For women in Nepal who have low-risk pregnancies, giving birth under the care of a midwife appears to be as safe as giving birth under the care of a physician, and is generally less invasive.1 In a study among women expected to have an uncomplicated labor and delivery, 13% of those cared for solely by midwives had a complication, a proportion no higher than that among those cared for by physicians. Midwife care was associated with a higher risk of artificial rupture of membranes but lower risks of use of oxytocin to augment labor, of warning signs of fetal distress, of episiotomy and of a cesarean delivery. Infants of women in the two groups were similarly healthy at birth. The likelihood that a woman would attend postnatal clinics and family planning clinics was greater among those cared for by midwives.
Women in labor who arrived at Patan Hospital in Lalitpur, Nepal, between November 1997 and February 1998 were enrolled in the study if screening indicated that they were at low risk for complications. The women received either care delivered solely by midwives (nurses and nurse-midwives) in an independent birthing center or care led by physicians in a maternity unit. The choice between the two was generally made by the women. Women cared for in the birthing center who developed complications were transferred to the maternity unit, but their outcomes were analyzed as birthing center outcomes. After delivery, researchers interviewed the women and reviewed their records to assess rates of interventions, complications and use of services.
Analyses were based on 550 women who received midwife-guided care and 438 women who received physician-guided care. The median ages of the women in the two groups were 23 and 24, respectively. Overall, the women had attended school for a median duration of 10 years, but women cared for by physicians had relatively more schooling. About three-fourths of the women reported that they had running water in their homes. Similar proportions in each group smoked and drank alcohol. The majority of women (67-75%) had received their pregnancy care at Patan Hospital, whereas the minority had received this care from private doctors (19-27%) or other providers.
Nearly equal proportions of women cared for by midwives and those attended by physicians had a complication during labor (13% and 15%, respectively), most commonly, a failure of labor to progress. Rates of individual types of complications were similar, with the exception of a lower rate of prolonged rupture of the membranes among women cared for by midwives (2% vs. 5%).
With respect to interventions, membranes were artificially ruptured in 53% of women cared for by midwives, compared with 42% of women cared for by physicians (risk ratio, 1.3). Substantially smaller proportions of women cared for by midwives than of those cared for by physicians were given oxytocin to augment labor (12% vs. 47%) or prostaglandins after rupture of the membranes to facilitate labor (fewer than 1% vs. 4%), corresponding to risk ratios of 0.3 and 0.1, respectively. Nonetheless, the duration of labor did not differ between groups.
Although the vast majority of women in both groups had normal vaginal deliveries (96% with midwife-delivered and 87% with physician-led care), those under the care of midwives were significantly more likely to have this type of delivery (risk ratio, 1.1). In turn, these women had a significantly lower risk of having a vacuum delivery* or a cesarean section relative to women who were cared for by physicians (0.3 and 0.4, respectively).
Slightly more than half of women had an episiotomy, and one-fifth developed a tear of the perineum. Compared with women cared for by physicians, those cared for by midwives had a lower risk of episiotomy (risk ratio, 0.6) but a higher risk of perineal tearing (1.7). When these two outcomes were combined, midwife care was associated with a significantly lower risk of any type of perineal trauma (0.8).
Relative to their counterparts who gave birth under the care of physicians, women attended by midwives were significantly less likely to show warning signs of fetal respiratory distress (risk ratio, 0.6). Compared with women who were not given oxytocin, those given the drug had nearly three times the risk of such warning signs (2.8). In addition, the likelihood of being given oxytocin was higher for women who had received their pregnancy care from a private provider rather than from a public provider (1.3).
Infants of women cared for by midwives and those of women receiving physician-led care had similar one-minute Apgar scores, but those born to women in the former group had a significantly lower risk of being admitted to the special baby unit than did those born to women in the latter group (risk ratio, 0.5). Three infants of women receiving care from midwives and four infants of women receiving physician-led care died; in all but one case, the cause of death was birth asphyxia.
After their delivery, roughly half of the women studied attended a postnatal care clinic at the hospital, and about a quarter visited a family planning clinic. Attendance for each type of care was greater among women whose labor and delivery had been attended by midwives than among those cared for by physicians (risk ratios, 1.3 and 1.9, respectively).
"Health care providers and communities should begin to see nurses and midwives as safe, qualified and desirable caregivers who can provide cost-effective services with low intervention rates," the researchers contend. More specifically, they conclude, their findings suggest that policymakers in developing countries should consider setting up additional pilot programs of the birthing center model.
1. Rana TG et al, Comparison of midwifery-led and consultant-led maternity care for low risk deliveries in Nepal, Health Policy and Planning, 2003, 18(3):330-337.
* A type of assisted vaginal delivery in which a vacuum extractor is used to pull a baby out of the birth canal.