newborn baby wrapped in a blanket

The Record Is Good for Babies Delivered by Midwives

By Moira Wyton, The Tyee, Local Journalism Initiative Reporter

Expanding midwifery care in British Columbia could help improve pregnancy outcomes for birthing parents and babies, particularly those  in rural and remote areas, according to a new study from B.C.-based  researchers.

Pregnant people under the  care of midwives were less likely to have underweight or preterm babies,  or to require the use of forceps, vacuums or caesarean sections to  deliver their babies than patients being cared for by only family doctors or  obstetricians, a Monday study in the Canadian Medical Association Journal found. 

And the benefits of midwifery were observed  in patients with high pregnancy risk assessments as well as those with  low and moderate risks.

“We found better outcomes for midwifery  clients more or less across the board,” said lead author Kathrin Stoll  of the University of British Columbia’s department of family practice.

Midwives provide patient  and family-centred care, most often for low-risk pregnancies and people  who want to give birth at home. They hold hospital privileges and are  regulated through the British Columbia College of Nurses and Midwives,  which determines when midwives must refer patients to specialized care  from a doctor or obstetrician.

As recent as 2020, about  15.6 per cent of births in B.C. were attended by midwives and one in  four child-bearing people had a midwife involved in their pregnancy,  birth or postpartum care.

But since B.C. became the second province  in Canada to regulate and integrate midwifery with the public  health-care system, most research has focused on their outcomes for  people with low-risk pregnancies. 

Monday’s study shows many people with  moderate and high risks want and receive midwifery care, Stoll said, and  suggests it is safe and can improve their outcomes when midwives are  well-integrated and supported with other care providers.

The study examined provincial data about  425,056 births in B.C. between 2008 and 2018, connecting each patient’s  risk assessment to the type of care provider they had and several key  birth outcomes. About 80 per cent of the births were low-risk, while 19  per cent were moderate and 0.5 per cent were high-risk.

The analysis found midwifery clients were  significantly less likely to have a caesarean delivery compared to  physician clients across risk strata, but particularly low-risk  patients. About 7.2 per cent of low-risk midwifery clients had caesarean  deliveries, compared to 12.2 per cent of physician clients and 43.2 per  cent of people followed by an obstetrician. 

In B.C., close to 37 per cent of babies are  delivered by caesarean section, a major and painful surgery the World  Health Organization has advised are only medically necessary in around  19 per cent of births when patients receive good care.

“It’s important to keep that rate low  because C-sections cause more pain, issues with future pregnancies and  longer hospital stays,” said Stoll, “And right now with our rate so  high, it’s estimated about half of them likely aren’t conferring any  medical benefit.”

Birth complications can have a huge impact  on the parent and their baby. If a baby is delivered preterm, their risk  of cerebral palsy and asthma increases.

Midwifery clients were half as likely to  have babies with low birth weights than patients followed by a doctor  and had preterm births 4.2 per cent of the time compared to 6.8 per cent  for doctors and 12.2 per cent for obstetricians.

High-risk midwifery and doctor patients had  their labour induced with oxytocin more than 18 per cent of the  time, compared to 8.4 per cent of the time with obstetricians.

But midwives’ clients were half as likely to need forceps or vacuum during a vaginal delivery than those followed by doctors.

“People might choose midwifery care because  they want a lower-intervention birth or have longer prenatal  appointments than doctors,” said Stoll. 

The findings suggest expanding  midwifery care has and could continue to improve care for pregnant  people and their babies, she added, but there aren’t enough midwives to  provide the care people want.

As of 2020, there were only about 300  midwives in B.C., and 28 more are accepted each year to the province’s  only midwifery program at the University of British Columbia. That  number will rise to 48 annually by September, the Ministry of Health  announced Friday.

Working midwives also face high levels of  burnout, according to a 2020 survey by the Midwives Association of  British Columbia. As many as one in five were considering leaving the profession at that time. 

A key contributor is their pay structure.  Midwives are paid by the province per trimester of care they provide to a  patient. The fee-for-service model disincentivizes midwives from taking  on complex patients that take more time but pay the same. Midwives successfully negotiated paid parental leave in 2021, but vacations and time spent on administrative duties remain unpaid. B.C. recently reformed a similar payment model for family doctors to  attract and retain them.

And it makes it nearly impossible for  midwives to make a living in remote Indigenous communities and rural  areas where they are desperately needed but birth rates are low.

“Improving access is most needed for  under-served communities, and it seems easy to just train more  midwives,” said Stoll. “But integrating them into the health-care system  isn’t enough if they’re not well-supported and paid to achieve good  outcomes for more complex patients.” 

Top photo credit: Newborn by Brooke Raymond via Flickr (CC BY SA, 2.0 License)

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