Birth Outcomes for Obstetrician- or Midwife-Led Intrapartum Care.

BACKGROUND

Studies suggest that midwifery care can decrease the rate of unplanned cesarean birth. In this study, we compared unplanned cesarean rates, labor interventions, and birth outcomes for mixed-risk patients receiving intrapartum care from obstetricians or midwives.

METHODS

We conducted a retrospective cohort study using perinatal data from a single academic tertiary center from 2013 to 2018. The sample included nulliparous and multiparous patients with a term, singleton, vertex fetus. We included induced and spontaneous labor as well as trial of labor after cesarean. We excluded patients with planned cesarean delivery or any high-risk diagnosis requiring obstetrician care.

RESULTS

Our cohort included 7694 patients. Of those, 3543 (46.0%) received intrapartum care from an obstetrician and 4151 (54.0%) from a midwife. The overall cesarean rate was 11.8%. Patients receiving midwifery care had significantly lower cesarean rates (8.9% vs. 15.2%; p < 0.01) overall and by adjusted analysis [aOR 0.49 (0.40-0.60) 95% CI]. Patients receiving obstetrician care more frequently experienced induction/augmentation, neuraxial anesthesia, and operative vaginal delivery. Obstetrician-led care was associated with increased lacerations, intra-amniotic infection, and severe maternal morbidity, while midwifery-led care was associated with increased rates of postpartum hemorrhage, blood transfusion, and shoulder dystocia.

DISCUSSION: Midwifery intrapartum care was associated with lower rates of unplanned cesarean birth in this mixed-risk cohort of laboring and induced patients. Wider integration of midwives for intrapartum care could increase vaginal delivery rates. Additional studies are needed to explore underlying mechanisms and implications for systems- and practice-based changes in the United States.