What We Know:

Current Research on The Benefits of Midwifery and Doula Care

Childbirth is the single most common cause for hospitalization in the United States, accounting for over 20% of all hospital discharges for women (US Bureau of Census, 1998). The midwifery model of care minimizes hospitalization and technological intervention in the birth process and results in birth and health outcomes equal or superior to those associated with obstetrical care. It also produces significant cost savings both to the individual consumer and to the health system. According to at least one researcher, reducing the number of unnecessary Cesarean sections alone could save $2 billion annually. Assuming that 50% of other obstetric interventions (induction or augmentation of labor, electronic fetal monitoring, epidurals, episiotomies, forceps, vacuum extractions) may also be unnecessary, another $5 billion could be saved annually.

MIDWIFERY CARE -- THE STANDARD WORLD-WIDE
Midwifery care is the standard for low-risk pregnancies in most countries world-wide. Although approximately 75% of all pregnancies in the United States are considered to be low-risk, only about 7% are attended by midwives. In industrialized countries that utilize this model, birth outcomes are superior to those in the United States and maternity care costs are lower.
See 2000 data from the National Center for Health Statistics for information on birth attendants.

SUMMARY OF RECENT RESEARCH FINDINGS
The bibliography below highlights a sample of recent research demonstrating the benefits of midwifery and doula care. Among recent findings:

Professional midwifery care is at least as safe as obstetrical care. Many studies show that midwifery care is safer.
Having a planned birth at home or in a birth center is as safe as giving birth in a hospital and considerably less expensive.
Midwifery and doula clients are very satisfied with the care they receive.
The continuous presence of a doula during labor significantly decreases the need for medical interventions and shortens the duration of labor.
Midwives use significantly fewer medical interventions than physicians. Increased use of midwifery care has the potential to lower overall societal healthcare costs.

For additional studies, visit PubMed, the U.S. National Library of Medicine's database of articles from over 4,000 biomedical journals http://pubmed.gov. Use search terms: home childbirth, midwifery, and doula.

