More than 90 percent of births in the U.S. are supervised by doctors, but a growing minority of women rely on midwives to provide their primary care. A new review, published by The Cochrane Library on Tuesday, lends support to that model, finding that consistent midwife care throughout pregnancy is linked with better outcomes for both mom and baby.
Compared with women who mainly saw family physicians or obstetricians, or whose care was shared by some mix of doctors, nurses and midwives, women who had a midwife as their lead provider had fewer interventions and were less likely to deliver a premature baby.
"Every woman should be aware of the benefits of midwifery-led care compared to obstetrician- or family physician-led care," said Maureen Corry, executive director of Childbirth Connection, a national nonprofit focused on maternal care, who did not work on the paper. “This new Cochrane review is full of good news news for women and babies."
The reviewers looked at 13 trials of more than 16,000 women who saw a small team of midwives throughout their pregnancy, or one primary midwife. Eight of the trials included women who were at low-risk for complications during pregnancy and birth, while five included higher-risk women. All of the midwives were licensed in their respective countries, and none of the trials looked at home births.
On the whole, women who saw midwives throughout their pregnancy were less likely to have an epidural painkiller, an episiotomy (an incision made from the vagina to anus during delivery), or a delivery using instruments, such as a vacuum or forceps. There were no differences in Cesarean birth rates.
Women who received continuous care from midwives also were less likely to have a baby before 37 weeks of gestation, or to lose their babies before 24 weeks.
Notably, higher-risk women who saw a midwife as their point-person did not have worse outcomes than low-risk women -- a discovery the researchers interpreted with cautious optimism.
"This is an important finding, because it means that midwives have something to offer women who are not low-risk, when they are coordinating care with a primary care physician or an OBGYN," argued review author Jane Sandall, with the division of women's health at Kings College, London.
For now, the researchers can only guess why continuous midwife care seems to confer important benefits.
"Having someone who is there for you, who you know is going to be there at your birth is important to women," said Sandall. "Because women know their midwives, and they're often easier to get in touch with them, the midwives are picking up any problems sooner and helping women get the right specialist input as early as possible."
The philosophy of midwifery, which tends to look at birth as a "social event as well as a clinical event," Sandall explained, may significantly influence birth outcomes. At this point, researchers cannot tease the two factors apart.
Although Sandall said she believes the findings have relevance in the U.S., none of the trials reviewed were American, and midwifery licensing standards and requirements vary from country to country. In the U.S., there are many types of midwives, including so-called "direct entry" midwives who often learn by apprenticeship and do not necessarily have formal credentials, although the American College of Obstetricians and Gynecologists staunchly opposes the provision of care by lay midwives or any midwives not certified by the American Midwifery certification Board or American College of Nurse-Midwives.
While the proportion of births in the U.S. attended by midwives is at an all-time high -- just over 8 percent -- the vast majority are attended by obstetricians. As more women learn about the potential benefits associated with midwifery, Corry said, more may consider it.
"Choosing a caregiver is one of the most important decisions a pregnant woman will make," Corry said. The choice "can influence the care they receive and the outcomes of that care, as well as the choices and options available to them, particularly during labor and birth."
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