BIRTH WITH A DOCTOR IN THE HOSPITAL: THE RESEARCH
The safety of doctor care in the hospital is supported by high-quality research evidence, including randomized controlled trials, which are the “gold standard” of medical research. Doctors delivering in the hospital in the US have excellent outcomes, with very low rates of perinatal mortality (babies dying around the time of birth) and neonatal mortality (babies dying just after birth).
Delivering with a doctor is likely to be the safest choice if you have a high-risk pregnancy. While there is little research comparing doctors’ high-risk outcomes to those for hospital-based midwives (because midwives refer any high-risk patients to doctors as a matter of policy), doctors are trained to take care of women with high-risk pregnancies and complicated labors, while midwives are trained to care for women with normal pregnancies and labors.
For low-risk women, the picture is a little different. While doctors generally have outcomes comparable to those for midwives delivering in the hospital, there is evidence to suggest that some outcomes may be better when low-risk women are attended by midwives. Doctors also have higher rates for some interventions than midwives.
1. OB AND MIDWIFE OUTCOMES ARE GENERALLY SIMILAR FOR LOW-RISK WOMEN DELIVERING IN THE HOSPITAL
Three large studies have looked at the differences in safety outcomes between midwives and doctors. The first is a systematic review of research that meets the “gold standard” for medical evidence. That review looked at studies from Canada, Australia, Ireland, and the UK. Although the other two studies do not meet the highest standard for research design, they are worth considering because they offer evidence specific to the United States.
Best evidence/ International Review:
A 2016 Cochrane review analyzed 15 prospective, randomized studies that examined outcomes for well over 17,000 babies and mothers delivering in Canada, Australia, Ireland, and the UK. Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD004667. This review compared outcomes for women who received midwife-led care versus outcomes for women who received either doctor-led care or joint care from midwives and doctors. The women in the studies had some risk factors in both the midwife and doctor/joint care groups, but they were mostly low-risk. None of the studies included out-of-hospital births. All 15 studies included in the review met the “gold standard” for research, because they were randomized, prospective, controlled studies.
The researchers found that most outcomes were similar for midwife-led care and doctor-led or joint care:
There were no differences between groups for fetal loss equal to/after 24 weeks and neonatal death, . . .perineal laceration requiring suturing, postpartum haemorrhage,. . . low birthweight infant, five minute Apgar score less than or equal to seven, neonatal convulsions, admission of infant to special care or neonatal intensive care unit(s) or in mean length of neonatal hospital stay (days).
However, the Cochrane review did find a few safety outcomes for low-risk women that were less good for doctor-led or joint care, notably:
[W]omen who received midwife-led continuity of care were . . .less likely to experience preterm birth, or lose their baby before 24 weeks’ gestation, and to lose their baby overall, although there were no differences in losing the baby after 24 weeks.
The authors conclude at page 23:
[T]he probability is that midwife-led continuity models of care are associated with a reduction in fetal loss and neonatal death by approximately 16%.
The Cochrane review looked only at the highest quality of evidence, so these findings are very reliable. However, none of the studies included in the review used data from the United States.
Good evidence/US Studies:
The first of the two US-focused studies is a 2012 systematic review of 21 studies comparing midwifery care and doctor care in the hospital. Johantgen, M., Fountain, L., Zangaro, G., Newhouse, R., Stanik-Hutt, J., White, K., Comparison of Labor and Delivery Care Provided by Certified Nurse-Midwives and Physicians: A Systematic Review, 1990 to 2008, Women’s Health Issues 22-1 (2012) e73–e81. Unlike the Cochrane review, this US review was not limited to randomized, controlled trials (although 2 of the 21 studies met that standard). Because the included studies were not all randomized, and because the study designs varied in how they accounted for differences in underlying risk, the US review is of lower quality than the Cochrane review. However, it still provides useful information about care in the United States.
Looking at the pooled data from these 21 studies, the researchers concluded that doctors and midwives delivering in the hospital had similar outcomes on most measures relating to infant health. On a few, however—Apgar score, birthweight, and rates of Neonatal Intensive Care Unit (NICU) admissions—outcomes were better overall for babies delivered by midwives (Table 3, “Infant outcomes”). In addition, the one outcome relating to maternal health—3rd or 4th degree perineal lacerations—was better for mothers attended by midwives.
