Potential benefits of midwifery care may suggest need for further implementation in US

Key takeaways:

• Midwives may have more time with patients to better communicate and lower the risk for intervention in pregnancy.
• OB/GYNs and midwives can look at pregnancy differently, which may cause differences in care.

Although midwives provide pregnant women with education and support during labor, which may result in a lower intervention likelihood, midwifery care in the U.S. is less utilized compared with other countries.

In most U.S. states, more than 90% of births are attended by physicians, according to Kate A. McLean, MD, MPH, FACOG, board-certified obstetrician and gynecologist in the Seattle area, despite most births being medically low risk and appropriate for midwifery care.

“When midwifery got its start in the United States, with granny midwives in the southern U.S., OB/GYNs essentially had a campaign to try to put midwives out of business and take their business for themselves,” McLean told Healio. “We started this narrative that the only safe and reasonable place for births was in the hospital, but early data, even from back then, suggest that the hospital outcomes were not better. If anything, they were worse.”

McLean; Elizabeth Nethery, RM, PhD, a postdoctoral researcher in the Collaboration for Outcomes Research and Evaluation at the University of British Columbia, Vancouver; and colleagues conducted a retrospective cohort analysis of births occurring from January 2016 to December 2020 at Northwest U.S. hospitals participating in the Obstetrical Care Outcomes Assessment Program.

Kate A. McLean

Births that occurred among low-risk women who received midwifery care were less likely to require induction (17.6% vs. 20.3%; RR = 0.74; 95% CI, 0.7-0.78), or have an epidural (58.9% vs. 76.3%; RR = 0.78; 95% CI, 0.77-0.8) or episiotomy (2.2% vs. 3.4%; RR = 0.68; 95% CI, 0.58-0.81) compared births among women without midwifery care. These women also had lower rates of cesarean birth compared with women without midwifery care (7.8% vs. 12.3%; RR = 0.68; 95% CI, 0.62-0.73). Researchers observed no corresponding increases in risk of adverse neonatal outcomes. These results led researchers to hypothesize that expanding midwifery care to 100% of low-risk births in the U.S. may save $340 million per year.

“Midwifery care also has a big impact in the prenatal and the postpartum period,” Nethery told Healio. “The prenatal education and shared decision making that occurs in a midwifery model of care, has huge benefits for birthing people and for the health care system at large because you can have those conversations about choice and what your options are, and you can have those in prenatal care.”

Potential benefits of midwifery

Midwives may spend more time with their patients, both in the birthing room and prenatally, and provide women with more education and support throughout their pregnancy, noted McLean. Midwives specialize in low-risk pregnancy, delivery and postpartum care, McLean said, so they continue to care for women in all stages unless patients require a higher level of care from an OB/GYN.

In the study, McLean and Nethery observed that infants of women who utilized midwifery care had lower risks for neonatal ICU admittance and overall morbidity.

“A prenatal care visit with a midwife, depending on the type of midwife in the U.S., can be anywhere from 20 minutes to an hour long as with some licensed midwives who do home births,” Maggie Bolton, certified nursing-midwife in Seattle, told Healio “Whereas physicians are often under different financial constraints, so their visits are shorter.”

Midwives also provide other types of prenatal care. One popular type of prenatal care, noted Bolton, is Centering Pregnancy. In this type of care model, pregnant women are grouped with others who are due to give birth around the same time. Their partners may also join in these visits, and the group participates in facilitated discussions surrounding pregnancy. This allows participants to have the expertise of their midwife and to learn from others who are going through the same experience. This leads to a different type of preparation than traditional prenatal care, noted Bolton.

OB/GYNs and midwives

OB/GYN training is different from midwifery training, according to Bolton, as OB/GYNs are trained in the traditional Western medical model of care framework in which pregnancy is managed like an illness. Comparatively, Bolton said, midwives look at pregnancy as a normal process that sometimes requires intervention. In this view, pregnancy is a normal physiological process requiring support, guidance and navigation, noted Bolton.

“Physicians are taught to identify illness and treat illness. For that reason, perhaps, we are more likely to over-intervene because that is the way that we’ve been trained, whereas midwives are trained to see birth as a normal physiologic process,” McLean said. “They think about intervention as it relates to birth differently, and we see that patients do better with that philosophy.”

Having a midwife at the bedside can also make interventions less likely, noted McLean. Midwives tend to be good communicators, she said, and whenever the pros and cons of an intervention is thoroughly discussed, the intervention becomes less likely.

“Unfortunately, physicians can sometimes be paternalistic, and we think that we know best for the patient,” McLean said. “Sometimes we don’t fully discuss things with people for that reason, whereas midwives are good at a shared decision-making model.”

Use of the shared decision-making model means that some patients of midwives are less likely to choose intervention in the birth setting after discussing what they want and their risk tolerance.

“Those conversations help patients explore and understand what the intervention is, what the likely outcome will be if you do it, if you don’t do it and what it means for them,” Bolton said. “This helps someone become more likely to feel empowered by their experience if they understand and feel like they’re a part of making that decision rather than being told that this is what needs to be done right now.”

Expanding midwifery care

Compared with the U.S., midwives play much larger roles in different health care systems. For example, in the U.K., midwives are the first point of contact for primary prenatal, intrapartum and postpartum care for all obstetric patients, noted Nethery. As needed, midwives work collaboratively with obstetricians when presented with higher risk conditions, she added, During labor, it is midwives who provide continuous care during labor in the U.K., as opposed to labor and delivery nurses, according to Nethery, as would happen in the U.S.

According to Bolton, transitioning from fee-for-service care to value-based care will make the biggest difference in expanding midwifery care in the U.S.

“Until compensation is tied to quality, I don't think we'll see much of a shift,” Bolton said. “But there are certain things that can be done, like hiring midwives onto quality committees and hospital systems that don't have midwives incorporated could hire midwives, even into a labor model if they don't have the capacity to hire midwives on as an entire midwifery program, providing prenatal care.”

According to Bolton, women must be educated at the beginning of their pregnancy about their options because many women do not know until later into their pregnancy that they can choose a home birth or hospital birth or have either a midwife or a physician. At that point, Bolton said, it can be uncomfortable to transfer providers.

“There's so many unknowns during pregnancy, so to be in that position can be difficult. But early education around what the options are could help integrate midwifery care into the maternal health spectrum,” Bolton said.

One way to make midwifery care more understood in the U.S. is to use data collection processes such as the Obstetrical Care Outcome Assessment Program (OBCOAP), which is an outcome “report card” that provides visibility for providers within a system and state. OBCOAP gives providers their statistics on labor, delivery and postpartum care on a quarterly basis and allows for physician staff to evaluate statistics to compare intervention rates with OB/GYNs and midwives, noted McLean.

“It's hard to argue with hard numbers. That's one of those things that can help us overcome stereotypes,” McLean said. “Unfortunately, we physicians have done a good job of perpetuating certain stories about midwifery, like midwifery care isn't as safe as seeing a doctor, when the data is clear that that's not true.”

In addition, noted Nethery, much of the research on midwifery care on a national level in the U.S. is done using birth certificate data, which do not reliably capture risk factors, low-risk or induction information. Instead, birth certificate data should be used for vital statistics, not research, according to Nethery.

“The value of doing good, high-quality studies with good, high-quality data cannot be overstated,” Nethery said. “And that's what we're trying to do with OBCOAP.”

For more information:

Maggie Bolton, can be reached at maggieboltonmidwife@gmail.com.

Kate A. McLean, MD, MPH, FACOG, can be reached at kmclean@gmail.com.

Elizabeth Nethery RM, PhD, can be reached at elizabeth.nethery@ubc.ca.