Women who are marginalized by poverty may be reaping the greatest benefits from midwifery care. This is the finding of a large study that we published with colleagues this week in the British Medical Journal Open.
We found that women who were eligible for government assistance and were seen by a midwife for prenatal care had significantly lower likelihood of preterm birth, small and low birth weight babies.
The study, which drew on evidence from 57,872 pregnancies, made sure that women who were seen by midwives were of comparable health status to women seen by general practitioners and obstetricians during the prenatal period.
A common belief is that midwifery care is only affordable for, and sought after by, wealthy and educated women. This is not always the case. Our research shows that midwifery care is an effective model of prenatal care for women living in lower socioeconomic circumstances.
We hope that this evidence may help pave the way for maternal health policy to address ongoing health disparities experienced by mothers and babies living in poverty in Canada.
Demand for midwives exceeds supply
Despite a long history of midwifery practice in Europe and North America, legislated midwifery care has only been available in Canada for the last 24 years.
In British Columbia, where midwifery care has expanded most rapidly, 22 per cent of births now have a midwife involved in care and demand for midwifery care continues to exceed supply.
The study reports that midwifery patients were 41 per cent less likely to have a small-for-gestational-age baby compared to patients of obstetricians (29 per cent compared to patients of general practitioners).
Preterm birth was 26 to 47 per cent less likely and low birth weight was 34 to 57 per cent less likely for patients of midwives, versus those of general practitioners or obstetricians.
These are important findings. At least one other report — an international Cochrane review combining the results of eight trials — found similar results for preterm birth for women in the general population.
Our study takes the findings reported in the Cochrane review a step further. It shows that women of lower socioeconomic means are not only accessing and using midwifery care provided under a universal health-care system, but are also benefiting remarkably in terms of having healthier birth outcomes than their counterparts seen by medical practitioners.
A deep clinician-patient relationship
On average, prenatal midwifery appointments last 30 to 60 minutes, and are designed to promote physical, social, emotional, cultural, spiritual and psychological health. This midwifery model of care may better address the social determinants of health that especially affect birth outcomes for vulnerable women, compared to other models of care.
Study results show patients of midwives to be 2.2 times more likely to have mental health conditions documented in their maternity records, compared to patients of general practitioners, and 3.4 times more likely than those of obstetricians.
The rate of documented depression for midwives’ patients was 18.8 per cent, close to that reported in the wider research literature (17.2 per cent). In contrast, documented depression was 12.8 per cent for general practitioners’ patients and 7.4 per cent for obstetricians’ patients.
That could be because midwifery patients may be more inclined to disclose sensitive information to their care providers because of the depth of the clinician-patient relationship fostered over time.
Midwifery patients were also more than twice as likely to have an adequate number of prenatal appointments, at the appropriate times, compared to general practitioner or obstetrician patients. Receiving adequate prenatal care has been shown to protect against preterm birth, stillbirth and infant death.
Health and cost benefits
An Alberta study measuring the cost-effectiveness of midwifery care reported savings of $1,172 per pregnancy for midwifery patients, compared to patients receiving standard prenatal care.
Mounting evidence suggests that the health and cost benefits of midwifery care are at least equivalent, if not better in some instances, for moms, babies and the health-care system. This debunks any notion of midwifery care being a second-class service.
Midwifery care is the fastest growing maternity care service in B.C., increasing in volume year-by-year since 2008.
The widespread adoption of midwifery care not only provides expanded choice in prenatal care options, but is a viable solution to the critical decline in the number of doctors offering maternity services and the continual shortage of rural physicians.
Provincial governments must step up
To address the demand for midwifery care, and to move it from the margins to a mainstream option, policy is needed which supports the continued expansion of midwifery care — for example by increasing the number of seats in provincial midwifery education programs.
This needs to include outreach to vulnerable women. And we need to increase public awareness of the availability of midwifery care, its coverage under health-care systems, the full range of services midwives provide and how to access them.
Midwives select where they will practise and their clientele. To encourage outreach to marginalized women, midwives may need to be compensated for the extra time involved in caring for women with higher socioeconomic risk.
The time has come to expand innovative and effective ways of meeting the needs of prenatal women, especially those with high social and economic needs. Access to and use of midwifery care is one such approach.
All provincial governments in Canada should step up and act, in line with the evidence.
Nazeem Muhajarine, Professor, Department of Community Health and Epidemiology and Director, Saskatchewan Population Health and Evaluation Research Unit, University of Saskatchewan and Daphne McRae, Postdoctoral Research Fellow in Population and Public Health, University of British Columbia