US midwives have low caesarean rate

BMJ 1995; 311 doi: (Published 25 November 1995) Cite this as: BMJ 1995;311:1387
  1. DEBORAH JOSEFSON, medical journalist
  1. New York

    Pregnancies attended to by certified nursemidwives are at least 50% less likely to end in caesarean sections, according to a study published by the Public Citizen Health Research Group in the US. The group, a leading private consumer advocacy organisation, based its report on a survey of 419 hospital based certified nurse-midwife practices and on 41 birthing centres.

    While almost a quarter of American babies are born by caesarean section, the rate was less than 12% for those births attended by certified nurse-midwives. Moreover, repeat births by caesarean section were also less likely for those mothers who chose nursemidwives to deliver their subsequent babies. Across the US three quarters of women who previously delivered by caesarean section have the procedure again. When delivered by qualified nurse-midwives only one third of such women have repeat caesarean sections.

    The consumer group contends that the rate of caesarean section in the US is excessive and believes that it can be reduced if certified nurse-midwives are used to deliver most babies. To that end, the group plans to lobby to change state laws and encourage a higher profile for nurse-midwives.

    Certified nurse-midwives delivered 5% of babies in the US (185000) in 1992. Of these, 95% were delivered in hospital, with most of the other births occurring in birthing centres. Only a small proportion of deliveries are performed in patients' homes.

    The group admits that most pregnancies delivered by certified nurse-midwives fall into the low risk category but states that certified nurse-midwives are also qualified to deliver moderate and high risk pregnancies.

    Dr Sydney Wolfe, director of the Public Citizen Health Research Group, said that “the report takes into account risk stratification.” One of the report's authors, Mary Gabay, said that risk stratification was assessed by asking the survey's respondents to mark whether they saw “low risk only” patients, a mixture of “mostly low risk patients, with moderately high risk patients co-managed with physicians,” or “high risk only” patients.

    Altogether 87% of the respondents noted that they cared for mostly low risk patients but also co-managed higher risk patients with physicians. Nine per cent of the nurse-midwives described their practice as exclusively high risk but stated that this risk assignment was due mainly to social factors such as poverty. Medical high risk factors, such as pre-eclampsia or gestational diabetes, may have existed in the population but were not specifically addressed. The study concluded: “It would appear that certified nurse-midwives' low caesarean section rate is not mainly due to the risk population they serve.”

    Responding to the report, Dr Hal Lawrence, the cochairman of the Collaborative Practice Advisory Group of the American College of Obstetrics and Gynecology, said: “I support the interaction of the team in a collaborative practice environment. Our primary goal is to provide the highest quality of care. I don't believe that nurse-midwives or physician assistants alone can provide it.”

    Most nurse-midwives currently practise under a strict protocol and in a hospital setting, where help from a physician is readily available in the event of an emergency. Certified nurse-midwives must be licensed registered nurses and in addition have passed a certification course in midwifery. Currently, about 4000 midwives and 32000 obstetricians practise in the US.


    Delivery by caesarean section: do midwives prevent this from happening?

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