Midwives Improve Outcomes, Says Cochrane Review

Troy Brown

August 23, 2013

Most women whose prenatal and childbirth care are led by a midwife have better outcomes compared with those whose care is led by a physician or shared among disciplines, according to a systematic review of 13 trials involving 16,242 women published August 22 in the Cochrane Database of Systematic Reviews.

Of the 13 trials reviewed, 8 included women at low risk for complications and 5 included women at high risk for complications. The researchers examined outcomes for mothers and babies including regional analgesia (epidural/spinal), caesarean delivery, instrumental vaginal birth (forceps/vacuum), spontaneous vaginal birth (as defined by trial authors), intact perineum, preterm birth (less than 37 weeks), and overall fetal loss and neonatal death (fetal loss at 24 weeks' gestation or later, which is the cut-off for viability in many countries).

Women whose pregnancy care was led by a midwife were less likely to have regional analgesia (average risk ratio [RR], 0.83; 95% confidence interval [CI] 0.76 - 0.90), episiotomy (average RR, 0.84; 95% CI, 0.76 - 0.92), and instrumental birth (average RR, 0.88; 95% CI, 0.81 - 0.96).

Women who had midwife-led care were more likely to have no intrapartum analgesia/anesthesia (average RR, 1.16; 95% CI, 1.04 - 1.31), spontaneous vaginal birth (average RR, 1.05; 95% CI, 1.03 - 1.08), attendance at birth by a known midwife (average RR, 7.83; 95% CI, 4.15 - 14.80), and a longer mean length of labor (in hours) (mean difference, 0.50 hours; 95% CI, 0.27 - 0.74 hours).

The average risk ratio for caesarean births did not differ between the groups (average RR, 0.93; 95% CI, 0.84 - 1.02).

Women who were randomly assigned to receive midwife-led care were less likely to have preterm birth (average RR, 0.77; 95% CI, 0.62 - 0.94) and fetal loss before 24 weeks' gestation (average RR, 0.81; 95% CI, 0.66 - 0.99). There were no differences between the groups for fetal loss/neonatal death at 24 weeks' gestation or more (average RR, 1.00; 95% CI, 0.67 - 1.51) or in overall fetal/neonatal death (average RR, 0.84; 95% CI, 0.71 - 1.00).

Most studies reported higher maternal satisfaction in the midwifery-led model.

A total of 5 studies estimated costs associated with each care model, but they were inconsistent in how they measured those costs: One study found higher costs for postnatal care led by a midwife, and another study found no differences in cost when compared with medical-led care.

"There is a lack of consistency in estimating maternity care cost among the available studies; however, there seems to be a trend towards the cost-saving effect of midwife-led continuity of care in comparison with medical-led care," the authors write.

Delayed Care Can Be "Catastrophic," says Ob/Gyn

Nancy S. Roberts, MD, system department chairman of Obstetrics and Gynecology at Main Line Health in Bryn Mawr, Pennsylvania, commented on the review in a telephone interview with Medscape Medical News.

"If you look at other specialties, whether it's primary care..., physician assistants or advanced practice nurses, they can have a wonderful relationship with patients. The one problem...is figuring out when the patient requires a higher level of care. If there is a delay in obtaining that higher level of care, the results can be catastrophic," Dr. Roberts said.

"There are some very obvious high-risk situations, like twins, triplets, a woman who is over 40, a woman with medical complications, [or] a woman with medical complications of pregnancy, who would not be appropriate for a midwife's practice," Dr. Roberts explained.

The effects of midwife-led continuity models of care on the health and well-being of mothers and babies in the longer postpartum period are unclear, the authors write.

"Future research should pay particular attention to outcomes that have been under-researched, but are causes of significant morbidity, including postpartum depression, urinary and faecal incontinence, duration of caesarean incision pain, pain during intercourse, prolonged perineal pain and birth injury (to the baby)," the authors note in their conclusion.

This review was supported by the Women's Health Academic Centre, King's Health Partners, King's College; Sheffield Hallam University; Health Services Executive; and Trinity College Dublin; and the National Institute for Health Research in the UK. One coauthor is also a coauthor in one of the trials included in this review, one coauthor was and is principal investigator in 2 studies evaluating models of midwife-led continuity of care and is a coinvestigator on the Birthplace in England Research Programme, a comparison of birth outcomes for women who give birth at home, in various types of midwifery units, and in hospital units with obstetric services. Dr. Roberts has disclosed no relevant financial relationships.

Cochrane Database Syst Rev. 2013;8:CD004667. Abstract

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