S. hospitals participating in an initiative for quality improvement (Souter 2019). Because obstetricians also care for women with pregnancy and health problems while midwives mostly care for women at low risk for complications, participants were limited to women with problem-free pregnancies. For example, women who had diabetes or high blood pressure, who smoked or who had labor induced (started artificially) for medical reasons, or who had a prior cesarean were excluded from the study. This left 3,816 women who received labor care from midwives and 19,284 who were managed by obstetricians.

Women with prior vaginal births benefited from midwifery care, but we’ll focus on 1st-time mothers because they are more likely to require medical intervention and to have cesarean or instrumental deliveries. Among 1st-time mothers, 1,710 were cared for in labor by midwives vs. 9,096 managed by obstetricians. Regarding labor management, women receiving midwifery care were less likely to:

  • have labor induced for non-medical reasons (15% vs. 20%). (Women having inductions for medical indications were excluded from the study.)
  • be in early labor (3 cm dilated or less) when admitted to the hospital (28% vs. 43%).
  • have a care provider rupture membranes (break the bag of waters) in labors that started on their own (57% vs. 67%) or as part of inducing labor (64% vs. 78%).
  • be given IV oxytocin to strengthen contractions in labors that began on their own (40% vs. 51%).
  • have an epidural in labors that began on their own (59% vs. 80%).
  • have an episiotomy (a cut made to enlarge the vaginal opening for birth) (4% vs. 7%).

First-time mothers cared for by midwives were also more likely to have a “physiologic birth,” defined as spontaneous onset of labor, no rupturing the membranes, no IV oxytocin, no epidural, spontaneous vaginal birth, and no episiotomy (9% vs. 3%), although rates were extremely low in both groups considering that this was an ultra-low-risk population. By contrast, a large U.S. home birth study reported a transfer to hospital rate among first-time mothers of 23%, which means that while some women may have had membranes ruptured during labor at home, and a few would have had episiotomies, much higher percentages of equally low-risk women had physiologic births, probably something more on the order of 60-70%. (Cheyney 2014).

Turning to outcomes, 1st-time mothers having midwifery care were less likely to:

  • have a cesarean delivery (11% vs. 21%). Twenty-one percent is a shockingly high number for women managed by obstetricians, considering that participants were healthy women carrying healthy babies.
  • have an instrumental vaginal delivery (6% vs. 11%).
  • have a tear extending from the vaginal opening into or through the anus (5% vs. 7%). (Note: In the U.S. and Canada, the usual type of episiotomy is a cut straight towards the anus [median or midline episiotomy] whereas in most of the rest of the world, the cut is angled off to the side [mediolateral episiotomy]. Midline episiotomies tend to promote anal tears, and mediolateral episiotomies appear to offer some protection against anal injury in instrumental vaginal deliveries.)

Rates of all other maternal outcomes were similar between groups, including the need for blood transfusion or the occurrence of any of a list of severe maternal adverse outcomes. Newborn outcomes were also similar between groups, including the need for resuscitation at birth, admission to an intensive care nursery, and injury during delivery. In other words, midwifery care had considerable advantages and no disadvantages.

Why Do Midwives Do Better?

The study’s findings shouldn’t surprise anyone. Every study comparing midwives with obstetricians has found that midwives achieve equally good or better maternal and newborn outcomes with less use of medical intervention and more use of physiologic care practices compared with obstetricians caring for similar women. (See “Taking a Deeper Dive” below for more details.)

As to why this might be so, heading up the list is decreased use of medical interventions because every intervention carries the potential of harm as well as benefit. If care providers intervene in situations where it could have been avoided by supportive care or just by having more patience, then women are exposed to the risks with no counterbalancing benefit. Furthermore, one intervention tends to beget the use of additional interventions to avert or fix the problems caused by the first one, each of which has its own adverse effects. Midwives are also more likely to engage in labor practices that promote the physiologic process such as encouraging mobility during the cervical dilation stage, recommending effective pushing positions, permitting eating and drinking, offering alternatives to epidurals such as soaking in warm water in a deep tub or N20 (laughing gas) inhalation, boosting confidence, and helping women work through anxieties or fears. Self-selection probably plays a role too. Women choosing midwifery care in countries where it isn’t the norm often do so because they want a different style of care. They don’t want an elective induction or plan on having an epidural, both of which are prime generators of the cascade of interventions.

