U.S. states with more support for midwives have better birth outcomes

(Reuters Health) - States with laws that make it easier for midwives to care for pregnant women and deliver babies may have better birth outcomes than states where it’s harder for midwives to provide care, a recent study suggests.

Researchers ranked each state based on how easy it was for midwives to practice and collaborate with obstetricians and other providers. Scores ranged from a low of 17 in North Carolina to a high of 61 in Washington, out of 100 points.

Higher scores were associated with significantly higher proportion of babies delivered by midwives, more spontaneous vaginal deliveries and higher rates of breastfeeding, the study found. Higher scores were also linked to fewer preterm births, underweight newborns and surgical cesarean section deliveries.

“Midwives have expertise and skills in facilitating the physiology of pregnancy, labor, birth, and newborn transition, and obstetricians and maternal fetal specialists have expertise and skills in addressing uncommon health concerns that may arise,” said lead study author Saraswathi Vedam of the University of British Columbia in Canada.

“The question is not whether it is better to have a midwife or a doctor, but the degree to which midwives and doctors are able to work together to provide the best care utilizing all of their expertise and abilities,” Vedam said by email.

Roughly nine in 10 U.S. births were handled by physicians in 2015, while about 9 percent were attended by certified nurse midwifes with advanced training or other midwives, researchers note in PLoS One.

Certified nurse midwives can get licensed in all 50 states and can provide well-woman gynecology and primary care as well as maternity care.

To assess how easy it is for midwives to care for women, researchers assessed licensing requirements, any restrictions on what type of care midwives can provide or where they can practice, any requirements for midwives to consult with physicians or refer patients to doctors for certain conditions, any laws regulating quality and safety of births in hospitals as well as at birthing centers or at home, and any laws regulating whether midwives can write prescriptions.

States with highest scores had licensing requirements for different types of midwives and gave midwives the most ability to care for women in different settings, write prescriptions and receive payments from Medicaid, the U.S. health insurance program for the poor.

States in the Northeast, Pacific Northwest and Southwest had the highest density of midwives, as measured by the number of midwives practicing for every 1,000 births.

States in the South had the lowest scores for midwifery policies, and these states also had the highest rates of premature births, underweight babies and infant mortality, the study found.

The study wasn’t a controlled experiment designed to prove whether or how midwives might mean better birth outcomes or how certain state policies regulating midwives might lead to better health for mothers or babies.

Because researchers looked at all policies together, the study also couldn’t shed light on what effect individual policies relating to midwife practice might mean for birth outcomes, the authors note.

Even so, the findings add to the evidence that birth outcomes may be better when midwives do more deliveries, said Erin Wright, a researcher at Johns Hopkins University School of Nursing in Baltimore who wasn’t involved in the study.

“This matters especially in the U.S. with regard to the abysmal rates of neonatal and maternal morbidity and mortality despite our high resource setting,” Wright said by email.

In many other countries, midwives handle 50 to 70 percent of births, Wright said.

“In these other countries physician care is reserved for those with an underlying or pregnancy induced medical condition,” Wright added. “Women with the medical co morbidities are likely best served with care from an obstetrician or by co management between a physician and a midwife depending on the condition and the setting.”

SOURCE: PLoS One, online February 21, 2018.