Certified Nurse-Midwifery Model of Care vs. Medical Model of Care:

Midwifery Care vs. U.S. Medical Care

Certified Nurse-Midwifery Model of Care vs. Medical Model of Care:

Models of care define how health care services are delivered and the underlying philosophies which dictate how these services are provided. Nurse-Midwifery and medical models of care are based on each profession’s perspective and training in pregnancy and birth. Each profession’s point of view is based on very different historical and philosophical bases, which affect professional attitudes regarding the manners in which they approach the care of pregnant women, the relationship between clinician and patient, and what interventions are required in order to provide responsible care.[1]

Between medicine and midwifery, the goals and objectives of care are similar, in that the health and safety of mother and baby are common objectives. However, the manner in which these goals are accomplished can be diverse between the two specialties.

Midwifery Model of Care

The traditional midwifery model of care (physiologic model) is based on the recognition that pregnancy and birth are normal life events that generally culminate in healthy outcomes. In nurse-midwifery, the health and wellness of mother and baby are baseline expectations. However, skill and attention are directed toward recognizing and managing potential medical complications or concerning deviations from the normal process of birth.

Certified Nurse-Midwives and Certified Midwives are educated to become specialists in normal pregnancy and childbirth. They obtain the education and experience to recognize abnormal developments in the birthing process.

Certified Nurse-Midwives and Certified Midwives cannot be specialists in normal birth without knowledge and recognition of developing abnormalities while managing the prenatal, intrapartum, and postnatal care of childbearing women. Prenatal assessments can uncover underlying medical issues in both mother and baby. For instance, the baby may be too big, too small, mal-positioned, in distress, coming prematurely, or no longer alive. Other medical issues, like hypertension, obesity, diabetes, substance abuse and a complicated medical and/or obstetrical history can reveal a constellation of potential complications.

Midwives Educated in Complications: Action And Mitigation

For instance, during the prenatal period, labor, and postpartum, seemingly normal mothers may develop hypertension and other issues which may point to the development of pre-eclampsia or HELLP syndrome. Expert fetal surveillance may also alert the nurse-midwife to a baby’s intolerance to labor. Certain acute events, such as fetal distress or prolapse of the umbilical cord, require immediate action from the midwife. Following delivery, the nurse-midwife may be called upon to manage a severe postpartum hemorrhage. There are many more examples of deviation from normal that nurse-midwives can recognize and manage in conjunction with communicating with an obstetrical consultant.

When will the doctor get here?
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Midwives Are Competent In Emergency Management

No CNM/CM will sit idly by, waiting for a doctor to show up and tell her what to do. CNMs and CMs are ever-alert for significant deviations from normal. Risk assessment and prevention strategies are inherent in midwifery education and care, including a detailed patient history and physical, laboratory testing, ultrasonography, radiography, fetal monitoring, intrauterine assessment, research, and consultation. Early recognition and intervention exist together with watchful assessment of the normal process. Consultation, collaboration, or transfer of care will be appropriately initiated when the CNM/CM recognizes deviations from normal. Usually, in the event of severe complications, the CNM/CM can remain involved, along with a physician consultant, in the care of the patient or will arrange for the smooth and expedient transition to high risk care, if that is the best choice. [2]

The midwifery model of care will always offer the chance for a normal birth. A 2013 Cochrane review comparing models of care indicated that women cared for by midwives were less likely to have an episiotomy, instrumental delivery, or a pre-term delivery. In addition, midwifery-led care resulted in fewer fetal losses prior to 24 weeks and more spontaneous vaginal deliveries than a women attended by physicians.[3]

Childbirth is extraordinary, regardless of how it is accomplished. The opportunity to experience a safe, natural birth, the way nature intends, is exquisite.

Medical Model of Care

An Obstetrics model of care is typically focused on pathological conditions. Obstetricians are educated to apply interventions in order to prevent or treat complications of pregnancy and childbirth. Attention is primarily focused on the abnormal. In addition to prevention of complications as a focus of obstetrical care, medicine emphasizes diagnosis and treatment of adverse events/complications that may occur.

As opposed to midwifery care, obstetrical prevention strategies emphasize the adverse events that might occur during pregnancy and birth and the surgical interventions to manage, mitigate or prevent them.

Naturally, obstetrical expertise may be required in the event of maternal/fetal distress. Distinctions between a midwifery model of care, and the medical model, are excessive obstetrical interventions that are routinely utilized in the care of low risk women who have not experienced any complications of pregnancy or labor.

