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Childbirth Connection

In choosing a maternity care provider, you will want to find a good match based on what is important to you. Maternity care providers have a broad range of practice styles. Some variation occurs from individual to individual. However, systematic reviews have identified overall differences between different types of maternity care providers – obstetrician-gynecologists (OB-GYNs), family physicians and midwives. In this section, we summarize systematic reviews that have been published since 2005 that report results with three or more studies. These rigorous summaries of best available evidence are the most trustworthy way to know the benefits and harms of specific practices. In one case, noted below, the most recent summary of best evidence is much older, but more recent individual studies suggest that its broad conclusions still hold.

How does maternity care led by physicians compare to care led by midwives?

In systematic reviews, the following outcomes occur more often with midwives:

  • Increased vaginal birth after cesarean (VBAC).Johantgen, M., Fountain, L., Zangaro, G., Newhouse, R., Stanik-Hutt, J., & White, K. (2012). Comparison of labor and delivery care provided by certified nurse-midwives and physicians: a systematic review, 1990 to 2008. Women’s Health Issues, 22, e73-81.
  • Less use of electronic fetal monitoring.Sutcliffe, K., Caird, J., Kavanagh, J., Rees, R., Oliver, K., Dickson, K., Woodman, J., Barnett-Paige, E., & Thomas, J. (2012). Comparing midwife-led and doctor-led maternity care: a systematic review of reviews. Journal of Advanced Nursing, 68(11), 2376-2386.
  • Less use of epidural and spinal analgesiaJohantgen, M., Fountain, L., Zangaro, G., Newhouse, R., Stanik-Hutt, J., & White, K. (2012). Comparison of labor and delivery care provided by certified nurse-midwives and physicians: a systematic review, 1990 to 2008. Women’s Health Issues, 22, e73-81;Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, CD004667;Sutcliffe, K., Caird, J., Kavanagh, J., Rees, R., Oliver, K., Dickson, K., Woodman, J., Barnett-Paige, E., & Thomas, J. (2012). Comparing midwife-led and doctor-led maternity care: a systematic review of reviews. Journal of Advanced Nursing, 68(11), 2376-2386.
  • Less use of any pain medication in labor.Sutcliffe, K., Caird, J., Kavanagh, J., Rees, R., Oliver, K., Dickson, K., Woodman, J., Barnett-Paige, E., & Thomas, J. (2012). Comparing midwife-led and doctor-led maternity care: a systematic review of reviews. Journal of Advanced Nursing, 68(11), 2376-2386.
  • More use of no pain medication.Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, CD004667.
  • Less use of episiotomy (a cut to widen the vaginal opening just before birth).Johantgen, M., Fountain, L., Zangaro, G., Newhouse, R., Stanik-Hutt, J., & White, K. (2012). Comparison of labor and delivery care provided by certified nurse-midwives and physicians: a systematic review, 1990 to 2008. Women’s Health Issues, 22, e73-81;Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, CD004667;Sutcliffe, K., Caird, J., Kavanagh, J., Rees, R., Oliver, K., Dickson, K., Woodman, J., Barnett-Paige, E., & Thomas, J. (2012). Comparing midwife-led and doctor-led maternity care: a systematic review of reviews. Journal of Advanced Nursing, 68(11), 2376-2386.
  • Increased vaginal birth with no forceps or vacuum (spontaneous).Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, CD004667;Sutcliffe, K., Caird, J., Kavanagh, J., Rees, R., Oliver, K., Dickson, K., Woodman, J., Barnett-Paige, E., & Thomas, J. (2012). Comparing midwife-led and doctor-led maternity care: a systematic review of reviews. Journal of Advanced Nursing, 68(11), 2376-2386.
  • Less use of vacuum extraction and forceps to help the baby out.Johantgen, M., Fountain, L., Zangaro, G., Newhouse, R., Stanik-Hutt, J., & White, K. (2012). Comparison of labor and delivery care provided by certified nurse-midwives and physicians: a systematic review, 1990 to 2008. Women’s Health Issues, 22, e73-81;Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, CD004667.
  • Increased initiation of breastfeeding.Johantgen, M., Fountain, L., Zangaro, G., Newhouse, R., Stanik-Hutt, J., & White, K. (2012). Comparison of labor and delivery care provided by certified nurse-midwives and physicians: a systematic review, 1990 to 2008. Women’s Health Issues, 22, e73-81.
  • Better psychological response (e.g., satisfaction, sense of control or confidence).Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, CD004667;Sutcliffe, K., Caird, J., Kavanagh, J., Rees, R., Oliver, K., Dickson, K., Woodman, J., Barnett-Paige, E., & Thomas, J. (2012). Comparing midwife-led and doctor-led maternity care: a systematic review of reviews. Journal of Advanced Nursing, 68(11), 2376-2386.
  • Lower costs.Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, CD004667.

