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When it comes to comparing outcomes with a midwife versus 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:
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:
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.
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:
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:
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:
Women are more likely to give their midwives:
Newborns may be less or equally likely to:
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