Lamaze International’s popular series, Research Summaries for Normal Birth, was discontinued in 2008 after four years of quarterly round-ups so that we could launchScience & Sensibility. In order to bring all of our research resources together in one place, we are adding the Research Summaries archive to Science & Sensibility.
In honor of National Midwifery Week, we present the Research Summaries archives on the safety and effectiveness of midwifery care. Although I only summarized three articles specifically about midwifery in my four years writing Research Summaries, many of the studies summarized in other topics were carried out by midwives and midwifery researchers. Together these bodies of research unwaveringly support midwifery care and midwife-led models of care for improving the health of mothers and infants.
1. Case Study Reveals Economic and Political Forces that Hinder Access to Midwifery Care
Goodman S (2007). Piercing the veil: the marginalization of midwives in the United States. Social science & medicine (1982), 65 (3), 610-21 PMID: 17475381
2. Pilot Study Suggests Midwifery Care Is Optimal for Moderate-Risk Women
Cragin L, & Kennedy HP (2006). Linking obstetric and midwifery practice with optimal outcomes.Journal of obstetric, gynecologic, and neonatal nursing : JOGNN / NAACOG, 35 (6), 779-85 PMID:17105644
3. Midwifery Process Places Emphasis on Keeping Birth Normal
Kennedy HP, & Shannon MT (2004). Keeping birth normal: research findings on midwifery care during childbirth. Journal of obstetric, gynecologic, and neonatal nursing : JOGNN / NAACOG, 33(5), 554-60 PMID: 15495700
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Case Study Reveals Economic and Political Forces that Hinder Access to Midwifery Care
Goodman, S. (2007). Piercing the veil: The marginalization of midwives in the United States. Social Science & Medicine, 65(3), 610-621.
Summary: This qualitative case study analysis illuminates the forces behind the underutilization of midwives in the U.S. maternity care system and the process of their professional marginalization. The researcher identified two prominent midwifery services that had good outcomes and were connected with prestigious and influential institutions. One was a university-affiliated hospital practice that had provided uninterrupted midwifery service to the community for nearly five decades. The other was a birth center in continuous operation for nearly 30 years and hospital-owned for the final seven. Both practices were threatened with closure in 2003. In the case of the university-affiliated practice, the midwives ultimately maintained their ability to practice but the hospital imposed restricted clinical practice guidelines resulting in an 84% decrease in the number of midwife-attended births and a number of midwives leaving the service. The birth center practice closed abruptly in a decision handed down by the hospital without the involvement of the center’s Board of Directors. In order to understand the circumstances behind the closures, the researcher conducted 52 in-depth interviews with midwives, nurses, service administrators, childbirth educators, policymakers, and physicians and reviewed archival data such as email correspondence, policy statements and memos.
In both cases, the publicly articulated reason for the attempted or actual closure of the midwifery services appeared to be reasonable. In the university-affiliated practice, the hospital claimed that too many of the women in the neighborhoods served by the hospital were high-risk and midwifery care was therefore unsafe. In the case of the birth center, the hospital reported that the decision to close was prompted by a 400% increase in malpractice insurance premiums. In neither case did the hospital provide any documentation or other evidence to support these rationales for closure. Interviews and analysis of archival data revealed that the midwifery services represented competition to the hospital, local physicians, or both. The case of the university-affiliated midwifery practice was particularly overt: the hospital had recently paid a multi-million dollar fine for double-billing the Medicaid program for births attended by midwives – once for the midwife and again for the consulting physician. When this fraudulent practice was discovered and the hospital was censured, midwives became a source of competition rather than income. In the case of the birth center, five-fold growth in the number of birth center births over the time the hospital had ownership may have appeared to be siphoning business away from the hospital’s labor and delivery unit. Despite these potentially powerful economic and political motives for closing the midwifery services, the public were led to believe that the decisions were driven by rational concerns about safety and liability. The author concluded, “In the cases studied, institutions successfully altered maternity care and diminished midwifery services without accountability for their actions. In fact, the elimination of midwives seemed to be a rational decision when framed in the context of patient safety and the rising cost of medical malpractice” (p. 9).
The author explored aspects of the U.S. health care system that facilitate professional marginalization of midwives. The most problematic is the way the U.S. medical education system is funded. Hospitals essentially get paid twice for care provided by medical residents because they can bill directly for the care and also receive large subsidies from the federal Medicare program in exchange for providing residency opportunities. The more residents a hospital employs, the more federal money they get, so there is a government-imposed disincentive for hospitals to employ midwives. Furthermore, in many states midwives must have formal practice agreements with physicians in order to obtain licenses, liability insurance, reimbursement, or hospital privileges. This requirement makes midwives dependent on their competition in order to gain access to employment. Finally, midwives’ reliance on low-tech care practices result in lower utilization of medical devices and services that may be separately billable.
Significance for Normal Birth: Advocates for improvements in maternity care are often at a loss to explain why childbearing women cannot access care providers who support normal birth. Normal, physiologic birth, it would seem, must be less costly than technology-intensive birth. Solving this paradox requires an understanding of the political and economic forces that foster dependency on high-cost obstetrics to the detriment of women and babies. While this study is small and focused on two specific examples of midwifery service closures, it provides important insight into the systemic forces that hinder women’s access to midwifery care despite a large body of evidence that midwives provide equal or better care than physicians with lower reliance on costly technical interventions. The study documents how our market-based health care system safeguards the interests of the medical profession which can often be at odds with those of women, babies, and society.
