November 17, 2008

New Cochrane Publication on Midwife-Led vs. Other Models of Maternity Care

The Cochrane Collaboration recently released a publication on midwifery-led care for childbirth compared with “other” or “shared care” models. The authors defined midwifery-led care as follows: “the midwife is the woman’s lead professional, but one or more consultations with medical staff are often part of routine practice.”

Other models generally means an ob/gyn as the lead professional (although nurses and midwives may be part of the support team), and shared care might have a varying lead professional depending on where the woman is and whether she is pregnant, in labor, or has already given birth. In other words, the review looks at maternal and neonatal outcomes not by strictly midwife vs. physician, but by who was primarily in charge of the woman’s care over the course of her pregnancy, including labor and the postpartum period.

The authors also note that the included studies were conducted in the public health systems of Australia, Canada, New Zealand and the United Kingdom, so it might be useful to look at the individual studies themselves to assess whether they would be applicable to the U.S. situation and population.

The authors also explain that they selected studies in which women were randomly allocated to midwifery-led vs. other models of care, and that consisted of low- or mixed-risk women. They selected 11 studies, and examined a number of outcomes such as hemorrhage, use of analgesia, induction of labor, c-section, episiotomy, maternal or neonatal death, breastfeeding initiation, and postpartum depression.

The authors concluded that women randomised to midwife-led models of care were less likely to have regional anesthesia/analgesia, instrumental birth, or episiotomy, and were more likely to have spontaneous vaginal birth, to initiate breastfeeding, and to report high perceptions of control during labor. There were no significant differences on a number of other outcomes, such as hemorrhage, neonatal death, labor augmentation or induction, c-section, or duration of hospital stay.

I do have questions about some of the outcomes and limitations of the paper which may require more in-depth analysis of the methods and the original studies. For example, the authors list as a finding that those in midwife-led teams were less likely to experience fetal loss or neonatal death less than 24 weeks; however, they note elsewhere that they included miscarriage and termination of pregnancy in the neonatal outcomes, and it’s not immediately apparent if this might have affected that finding. Readers also might have expected, for example, a lower c-section rate with the midwife-led teams, but it’s not entirely clear how the protocols in place during each individual study affected this decision-making.

Although it is not likely to be a defining paper on midwifery care and choice of birth providers, this Cochrane piece does suggest an interesting consideration – that maternity care often happens via teams of providers working together, and women may want to be better informed about who is primarily in charge of those teams and how that control is negotiated in practice.


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