This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth. Today we’ll look at the third “P” of my 10 “P’s” of keeping labor shorter and birth safer — professionals.
When the literature discusses the effect of the care giver on birth, it generally discusses the midwife or the physician. However, there is at least one study that suggests that the choice of the nurse we use in labor can effect outcome.
“Nursing care has been shown to influence length of labor, use of pain medications, and women’s physiological outcomes … this retrospective study … in a large not for profit hospital … with nulliparous women … (showed) large differences in cesarean birth rates between nurses in the lowest quintile (4.9%) and the highest quintile (19%) … the lowest quintile (also showed) the shortest times form assumption of care to delivery … (and were) less likely to have forceps … (and) more likely to use a form to record psychosocial data than the nurses in the highest quintile.”(49)
There is some risk-controlled data that compares the outcomes of midwives and family physicians.
“Family physicians and nurse midwives managed patients in labor similarly, but nurse midwives were more likely to achieve vaginal delivery and do so without an episiotomy (40% vs 30% primip, p=.02; 20% vs 10% multip, p=.007).
Primiparous women managed by family physicians were more likely to under go cesarean section resulting from the diagnosis of dystocia (14% vs 8%, P=.05) … with a relative risk of 2.79 for cesarean if patients had their labor managed by a family physician (p<.001).”(46)
In addition, “family physicians fall between the higher episiotomy (and intervention) rates of obstetricians and the lower rates of midwives.”(46)
However, “similarities in the obstetrical philosophies of family physicians and nurse midwives have led some to suggest that a natural alliance should exist between these health professionals. However, there are only a few descriptions of successful alliances of midwives and family physicians.”(46)
“Most family physicians have philosophical and practice styles that are similar and maternity care outcomes that are remarkably similar (to midwives)…and (family physicians and midwives) should work closer together. The potential advantages are numerous and the disadvantages more imagined that real.”(39)
At least 15 studies compare midwives to physicians (obstetricians or obstetricians and family physicians).(50)
One randomized, controlled trial in Canada typifies the results of most: “… midwives are less likely to use a variety of interventions such as cesarean delivery (4.0% vs. 15.1%), episiotomy (15.5% vs. 32.9%), epidural (12.9% vs. 23.7%), along with a reduction in the use of routine ultrasound, intravenous drug use, hospital length of stay, and neonatal ICU admission.”(51)
It appears that midwives keep normal labor normal more often than their physician colleagues and that their utilization in a “… health care system is an appropriate use of health care dollars,”(51) especially since the trend in this study is confirmed by meta-analysis.(50)
There is some data, controlled for patient risk status, that compares the outcomes of family physicians and obstetrician-gynecologists. One report states that “…the observed socioeconomic biases in the use of cesarean sections (by obstetricians) have not been reported for maternity care rendered by family physicians.”(52)
Another says that “Obstetricians performed episiotomies more frequently, used oxytocin augmentation more often, and supervised labors during which an increased frequency of major lacerations in patients occurred.”(53)
“Family physicians and obstetricians differ in their management of labor and delivery. In general, … family physicians tend to use less oxytocin both for induction and augmentation and were less likely to perform invasive interventions such as amniotomy, episiotomy, and instrument delivery. Family physicians have been reported to have cesarean section rates that were approximately 33% less than the rates of obstetricians in the same institution.”(46)
“(Low-risk) patients of obstetricians were almost three times as likely to have a cesarean delivery than were family physicians; cesarean section rate was 11.3% for obstetricians compared to 3.8% for family physicians (p=.0052).”(54)
“Even after adjustment for … risk, obstetrician-supervised teaching services had … more frequent use of epidural anesthesia, and higher episiotomy and cesarean section rates than family practice teaching services.”(55)
Although all these data contain significant selection bias,(53) at the very least there appears to be no harm to the midwife’s or family physician’s noninterventional approach to labor: “The style of obstetrical management by (midwives and) family physicians is characterized by significantly less intervention during labor. Yet this style of management does not adversely affect maternal and newborn outcomes.”(56)
“Taken overall, it appears that the literature paints a picture that could be interpreted to say that if one wants to keep normal labor normal, one should utilize more midwives and family physicians and reserve most obstetrician services for the specialized cases they are best trained to manage.”(42)
Certainly, it seems appropriate to ask physicians or policy makers who oppose maternity care provision by midwives or family physicians to replicate better (or, at least equivalent) outcomes.
