Midwives Vs Doctors

Quick Me-Update first: I had a nasty stomach bug last week, the first bout of vomiting of which coincided with the first dose of clomiphene for this cycle (about 1.5h after I took it). I was initially a little worried that I possibly hadn’t absorbed enough of the drug, but then I remembered that this is a monitored cycle, so we just wouldn’t go ahead with Sperm Day this month if there was no egg developing upon the ultrasound scan. I did ring the nurse, and she concurred. I also asked her whether me being run down could affect my chances of successful fertilization, and she said that as far as anyone is aware it doesn’t – a lot of women accidentally get pregnant while in the middle of e.g. the ‘flu (at which I thought “how do they have the energy for sex when they have the ‘flu!?”).

So: first LH test of the cycle is tomorrow, with (hopefully) Sperm Day falling on a weekend day. Mood-wise, I am starting to think I am never going to get pregnant, even though it has only failed four times. But things are getting pretty close financially, which is making me worry that I will run out of money before I am eligible for public funding. Plus I just saw on the FA website that IVF costs $2500 or so more than I thought it did – and it was already hideous ($8000 for the procedure, $2000-4000 for the drugs, and now $2500 for the donor sperm and ICSI – although why they can’t just do normal IVF initially with donor sperm I don’t know; then $1850 per frozen extra embryo implant in future cycles). It has been an expensive year, and I am still not pregnant. I WAS SUPPOSED TO BE PREGNANT FOR XMAS – not much time left to achieve that!

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Anyway – on to the reason I am posting today. DISCLAIMER: I am neither a doctor nor a midwife, and am basing any opinions solely on having read many many medical studies in my time. However, I freely admit that I may misinterpret results or statistics, as I have never had to conduct a study myself, and thus do not have an in-depth knowledge of such things.

In the New Zealand media today there were several articles about a recently published study, conducted in NZ, that found that women who have midwives as lead maternity carers (LMCs) were more likely to have babies with particular adverse events than women whose LMCs were obstetricians or GPs. This is surprising, as midwives are generally held to be better for mother and baby, barring complications.

This was obviously of interest to me, as someone hoping to give birth in the next year, and I have been thinking about this since deciding on this path. As a decrepit crone of a potential mother at 36 (at least 37 by the time I actually give birth), I would already be at risk of complications, and if it is a multiple pregnancy that just adds more. However, I am also healthy (no pre-existing hypertension or diabetes), have never been a smoker, and have a BMI <25 – these all make me low risk. So, up until now, I was thinking I would try to have a midwife as a LMC, unless the consensus is that because of my age I should go with a doctor.

A recent Cochrane review of 15 studies involving 17,674 mothers found that mothers who used midwives were more likely to be satisfied with their care and less likely to experience interventions or preterm birth; other factors (e.g. various adverse events) were similar between midwives and other models of care. Interestingly, caesarean birth rates were similar between the two (I really don’t want one, and this was another reason I was leaning towards midwives, as I had heard doctors are more likely to go there).

This Cochrane review included studies from several countries; New Zealand was not one of them. This is important, as the system in NZ is different from most other countries, in that we have an autonomous midwife-led system, meaning that the midwife can be in sole charge, instead of being a part of a greater team. Apparently only us and The Netherlands do this – and this is why the Otago University researchers considered it necessary to do this study, as data may be different for us.

To summarise, the NZ study included 244,047 women with pregnancies that did not have major abnormalities (223,385 used midwives as their first registered LMC; 20,662 used doctors), over a period between 2008 and 2012. They found that, while mortality outcomes (e.g. stillbirth and neonatal mortality) were similar between groups, midwife-led care was significantly more likely than doctor-led care to result in adverse events such as a low Apgar score (48% more likely), birth-related asphyxia (55% more likely), and neonatal encephalopathy (39% more likely). The 21% difference in risk of intrauterine hypoxia was not statistically significant. This was all after adjusting for things that might affect the outcome, such as age, ethnicity, deprivation, BMI, smoking, whether this was the first pregnancy, pre-existing conditions, etc. And the associations were even stronger when the groups were both limited to only include mothers at low risk.

While this looks worrying, it is good to remember that these were all relatively low incidences – 1.0 and 0.5% of midwife- and doctor-led resulted in a low Apgar score, 0.5 and 0.2%, respectively, resulted in birth-related asphyxia, and 0.2 and 0.1% in neonatal encephalopathy. However – any decrease in risk is a good thing! Especially with such an important thing as this! Surely?

Things to remember with this study:

  • NZ still has a good maternity system, going by global standards, so these risks are small
  • Having said that, these results are interesting, and warrant further investigation
  • Demographics – age, ethnicity, deprivation, parity, trimester of LMC registration, BMI and smoking status – were all very significantly different between the groups. However, the authors consider this to have been covered by the control outcome they used (small for gestational age; no significant difference between the groups), as well as adjustments for these factors in their calculations
  • This was a retrospective study – thus, the data supply was set (the authors could not get further information than that which was already available) and potentially limited

SO. Now I don’t know what I want to do. I am sort of leaning back towards obstetrician-led care (probably with a midwife as well) – I was already kind of on the fence given my decrepitude, and this does add to that. I am planning on getting medical advice once I am pregnant (if that ever happens), of course – I will particularly ask FA what they think, as they must deal with older mothers quite a lot.

Hopefully this hasn’t been too dry (or too hastily written) for y’all – I thought it was really interesting, so wanted to discuss it.

EDITED TO ADD: The NZ midwives do not agree with this study, and say that demographics play a bigger part than the study let on.

EDITED TO ADD (PART DEUX): I wanted to add another disclaimer that I know very little, as yet, about the NZ birthing system, as I have not wanted to count my chickens – as such, there is a chance I got something wrong in that summary – I was just going by my understanding from reading the study. 

 

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2 thoughts on “Midwives Vs Doctors

  1. http://thespinoff.co.nz/parenting/08-10-2016/are-we-ok-mum-a-deep-dive-into-the-state-of-maternity-care-in-new-zealand/ You might be interested to read this article regarding the recent study. From what I’ve read over the past few years (sorry, don’t have exact links/details to studies) the NZ model of predominantly midwife led care results in better outcomes overall for women, and no real difference in baby’s outcomes between midwife and doctor led care (for ‘normal’ low-risk women) so be reassured that having a midwife as LMC does not mean you will receive care that is ‘worse’ than if you went with an obstetrician. If you have a midwife as LMC and you do run into unexpected issues putting you at ‘high-risk’ then you will be referred to an obstetrician at that point and may have shared care (both midwife and obstetrician care) or be transferred to the obstetrician as your LMC, and in both cases this would be publicly funded. Anecdotally, you generally receive more visits (before and after labour) with a midwife as LMC, and have more ‘access’ to them in between appointments than with an obstetrician, but you get more scans and testing at visits with obstetrician as LMC.

    Liked by 1 person

    1. Thank you – I saw this article too, and thought it was well argued. I am back to thinking a midwife is the right starting point, at least – I may well need to get an obstetrician involved anyway (as a result of being slightly older than most new mums), but I think a midwife would definitely be good to have around as main contact. Plus saving several thousand dollars is a total bonus.

      From what I understand, one can choose a midwife who is independent or one who is affiliated with the hospital – I will need to look into the options further when I am closer to the time (or at least pregnant 🙂).

      Like

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