In fact, as my contrast with midwives caring for women outside of the hospital suggests, the midwives in this study didn’t do nearly as well as they could have. One problem of studies like this one is that practitioner type is a stand in for model of care. But not all midwives practice physiologic care, and some of those who want to may be constrained by hospital or their employer physician’s policies. Even midwives in independent practice may be constrained by the need to keep their back-up obstetricians sweet. What is more, not all obstetricians practice medical-model management. A comparison between physiologic care and medical management, regardless of practitioner, would almost certainly show even greater benefits for physiologic care.

The Take-Away

  • The odds of having physiologic care are better with a midwife. Health permitting, look for a midwife instead of an obstetrician.
  • Hospital or physician policies may constrain the provision of physiologic care. Health permitting, plan to have your baby at a freestanding birth center, that is, a birth center that isn’t inside of a hospital, or at home.
  • Plan ahead; if you think a midwife might be right for you, and you’re not currently pregnant. choose an insurance plan that includes midwives during open enrollment. Bonus: Many midwives also do well-woman gyne care, which you may find more to your liking as well.
  • Comparing outcomes by care provider isn’t the same thing as comparing models of care. Care providers may not practice according to what is typical for their type. Interview potential care providers (or your current providers) to see if they practice physiologic care. My video, “Tips for Choosing an Obstetrician or Midwife,” can help with this.
  • Decreased use of medical intervention is a major reason why midwives achieve better outcomes. Make sure your birth plans align with principles of physiologic care. Specifically, unless there’s a medical indication for inducing labor, plan on waiting for labor to start on its own and plan to cope with the pain of labor by means other than an epidural.

Taking a Deeper Dive

Midwife-led care achieves equally good or better maternal and newborn outcomes with less use of medical management and more use of physiologic care.

Note: References in italics are systematic reviews (studies of studies on a particular topic). Many systematic reviews pool data among the studies (meta-analyses), which strengthens their conclusions.

Most systematic reviews and studies find that women under a midwife’s care are less likely to have:

  • labor induction (Altman 2017; Harvey 1996; Johantgen 2012; Sutcliffe 2012),
  • continuous fetal monitoring (Jackson 2003; Janssen 2007; Oakley 1995; Rosenblatt 1997),
  • a routine IV (Harvey 1996; Jackson 2003; Oakley 1995; Sutcliffe 2012),
  • membranes ruptured (Altman 2017; Bodner-Adler 2004; Carlson 2018; Harvey 1996; Hueston 1993; Jackson 2003; Oakley 1995; Sutcliffe 2012),
  • IV oxytocin to strengthen labor (Altman 2017; Bernitz 2011; Bodner-Adler 2004; Harvey 1996; Jackson 2003; Johantgen 2012; Sutcliffe 2012),
  • epidural analgesia (Altman 2017; Bernitz 2011; Carlson 2018; Harvey 1996; Janssen 2002; Johantgen 2012; Sutcliffe 2012), or
  • an episiotomy (Bodner-Adler 2004; Browne 2010; Harvey 1996; Johantgen 2012; Schimmel 1994; Shorten 2002; Sutcliffe 2012; Sze 2008).

Studies that don’t find reduced rates find similar rates with two exceptions: a study found that obstetric residents used episiotomy less often than midwives (Sze 2008), and a study of midwives vs. family physicians found that midwives were more likely to rupture membranes in 1st-time mothers (Hueston 1993).

Women cared for by midwives are more likely to:

  • drink and eat in labor (Cragin 2006; Jackson 2003),
  • be up and around in labor (Cragin 2006; Jackson 2003; Oakley 1995). and
  • give birth in a position other than on their backs (Bodner-Adler 2004).

Probably because of a combination of differing philosophies and less use of medical intervention and therefore avoidance of their potential harms, midwifery care results in maternal and newborn outcomes that may be better, or at least are no worse, than with physician management. Specifically, women under a midwife’s care may be less or equally likely to have:

  • an instrumental vaginal delivery (Altman 2017; Bernitz 2011; Carlson 2018; Harvey 1996; Jackson 2003; Johantgen 2012; Nijagal 2015; Sutcliffe 2012),
  • a cesarean delivery (Altman 2017; Bernitz 2011; Carlson 2018; Harvey 1996; Janssen 2007; Johantgen 2012; Nijagal 2015; Schimmel 1994; Sutcliffe 2012),
  • or a tear into or through the anal sphincter (Altman 2017; Bernitz 2011; Bodner-Adler 2004; Browne 2010; Chambliss 1992; Harvey 1996; Hueston 1993; Janssen 2007; Oakley 1996; Schimmel 1994; Sze 2008).

Women are more likely to give their midwives:

  • higher satisfaction ratings (Bernitz 2016; Fair 2012).