In systematic reviews, the following outcomes are not different between physicians and midwives:

  • “Fetal distress” during labor.Sutcliffe, K., Caird, J., Kavanagh, J., Rees, R., Oliver, K., Dickson, K., Woodman, J., Barnett-Paige, E., & Thomas, J. (2012). Comparing midwife-led and doctor-led maternity care: a systematic review of reviews. Journal of Advanced Nursing, 68(11), 2376-2386.
  • Use of IV (intravenous) fluids in labor.Sutcliffe, K., Caird, J., Kavanagh, J., Rees, R., Oliver, K., Dickson, K., Woodman, J., Barnett-Paige, E., & Thomas, J. (2012). Comparing midwife-led and doctor-led maternity care: a systematic review of reviews. Journal of Advanced Nursing, 68(11), 2376-2386.
  • Newborn condition just after birth.Johantgen, M., Fountain, L., Zangaro, G., Newhouse, R., Stanik-Hutt, J., & White, K. (2012). Comparison of labor and delivery care provided by certified nurse-midwives and physicians: a systematic review, 1990 to 2008. Women’s Health Issues, 22, e73-81;Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, CD004667;Sutcliffe, K., Caird, J., Kavanagh, J., Rees, R., Oliver, K., Dickson, K., Woodman, J., Barnett-Paige, E., & Thomas, J. (2012). Comparing midwife-led and doctor-led maternity care: a systematic review of reviews. Journal of Advanced Nursing, 68(11), 2376-2386.
  • Newborn convulsions.Sutcliffe, K., Caird, J., Kavanagh, J., Rees, R., Oliver, K., Dickson, K., Woodman, J., Barnett-Paige, E., & Thomas, J. (2012). Comparing midwife-led and doctor-led maternity care: a systematic review of reviews. Journal of Advanced Nursing, 68(11), 2376-2386.
  • Newborn admission to a neonatal intensive care unit.Johantgen, M., Fountain, L., Zangaro, G., Newhouse, R., Stanik-Hutt, J., & White, K. (2012). Comparison of labor and delivery care provided by certified nurse-midwives and physicians: a systematic review, 1990 to 2008. Women’s Health Issues, 22, e73-81;Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, CD004667;Sutcliffe, K., Caird, J., Kavanagh, J., Rees, R., Oliver, K., Dickson, K., Woodman, J., Barnett-Paige, E., & Thomas, J. (2012). Comparing midwife-led and doctor-led maternity care: a systematic review of reviews. Journal of Advanced Nursing, 68(11), 2376-2386.
  • Perineum (area between vaginal and anal openings) with no tear or cut (intact).Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, CD004667.
  • Maternal excess bleeding (hemorrhage), either in pregnancy or after birth.Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, CD004667;Sutcliffe, K., Caird, J., Kavanagh, J., Rees, R., Oliver, K., Dickson, K., Woodman, J., Barnett-Paige, E., & Thomas, J. (2012). Comparing midwife-led and doctor-led maternity care: a systematic review of reviews. Journal of Advanced Nursing, 68(11), 2376-2386.
  • Removal of placenta by hand (manual).Sutcliffe, K., Caird, J., Kavanagh, J., Rees, R., Oliver, K., Dickson, K., Woodman, J., Barnett-Paige, E., & Thomas, J. (2012). Comparing midwife-led and doctor-led maternity care: a systematic review of reviews. Journal of Advanced Nursing, 68(11), 2376-2386.
  • Fetal loss (before or after 24 weeks) or newborn death.Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, CD004667.