Routine interventions, such as scheduled cesarean sections and instrumental deliveries, have shown a tendency toward adverse outcomes for both mothers and babies. Medical training and education for physicians does not, typically, include the development of skills to support the natural progression of pregnancy and birth. Medical/obstetrical models of care are far more prevalent in the U.S. than other countries’ models of patience and support for the natural processes of birth.[4]

Respectful Co-Management In Emergency Situations

Despite differing approaches to care, obstetrical and midwifery expertise can be mutually beneficial. Voluntary and respectful co-management can be beneficial when combining the talents and expertise of both specialties. In a very high risk maternity situation, a woman is likely to benefit from the best of both worlds. A successful merging of apparently divergent philosophies of care and management depends on a concerted effort to encourage communication, cooperation, and mutual respect. All of these are dependent, however, on a healthy culture of care within the institution where the co-management is taking place. In a dysfunctional culture of care, with outdated provider hierarchies, and lacking cooperative components, the risk of miscommunication and discord is enhanced. This may inevitably lead to an increased risk for legal liability.

Midwifery Outside of the U.S.

In many modern, industrialized countries, except the United States, professional midwives coordinate the care for the majority of childbearing women and only collaborate with obstetricians or other specialists in the event of medical or obstetrical complications and concerning risk factors.

In countries like Sweden, Norway, Great Britain, and France, to name a few, normally presenting pregnant women are exclusively cared for by midwives. Physicians are only involved if there are concerning deviations from normal or a need for surgical intervention. For decades, this has demonstrated a system of care which is efficient, safe, and satisfying for women. Furthermore, this has been reflected in maternal and infant mortality rates which are significantly and consistently lower than those in the United States.

In 2023, the U.S. rate for maternal deaths per 100,000 live births was 32.9, reflecting 10 times the estimated rates of other high-income countries, including Australia, Austria, Israel, Japan and Spain, which reported 2-3 deaths per 100,000 in 2020. In regard to current World Health Organization calculations, the United States ranks 55th in the world, behind even countries at war, like Russia and Ukraine. For infant mortality rate, the U.S. has 5.6 infant deaths per 1,000 live births for 2022; up from 5.44 per 1000 in 2021. This rate was reported as 50th among 195 countries and territories measured. These statistics are higher than many other developed countries like Sweden (2.15 per 1000) and Japan (1.82 per 1000). Although the United States’ compilation of statistics is reportedly broader than other countries’, which supposedly makes its statistics look worse, verified U.S. rates for maternal and infant death in childbirth are still abysmal compared with other industrialized countries in Asia and the western world.*

Maternal Deaths in the U.S. and Women of Color

Notably, in the United States, maternal deaths are not spread equally across race and demographic (although statistics from Great Britain fail to show any significant differences in rates of death between higher and lower economic status).

In the U.S., the women most likely to die before and after childbirth are Black women, in urban and rural communities, not necessarily related to economic status.** [5] Black women in America are three times more likely to die from childbirth-related causes than White women. Various local statistics feature even higher numbers. Public health statistics from the city of Chicago site Black maternal deaths being 6 times higher than for White women.***

Midwifery in Great Britain

Maternity care in Britain emphasizes a smooth coordination between midwives and physicians. Midwives in Britain do not practice under the control or supervision of obstetricians, nor are collaborative agreements legally required between physicians and midwives. Midwives are recognized as independent clinicians in their own right. Pregnancies are triaged into two categories: Low risk and high risk. Forty-five percent of low risk women are seen exclusively by midwives. Of this 45%, one fourth of women end up being referred and transferred to physician care. High risk women can be seen by both midwives and obstetricians. Specialist care may also be provided when necessary. If pregnancy proceeds normally, it is probable that a low risk pregnancy patient will not see a physician for the entire gestation of nine months, including delivery. Labor wards for high risk patients and maternity units for low risk deliveries are purposely situated adjacent to each other. British obstetricians have stated that: “We are very good at sliding patients between high and low risk models of care.” Normal women are normalized and high risk women are medicalized.[6]

Despite significant evidence supporting the proposition that maternity care systems emphasizing midwifery have lower rates of childbirth complications and maternal death, the United States stubbornly adheres to a hierarchy of maternity care in childbirth, embracing the medical model, and undermining midwives.

1 Rooks, JP. The Midwifery Model of Care. J of Nurse-Midwifery. 1999;44(4):370-374

2 Rooks supra note at 40.

3 https://www.ourbodies ourselves.org/book-excerpts/health-arrticle/models-of-maternity-care/.

4 Rooks supra note at 40

5 Supra note 42 at 3

6 Propublica/NPR. Why Giving Birth is Safer in Britain Than the U.S. Kate Wormerly reporting. https://www.propublica.org./article/why-giving-birth-is-safer-in-britain-than-the-u-s/amp.

*U.S. Using Enhanced Vital Records 2016-2017. American Journal of Public Health III, no. 9. (2021) 673-681.

** https://onehealthtrust.org.

***Janine Valerie Logan, Opinion coordinator; Voices. USA Today. https://www.usatoday.com/story/opinion/voices/2023/10/30/black-maternal-health-birth-equality-need-midwives/71322387007/.

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