As a result of outcomes such as those discussed above “… a recently described maternity model … had nurse-midwives for care of routine obstetric and newborn patients; family physicians in an intermediate role, particularly with assisted deliveries, complicated pregnancies, and sicker newborns; and obstetricians providing cesarean sections and high-risk consultations.”(42)
In Great Britain, the differences in providers, their philosophies, their practice styles and their outcomes is leading to an environment where “both general practitioners and midwives are to be involved in the training of future obstetricians and both will take part in their assessment. Already obstetricians no longer teach or examine midwives.”(57)
However, all maternity caretakers should be “… knowledgeable in obstetric crisis management …”(39,42) (such as is taught in the Advance Life Support in Obstetrics [ALSO] Course(58-60)), and they should be ,”… trained…in a philosophy of noninterventional, patient-centered, not facility-centered, maternity care and birthing based on the view that birth, a life event, more often than not needs practitioners who are adept at the ancient art of ‘doing nothing.’ They will know when it is suitable ‘to do nothing,’ when they are appropriately ‘doing nothing,’ and will do it well. In fact, they should know how to and when to ‘do nothing’ extremely well.”(39)
Here’s the entire series:
(39) Larimore WL, Reynolds JL. Family practice maternity care in America: ruminations on reproducing an endangered species – family physicians who deliver babies. J Am Bd Fam Pract 1994;7:1-11
(42) Nesbitt TS. Rural maternity care: new models of access. Birth 1996;23:161-5.
(46) Hueston WJ, Rudy MA. A comparison of labor and delivery management between nurse midwives and family physicians. J Fam Pract 1993;37:449-454.
(47) Thornton JG, Lilford RJ. Active management of labour: current knowledge and research issues. BMJ 1994;309:366-369.
(48) Hodnett ED. Support from caregivers during childbirth. In: Pregnancy and childbirth module (eds. Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP), ‘Cochrane Database of Systematic Reviews’: Review No. 03871, 3 October 1994. Oxford: Update Software, 1994, Disk Issue 1.
(49) Radin TG, Harmon JS, Hanson DA. Nurses’ care during labor: its effects on the cesarean birth rate of healthy, nulliparous women. Birth 1993;20:14-20.
(50) Brown SA, Grimes DE. Nurse practitioners and certified nurse midwives: a meta-analysis of nurses in primary care. Washington, DC: American Nurses’ Association 1993.
(51) Harvey S, Jarrell J, Brant R, Stainton C, Rach D. A randomized, controlled trial of nurse midwifery care. Birth 1996;23:128-33.
(52) Hueston WJ. Obstetric referral in family practice. J Fam Pract 1994;38:368-372.
(53) Chambliss LR, Daly C, McDearis AL, et. al. The role of selection bias in comparing cesarean birth rates between physician and midwife management. Obstet Gynecol 1992;80:161-165.
(54) Applegate JA, Walhout MF. Cesarean section rate: a comparison between family physicians and obstetricians. Fam Pract Res J 1992;12:255-262.
(55) Hueston WJ, Rudy M. Differences in labor and delivery experience in family physician- and obstetrician-supervised teaching services. Fam Med 1995;27:182-187.
(56) MacDonald SE, Voaklander K, Birtwhistle RV. A comparison of family physicians’ and obstetricians’ intrapartum management of low-risk pregnancies. J Fam Pract 1993;37:457-462
(57) Mathews D. Birth of the midwife/obstetrician. Lancet 1995;345:532.
(58) Beasley JW, Damos JR, Roberts RG, Nesbitt TS. The advanced life support in obstetrics course. A national program to enhance obstetric emergency skills and to support maternity care practice. Arch Fam Med 1995;4:206
(59) Beasley JW, Damos JR, Roberts RG, Nesbitt TS. The advanced life support in obstetrics course. A national program to enhance obstetric emergency skills and to support maternity care practice. Arch Fam Med 1994;3:1037-41.
(60) Beasley JW, Byrd JE, Damos JR, Roberts RG, Koller WS. Advanced life support in obstetrics course [editorial]. Am Fam Physician 1993;47:579-80.
(61) Simpkin P. Reducing pain and enhancing progress in labor: a guide to nonpharmcologic methods for maternity caregivers. Birth 1995;22:161-71.