US midwife-attended hospital births are increasing while physician-attended hospital births are decreasing: 2003–2018

Abstract

The World Health Organization has designated 2020 as the International Year of the Nurse and the Midwife. A diverse workforce including midwives has been found to benefit pregnancy outcomes. The “Obstetric Care Consensus” published jointly by several professional organizations including the American College of Obstetricians and Gynecologists placed certified midwives and certified nurse-midwives on the same level with obstetrician-gynecologists and family physicians by stating that “Every birth should be attended by at least 1 qualified birthing professional (midwife, family physician, or ob-gyn).”1Kilpatrick S.J. Kathryn Menard M. et al.American Association of Birth Centers, Association of Women's Health, Obstetric and Neonatal Nurses, American College of Obstetricians and Gynecologists, Society for Maternal-Fetal MedicineObstetric Care consensus #9: levels of maternal care (replaces obstetric care consensus number 2, February 2015).Am J Obstet Gynecol. 2019; 221: B19-B30Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Most countries (6 of 9) recommend that low-risk women see only general practitioners or midwives for prenatal care.2Friedman Peahl A. Heisler M. Essenmacher L.K. et al.A comparison of international prenatal care guidelines for low-risk women to inform high-value care.Am J Obstet Gynecol. 2020; ([Epub ahead of print])Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Even though a large proportion of obstetric hospital deliveries are attended by midwives in other high-income countries (in the Netherlands, there are 3150 midwives compared with 805 active obstetrician-gynecologists3Koninklijke Nederlandse organisatie van VerloskundigenMidwifery in the Netherlands 2017.https://www.europeanmidwives.com/upload/filemanager/content-galleries/members-map/knov.pdfDate accessed: March 3, 2020Google Scholar; in Germany, by law, each delivery has to be attended by a midwife), only a minority of deliveries in the United States are carried out by midwives. Our objective was to identify for the first time recent trends in midwife-attended US hospital births. We used the natality public-use data from 2003 to 2018 to describe recent trends in midwife (certified nurse-midwives plus “other” midwives)-attended hospital deliveries and compared them with physician (MD plus DO)-attended hospital births. The study population included 63,905,750 hospital births in the United States between 2003 and 2018, which represented 98.78% of all US births (N=64,698,156). Of all hospital births, 99.55% (n=63,619,400) were attended by either a midwife or a physician, whereas 0.45% (n=286,268) were attended by someone else, unknown, not stated, or not reported. There were 4,935,581 deliveries by certified nurse-midwives, 86,620 by “other” midwives, 54,818,406 by medical doctors, and 3,778,793 by osteopathic doctors. The data on yearly hospital deliveries by birth attendants are presented in the Table. From 2003 to 2018, US hospital births dropped overall by 322,268 (8.66%), from 4,051,987 in 2003 to 3,701,183 in 2018. Midwife-attended hospital births increased by 36,144 (11.83%), from 305,791 in 2003 to 3,415,657 in 2018 (7.4%–9% of hospital births). Physician-attended hospital births decreased by 9.73%, from 3,730,008 in 2003 to 3,366,916 in 2018 (92%–90.3% of hospital births). There was a 29.31% increase in the proportion of vaginal hospital deliveries attended by midwives between 2003 and 2018, from 10.48% (n=305,513) in 2003 to 13.56% (n=341,654) in 2018. Midwives attended 1 in 9.5 vaginal hospital births in 2003 and 1 in 7.4 vaginal hospital births in 2018.TableTrends in US hospital births by birth attendant (2003–2018)YearMidwives, n (%)Physicians, n (%)All hospitals, n2003305,513 (7.4)3,730,008 (92)4,051,6382004302,856 (7.3)3,753,571 (92.1)4,071,5482005300,903 (7.2)3,786,315 (92.3)4,103,5742006311,364 (7.3)3,901,518 (92.3)4,230,0862007314,864 (7.2)3,940,912 (92.2)4,275,7622008310,044 (7.3)3,876,754 (92.2)4,204,6992009305,665 (7.4)3,763,781 (92.1)4,086,2892010303,106 (7.6)3,633,469 (91.9)3,952,0762011300,072 (7.5)3,585,862 (91.9)3,903,5692012303,184 (7.6)3,580,382 (91.8)3,899,0892013308,221 (7.8)3,550,972 (91.6)3,876,0422014320,148 (8.0)3,592,121 (91.4)3,928,2722015326,596 (8.2)3,569,794 (91.1)3,917,2982016332,076 (8.4)3,529,055 (90.9)3,883,2552017335,932 (8.7)3,435,769 (90.6)3,793,2722018341,657 (9.0)3,366,916 (90.3)3,729,199Grünebaum. US midwife-attended hospital births are increasing. Am J Obstet Gynecol 2020. Open table in a new tab Grünebaum. US midwife-attended hospital births are increasing. Am J Obstet Gynecol 2020. Our study shows that midwife-attended hospital births in the United States have increased despite the overall decrease in the total number of US hospital births, whereas physician-attended hospital births have decreased. This increase in midwife-attended hospital births becomes even more pronounced for hospital vaginal births. Studies have consistently shown that midwife-attended births have lower rates of interventions, and it has been recommended to increase midwifery births in the United States.4National Academies of Sciences, Engineering, and MedicineBirth Settings in America: Outcomes, Quality, Access, and Choice.https://www.nap.edu/catalog/25636/birth-settings-in-america-outcomes-quality-access-and-choiceDate accessed: March 8, 2020Google Scholar Considering that out-of-hospital births are associated with manyfold increased neonatal risks,5Grünebaum A. McCullough L.B. Orosz B. Chervenak F.A. Neonatal mortality in the United States is related to location of birth (hospital versus home) rather than the type of birth attendant.Am J Obstet Gynecol. 2020; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (9) Google Scholar it appears that women may more likely choose midwifery care in the hospital over physician-attended deliveries partly to avoid routine use of medical interventions. It will be important to identify the impact of this change on interventions in future years including cesarean deliveries. Obstetricians have the professional responsibility to educate low-risk pregnant women about the midwifery model of hospital delivery and offer them a choice in hospital birth attendants when available.