More women at low risk of problems should have midwife led care, says King’s FundBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1495 (Published 07 March 2011) Cite this as: BMJ 2011;342:d1495
All rapid responses
Midwife led care is not appropriate for all low risk women, and its cost-effectiveness is not proven
The King's Fund report states that "Key underpinning principles [of
UK Health policy] are that pregnancy and birth are normal life events and
that all women, regardless of risk profile, should be offered the most
positive birth experience possible." This is important, given that
American research has just added to the growing body of evidence that
women planning a cesarean are more likely to have a positive experience
than those planning a vaginal birth. Also published in March 2011,
Blomquist et al found that at eight weeks postpartum, the cesarean group
reported higher satisfaction ratings, higher scores for fulfillment, lower
scores for distress, and lower scores for difficulty. The authors conclude
that "Maternal satisfaction with childbirth may be improved by efforts to
reduce unplanned cesarean, but also by support for maternal-choice
The King's Fund report does not recognize that for low risk women who
plan a prophylactic cesarean birth (i.e. they have made the informed
decision to deliver their baby at 39+ weeks' gestation in order to avoid
the unpredictable infant and maternal risks associated with a trial of
labor), midwife led care is simply not appropriate; women requesting a
cesarean birth usually prefer (and indeed need) obstetrician led care. Yet
it is equally reasonable to assume that women planning a cesarean for
medical or obstetrical reasons might not necessarily require midwife care
either. That said, the report does highlight the example of Bedford
Hospital's use of "nurses to provide pre- and peri-operative care for
women having caesarean sections in order to release more midwife time for
antenatal screening and surveillance and one-to-one care in labour," which
certainly reflects the King's Fund's aim of "getting the right people in
the right place at the right time".
But in terms of its discussion about the "cost-effectiveness" of
midwife led care for low- and medium-risk women, unfortunately, the King's
Fund report is fundamentally flawed. By its own admission, it does not
include the "long-term costs and outcomes" associated with different birth
types or models of care (which go beyond the intrapartum period but are
directly attributable costs). For example, the vast ongoing expense
associated with obstetrics litigation; last year alone, this cost the NHS
301 million pounds. There is also the cost of treating babies (often
throughout their childhood) and/or mothers who are injured during birth;
and even successful, low-risk, "normal" births can result in trauma
counseling or rehospitalization for repairs to the pelvic floor, for
example, - none of which are accounted for here.
Finally, it is essential to recognize that without hindsight,
identifying "low risk" pregnancies is both challenging and changeable, and
should not be presented as anything less. While the majority of low risk
pregnancies may have no problems, it remains impossible to accurately
predict those that will. The Netherlands, for example, employs a model of
maternity care that seeks to identify low risk pregnancies, but we now
know that its perinatal mortality rate is one of the worst in Europe (and
that's even given the fact that its "live birth" data has gestational and
birth weight limits, unlike our own). Therefore, if women are to make a
truly informed choice about where and how they give birth, as promised by
the government, then it is essential that they are provided with all of
the facts about different models of maternity care (which this report does
not provide), but also, that a prescribed staffing model is not foisted on
them against their will.
This response is not a criticism of midwife led care perse, but
rather, a criticism of hypothesizing that it might be the most cost-
effective approach, of any inference that pregnancies can be reliably
identified as low risk, and of assuming that all women identified as low
risk would choose a midwife over an obstetrician.
(1) Mothers' Satisfaction with Planned Vaginal and Planned Cesarean
Birth. Blomquist JL, Quiroz LH, Macmillan D, McCullough A, Handa VL. Am J
Perinatol. 2011 Mar 4. http://www.ncbi.nlm.nih.gov/pubmed/21380993
(2) Meagan Zimbeck, Ashna Mohangoo, and Jennifer Zeitlin, "The
European perinatal health report: delivering comparable data for examining
differences in maternal and infant health," European Journal of
Obstetrics, Gynecology, and Reproductive Biology 146, no. 2 (October
Competing interests: No competing interests
The radiation doses given are all very old data. major technology
advances have occurred over last 2 years.
Eg Cardiac CT doses are now extremely low.
Incorrect publication of data will result in deaths due to patients and
referring doctors delaying or declining necessary tests.
I have asked Philips to respond to the cardiac dose question and
confirms my experience in over 2000 cases with doses < 5mSV.
To follow is their response . I work with both Philips And Toshiba systems
both of which are much lower dose than quoted and I know the same applies
to GE and Siemens systems.
Response as follows
Hello Dr Sesel,
From a Philips Healthcare standpoint the numbers quoted in the
article appear way out of date.? That is not to say that patients are not
receiving such doses in somey instances due to poor technique, poor
patient preparation, inappropriate protocol or technique selection, or re-
The Philips CT systems range between 10 and 12mSv for fully
retrospectively gated spiral scanning, 5-6mSv for dose modulated
prospectively gated spiral and around 2-3mSv in prospective axial step-and
IDose4, Philips exclusive 4th generation of iterative reconstruction
technique further reduces any of the above doses by a factor of up to 80%,
which means that routine coronary angiography can be achieved in a little
Competing interests: No competing interests
While we do not disagree with the findings of the King's Fund with
regard to availability of midwifery lead care (1), it is well accepted
that all health professionals involved in the care of the newborn at birth
should have the knowledge and skills for initiating resuscitation (2) and
thus we find the accompanying image concerning. This appears to
demonstrate a health professional, presumably a midwife given the
associated article, administering oro-pharyngeal suction without direct
visualisation to a newborn baby.
We can think of no circumstance in current Resuscitation Council (UK)
Newborn Life Support teaching where this would be appropriate, and
furthermore suction administered without direct visualisation of the oro-
pharynx in this way can be harmful, potentially leading to vagal
bradycardia and trauma (2). At birth vigorous newborns are well equipped
to clear amniotic fluid and to establish a resting lung volume without
assistance (3), and routine suction of babies delivered through meconium
stained liquor is no longer recommended following several well designed
randomised controlled trials (4-5). Infants deemed to potentially require
resuscitation should be dried, wrapped and assessed, then treated using
the standard airway, breathing and circulation approach well known to
health professionals involved in newborn life support. Airway management
in the newborn focuses on airway opening techniques and adjuncts, as
obstruction with particulate material is uncommon. While suction may be
appropriate in rare cases, this should only ever be performed under direct
We are concerned that linking an article about midwifery led care
with this image of sub-optimal newborn resuscitation misrepresents the
highly skilled contribution that midwives make in the field of newborn
1. Mayor S. Women at low risk of problems should have midwife led
care. BMJ. 2011;342:d1495.
2. Resuscitation Council (UK). Newborn Life Support. Second ed.
Richmond S, editor. London: Resuscitation Council (UK); 2006.
3. Lind J. Initiation of breathing in the newborn infant. J Ir Med
Assoc. 1962 Apr;50:88-93.
4. Vain NE, Szyld EG, Prudent LM, Wiswell TE, Aguilar AM, Vivas NI.
Oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates
before delivery of their shoulders: multicentre, randomised controlled
trial. Lancet. 2004 Aug 14-20;364(9434):597-602.
5. Wiswell TE, Gannon CM, Jacob J, Goldsmith L, Szyld E, Weiss K, et
al. Delivery room management of the apparently vigorous meconium-stained
neonate: results of the multicenter, international collaborative trial.
Pediatrics. 2000 Jan;105(1 Pt 1):1-7.
Competing interests: CG and CB are Resuscitation Council (UK) Newborn Life Support instructors.