Intended for healthcare professionals

Letters Positive birth experience

Midwife led care may not be appropriate or cost effective

BMJ 2011; 342 doi: (Published 18 April 2011) Cite this as: BMJ 2011;342:d2298
  1. Pauline M Hull, editor, electivecesarean.com1
  1. 1Farnham, Surrey, UK
  1. info{at}
  • Competing interests: None declared.

The King’s Fund report states that one of the “key underpinning principles” of maternity health policy is that “all women, regardless of risk profile, should be offered the most positive birth experience possible.”1

American researchers have recently added to the growing body of evidence that women planning a caesarean birth are more likely to have a positive experience than those planning a vaginal birth, the caesarean group reporting higher satisfaction ratings, higher scores for fulfilment, lower scores for distress, and lower scores for difficulty.2 3 The King’s Fund report, however, does not recognise that for low risk women who plan a prophylactic caesarean birth (the informed decision to deliver at 39 or more weeks’ gestation to avoid the unpredictable infant and maternal risks associated with a trial of labour), midwife led care is not appropriate: obstetrician led care is.

The report also does not include the long term costs and outcomes of different birth types or models of care. Substantial, directly attributable costs beyond the intrapartum period exist, including NHS obstetrics litigation (£301m last year) and treatment of babies and mothers injured during even “normal, low risk” births—for example, brachial plexus palsy, trauma counselling, and pelvic floor surgery.

Identifying low risk pregnancies is also costly. The Netherlands has one of the worst perinatal mortality rates in Europe,4 despite including gestational and weight limits in its “live birth” data, which does not happen in the UK.

I do not criticise midwife led care itself, but the hypothesis that it is the most cost effective approach and the inference that women at low risk can be reliably identified and should all choose a midwife over an obstetrician.


Cite this as: BMJ 2011;342:d2298