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 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 oral 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. Vacation, parental leave and time spent on administrative duties are also 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.”
