Rural Texan Mothers Need Midwives: A Literature Review of Midwife-led Care and Inequities of Women’s Healthcare at the State-level

Low-risk pregnant women cared for by midwives have similar birth outcomes to women cared for by physicians, although experiencing fewer medical procedures. However, limited research has assessed cost implications in the United States. Using national data, we assessed costs and resource use of midwife-led care vs obstetrician-led care for low-risk pregnancies using a decision-analytic approach. We developed a decision-analytic model of costs (health plan payments to clinicians) and use of medical procedures during childbirth (epidural analgesia, labor induction, cesarean birth, episiotomy) and outcomes of care (birth at preterm gestation) that may differ with midwife-led vs obstetrician-led care. Model parameters for obstetric procedures were generated using Listening to Mothers III data, a national survey of women who gave birth in US hospitals in 2011-2012 and other published estimates. Cost estimates came from published or publicly available information on health insurance claims payments. The costs of childbirth for low-risk women with midwife-led care were, on average, $2262 less than births to low-risk women cared for by obstetricians. These cost differences derive from lower rates of preterm birth and episiotomy among women with midwife-led care, compared with obstetrician-led care. Across the population of US women with low-risk births each year (approximately 2.6 million), the model predicted substantially fewer preterm births (167259 vs 219427 for midwife-led vs obstetrician-led care) and fewer episiotomies (170504 vs 415686, for midwife-led vs obstetrician-led care). A shift from obstetrician-led care to midwife-led care for low-risk pregnancies could be cost saving.

BackgroundInternationally, a typical model of maternity care is a medically led system with varying levels of midwifery input. New Zealand has a midwife-led model of care, and there are movements in other countries to adopt such a system. There is a paucity of systemic evaluation that formally investigates safety-related outcomes in relationship to midwife-led care within an entire maternity service. The main objective of this study was to compare major adverse perinatal outcomes between midwife-led and medical-led maternity care in New Zealand.Methods and FindingsThis was a population-based retrospective cohort study. Participants were mother/baby pairs for all 244,047 singleton, term deliveries occurring between 1 January 2008 and 31 December 2012 in New Zealand in which no major fetal, neonatal, chromosomal or metabolic abnormality was identified and the mother was first registered with a midwife, obstetrician, or general practitioner as lead maternity carer. Main outcome measures were low Apgar score at five min, intrauterine hypoxia, birth-related asphyxia, neonatal encephalopathy, small for gestational age (as a negative control), and mortality outcomes (perinatal related mortality, stillbirth, and neonatal mortality). Logistic regression models were fitted, with crude and adjusted odds ratios (ORs) generated for each outcome for midwife-led versus medical-led care (based on lead maternity carer at first registration) with 95% confidence intervals. Fully adjusted models included age, ethnicity, deprivation, trimester of registration, parity, smoking, body mass index (BMI), and pre-existing diabetes and/or hypertension in the model. Of the 244,047 pregnancies included in the study, 223,385 (91.5%) were first registered with a midwife lead maternity carer, and 20,662 (8.5%) with a medical lead maternity carer. Adjusted ORs showed that medical-led births were associated with lower odds of an Apgar score of less than seven at 5 min (OR 0.52; 95% confidence interval 0.43–0.64), intrauterine hypoxia (OR 0.79; 0.62–1.02), birth-related asphyxia (OR 0.45; 0.32–0.62), and neonatal encephalopathy (OR 0.61; 0.38–0.97). No association was found between lead carer at first registration and being small for gestational age (SGA), which was included as a negative control (OR 1.00; 0.95–1.05). It was not possible to definitively determine whether one model of care was associated with fewer infant deaths, with ORs for the medical-led model compared with the midwife-led model being 0.80 (0.54–1.19) for perinatal related mortality, 0.86 (0.55–1.34) for stillbirth, and 0.62 (0.25–1.53) for neonatal mortality. Major limitations were related to the use of routine data in which some variables lacked detail; for example, we were unable to differentiate the midwife-led group into those who had received medical input during pregnancy and those who had not.ConclusionsThere is an unexplained excess of adverse events in midwife-led deliveries in New Zealand where midwives practice autonomously. The findings are of concern and demonstrate a need for further research that specifically investigates the reasons for the apparent excess of adverse outcomes in mothers with midwife-led care. These findings should be interpreted in the context of New Zealand’s internationally comparable birth outcomes and in the context of research that supports the many benefits of midwife-led care, such as greater patient satisfaction and lower intervention rates.

A report of a systematic review of reviews which examines the impact of having midwives-led maternity care for low-risk women, rather than physicians. A rising birth rate, increasing complexity of births, and economic constraints pose difficulties for maternity services in the UK. Evidence about the most effective, cost-effective, and efficient ways to give maternity services is needed. Searches were carried out in August-September 2009 of ten electronic databases, 16 key nursing and research websites, and reference lists of 56 relevant reviews. We also contacted 38 experts for information. No date restrictions were employed. A narrative review of systematic reviews or 'meta review' was conducted using transparent and systematic procedures to limit bias at all stages. Systematic reviews that compared midwife-led care during pregnancy and birth with physician-led care were eligible for inclusion. Three meta-analytic reviews were included. Midwife-led care for low-risk women was found to be better for a range of maternal outcomes, reduced the number of procedures in labour, and increased satisfaction with care. For some maternal, foetal, and neonatal outcomes reviews found no evidence that care led by midwives is different to that led by physicians. No adverse outcomes associated with midwife-led care were identified. For low-risk women, health and other benefits can result from having their maternity care led by midwives rather than physicians. Moreover, there appear to be no negative impacts on mothers and infants receiving midwife-led care.

The provision of midwife-led care in low-and middle-income countries: An integrative review

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BackgroundEvidence from high-income countries demonstrate improvements in maternal and neonatal health with midwife-led care. Midwife-led care is pivotal to meet the United Nations’ Sustainable Development Goals. Despite this, successful implementation of midwife-led care in low- and middle-income countries (LMICs) has been limited. It is therefore necessary to understand the factors that influence the implementation of midwife-led care. AimThis systematic review aimed to synthesize the evidence on barriers and facilitators to the implementation of midwife-led care for childbearing women in LMICs from the perspectives of care recipients, providers and wider stakeholders. MethodsA mixed-methods systematic review was conducted of primary research studies that expressed the views of those involved in or affected by the implementation of midwife-led care in LMICs. Reporting followed PRISMA guidelines. MEDLINE, EMBASE, PsychINFO, CINAHL, Maternity and Infant Care database (MIDIRS), Global Health and Web of Science databases were systematically searched. Methodological quality was assessed using the Mixed Methods Appraisal Tool (MMAT). Data was analysed and synthesized using the Supporting the Use of Research Evidence (SURE) framework to identify barriers and enabling factors to implementing midwife-led care. FindingsA total of 31 studies from 21 LMICs were included. At the care recipient level, women need adequate knowledge and confidence about midwife-led care to utilise services. At the care provider level, strengthening midwifery education and practice by employing experienced educators and supervisors is essential. Findings also suggest that increased collaboration between funders, professional organisations, practitioners, communities, and the government is necessary for successful implementation. However, adequate and sustained funding for midwife-led care programs is often lacking and political instability contributes to poor implementation in LMICs. Conclusion and implications for practice and researchThere are several enabling factors which increase the success and sustainability of the midwife-led model of care in LMICs. However, current practice guidelines and strategic frameworks need to better reflect the infrastructure and resource limitations of health settings in LMICs.

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