Areas Where Independent Midwives Practise Have Lower C-Section Rates

Areas Where Independent Midwives Practise Have Lower C-Section Rates

We know that your choice of maternity care provider has a big impact on your pregnancy, birth and postnatal period.

However, a new study shows that the way your maternity care providers, specifically midwives, are allowed to practise also has a significant effect on your pregnancy outcome.

A recent study found that US states where midwives are allowed to practise autonomously, have lower c-section rates and improved birth outcomes than states where midwives do not practise autonomously.

In the US, ‘midwife’ can mean several things. It’s a term that covers certified professional midwives (CPM), certified midwives (CM) and certified nurse midwives (CNM). All have varying levels of professional training. This recent study uses the term midwife to mean a CNM, which is a licensed nurse who has gone on to receive a graduate degree in midwifery.

While the availability of midwifery care has been shown to improve birth outcomes, this study shows that how they are allowed to practise determines how much of an impact they’re able to have. In some states midwives are able to practise autonomously, meaning they do not need to work for, or have a collaborative practice agreement with, an obstetrician or other physician. In other states, midwives are only able to practise with some level of agreement to be overseen by an obstetrician or other physician.

Why Might More Autonomy In Midwifery Care Lead To Improved Outcomes?

Midwives and obstetricians are trained very differently. In general, midwives are trained to understand normal physiological birth and to step in only if things deviate from that normal. Most obstetrical training treats birth as a medical process that could go wrong at any point and should therefore be medically managed to avoid any possible negative outcomes. Unfortunately, medically managing a low risk birth isn’t without risk, and so in some cases obstetrical care can lead to poorer outcomes.

Midwifery care itself is linked to improved maternal and fetal outcomes. Often midwifery care means continuity of care and a holistic approach. This means a mother establishes a relationship with her care provider, and they work together to have a healthy pregnancy, birth and postnatal period. They discuss prenatal wellness, diet, and birth options, while also encouraging lots of postnatal rest.

However, what happens if the mother and midwife get to the birth stage and things deviate just a bit from the expected birth pattern? Or what if the mother goes slightly past her estimated due date? Well, if the midwife is allowed full autonomy, she might make lower intervention choices to manage the birth, using higher intervention choices only when necessary. If she’s not allowed full autonomy, the care choices might be made by the obstetrician, who is probably trained to make higher intervention choices.

13% Lower Risk Of C-Section, 13% Lower Risk Of Pre-Term Birth And 11% Lower Risk Of Low Birthweight

The study found states with autonomous midwifery care have better overall outcomes than states where midwives are not able to practise without answering to an obstetrician. Based on data from 12 million births from 2009-2011, the research found that states with autonomous care have a 13% lower risk of c-section, a 13% lower risk of pre-term birth and an 11% lower risk of low birthweight babies.

The current US c-section rate is over 30%, more than double the World Health Organization’s recommendation of 10-15%. Pre-term birth is linked to infant morbidity and mortality, and low birthweight is also linked to health concerns.

What Does This Study Mean?

This study confirms what many other studies have found: midwifery care is linked to better birth outcomes for both mother and baby. What is unique about this study is that it also shows how healthcare regulations have an impact on care. In states where midwives are able to practise autonomously, women have a 60% increased chance of the birth being attended by a certified nurse midwife.

Chances are, learning about your state’s midwifery regulations isn’t going to lead to you moving to another state before having your next baby. However, what it can tell you is that you might need to make a more informed choice about who your care provider will be (e.g. learning about who your midwife’s backup obstetrician is, and their birth statistics). It also tells you that if you have the opportunity to influence your state’s healthcare legislation, you also have the opportunity to influence birth outcomes.



Maria Silver Pyanov is the mom of four energetic boys, a doula, and a childbirth educator. She is an advocate for birth options, and adequate prenatal care and support. She believes in the importance of rebuilding the village so no parent feels unsupported.

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