BC study shows integrated midwifery care safe for moderate- and high-risk pregnancies

In British Columbia, midwives provide safe primary care for people with varied levels of risk, contrary to the belief that most manage only low-risk pregnancies, according to new research in CMAJ (Canadian Medical Association Journal) https://www.cmaj.ca/lookup/doi/10.1503/cmaj.220453.

Midwives have been regulated primary health care providers in BC since 1998, usually providing medical care in pregnancy, birth and up to 3 months after birth.

To understand the outcomes of childbearing people in BC with a midwife as the most responsible provider (MRP) who provided the most care, researchers looked at outcomes of midwifery clients compared with people cared for by a family physician or obstetrician. Of the 425 056 births in the study, 63 151 (14.9%) had a midwife as their MRP, 189 679 (44.6%) a family physician and 172 226 (40.5%) an obstetrician. The proportion of births that had a midwife listed as MRP increased from 9.2% to 19.8% over the study period.

Clients whose MRP was a midwife were less likely to have preterm births and low-birth-weight babies whether at low, moderate or high risk of complications, compared with those with a physician MRP. Cesarean delivery rates increased for midwife clients as medical risk increased but were lower than rates for people with physician MRPs.

"As medical risk increases, both midwives and family physicians collaborate increasingly and appropriately with obstetrician specialists," writes Dr. Kathrin Stoll, Department of Family Practice, University of British Columbia, with coauthors. "The study provides evidence for the safety and efficacy of midwife-led care across medical risk strata in BC."

Over the study period (2008–2018), the proportion of people with midwives as their MPR increased for all low-risk, moderate-risk and high-risk births.

Despite increases in midwifery care during the study period, Canada has some of the lowest rates of midwifery access in the world and increasing rates of cesarean delivery.

"[T]he study provides population-level evidence that midwives provide safe primary care for clients with varied levels of medical risk. If scaled up, the expansion of midwifery in BC holds potential for meeting national mandates to lower obstetric intervention rates and to increase access to midwifery care to under-served communities," the authors write.

They recommend that expansion of midwifery should be supported by policies and payment structures that enable retention of midwives, health system integration and collaboration with physician colleagues.

In a related editorial https://www.cmaj.ca/lookup/doi/10.1503/cmaj.230113, Dr. Shannon Charlebois, a family physician and editor, CMAJ, writes "Midwives can provide continuity of maternal care and spend an amount of dedicated time with their patients that cannot be matched by physicians" but notes that as other parts of Canada are less advanced in midwifery care, the study findings may not be widely applicable.

"For many people who give birth, midwifery is a safe, evidence-based, appropriate option that they should be able to choose to access," Dr. Charlebois writes. "For others, obstetric care from a physician may be preferred or more appropriate. Therefore, trust and willingness to collaborate must continue to develop between physicians and their midwife colleagues; this will be enhanced by careful planning of services that can ensure safe systems of integrated obstetric care in all Canadian jurisdictions."