Midwifery-led care, the AMA, and the Cochrane Collaboration: who do you believe?

The Australian Medical Association on midwifery-led care in maternity services, September 2008:

“[…] midwifery services were expanded without any reference to the medical profession and without any clear evidence base around the impact on safety and clinical outcomes for patients. This has introduced significant uncertainty about the lines of responsibility for patient care and increased risk in respect of health outcomes for patients.”

Rosanna Capolingua, head of the AMA:

“Midwives are very involved in obstetric care right now in a team environment under medical supervision and that model works very well. It’s not about Medicare, it’s about the medical supervision and the safety for the patient.”

The Cochrane Collaboration, the largest and most reputable collection of evidence-based medicine reviews in the world, on “Midwife-led versus other models of care for childbearing women”[1,2], 8 Oct 2008 (emphasis is mine):

The review of midwife-led care covered midwives providing care antenatally, during labour and postnatally. This was compared with models of medical-led care and shared care, and identified 11 trials, involving 12,276 women.

Midwife-led care was associated with several benefits for mothers and babies, and had no identified adverse effects.

The main benefits were a reduced risk of losing a baby before 24 weeks. Also during labour, there was a reduced use of regional analgesia, with fewer episiotomies or instrumental births. Midwife-led care also increased the woman’s chance of being cared for in labour by a midwife she had got to know. It also increased the chance of a spontaneous vaginal birth and initiation of breastfeeding. In addition, midwife-led care led to more women feeling they were in control during labour. There was no difference in risk of a mother losing her baby after 24 weeks.

The review concluded that all women should be offered midwife-led models of care.

Who do you believe?

While you’re deciding, it’s worth contemplating a flipping of the way the data is reported in this study. Try this:

The main risk of a medical model of care was an increased risk of losing a baby before 24 weeks. Also during labour, there was an increased use of regional analgesia, with more episiotomies and instrumental births. Medical-led care also decreased the woman’s chance of being cared for in labour by a person she had got to know. It also decreased the chance of a spontaneous vaginal birth and decreased initiation of breastfeeding. In addition, medical-led care led to fewer women feeling they were in control during labour.

Language. It’s a powerful thing.


[1] Read the full text of the Cochrane Collaboration report here.

[2] Some background on the models of care examined:

[…] Some models of midwife-led care provide a service through a team of midwives sharing a caseload, often called ‘team’ midwifery. Another model is ‘caseload midwifery’, where the aim is to offer greater continuity of caregiver throughout the episode of care. Caseload midwifery aims to ensure that the woman receives all her care from one midwife or her/his practice partner. By contrast, medical-led models of care are where an obstetrician or family physician is primarily responsible for care. In shared-care models, responsibility is shared between different healthcare professionals.

Further reading from Hoyden About Town:

“Death twice as likely by caesarean”?

Western Australian Birth Statistics

Skyrocketing caesarian section rate means placenta accreta is no longer just the fine print

The WHO on Birth: the “Fortaleza Declaration”

“Safe Motherhood: Care in Normal Birth

Categories: ethics & philosophy, gender & feminism, health, medicine

Tags: , , , ,

6 replies

  1. Capolingua is obsessed with keeping doctors in charge of all medical care – she gave The Australian a hypothetical about someone with cancer seeing dieticians and therapists instead of being diagnosed by a doctor. I found this particularly amusing because I had cancer go undiagnosed for 18 months under the care of several doctors (who referred me to a dietician and a counsellor because obviously I was just fat and lazy). The cancer was found by an audiologist. This is just another example of Capolingua dismissing the expertise of anyone other than doctors, in the face of all evidence.

  2. [Note from mod: If any of you really want to engage Amy Tuteur, please do so at her blog. You’ll find the relevant post here. ~L]
    This study does NOT compare to midwife care to doctor care. ALL women in BOTH arms of the study were cared for by BOTH midwives and obstetricians. The study compared midwife led team care with other forms of team care. That’s why the study is titled “Midwife-led versus other models of care for childbearing women”; it is not titled midwife are vs. other models.
    In addition, the study itself if poorly done. The authors identified 31 studies comparing team care. They included only 11 studies in their analysis and excluded the other 20. The authors provide no uniform criteria for why some studies were included and others were not. It appears that they simply included the ones they liked and excluded the ones they didn’t like. That calls the results of the study into question.
    In any case, the key point is this: The study never looked at midwife care vs. doctor care. It only looked at different forms of team care.

  3. Nothing to add except thank you so much for continuing to post these links; it’s not easy to find Australian-based (or non-American based) information on this issue if you’re not a medical practitioner, and it gives me ammunition when I can point to them.
    I’m currently weathering being told that I am ‘brave’ (read: criminally irresponsible) for choosing a small, public, country hospital over a big private hospital to have my baby. I try and explain that the choice was entirely due to the fact that the former has a midwife-led practise (well, it’s a shared care model with GP-obs, all of whom are female and have a lot of respect for the midwifes) which is what I wanted.
    (This is not true, I wanted a home birth, but it’s easier just to not bring that up).
    And I constantly get ‘but what if something goes wrong’, as if my choice is this selfish and self-indulgent decision that ignores what is best for the baby as opposed to a decision made because birth outcomes are better in this model.
    Um. Anyway, didn’t mean to rant. Just wanted to thank you for continuing to reassure me. I’m smart, resourceful and highly educated – I’ve never before experienced this level of manipulation to let go of my own research and convictions in favour of the norm. Never.

  4. Of course Amy Tuteur, so-called MD, would say that – she’s a paid shill for ACOG.

  5. Rant away, rainne. I’ve got little time for Capolingua & co’s attempts to centralise maternity care to cities and large regional hospitals only. All this leads to is women being separated from their families for very long periods while awaiting labour, more early inductions and unnecessary C sections for those who don’t want to spend up to a month hanging around the big smoke, and more women birthing on gravel tracks in transit.


  1. Maternity Services Review: Medicare payments to OBs up from $77m to $211m since 2004. — Hoyden About Town
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