Radical, systemic reforms are needed if the United States hopes to achieve a high-functioning maternity care system, characterized by effective, high-quality care, universal access, and cost containment. Evidence from countries with excellent maternity care outcomes suggest that eliminating barriers to midwifery care must be a priority. Birth advocates can begin by calling for accountability and transparency from hospitals and maternity care providers.
Pilot Study Suggests Midwifery Care Is Optimal for Moderate-Risk Women
Cragin L, Kennedy HP. (2006) Linking obstetric and midwifery practice with optimal outcomes. Journal of Obstetric, Gynecologic and Neonatal Nursing, 35(6), 779-85.
Summary: This study compared the pregnancy, birth and postpartum care practices and outcomes experienced by 196 moderate-risk women receiving nurse midwifery care with those of 179 similar women receiving physician care in the same hospital-based faculty practice. Each woman was assigned an “Optimality Index – US” score, calculated from 40 variables measuring optimal health status, care practices and outcomes. A companion “Perinatal Background Index” (PBI) score that captured demographic and health history was also assigned. Together, the two scores provide a valid measure of the process and outcomes of care within the context of the clinical situation of the individual woman.
Women in the midwife group had significantly higher optimality scores than women in the physician group (79% versus 70%). While some of this difference was attributable to differences in baseline medical risks (as measured by significant differences in PBI score), statistical analysis revealed that the provider type (i.e. midwife or physician) was twice as predictive of optimality scores. The cesarean section rate was 13% among women in the midwife group versus 34% in the physician group, a difference that also was not explained by health status alone. (The rates were 5.6% and 15.6% respectively after excluding women with preexisting chronic medical conditions.) In various statistical analyses, only type of provider accurately predicted cesarean rates in the two groups.
Women in the midwife group were more likely to drink or eat (95% versus 80%), maintain mobility in labor (68% versus 28%), and use non-pharmacologic methods of pain relief (88% versus 51%). Epidural use was lower in the midwife group (31% versus 51%), as was use of any pharmacologic pain relief methods (64% versus 82%).
Significance for Normal Birth: Traditional measures of maternity care outcomes have focused on morbidity and mortality indicators. This approach has several drawbacks. In the United States morbidity and mortality are fortunately rare, so studies assessing these outcomes must be large in order to demonstrate significant differences. Furthermore, these “negative” indicators are poor measures of the effectiveness of care that is intended to promote “positive” outcomes like health and wellness in population experiencing a physiologically normal process. The Optimality Index – US has emerged as an important new tool for measuring maternity care to capture both the process and outcomes of different styles of practice.
In this and other studies, midwifery care has been associated with high optimality, demonstrating appropriate use of interventions and good outcomes given the individual women’s clinical situations. Midwives are often assumed to care for only low-risk women but many midwives also care for women at moderate or high risk. This study finds that midwifery may be optimal for moderate risk population by promoting good outcomes with less reliance on technological and surgical intervention and a greater attention to the care practices that support normal birth.
Midwifery Process Places Emphasis on Keeping Birth Normal
Kennedy, H. P., & Shannon, M. T. (2004). Keeping birth normal: research findings on midwifery care during childbirth. JOGNN – Journal of Obstetric, Gynecologic, & Neonatal Nursing, 33(5), 554-560.
Summary: This qualitative study describes key aspects of the process of midwifery care. Eleven certified nurse-midwives completed interviews about how they achieve the objective of being “with women” in pregnancy and childbirth. These midwives had been previously identified as “exemplary” based on their clinical expertise and midwifery philosophy, and had participated in a study where “support for normalcy” was identified as central to the midwifery process. Narrative analysis was used to examine the responses in the current study. A series of coding and interpretive decision making allowed the researchers to organize and analyze the midwives’ narratives. The research team was comprised entirely of midwives, but secondary analysis was done by non-midwife researchers to enhance validity of the study.
The theme about which the midwives spoke most frequently was “support for normalcy.” The researchers analyzed this theme and found several elements that contributed to this process: 1) belief in the normalcy of birth, 2) tolerance of wide variations of normal within a defined circle of safety, 3) belief in the woman’s strength, 4) The physical act of being present with women, and 5) teaching students to believe and trust in normal birth. Through their narratives, the midwives described the task of balancing their belief in normalcy with vigilant assessment to help determine when technological intervention was truly needed. The study authors discuss limitations to their study, including the participants’ knowledge of the purpose of the study and the likelihood that the midwives did not comprise a representative sample. But they conclude that midwives’ “finely tuned balance of navigating between low- and high-technological worlds may hold clues to the differences between midwifery and medical models of care.
Significance for Normal Birth: This study illuminates aspects of the midwifery model of care that support the normalcy of birth. While the study does not compare the midwifery process with that of physicians, it identifies frustrations of exemplary midwives who work within a medical model of care, suggesting that our system does not address birth as a normal physiologic process. It appears very likely from the results of this study that normal birth is most likely to be achieved when midwives attend women in labor and birth. However, efforts must be made to enhance the ability of midwives to practice within a midwifery model, unencumbered by protocols and practice standards that regard birth as a pathologic process.