For some outcomes, conclusions differed across systematic reviews: The following outcomes were either better with midwives (less intervention or better newborn outcomes) or not different between midwives and doctors:

  • Hospitalization in pregnancy: less with midwivesSutcliffe, K., Caird, J., Kavanagh, J., Rees, R., Oliver, K., Dickson, K., Woodman, J., Barnett-Paige, E., & Thomas, J. (2012). Comparing midwife-led and doctor-led maternity care: a systematic review of reviews. Journal of Advanced Nursing, 68(11), 2376-2386. or not different.Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, CD004667.
  • Preterm birth: less with midwivesSandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, CD004667. or not different.Sutcliffe, K., Caird, J., Kavanagh, J., Rees, R., Oliver, K., Dickson, K., Woodman, J., Barnett-Paige, E., & Thomas, J. (2012). Comparing midwife-led and doctor-led maternity care: a systematic review of reviews. Journal of Advanced Nursing, 68(11), 2376-2386.
  • Low birth weight newborn: less with midwives or not different.Johantgen, M., Fountain, L., Zangaro, G., Newhouse, R., Stanik-Hutt, J., & White, K. (2012). Comparison of labor and delivery care provided by certified nurse-midwives and physicians: a systematic review, 1990 to 2008. Women’s Health Issues, 22, e73-81;Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, CD004667;Sutcliffe, K., Caird, J., Kavanagh, J., Rees, R., Oliver, K., Dickson, K., Woodman, J., Barnett-Paige, E., & Thomas, J. (2012). Comparing midwife-led and doctor-led maternity care: a systematic review of reviews. Journal of Advanced Nursing, 68(11), 2376-2386.
  • Labor augmentation (“pitocin” to speed up labor); less with midwivesJohantgen, M., Fountain, L., Zangaro, G., Newhouse, R., Stanik-Hutt, J., & White, K. (2012). Comparison of labor and delivery care provided by certified nurse-midwives and physicians: a systematic review, 1990 to 2008. Women’s Health Issues, 22, e73-81;Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, CD004667. or not different.Sutcliffe, K., Caird, J., Kavanagh, J., Rees, R., Oliver, K., Dickson, K., Woodman, J., Barnett-Paige, E., & Thomas, J. (2012). Comparing midwife-led and doctor-led maternity care: a systematic review of reviews. Journal of Advanced Nursing, 68(11), 2376-2386.
  • Breaking of membranes: less with midwivesSandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, CD004667. or not different.Sutcliffe, K., Caird, J., Kavanagh, J., Rees, R., Oliver, K., Dickson, K., Woodman, J., Barnett-Paige, E., & Thomas, J. (2012). Comparing midwife-led and doctor-led maternity care: a systematic review of reviews. Journal of Advanced Nursing, 68(11), 2376-2386.
  • Labor induction: less with midwives,Johantgen, M., Fountain, L., Zangaro, G., Newhouse, R., Stanik-Hutt, J., & White, K. (2012). Comparison of labor and delivery care provided by certified nurse-midwives and physicians: a systematic review, 1990 to 2008. Women’s Health Issues, 22, e73-81.or not different.Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, CD004667;Sutcliffe, K., Caird, J., Kavanagh, J., Rees, R., Oliver, K., Dickson, K., Woodman, J., Barnett-Paige, E., & Thomas, J. (2012). Comparing midwife-led and doctor-led maternity care: a systematic review of reviews. Journal of Advanced Nursing, 68(11), 2376-2386.
  • Cesarean birth: less with midwivesJohantgen, M., Fountain, L., Zangaro, G., Newhouse, R., Stanik-Hutt, J., & White, K. (2012). Comparison of labor and delivery care provided by certified nurse-midwives and physicians: a systematic review, 1990 to 2008. Women’s Health Issues, 22, e73-81.or not different.Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, CD004667;Sutcliffe, K., Caird, J., Kavanagh, J., Rees, R., Oliver, K., Dickson, K., Woodman, J., Barnett-Paige, E., & Thomas, J. (2012). Comparing midwife-led and doctor-led maternity care: a systematic review of reviews. Journal of Advanced Nursing, 68(11), 2376-2386.

How does maternity care led by obstetricians compared to care led by family physicians?

