Sunday, October 12, 2008

Midwife-led care

Want to decrease the likelihood that you'll have an episiotomy, an instrumental delivery, or use pain medications (both IV narcotics and epidural/spinal anesthesia) during labor? Want to reduce the need for hospitalization during pregnancy? Want to increase the odds that you'll have a spontaneous vaginal birth, that you will feel in control during labor and birth, that you will know the birth attendant actually present when you go into labor, and that you will initiate breastfeeding? Want to reduce the chance that you will lose your baby during the first 24 weeks of gestation? Want a shorter hospital stay for your baby? Want all these benefits, with no increase in overall fetal or neotatal death rates?

Choose a midwife!

The Cochrane Library just published results from 11 trials, totaling 12,276 women, of women randomly assigned to midwife-led care, versus other forms of care (care with family physicians or obstetricians, or shared between several health care professionals). In other words, these studies were not of women who self-selected midwives to care for them, but of women who were randomly assigned to either group. They found a host of benefits to having a midwife as the primary care provider, with no identified adverse effects.

I haven't yet downloaded the full text of the study, but I assume that the midwife-led care in the trials was entirely or primarily hospital-based. In other words, these benefits apply to the 98-99% of women who choose hospital birth in North America and other industrialized countries, not just to the 1-2% who choose home birth or birth centers.

Here is a "plain language summary" of the Cochrane findings:

Midwife-led versus other models of care for childbearing women

Midwife-led care confers benefits for pregnant women and their babies and is recommended.

In many parts of the world, midwives are the primary providers of care for childbearing women. Elsewhere it may be medical doctors or family physicians who have the main responsibility for care, or the responsibility may be shared. The underpinning philosophy of midwife-led care is normality and being cared for by a known and trusted midwife during labour. There is an emphasis on the natural ability of women to experience birth with minimum intervention. Some models of midwife-led care provide a service through a team of midwives sharing a caseload, often called 'team' midwifery. Another model is 'caseload midwifery', where the aim is to offer greater continuity of caregiver throughout the episode of care. Caseload midwifery aims to ensure that the woman receives all her care from one midwife or her/his practice partner. By contrast, medical-led models of care are where an obstetrician or family physician is primarily responsible for care. In shared-care models, responsibility is shared between different healthcare professionals.

The review of midwife-led care covered midwives providing care antenatally, during labour and postnatally. This was compared with models of medical-led care and shared care, and identified 11 trials, involving 12,276 women. Midwife-led care was associated with several benefits for mothers and babies, and had no identified adverse effects. The main benefits were a reduced risk of losing a baby before 24 weeks. Also during labour, there was a reduced use of regional analgesia, with fewer episiotomies or instrumental births. Midwife-led care also increased the woman's chance of being cared for in labour by a midwife she had got to know. It also increased the chance of a spontaneous vaginal birth and initiation of breastfeeding. In addition, midwife-led care led to more women feeling they were in control during labour. There was no difference in risk of a mother losing her baby after 24 weeks. The review concluded that all women should be offered midwife-led models of care.


  1. (In response to a comment that the study did not compare midwife-led with doctor care):

    Actually, the study did. It compared the intervention group (midwife-led care, either with midwife teams or caseload midwifery) with other models of care (control group). From the Cochrane report:

    "Other models of care include:
    (a)Obstetrician-provided care. This is common in North America,
    where obstetricians are the primary providers of antenatal care for most childbearing women. An obstetrician (not necessarily the one who provides antenatal care) is present for the birth, and nurses provide intrapartum and postnatal care.
    (b) Family doctor-provided care, with referral to specialist obstetric care as needed. Obstetric nurses or midwives provide intrapartum and immediate postnatal care but not at a decision making level, and a medical doctor is present for the birth.
    (c) Shared models of care, where responsibility for the organisation
    and delivery of care, throughout initial booking to the postnatal
    period, is shared between different health professionals."

    Midwife-led care was defined as care where "the midwife is
    the lead professional in the planning, organisation and delivery of care given to a woman from initial booking to the postnatal period." This doesn't mean a woman can never see a physician if warranted, but that the midwife is the primary care provider and does most or all of the woman's care, from pregnancy to birth to postpartum.

  2. lol, you must be referring to 'the mad one' and her commentary? we wait to see whether this will change practice..when the bottom line is the dollar and society can 'get away with' altering the control heirarchy which surrounds birth maybe we will see some change. its interesting, when i was teaching public health and epi to 3rd yr med students, one of the things we tried to get across was that the research showed that if you had a good, honest and equal relationship with your patients then litigation rates reduced dramatically. midwifery care is cheaper and offers the woman more consult time. maybe ob practice will be responsible for its own demise.