ANNOTATED BIBLIOGRAPHY OF CURRENT RESEARCH:
THE BENEFITS OF MIDWIFERY AND DOULA CARE

American Public Health Association. (2001) 20004: Supporting Access to Midwifery Services in the United States (Position Paper). American Journal of Public Health. 91(3): 7-10.
"The American Public Health Association takes a position in support of midwifery as a key strategy for improving access to care for childbearing families. In terms of quality, satisfaction, and costs, the midwifery model for pregnancy and maternity care has been found to be beneficial to women and families, resulting in good outcomes and cost savings."
Anderson, RE, Anderson, DA. (1999) The cost effectiveness of home birth. Journal of Nurse Midwivery. 44(1): 30-35.
This study lists average costs (1998, 1991, 1987) for home, birth center, and hospital births from data collected in U.S. The results show that home and birth center births are significantly less expensive than hospital births.
Baldwin, KA. (1999) The midwifery solution to contemporary problems in American obstetrics. Journal of Nurse Midwifery 44(1):75-79.
"This article focuses on midwifery as one solution to many of the problems that confront contemporary American obstetrics. Documented evidence with historic perspective that supports the view that midwifery should become the mainstream in maternity care in the United States, not an alternative, is presented."
Campero L, Garcia C, Diaz C, Ortiz O. et al. (1998) Alone, I wouldn't have known what to do: A qualitative study on social support during labor and delivery and Mexico. Social Science and Medicine. 47(3): 395-403.
Sixteen in-depth interviews were held with women in the immediate postpartum period (eight of whom had been accompanied by a doula and eight who had not) before they were discharged from hospital, and the results were analyzed using qualitative techniques. The interviews showed that the women accompanied by doulas had more positive childbirth experiences. The differences between both groups related to their perceptions of the childbirth experience; the treatment they received from hospital staff; the information they were given and how well they understood it; their perception of hospital routines; and their feelings about cesarean sections.
Cawthon L. (1996) Planned home births: outcomes among Medicaid women in Washington State. Olympia: Office of Research and Data Analysis, Washington State Department of Social and Health Services.
This retrospective study found very low rates of poor outcomes among Medicaid women in Washington State who planned home births and received some or all of their prenatal care from licensed midwives.
De Koninck M, Blais R, Joubert P, Gagnon C. (2001) Comparing women's assessment of midwifery and medical care in Quebec, Canada. J Midwifery Womens Health 2001 Mar-Apr;46(2):60-7.
Two to three months after birth, 933 midwifery clients and 1,000 physicians' clients, matched on several characteristics, responded to a mailed questionnaire. Results showed that women from both groups were generally satisfied with the care they received, although women who received midwifery care were assessed as more positive on every issue surveyed. Midwifery clients had a greater number of and longer prenatal visits, they perceived their care to be more personalized, and more of them breastfed their infants.
Dower, CM, Miller JE. Taskforce on Midwifery. (1999) Charting a course for the 21st century: the future of midwifery. San Francisco: Pew Health Professions Commission and UCSF Center for the Health Professions.
The Taskforce offered recommendations incorporating its vision that the midwives model of care should be embraced by, and available to all women and their families. To access the full report: Charting a Course for the 21st Century: The Future of Midwifery
Durand, AM. (1992) The safety of home birth: The Farm study. American Journal of Public Health. 82(3): 450-453.
In this study of 1,707 midwife-attended home births, birth outcomes were comparable to those for low-risk hospital births. The rate of operative assistance for home births was much lower than for hospital births. "Support by the medical and legal communities for those electing and those attending, home birth should not be withheld on the grounds that this option is inherently unsafe."
Gillis SL. (1995) Why do women in Washington State choose licensed midwives as their pregnancy and childbirth care providers and are they satisfied with their choice? Department of Women Studies. Seattle: University of Washington.
Gillis found several recurring themes which influenced women to choose a licensed midwife. These included desires for home birth; personalized care; control of their surroundings and bodies; and a healthy, intimate birth experience. She also found that women in her sample were very satisfied with their midwifery care.
Gordon NP, Walton D, McAdam E, et al. (1999) Effects of providing hospital-based doulas in health maintenance organization hospitals. Obstetrics and Gynecology. 93(3): 422-6.
A randomized study of 264 births showed that women attended by doulas during labor had significantly less epidural use and were significantly more likely to rate the birth experience as good than those who did not have doulas.
Hayes KE. (1996) Satisfaction with midwifery care among women who choose home birth: the development of a questionnaire. School of Nursing. Seattle: University of Washington.
In this review of the literature on satisfaction and home birth (typically attended by licensed midwives), Hays reported high satisfaction ratings by women who chose home birth. She also found that these women would make the same choice again.
Hodnett ED. (1999) Caregiver support for women during childbirth. Cochrane Library of Systematic Reviews. Electronic edition. May 17, 1999.
Fourteen clinical trials, involving more than 5,000 women, were analyzed. The continuous presence of a support person, (including nurses, midwives, childbirth educators, doulas, friends, or family members) reduced the likelihood of episiotomy, cesarean delivery, a 5-minute Apgar score of less than 7, and medication for pain relief. Continuous support was also associated with a slight reduction in duration of labor.
Janssen, P. et al. (1994) Licensed midwife-attended out-of-hospital births in Washington state: are they safe? Birth 21(3):141-148.
This study of Washington state birth certificate data, linked to infant death certificates, compared outcomes for births attended by licensed midwives, physicians, and certified-nurse midwives. On outcome measures such as low birth weight, five-minute Apgar scores, and neonatal and postneonatal mortality, the investigators reported no difference in outcomes between midwife-attended and physician-attended births.
Kenneth C Johnson and Betty-Anne Daviss, Outcomes of planned home births with certified professional midwives: large prospective study in North America, BMJ, Jun 2005; 330: 1416
This prospective study of more than 5,000 births in US and Canada concludes that "Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States."
Langer A, Campero L, Garcia C, Reynoso S. (1998) Effects of psychosocial support during labour and childbirth on breastfeeding, medical interventions, and mothers' wellbeing in a Mexican public hospital: a randomised clinical trial. British Journal of Obstetrics and Gynecology. 105(10):1056-63.
