Births Attended by Midwives Safe, Need Fewer Interventions

Elizabeth DeVita-Raeburn

January 13, 2012

January 13, 2012 — A review of 21 studies comparing births attended by certified nurse midwives or physicians found no difference in infant outcomes between the 2 groups, and less use of interventions such as labor induction, episiotomy, and epidurals by the nurses.

The review, published in the January 2012 issue of Women's Health Issues, also found reduced incidence of perineal lacerations and a higher likelihood of breast-feeding in births attended by certified nurse midwives.

Nurse midwives' view of birth as a natural process, and their tendency to rely less on invasive procedures, makes them "well-positioned to influence maternity care practices [in a way] that can optimize maternal and neonatal outcomes," write Meg Johantgen, PhD, RN, associate professor in the University of Maryland School of Nursing in Baltimore, and lead author of the study. The authors also suggest that the use of certified nurse midwives might be a solution to the projected shortage in obstetrician-gynecologists.

"I respect midwives. And I do think their noninvasive approach is very helpful," Mary Rosser, MD, PhD, assistant professor of obstetrics, gynecology, and women's health at Montefiore Medical Center in New York City, told Medscape Medical News. The presence of midwives can serve as a reminder, she says, "that the woman does the work, and we're just there to assist the majority of the time."

However, Dr. Rosser said, replacing physicians with certified nurse midwives to make up for shortages is not ideal. "You cannot predict who will have a postpartum hemorrhage, and there are situations where you do need interventions like a [cesarean]-section, or episiotomies, or forceps," Dr. Rosser said. "There does need to be recognition that physicians are important for backing [midwives] up in serious situations."

Midwife-attended births increased by 33% between 1996 and 2008, with nurse midwives attending in most of them, according to the study's authors.

Such use of advanced-practice nurses in areas traditionally served by physicians is, they write, a potentially important way to expand access to high-quality healthcare, especially for underserved populations. Yet there is only limited evidence of its effectiveness compared with that of other providers. "The intent of this study was to provide the scientific evidence needed to make informed decisions about obstetrical care delivery and about health care workforce policies," write the authors.

This review is the first systematic meta-review comparing physician attended births to those attended by certified nurse midwives over the course of 2 decades, the authors write.

The authors collected 21 studies published between 1990 and 2008 that quantitatively measured the performance of certified nurse midwives vs physicians in both the process of care and outcome. The majority of the studies were observational retrospective cohort designs that used existing administrative databases or medical record review.

The authors noted some important limitations to the study. The reviewers were all nurses, which may have introduced bias, and it was not always clear how women were selected for care by a certified nurse midwife vs a physician in the studies chosen for analysis. Women who have midwife-attended deliveries tend to be at lower risk for complications in the first place, and the women in the study who required more invasive interventions during their care may also have been transferred to physicians.

Even with these limitations, however, the authors say the evidence suggests that care by certified nurse midwives is safe and effective, and that nurse midwives "should be better utilized to address the projected health care workforce shortages."

"It is nice to know there are midwives there for this gap," Dr. Rosser said. "It's an interesting way to figure out how to deal with it." But care needs to be delivered in collaboration, she cautioned. "We're all a team."

The study was supported by Tri-Council for Nursing and the Advanced Practice Registered Nurse Alliance. The authors have disclosed no relevant financial relationships.

Women's Health Issues. 2012;22:e73-e81. Full text


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