  3. Thanks for putting this in, Rixa. Unfortunately, the full study is not freely available, and "the good doctor" was trying to imply that the "midwife-led" care only had a midwife as a figurehead leader for the "team" of care providers. Of course, since what she said went completely counter to the abstract and "plain language summary" I couldn't believe her -- knowing how she twists everything that disagrees with her, I simply don't trust her.


  4. Kathy, I can send you a PDF of the full study. Email me.

    Even the abstract is very clear that it's comparing care with the midwife as primary care provider, against physician-led care or shared care. I don't see how it's that hard to understand.

  5. It's very funny over there at the moment. She can't respond to being called out on yet again thinking she is the only one to be able to accurately interpret a study. It's quite amusing.

  6. heck! even the title of the report is specific, "Midwife-led versus other models of care for childbearing women"

    That's not tough to understand. Of course, when you are grasping at straws anymore to try to disprove anything, you'll resort to anything I suppose.

  7. Rixa, Would you send it to me as well?
    Off to see what the mad doctor as to say murhwaaaaaaaaaaa

  8. The full study is available on the Cochrane Collaboration website.

    I don't think you can say that the review concludes "choose a midwife" in US context. The review looks at midwife-led care in healthcare systems (Australia, Canada, UK) where midwives are recognized autonomous professionals who have parity with Obs and work in partnership with them. It does not look at midwife-led care in the US context.

  9. Being from New Zealand, I have to agree with the previous commenter. There is a vast difference between midwifery in the US and that in the UK, NZ and other places where midwifery has always been an integral part of the provision of services for pregnant women. That being said, while it may overall give benefits it's not always working that well given pressures such as staff shortages, funding issues and lack of integration of services in our public health system and I would imagine other countries with similar models would face similar issues too. They have recently done a long overdue review in our area and found some problems. Review finds maternity service gaps: or Babies and mums at risk, says review:

  10. I think Midwifes might be the only show in town soon. I agree with Yehundit that you cannot compare UK midwifes with USA midwifes.

    There is some talk of teaching the nurses to deliver the babies. We could afford more nurses and catching a baby is easy until you get into trouble. I wouldn't mind catching. I have before and most of the OB's I trust to back me up. Also when you have a midwife already in the room the mood of the room does not change drastically when the woman is crowning. Which is nice.

    I hate to have a good connection with my patients while pushing only to have the Doc and sometimes midwife, come in turn on all the lights mess with the instruments and make a bunch of waves in the mood. I would much rather prefer they wait outside and come in if I need them. Unless it is a Doc that the patient is fond of and in that cases the Doc is usually already in the room.

  11. Well, it's important to remember that this blog is not for an exclusively American audience. Remember that even my own household is of mixed nationalities! Readers come from all over North America, Europe, and the British Commonwealth. And some even more faraway places.

    Leaving aside the question of non-nurse midwives in the US (which I don't think anyone ever said applies directly to the Cochrane findings, since it was of mainly hospital-based care) I do think that you could apply the conclusions to US hospital-based CNMs who generally do have autonomy to practice and are part of the health care system. In most places they work autonomously (or mainly so; sometimes they need a collaborative agreement with a physician, but they still remain the woman's primary care provider and only consult when necessary).

    Any U.S. CNMs care to share their thoughts?

  12. (Sorry not a nurse midwife here, just a wink to Pinky:) Hey Pinky I have a T-shirt slogan for you:
    Pinky for Midwife!

    Seriously, seriously, I know I've asked you before and I'm sure all the extra coursework without the pay raise is not exactly tempting, but you would make a stellar CNM. That way you could have an even better relationship with your patients and catch all the babies!

  13. Pinky, why don't you train as a CNM? I agree, it must be horrible (for you and the woman) to provide the labour care and then have someone else arrive at the end of second stage for the delivery.

  14. How is it that midwifery can lessen the chance of losing a baby before 24 weeks. I just lost a baby at 24 weeks. and would like to know what a midwife does differently than a doctor before that stage. Thanks

  15. I don't know if the report addressed why this was the case; they probably just discussed the statistical probabilities but not the causality. My hunch is that it comes from a variety of factors that are characteristic of midwifery-led care: more time spent with women at prenatal visits; more attention to the woman's emotional, mental, and psychological health, her home environment, her stresses and worries, rather than just the physical aspects of pregnancy; greater emphasis on nutrition and self-care, etc.

  16. Hey good news on the midwife front in Canada! The Alberta Government has just agreed to pay for midwives starting April 2009! I would love to think that most women would switch right over, but I know it may be a longer process then that. Still it's great to have the option now! It cost $3500 before so it wasn't something most families could consider, including ourselves. I've had 4 decent hosptial births thankfully, but my next will be at home now!!

  17. Yeah, I just saw the news a day or two ago. That is great!


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