The most recent review to answer this question is well done, summarizes many studies, but is quite old.Klein, M. (1993). The effectiveness of family practice maternity care. Primary Care, 20(3), 523-536. It concludes:

“Research into general and family practice obstetrics has failed to provide a single example of adverse outcomes attributable to this type of care. In fact, when differences have been found, they favor FP care, whether for women at low risk or when organized regionally so as to promote the appropriate transfer of women with special needs best met in [more specialized hospitals]. Moreover, reserving high-touch and low-tech care for appropriately selected populations cared for by providers principally oriented to this type of care (GPs, FPs, midwives, and some obstetricians) has proven to be better in terms of medical outcomes, cost, convenience, and for humanistic, psychological, cultural, and family reasons (Klein 1993, p. 533).”

Rigorous, more current, reviews to answer this question are urgently needed. It is helpful to know that more recent individual studies are consistent with the earlier review.See Abenheim, H.A., Welt, M., Sabbah, R., & Audibert, F. (2007). Obstetrician or family physician: are vaginal deliveries managed differently? Journal of Obstetrics and Gynaecology of Canada, 29(10), 801-5 or Aubrey-Bassler, K., Cullen, R., Simms, A., Asghari, S., Crane, J., Wang, P., & Godwin, M. (2015). Outcomes of deliveries by family physicians or obstetricians: a population-based cohort study using an instrumental variable. Canadian Medical Association Journal, 187(15), 1125-1132.

What is most important to making sure I have a satisfying childbirth experience?

A systematic review of the best available researchHodnett, E.D. (2002). Pain and women’s satisfaction with the experience of childbirth: a systematic review. American Journal of Obstetrics and Gynecology, 186(5), S160-72. found that the following four factors make the greatest contribution to women’s satisfaction with their childbirth experience:

  • Having good support from care providers.
  • Having a high-quality relationship with care providers.
  • Being involved in decision-making about care.
  • Having better-than-expected experiences (or having high expectations).

Choosing a maternity care provider and a birth setting with care providers that offer these experiences can make a big difference in your satisfaction!

How can I become familiar with my options before making my decision?

Your maternity care provider will be working intimately with you and your family through one of the most important times of your life. It’s OK to take time to make this decision and talk to different care providers.

This visit is often a “consultation” rather than an “intake” visit and gives you a chance to gather information before you commit to working with one care provider or another. Find out in advance whether the office charges for such a visit and if your insurance company will pay for a consultation. Some practices offer regular informal get-togethers for newly pregnant women to meet with care providers and learn about the practice.

You may want to ask your partner or a friend or relative to come with you to the interview. This will allow you to discuss your thoughts and impressions afterward with someone you know and trust. Here are some tips for the consultation:

  • Write down and bring a list of your questions. Here are suggested questions for midwives and for physicians.
  • Refer to your list throughout and ensure you get all of your questions answered. This also allows you to compare answers across different care providers.
  • Tell the care provider that your needs and preferences are important to you, and you are eager to be involved in decisions about your care.
  • Show respect for the care provider’s time by being organized and efficient.
  • Ask to meet anyone else who may be “on call” to attend your birth; even if practitioners work together in some capacity, their philosophy and approach can differ.
  • Plan to tour the birth setting, as the decision about your care provider goes hand in hand with the decision about your place of birth.

Coming out of the consultation, it may be helpful to reflect on these questions:

  • Is this person listening to me and respectful of my wish to make careful decisions?
  • Is this person willing to take the time to answer my questions to my satisfaction?
  • Does this person share my vision for my maternity care and birth?
  • Do I think that I can feel comfortable with and trust this person?
  • Can I get what I want from this person?
  • Does this feel right for me?

Follow your instincts. Only you can make the decision that is right for you. If you have concerns, even if you are well into your pregnancy and prenatal care, it may be important to explore other options.

What if I begin to have doubts about my choice of care provider?

Remember that if you have concerns and have not been able to resolve them through open and respectful communication with your original care provider, you can explore other options. Even if it is late in your pregnancy, you can switch to a different care provider if:

  • You have enough time to explore options and find a situation that you believe will work better for you.
  • The new care provider or setting has no policies that prevent you from making this change at that time in your pregnancy.
  • Your insurance will cover the new arrangements, or you are willing and able to pay out of pocket.

You may have to change your care provider and/or birth setting to get what you want. Some care providers do not accept “late transfers,” so don’t delay in seeking new arrangements if you come to feel that your initial choice is a poor fit for your needs.

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