Best Evidence: Caregiver

Best evidence: When making important maternity decisions, women should have information from the best available research about the safety and effectiveness of different choices. In general, we can be most confident about results of systematic reviews that summarize randomized controlled trials (or RCTs, a type of study).

Unfortunately, for many decisions, we must rely on less definitive research; and many important questions — even in the case of widely used drugs, tests, and procedures — have hardly been studied at all. Although this situation is discouraging, an awareness of weak or missing evidence can help you make more informed choices about care.

What is the bottom line?

What is the best evidence about advantages and disadvantages of different types of maternity caregivers available in the U.S.?

What factors most contribute to women's satisfaction in childbirth?

What is the bottom line?

Neither systematic reviews nor randomized controlled trials are available to compare the relative safety and effectiveness of birth in the U.S. with different types of caregivers. The best available research suggests that low-risk women and infants who work with midwives have comparable and possibly better outcomes and receive fewer interventions than similar women who work with physicians. Well women who receive maternity care from family physicians generally have comparable outcomes to similar women being cared for by obstetricians, with less use of interventions. Caregivers who limit routine use of interventions with low-risk women appear to be most consistent with the best evidence about common interventions.

Despite these overall patterns, the practice styles of individual caregivers vary. The attitudes and style of individual caregivers, as well as the specific care environment, have a major impact on the type of care that a woman receives.

What is the best evidence about advantages and disadvantages of different types of maternity caregivers available in the U.S.?

The information summarized here considers comparisons between different types of maternity caregivers in the past two decades. The focus is on U.S. studies, due to wide variation in background and practice arrangements of maternity caregivers throughout the world. The conclusions do not apply to women or infants with serious health problems or at high risk for developing such problems. At this time, systematic reviews and randomized controlled trials — the preferred types of research — are not available to make these comparisons. Although less definitive, the many available individual studies, and several less formal reviews, show consistent patterns.

Care by certified nurse-midwives (CNMs) is generally associated with a lower likelihood of using various labor and birth interventions than maternity care with doctors. The care of family physicians tends to involve less intervention than care by obstetricians. The many studies comparing two or three types of caregivers have generally found that providing more interventions does not lead to better outcomes. These results have generally been found for well, low-risk women and for women in challenging social circumstances (for example, low-income or adolescent mothers).

Raisler (2000) reviews studies comparing midwifery care (primarily CNMs) to physician care in the U.S. Klein and Zander (1989) review earlier studies comparing maternity care by family physicians and obstetricians. More recent individual studies are consistent with findings of the earlier review. The available body of research does not provide a good basis for comparing care and outcomes of either osteopathic physicians or midwives who are not CNMs. It is reasonable to assume that midwives who are not CNMs and practice in out-of-hospital settings have low rates of intervention in comparison with other types of maternity caregivers.

Very large studies are needed to understand patterns of rare but serious events, such as newborn death. One study compared over 150,000 births attended by nurse-midwives in the U.S. in 1991 to nearly 700,000 births attended by physicians that year (MacDorman and Singh 1998). The authors made adjustments to account for differences in medical and social risk factors in the two groups. They found that women attended by nurse-midwives were less likely than similar women attended by physicians to experience:
  • the birth of a baby with low birthweight
  • the death of their baby in the first four weeks of life
  • the death of their baby in the first year of life.
Babies in the nurse-midwifery group also had a higher average birthweight. This study groups all physicians together and provides no information to compare different types of physicians.

What factors most contribute to women's satisfaction in childbirth?

Unfortunately, the comparison studies described above generally did not look at and compare women's own views of their care. In choosing your caregiver, it may be helpful to consider results of research about satisfaction in childbirth. A systematic review of the best available research (Hodnett 2002) finds that the following four factors make the greatest contribution to women's satisfaction in childbirth:
  • having good support from caregivers
  • having a high-quality relationship with caregivers
  • being involved in decision-making about care
  • having better-than-expected experiences (or having high expectations).
Choosing a maternity caregiver and a birth setting with caregivers that can provide this type of care can make a big difference in your satisfaction!


Hodnett ED. Pain and women's satisfaction with the experience of childbirth: a systematic review. American Journal of Obstetrics and Gynecology 186,5 (2002) S160-72.

Klein M and Zander L. The role of the family practitioner in maternity care. In: Chalmers I, Enkin M and Keirse MJNC, eds. Effective Care in Pregnancy and Childbirth, volume I. New York: Oxford University Press, 1989, pp. 181-89.

MacDorman MF and Singh GK. midwifery care, social and medical risk factors, and birth outcomes in the USA. Journal of Epidemiology and Community Health 52,5 (1998) 310-17.

Raisler J. midwifery care research: What questions are being asked? What lessons have been learned? Journal of Midwifery & Women's Health 54,1 (2000) 20-36.

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Tips & Tools: Caregiver

Most recent page update: 10/23/2012

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