This study examined 724 births for the effect of social support provided by a doula. The frequency of exclusive breastfeeding one month after birth was significantly higher in the group of women attended by doulas, as were the behaviors that promote breastfeeding. More doula-attended women perceived a high degree of control over the delivery experience, and the duration of labor was shorter than in the group of women who did not have the services of a doula.
Law YY, Lam KY. (1999) A randomized controlled trial comparing midwife-managed care and obstetrician-managed care for women assessed to be at low-risk in the initial intrapartum period. Journal of Obstetric and Gynecology Research. 25(2): 107-112.
This study compared outcomes for 413 women attended by midwives and 637 women attended by obstetricians in a hospital setting in Hong Kong. Women attended by midwives had less oxytocin augmentation and intravenous infusion. Other outcomes were similar for both groups of women. Conclusion: "Midwife-managed care is as safe as obstetrician-managed care for women who [are] assessed to be at low-risk in the intrapartum period."
MacDorman, MF, Singh, GK. (1998) Midwifery care, social and medical risk factors, and birth outcomes in the United States. Journal of Epidemiology and Community Health. 52(5): 310-323.
This study compared birth outcomes and infant mortality rates for all births that took place in the United States in 1991 that were attended by physicians and certified nurse midwives. "For singleton, vaginal births at 35-43 weeks of gestation, the adjusted risk of infant mortality was 19% lower for certified-nurse midwife than for physician attended births; the risk of neonatal mortality was 31% lower."
Myers-Ciecko, J. (1999) Evolution and current status of direct-entry midwifery education, regulation, and practice in the United States with examples from Washington State. Journal of Nurse-Midwifery. 44(4): 384-393.
This article cites examples from Washington State to describe the reemergence of direct-entry midwifery in the United States. In Washington, state policies have supported the development of direct-entry midwifery and influenced the integration of professional direct-entry midwives into managed care systems.
Oakley D, Murray ME, Murtland T, et al. (1996) Comparisons of outcomes of maternity care by obstetricians and certified nurse-midwives. Obstetrics and Gynecology. 88(5): 823-829.
Pregnancy outcomes were compared for 710 women cared for by private obstetricians and 471 cared for by certified nurse-midwives. Outcomes for nurse-midwife clients were superior to those for obstetrician clients, including satisfaction with care, third- or fourth- degree perineal lacerations, number of complications, and infant remaining with mother for the entire hospital stay.
Olsen, Ole. (1997) Meta-analysis of the safety of home birth. Birth 24(1): 4-13.
This meta-analysis of six observational studies, including 24,092 primarily low-risk pregnant women, examined the safety of planned home birth compared with planned hospital birth. The principal difference in outcomes was a lower frequency of low Apgar scores in the home birth group. Also, fewer medical interventions occurred in the home birth group. "Home birth is an acceptable alternative to hospital confinement for selected pregnant women, and leads to reduced medical interventions."
Schlenzka, Peter F. (1999) Safety of alternative approaches to childbirth (Doctoral dissertation, Stanford University).
This examination of outcomes and intervention rates in midwife and physician care of women with uncomplicated pregnancies in California found a cesarean rate of 6.3% for women receiving midwifery care compared to 22.1% for women receiving physician care. The author projects a savings of over $2 billion annually in the U.S. if the cesarean rate were lowered to 10% of all births.
Scott KD, Berkowitz G, Klaus M. (2000) A comparison of intermittent and continuous support during labor: a meta-analysis. American Journal of Obstetrics and Gynecology. 8(17): 16, 19.
This meta-analysis of 11 clinical trials showed that continuous labor support, when compared with no doula support, was significantly associated with shorter labors, and decreased need for the use of any analgesia, oxytocin augmentation, cesarean sections, and use of forceps.
Scott KD, Klaus PH, Klaus MH. (1999) The obstetrical and postpartum benefits of continuous support during childbirth. Journal of Women's Health and Gender Based Medicine. 8(10): 1257-64.
The evidence from twelve individual controlled trials and three meta-analyses was examined. Emotional and physical support provided by doulas significantly shortened labor and decreased the need for cesarean deliveries, forceps and vacuum extraction, oxytocin augmentation, and analgesia. Doula-supported mothers also rated childbirth as less difficult and painful than did women not supported by a doula.
Spurgeon P, Hicks C, Barwell F. (2001) Antenatal, delivery and postnatal comparisons of maternal satisfaction with two pilot Changing Childbirth schemes compared with a traditional model of care. Midwifery 17(2):123-32.
In this British study, the birth outcomes of 215 women who received maternity care from midwives and 118 women who received care from obstetricians were compared. Midwifery-led care was much preferred by clients to obstetrician-led care and did not lead to any deficits in clinical outcomes.
State of Washington Department of Licensing. (1988) An assessment of childbirth outcomes in Washington SSB 5163 Report to the Legislature.
"Findings: certified nurse midwives and licensed midwives have a lower rate of negative outcomes than physicians and osteopaths, which indicates provision of services within the scope of practice and appropriate referral of potential problems to the medical community."
Turnbull D, Holmes A, Shields N, et al. (1996) Randomised, controlled trial of efficacy of midwife-managed care. Lancet 348(9022): 213-218.
This randomized controlled trial compared the birth outcomes of 648 women with low-risk pregnancies assigned midwife-managed care and 651 women with low-risk pregnancies assigned shared care. Women in the midwife-managed group were less likely than women in shared care to have induction of labor, more likely to have an intact perineum, and less likely to have an episiotomy. Women in both groups reported satisfaction with their care but the midwife-managed group were significantly more satisfied. "We conclude that midwife-managed care for healthy women, integrated within existing services, is clinically effective and enhances women's satisfaction with maternity care."

Zhang J, Bernasko J, Leybovich E, et al. (1996) Continuous labor support from labor attendant for primiparous women: a meta-analysis. Obstetrics and Gynecology. 88(4) part 2: 739-744.
This meta-analysis analyzed the data from four randomized clinical trials on the effects of continuous labor support that were published from 1965 to May, 1995. The analysis suggested that continuous labor support by a labor attendant shortens the duration of labor and doubles spontaneous vaginal birth (through lower incidence of cesarean sections, oxytocin use, and forceps use). Women with labor support also reported higher satisfaction and a better postpartum experience.

Also visit Citizens for Midwifery's Resources pages.

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