So, like the Cochrane review, this systematic review of data specifically from the US found that outcomes for hospital birth were generally similar for doctors and midwives, but that a few outcomes were better for midwives than for doctors.
The second study from the US is a very large retrospective cohort study of home birth outcomes published in 2017. Grünebaum A, McCullough LB, Sapra KJ, et al. Planned home births: the need for additional contraindications. Am J Obstet Gynecol 2017;216:401.e1-8.
The goal of this study was to look at home birth outcomes, not to investigate differences between hospital midwives and doctors. In order to have a basis for comparing home birth outcomes, however, the researchers also looked separately at outcomes for hospital births attended by Certified Nurse Midwives (CNMs) and hospital births attended by doctors.
After excluding multiples, preterm infants, and babies with low birthweight or congenital anomalies, the researchers were left with a data pool that included outcomes for nearly 13 million births, of which over 1 million were midwife-attended births in the hospital, nearly 12 million were doctor-attended births in the hospital, and not quite 100,000 were planned home births.
In this very large sample, researchers found a somewhat higher overall infant mortality rate for doctor-attended hospital births compared to midwife-attended hospital births (5.09 per 10,000 births versus 3.08 per 10,000 births) (Table 2). When researchers separated the data for various risk factors, including number of previous births, gestational age over 41 weeks, maternal age over 35 years, breech presentation, and previous cesarean birth, babies delivered by doctors had somewhat higher rates of neonatal mortality in every group except breech presentation (Table 3).
This study did not randomize women into midwife or doctor care groups. So, while the researchers controlled for many risk factors, it is possible that the doctor-attended group was overall higher-risk.
Nonetheless, the Grünebaum study offers some evidence to suggest that while outcomes for low-risk women who deliver in the hospital are generally similar for doctors and midwives, midwives may have have better outcomes overall.
THINKING ABOUT SAFETY
2. INTERVENTION RATES ARE OVERALL HIGHER FOR DOCTORS
Two of the three major studies comparing midwife and doctor care in the hospital looked at intervention rates as well as outcomes. These studies found that intervention rates for doctors are the same as or higher than intervention rates for midwives in every category.
The Cochrane review found similar intervention rates when comparing doctor-led or joint care to midwife-led care on most measures. However, several intervention rates were lower for midwife-led care and none were lower for doctor or joint care:
The main benefits were that women who received midwife-led continuity of care were less likely to have an epidural. In addition, fewer women had episiotomies or instrumental births. Women’s chances of a spontaneous vaginal birth were also increased and there was no difference in the number of caesarean births. In addition, women were more likely to be cared for in labour by midwives they already knew. The review identified no adverse effects compared with other models.
The 2012 systematic review of US studies by Johantgen et al. showed similar results. While many intervention rates were similar for midwives and doctors, some were clearly higher for doctors:
The four measures related to the process of birth have similar findings that favor the CNMs in the use of fewer cesarean deliveries, operative vaginal deliveries (forceps or vacuum), and episiotomy; and more vaginal births after cesarean delivery.
Overall, then, the evidence suggests doctors have intervention rates that are similar to those of midwives for some measures and higher for others.
SO WHAT DOES THIS ALL MEAN FOR YOU?
Birth with a doctor in the hospital is overall a very safe choice, and is likely to be the safest choice if you have certain risk factors or complications in pregnancy.
If you are low-risk, choosing a doctor in the hospital is associated with higher intervention rates on some measures, and there is some evidence suggesting higher neonatal mortality rates.
Keep in mind, though, that doctors vary widely in their approach. Some practice very much like midwives; others practice the medical model of care, routinely using interventions and actively managing labor.
The same is true for hospitals. Some have very high rates of interventions, others don’t. Some have excellent safety outcomes, others don’t. As just one example, hospitals in the Chicago area have risk-adjusted cesarean birth rates that vary from 15% to 38%. So even with the same risk factors, you can substantially reduce your risk of having a C-section just by choosing the right hospital.
So if you are considering a hospital birth and want to choose between a midwife and a doctor, it is certainly helpful to understand the research comparing outcomes and intervention rates. But you will also want to seek out information about the outcomes and intervention rates of the particular hospitals and doctors or midwives you are considering.