Newborns may be less or equally likely to:

  • experience serious morbidity (Jackson 2003),
  • require admission to newborn intensive care (Altman 2017; Bernitz 2011; Cragin 2006; Harvey 1996; Oakley 1996; Johantgen 2012),
  • or to die in the newborn period (MacDorman 1998),
    And more likely to
  • be breastfed (Johantgen 2012).

References

Altman MR, Murphy SM, Fitzgerald CE, et al. The Cost of Nurse-Midwifery Care: Use of Interventions, Resources, and Associated Costs in the Hospital Setting. Womens Health Issues 2017;27(4):434-40.

Bernitz S, Rolland R, Blix E, et al. Is the operative delivery rate in low-risk women dependent on the level of birth care? A randomised controlled trial. BJOG 2011;118(11):1357-64.

Bodner-Adler B, Bodner K, Kimberger O, et al. Influence of the birth attendant on maternal and neonatal outcomes during normal vaginal delivery: a comparison between midwife and physician management. Wiener Klinische Wochenschrift 2004;116(11-12):379-84.

Browne M, Jacobs M, Lahiff M, et al. Perineal injury in nulliparous women giving birth at a community hospital: reduced risk in births attended by certified nurse-midwives. J Midwifery Womens Health 2010;55(3):243-9.

Carlson NS, Corwin EJ, Hernandez TL, et al. Association between provider type and cesarean birth in healthy nulliparous laboring women: A retrospective cohort study. Birth 2018;45(2):159-68.

Chambliss LR, Daly C, Medearis AL, et al. The role of selection bias in comparing cesarean birth rates between physician and midwifery management. Obstet Gynecol 1992;80(2):161-5.

Cragin L, Kennedy HP. Linking obstetric and midwifery practice with optimal outcomes. J Obstet Gynecol Neonatal Nurs 2006;35(6):779-85.

Fair CD, Morrison TE. The relationship between prenatal control, expectations, experienced control, and birth satisfaction among primiparous women. Midwifery 2012;28(1):39-44.

Harvey S, Jarrell J, Brant R, et al. A randomized, controlled trial of nurse-midwifery care. Birth 1996;23(3):128-35.

Hueston WJ, Rudy M. A comparison of labor and delivery management between nurse midwives and family physicians. J Fam Pract 1993;37(5):449-54.

Jackson DJ, Lang JM, Swartz WH, et al. Outcomes, safety, and resource utilization in a collaborative care birth center program compared with traditional physician-based perinatal care. Am J Public Health 2003;93(6):999-1006.

Janssen PA, Lee SK, Ryan EM, et al. Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. CMAJ 2002;166(3):315-23.

Janssen PA, Ryan EM, Etches DJ, et al. Outcomes of planned hospital birth attended by midwives compared with physicians in British Columbia. Birth 2007;34(2):140-7.

Johantgen M, Fountain L, Zangaro G, et al. Comparison of labor and delivery care provided by certified nurse-midwives and physicians: a systematic review, 1990 to 2008. Womens Health Issues 2012;22(1):e73-81.

MacDorman MF, Singh GK. Midwifery care, social and medical risk factors, and birth outcomes in the USA. J Epidemiol Community Health 1998;52(5):310-7.

Nijagal MA, Kuppermann M, Nakagawa S, et al. Two practice models in one labor and delivery unit: association with cesarean delivery rates. Am J Obstet Gynecol 2015;212(4):491 e1-8.

Oakley D, Murtland T, Mayes F, et al. Processes of care. Comparisons of certified nurse-midwives and obstetricians. J Nurse Midwifery 1995;40(5):399-409.

Rosenblatt RA, Dobie SA, Hart LG, et al. Interspecialty differences in the obstetric care of low-risk women. Am J Public Health 1997;87(3):344-51.

Schimmel LM, Lee KA, Benner PE, et al. A comparison of outcomes between joint and physician-only obstetric practices. Birth 1994;21(4):197-205.

Shorten A, Donsante J, Shorten B. Birth position, accoucheur, and perineal outcomes: informing women about choices for vaginal birth. Birth 2002;29(1):18-27.

Souter V, Nethery E, Kopas ML, et al. Comparison of Midwifery and Obstetric Care in Low-Risk Hospital Births. Obstet Gynecol 2019;134(5):1056-65.

Sutcliffe K, Caird J, Kavanagh J, et al. Comparing midwife-led and doctor-led maternity care: a systematic review of reviews. J Adv Nurs 2012;68(11):2376-86.

Sze EH, Ciarleglio M, Hobbs G. Risk factors associated with anal sphincter tear difference among midwife, private obstetrician, and resident deliveries. Int Urogynecol J Pelvic Floor Dysfunct 2008;19(8):1141-4.

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