Midwifery Review: Adding Care by Midwives Improves Birth Outcomes

The practice of midwifery is less common in the United States than in other countries and other cultures, which is a shame because adding care by midwives generally improves childbirth outcomes, according to two Yale faculty members who have published an “Expert Review” article on the topic in the American Journal of Obstetrics & Gynecology.

Holly Powell Kennedy, PhD, MSN, CNM, the Helen Varney Professor of Midwifery, and Joan Combellick, PhD, MPH, MSN, CNM, assistant professor of nursing, along with their colleagues, examined the scientific literature related to midwifery and childbirth, and conclude that many measures of successful pregnancy are elevated when midwives play a central role.

They cite the approach to midwifery that is standard in other countries, especially in wealthy European nations, where women have as much as seven times the access to midwives that they do in the United States. They report that midwifery care has improved outcomes by 56 different measures—including lower morbidity and mortality among mothers and newborns, fewer preterm births and low birthweight infants, and reduced interventions in labor.

The authors acknowledge that differences in those countries’ overall health systems make a substantial contribution to good outcomes, but say it’s the integral role of midwives that matters most. “In other countries, midwives make up the basic maternity care provider workforce, and then, obstetricians are used as the specialists that they are, surgeons who are there to handle complications,” says Combellick. “[Midwives] are the experts in normal childbirth, which happens the majority of the time.” Combellick adds that midwives also extend their care beyond pregnancy. “We also do well-person preventive care, across the lifespan from teenagers through postmenopausal people, so it isn’t only pregnancy-related.”

But the continuum of pregnancy, birth, and postnatal care is what midwives are best known for, and where the contribution of midwives can differ sharply from what is often considered standard care. Kennedy says a very basic way that outcomes can improve is because prenatal care by midwives is not squeezed into appointments of a set duration, where the provider may not have the time to fully answer the patient’s questions. Kennedy notes that in some settings, midwives caring for a woman throughout the pregnancy bring continuity and can structure longer appointments. Having more time permits building better rapport with a mother-to-be and helps her feel more respected, which often translates into a smoother pregnancy.

“In our paper, we discuss some of the research done about respect. It’s true for any kind of health care, but particularly in prenatal care,” says Kennedy. “It can amount to being highly disrespected and simply having to wait two hours for a very short prenatal visit. If people aren’t feeling respected or safe, they’re less likely to keep coming in for prenatal care.” Combellick adds that this can be especially true for women of color, for whom the cumulative race-based disrespect they endure in their daily lives can make the pressures of pregnancy more intense.

When the time for delivery arrives, a few statistics are especially striking. First-time mothers giving birth at medical centers where midwives were on their care team were 74% less likely to have their labor induced, 75% less likely to receive oxytocin augmentation, and 12% less likely to deliver by cesarean than their counterparts at medical centers without midwives in attendance.

Combellick says that on a collaborative team, the pregnant person is at the center of care, with everyone contributing their particular expertise. Whether to wait and allow labor to continue at its own pace, to induce, or to perform a cesarean can generally be a shared decision that involves patient understanding and consent. “We are collaborators,” says Combellick. “We work in conjunction with physicians. To have two viewpoints thinking about one person is a really strong style of care.”

At Yale, Kennedy and Combellick contribute to the midwifery faculty practice supporting student midwives as they learn. Faculty practice midwives are also active with obstetricians-in-training. “We contribute to the resident training program,” Combellick says. “So the residents, when they first come, are assigned to follow a midwife. Around the country, midwives often play a role in demonstrating ‘here’s what normal physiologic birth looks like,’ and that occurs at Yale.”

Hugh S. Taylor, MD, chair and Anita O’Keeffe Young Professor of Obstetrics, Gynecology & Reproductive Sciences at Yale School of Medicine, says this collaboration has been good for all involved. “It’s important that all of our practitioners get exposure and training on the collaborative practice model. The trainees participate in these teams and get a living example of how collaboration results in outstanding care. It was very important to establish that program—not only for patient care but for our residents and students.”

Taylor says that both for prenatal care and during deliveries, the presence of midwives on the care team can be invaluable. “Most of the prenatal care in our collaborative practice is delivered by midwives, with appropriate escalation and/or referral when things get complicated. If somebody develops diabetes or high blood pressure in pregnancy, we get the physician involved. However, for routine prenatal care or uncomplicated deliveries, we try to keep the physician in the background.”

Kennedy and Combellick both hope that the profile of midwifery in this country will rise, both through growing what Combellick now calls a “relatively small midwifery workforce” that attends only 10 to 12% of births in the United States, and by reforming practices related to health care delivery at large. “It’s not a simple, magical thing about the midwife,” Kennedy concludes, “but really about the model of care: that it’s accessible, it’s available, it’s respectful.” Those changes for the better, they say, would be nothing short of radical, and they are doing their part to gather the available evidence and advocate for change to happen.