In a new, hospital-level analysis by health policy researcher Laura Attanasio at the University of Massachusetts Amherst and Katy Kozhimannnil at the University of Minnesota School of Public Health, they report that women who gave birth at hospitals that had a larger percentage of midwife-attended births were less likely to have two specific medical interventions, cesarean delivery and episiotomy.
Attanasio, an assistant professor of health policy and management at UMass Amherst's School of Public Health and Health Sciences, explains that a growing body of research at the individual level has shown that compared to women cared for by physicians, women considered at low-risk for complications in childbirth who receive care from midwives have good outcomes that include lower use of interventions such as cesarean delivery.
The researchers analyzed hospital-level data reported in New York State over one year. Details appear in the current Journal of Midwifery & Women's Health. Their study analyzes the experiences of individual women; an accompanying policy brief looks at hospital rates of medical interventions at the time of childbirth.
The authors say their findings raise the possibility that greater access to midwifery care, which is low in the United States, might enhance perinatal care and lower costs for low-risk women. In 2014, the year of the study, Attanasio and Kozhimannil point out that midwives attended just 9 percent of U.S. births, compared to more than 66 percent in other western countries such as Australia, France and the U.K.
They add, "More midwife-attended births may be correlated with fewer obstetric procedures, which could lower costs without lowering the quality of care. This raises the possibility of improving value in maternity care through greater access to midwifery care for childbearing women in the United States."
The researchers used the Healthcare Cost and Utilization Project State Inpatient Database data for New York and New York State Department of Health data on the percentage of midwife-attended births at hospitals in the state in 2014 to estimate the association between the hospital-level percentage of midwife-attended births and four outcomes among low-risk women: induced labor, cesarean delivery, episiotomy and severe obstetric morbidity - that is, unintended outcomes of labor or delivery that have significant negative effects on the mother's health.
Of the 126 hospitals included, the researchers say, about 25 percent of the hospitals had no midwives present. About 50 percent had some midwives present, but they attended less than 15 percent of births, while at 7 percent of the hospitals, midwives attended over 40 percent of births. They controlled for such variables as mother's age, insurance type, and diagnosis of diabetes and hypertension.
Key findings were:
- Women who gave birth at hospitals with more midwife-attended births had lower odds of delivering by cesarean and lower odds of episiotomy.
- Hospital-level percentage of midwife-attended births was not associated with changes in labor induction or severe obstetric morbidity.
Attanasio says, "This study is contributing to a body of research which shows that good outcomes for women at low risk in childbirth go hand-in-hand with lower use of medical procedures. And, there is increasing attention now to overuse of cesarean and other procedures that are not resulting in better outcomes for mom and baby."
Kozhimannil adds that the findings imply that a greater midwifery presence may have important clinical benefits. "From a policy perspective, this study should encourage legislators and regulators to consider efforts to safely expand access to midwifery care for low-risk pregnancies," she notes.
Several states are considering expanding midwives' scope of practice as New York State did in 2010 for certified nurse midwives, Attanasio says. "I hope that this work contributes to the evidence related to promoting the quality and value in maternity care that midwives can bring. A number of studies have shown that expanding their scope of practice and giving midwives more autonomy can increase women's access to midwifery care."
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