December 12, 2013

Cochrane Review: The Safety and Benefits of Midwives Overseeing Maternity Care

Midwife-Led Continuity Models Versus Other Models of Care for Childbearing WomenIf you’re pregnant and living in the United State, it’s likely that an obstetrician will oversee your maternity care and childbirth. In other countries, however, midwives commonly provide care, assuming the pregnancy is low-risk.

An updated Cochrane review aimed to figure out whether patient outcomes vary by who is leading the care team.

Cochrane compiles findings from multiple studies into systematic reviews, considered top-notch for determining the best evidence-based care. In this instance, the authors looked at outcomes for moms and babies of what the authors refer to as “midwife-led continuity models of care” — defined as incorporating a midwifery perspective of minimizing routine intervention during birth, and midwives acting as the lead professionals in organizing and delivering care before, during and after birth.

They considered 13 studies representing 6,242 women in Australia, Canada, Ireland, New Zealand and the United Kingdom that compared the effects of midwife-led continuity models of care with other models: eight studies compared it to a shared model of care (responsibility is shared between different care providers); three studies compared it to medical-led models of care (what we’re most used to in the United States); and two studies compared it to various options of standard care, including midwife-led (with varying levels of continuity), medical-led, and shared care.

All of the studies looked at licensed midwives in hospital birth settings.

In the final review, “Midwife-Led Continuity Models Versus Other Models of Care for Childbearing Women,” the authors report that the midwife-led continuity models of care were associated with some benefits, including a decreased likelihood of episiotomy or instrumental birth, and decreased likelihood of preterm birth or loss of the fetus before 24 weeks’ gestation. Women cared for under this model were more likely to have spontaneous vaginal birth; they also had slightly longer labors and were less likely to use any pain relief.

There were no differences between groups in rates of cesarean birth (although the authors suggest more data may be needed), or overall fetal loss or neonatal death. There were no specific adverse effects attributed to midwife-led continuity of care models.

The Royal College of Obstetricians and Gynaecologists (a UK professional organization) essentially agreed with the message of the review, noting that while other types of specialists should be available for high-risk pregnancies and emergencies, “more women with low-risk pregnancies should be given the option of midwifery-led care.”

While noting that additional research is needed, the Cochrane authors’ recommend what has become standard practice in many parts of the world: “Most women should be offered midwife-led continuity models of care and women should be encouraged to ask for this option although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.”

While the midwifery model of care — especially midwife-led continuity care — is not standard practice in the United States, midwives and other health advocates have been working to change that. Some academic medical centers now incorporate midwives into their care teams for hospital births, for example, though not all teams are midwife-led.

In this JAMA News item, nursing professor and American Journal of Nursing Editor Diana Mason argues for increased access to midwives and birth centers for low-risk births to meet consumer choice and to combat the high cost of maternity care. Mason writes:

We need to question the basic framework for designing maternity services: should it be one in which pregnancy and birth are viewed as normal life transitions or as diseases? This is not just a philosophical issue. The midwifery model of care views birthing as a normal physiologic process and involves care that includes the identification of women at risk for complications and in need of management by an obstetrician.

Women’s health advocates are also pushing for broader reform of the maternity care system, including better and increased support of women before, during, and after birth; expanded choice in birth settings; an emphasis on medical evidence; and improved staffing of maternity care teams.

These issues and other concerns are addressed in the 2020 Vision for A High-Quality, High-Value Maternity Care System – prepared for Childbirth Connection’s Transforming Maternity Care symposium — which focuses on woman-centered care that “respects the values, culture, choices, and preferences of the woman, and her family, as relevant, within the context of promoting optimal health outcomes.”

To learn more about the midwifery model of care, check out this excerpt from “Our Bodies, Ourselves,” and the resources from Childbirth Connection. To find a practice with nurse-midwives in your area, try the ACNM’s Find a Midwife search tool.


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