Birthing Buddies: Midwives’ delivery success rate better than physicians [The Journal]
by Hope Katz Gibbs
Aug. 16, 1998
Janis Guyot of Alexandria, Va., is alternately squatting on the floor, wiggling on the bed and panting in the shower. The pain of labor is so unbearable that nothing helps. Except, maybe, midwife Catherine Armstrong.
For hours, Guyot suffered through contractions during the birth of her second child, a 9-pound son named Parker, born Aug. 2. Armstrong, one of five midwives working with four physicians at the Physician and Midwife Collaborative Practice in Alexandria, was down on the floor beside Guyot, holding her hand and talking her through the painful contractions.
“Having Catherine there with me made giving birth a more positive experience,” says Guyot, 37. “When my friends have used physician-only practices, they say the doctors came in to the labor room to check on them periodically but never stayed for long and left the hand-holding to the labor and delivery nurse.
“I had the nurse there to help me, which was great, but Catherine was also there during the entire labor. She held my hand a lot. She helped me breathe through the really hard contractions and she explained what options I had for drugs when the labor got too hard to handle,” Guyot says.
It turns out that kind words and encouragement from a midwife during labor is much more than lip service.
A recent study conducted by the National Center for Health Statistics found that births attended by certified nurse midwives have a 19 percent lower risk of infant death than did births attended by physicians.
The study, published in May in the Journal of Epidemiology and Community Health, also found the risk of neonatal mortality (an infant death occurring in the first 28 days of life) was 33 percent lower and the risk of delivering a low birth weight infant was 31 percent lower when a midwife was the birth attendant.
Although other studies comparing physicians and midwives have been conducted before, this is the first federally-funded research project to examine the infant mortality risks for all babies delivered by certified nurse midwives in the United States.
Naysayers call the study hogwash.
“I don’t understand how they could get those findings,” says one obstetrician in Northern Virginia who asked not to be named. “Most of the studies like these are garbage. To get accurate results on birth outcomes, you would have to look at the data from the birth record, not just the birth certificate. Even if a doctor were involved in the delivery, it wouldn’t have been marked on a birth certificate if a midwife were the one who delivered the baby. That could very well be the case in this area, because every hospital in the region requires that a physician be present when a midwife is delivering a baby.”
Of course midwives have good outcomes, the obstetrician says, because they don’t handle high-risk pregnancies, such as diabetic patients, breach babies and twins.
But the study’s authors, NCHS researchers Marian MacDorman and Gopal Singh, took the risk factors into account when they reviewed 4 million birth certificates from 1991 of babies delivered at 35-43 weeks of gestation by either physicians or certified nurse midwives.
They adjusted for the fact that certified nurse midwives attended a greater proportion of women who are at higher risk for poor birth outcomes, like blacks, Native Americans, teen-agers, unmarried women and those with less than a high school education, and that physicians attended a slightly higher proportion of births with medical complications.
Still, the findings showed birth outcomes for certified nurse midwives were better, even after socio-demographic and medical risk factors were controlled for in statistical analyses.
Why? “Most certified nurse midwives are with their patients on a one-on-one basis during the entire labor and delivery process, providing patient care and more emotional support, in contrast with physician care, which is more often episodic,” MacDorman writes in the study.
He notes that NCHS chose to conduct this study because dozens of doctors nationwide regularly called to find out if the federal organization had any statistics about midwife-assisted birth outcomes.
“I was actually pleased to see this outcome because midwives tend to catch a lot of flak from physicians who feel the midwives are treading on their turf,” she says.
However, some local physicians couldn’t be happier with the outcome of the NCHS research.
“This study appears to confirm our own findings,” says Dr. David Giammittorio of the Physician and Midwife Collaborative Practice. “We believe that the midwife-doctor collaborative practice mode of practice delivers higher quality, more compassionate, as well as cost-effective obstetrical services.”
He says his Caesarean section rates are about one half the area and national averages, “and our episiotomy rates are dramatically lower than physician-only practices. Plus, patient satisfaction is high. Because of our low C-section rates, our associated hospital cost profile tends to be lower because of the difference of stay after a C-section and the higher operating room costs.”
And, of course, most midwives feel vindicated by the study’s results.
“Finally, data that confirms what midwives have known all along,” says Karen Gonzales, a midwife who works with Giammittorio. “The increased amount of time we spend with pregnant women, while they are pregnant and when they are in labor, usually leads to an easier and healthier birth experience for babies and moms.”
This formula isn’t magic—it is common sense, says Marion McCartney, director of professional services at the American College of Nurses and Midwives in Washington.
“The current system of medical care takes away from the woman. Doctors make all the decisions,” McCartney says. “Physicians often give pregnant women tons of tests but little education or encouragement. Tests are important, but they are only part of having a
healthy pregnancy and a healthy baby. Midwives spend time with patients. They respect them. That’s the reason for the difference in outcomes.”
The ACNM estimates there are approximately 5,000 practicing certified midwives nationwide, including an estimated 225 midwives in Maryland and 42 in Virginia.
The kinder, gentler and empowering approach of midwives is very attractive to many pregnant women. Ten years ago, midwives, or an estimated 116,000 babies delivered 3.4 percept of babies born in the U.S.— an estimated 116,000 babies. By 1995, the most recent figures available, those numbers nearly doubled when midwives delivered 216,768 babies, accounting for 5.6 percent of the births in the U.S.
Although for centuries midwives delivered babies in homes, the trend of the 1990s is to deliver in a hospital. The ACNM estimates 96 percent of the midwife-delivered babies are born in hospitals, while only 3 percent are delivered in freestanding birth centers, and 1 percent in homes.
Only a few midwifery practices in the region even offer the option of a home birth or birthing centers. One of the oldest in the area is The Maternity Center in Bethesda, Md. Since its founding in 1975, about 5,000 babies have been delivered at the free-standing center on Bells Mill Road and at home, and since September 1996 at Shady Grove Hospital.
In July 1996, the Maternity Center expanded its operation and opened a second office in Greenbelt. Md. After 100 births, though, investors decided to close the satellite center. It closes this month.
Director Barbara Vaughey attributes the second center’s demise to financial difficulties.
“Investors put about $1 million into the project and weren’t getting their money back fast enough,” Vaughey says. “It is a real shame, especially in light of this very positive study and because business was really picking up. We bad 16 pregnant women hire us in March, and our numbers were going up every month. I think we would have broken even in six more months. The investors just decided they couldn’t hold on any longer, though.”
The Bethesda center, though, continues to do very well, Vaughey says. About 30 babies are delivered each month.
Midwives at Birth Care and Women’s Health in Alexandria are also busy. The first freestanding birth center in Virginia, Birth Care delivers about 15 to 20 babies at home or at its King Street center. Since its founding in 1987, the staff at Birth Care has delivered 1,500 babies.
Here again, the personal connection she and the three other midwives on staff develop with patients appeals to many pregnant women, co-owner Alice Bailes says.
‘We spend nine months getting to know our moms,” she says. “We earn their trust, talk to them about how to have a healthy pregnancy and basically make them feel comfortable. If you have someone delivering your baby who you trust and know is skilled and sympathetic, you are likely to feel less stress, need less anesthesia, and have a healthier baby, less at risk for being born prematurely or at a low birth weight. It’s great that there is now a study to back up what mid-wives have always known.”