Influence of midwifery presence in United States centers on labor care and outcomes of low‐risk parous women: A Consortium on Safe Labor study

Abstract

Background: Sixty percent of United States births are to multiparous women. Hospitallevel policies and culture may influence intrapartum care and birth outcomes for this large population, yet have been poorly explored using a large, diverse sample. We sought to use national United States data to analyze the association between midwifery presence in maternity care teams and the birth processes and outcomes of low-risk parous women. Methods: We conducted a retrospective cohort study using Consortium on Safe Labor data from low-risk parous women in either interprofessional care (n = 12 125) or noninterprofessional care centers (n = 8996). Unadjusted, adjusted (age, race, health insurance type), propensity-adjusted, and propensity-matched logistic regression models were used to assess processes and outcomes. Results: There was concordance in outcome differences across regression models. With propensity score matching, women at interprofessional centers, compared with women at noninterprofessional centers, were 85% less likely to have labor induced (risk ratio [RR] 0.15; 95% CI 0.14-0.17). The risk for primary cesarean birth among low-risk parous women was 36% lower at interprofessional centers (RR 0.64; 95% CI 00.52-0.79), whereas the likelihood of vaginal birth after cesarean for this population was 31% higher (RR 1.31; 95% CI 1.10-1.56). There were no significant differences in neonatal outcomes. Conclusions: Parous women have significantly higher rates of vaginal birth, including vaginal birth after cesarean, and lower likelihood of labor induction when cared for in centers with midwives. Our findings are consistent with smaller analyses of midwifery practice and support integrated, team-based models of perinatal care to improve maternal outcomes. K E Y W O R D Scesarean, culture, induced labor, midwifery, multiparous, obstetrics, oxytocin, parturition 488 | CARLSON et AL.

Geospatial variation in caesarean delivery

“…Differences in caesarean rates based on the presence of midwives and family physicians suggest that practice differences between types of providers play some role in variation. (Carlson et al, ; Neal et al, ; Prasad et al, ) This conclusion is supported by the association between high caesarean rate clusters and counties without midwives in these data. In 2011, the last survey performed, less than 15% of PCSAs in Georgia had family physicians providing delivery care.…”

Preventing Cesarean Birth in Women with Obesity: Influence of Unit‐Level Midwifery Presence on Use of Cesarean among Women in the Consortium on Safe Labor Data Set

“…Key findings are that healthy women who labored at centers with a midwifery unit‐level presence had lower odds of unplanned cesarean birth and longer labor durations than women at centers without midwives. As demonstrated in our previous analyses using this sample of women, neonatal outcomes in centers with versus without unit‐level midwifery presence were similar between these groups …”

“…The Emory University Institutional Review Board and the Eunice Kennedy Shriver National Institute of Child Health and Human Development both approved this secondary analysis. More details on the methodology used to generate this sample are available in previous publications …”

Intrapartum Care and Experiences of Women with Midwives Versus Obstetricians in the Listening to Mothers in California Survey

“…Because the analysis was limited to hospital births and because certified nurse‐midwives (CNMs) attended 99.7% of all midwife‐attended hospital births in California in 2016, the data we report here essentially constitute a study of CNM hospital practice in California. Multiple prior studies have examined pregnancy and birth care provided by midwives, relying primarily on vital statistics, hospital discharge data sets, subsets of the National Health Interview Survey, and abstracted hospital health records . Far less common are studies of midwifery that rely on women's own perspectives concerning their pregnancy and birth care …”

“…A growing body of evidence finds midwifery care associated with benefits to nulliparous or multiparous women during the prenatal, intrapartum, and postpartum periods. Benefits are primarily seen in lower rates of medical interventions during the intrapartum period, including less use of labor induction, epidural analgesia, and episiotomy .…”