All women should be offered a midwife

That is the conclusion reached by a team of researchers that looked at

All published and unpublished trials in which pregnant women are randomly allocated to midwife-led or other models of care during pregnancy, and where care is provided during the ante- and intrapartum period in the midwife-led model.

Since the allocation was random, it means that all of the women were low-risk at the start of pregnancy, and all could have had midwifery care. And those that did have the model of care most associated with midwives had better results than those who were randomly assigned to obstetricians or family physicians.

These trials included over 12,000 women, and found that,

Women who had midwife-led models of care were less likely to experience

  • antenatal hospitalisation
  • the use of regional analgesia
  • episiotomy
  • and instrumental delivery

and were more likely to experience

  • no intrapartum analgesia/anaesthesia
  • spontaneous vaginal birth
  • to feel in control during labour and childbirth
  • attendance at birth by a known midwife
  • and initiate breastfeeding

In addition, women who were randomised to receive midwife-led care were less likely to experience fetal loss before 24 weeks’ gestation, and their babies were more likely to have a shorter length of hospital stay. There were no statistically significant differences between groups for overall fetal loss/neonatal death, or fetal loss/neonatal death of at least 24 weeks.

Let me reiterate — these women were randomly assigned to either midwives or obstetricians, so they were not biased by self-selection. There may be a vast difference between the super-crunchy, all-organic, no-vaccinating, cloth-diapering hippie mama who embraces homebirth as the best way to ensure a natural birth, just as she works hard to ensure a natural everything else in her life, and a typical mainstream mom who does not. [And just for the record, I’m not denigrating either choice, and find myself somewhere in the middle, but closer to the “mainstream mama.”] These women did not choose midwives out of some personal preference — they were chosen to have midwives randomly. And fewer of them had a miscarriage or otherwise lost their baby prior to 24 weeks of gestation.

This is in addition to all of the other benefits listed above.

I’ve previously written about the difficulty in studies comparing midwives and doctors, and home-birth and hospital birth, because of different criteria that midwives may have, while doctors accept both low- and high-risk women. I wished out loud for a study which compared identical client profiles of both midwives and doctors to see how they fared under the two different models of care. “Ask and ye shall receive,” I guess.

Let me repeat the authors’ conclusions:

All women should be offered midwife-led models of care and women should be encouraged to ask for this option.

My thanks to Lisa for first blogging about this and bringing it to my attention.

6 Responses

  1. “Let me reiterate — these women were randomly assigned to either midwives or obstetricians, so they were not biased by self-selection.”

    Wrong again. You didn’t even bother to read the paper, so you don’t know what it said.

    ALL women in BOTH arms of the study were cared for by BOTH midwives and obstetricians. The study compared midwife LED team care with other forms of team care. That’s why the study is titled “Midwife-led versus other models of care for childbearing women” it is not titled midwife are vs. other models.

  2. Well, now, this was not just *one* study but a review of *eleven* studies. But it still shows that midwives should be the leaders in the care of pregnant women, not obstetricians. And that when midwives are the care providers when women give birth, that they have better outcomes with fewer interventions.

  3. “Well, now, this was not just *one* study but a review of *eleven* studies”

    No, that’s not true, either.

    I’m glad that you acknowledge that your original claim is not true. You should edit your post to fix your major mistake. This is not a study comparing midwife care to doctor care. Women in both arms of the study were cared for by BOTH midwives and doctors.

    Second, the studies they chose to include have wildly varying control groups so it is not clear that the results are even meaningful.

    Third, I’m not even sure of the purpose of the study. Midwives led teams are better than teams led by other providers? So what? So we can announce that midwives are the leaders of the team and that improves outcomes? They need to provide a mechanism to substantiate the claim that naming the midwife the “leader” of the team has any impact on the outcome when the team contains both midwives and obstetricians.

  4. Amy, I made no such acknowledgment; and it is a review of 11 trials. I don’t trust someone who is so biased against home-birth that she can’t reliably distinguish between babies who are born alive and those born dead; nor between babies who are of different races. And knowing how you willfully misinterpret the CDC data doesn’t make me feel too comfortable in accepting your say-so on what this study does or does not do. The “plain language summary” defines what they consider to be “midwife led care”, which seems pretty obvious that it is not just having a midwife being a figurehead of a team of obstetricians who are the “real” care providers.

    “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.”

    So, midwives were the primary care provider for these women both during pregnancy as well as during labor. They may have seen other doctors from time to time — many women in America who have a midwife will also see an OB at least once, and perhaps many times (shadow care), but the person who was in charge of the care was the midwife.

    I know how you take things out of context and make it sound as if it said one thing when it really didn’t — you’ve done it to me as well as to many other people and studies, so you’ll forgive me if I simply don’t believe what you say. Perhaps if you were a tad more trust-worthy I would believe you, but as it stands now, I’m not going on your say-so.

  5. How would you know what the study shows? You haven’t read it.

  6. My son is sick today, but I am in the process of reading the full study. The sad thing is, though I may not have read the whole thing yet, it seems that I understand it better than you do, when you have claimed to have read it. So far, I haven’t found anything to substantiate your claims, but quite a bit to contradict them. The study authors define “midwife-led care”, and it is not just happening to have a midwife head a team of obstetricians who provide the “real care.” The fact that the women in the midwife groups see an obstetrician at least once during pregnancy is not surprising — I consider that to be par for the course. I saw my midwives’ back-up doctors once during each pregnancy. That doesn’t mean that the 5-10 minute “meet and greet” at 30-35 weeks had anything to do with the care I received during pregnancy or birth from my midwife. The meeting was merely so that the doctor would not be a total stranger if I should have needed to transfer.

    Anyway, it’s getting late and I need to put my kids to bed and get some sleep myself — my son threw up today, and it’s possible he’ll get a poor night’s sleep tonight so I can’t stay up to all hours of the night.

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