Comparison of maternal and neonatal outcomes of midwifery-led care with routine midwifery care: a retrospective cohort study

In 2020, the global maternal mortality rate (MMR) was estimated at 223 deaths per 100,000 live births, marking a reduction of approximately one-third from the year 2000. During the first five years (2016 to 2020) of the adoption of the SDGs (Sustainable Development Goals), the MMR decreased significantly across 31 countries, although in 17 countries it is still on the rise. The SDG statement explicitly emphasizes the reduction of the MMR, However, it also highlights the necessity of expanding the focus beyond mere survival to include broader health outcomes [1].

Three-quarters of maternal deaths in developing countries including Iran are attributed to direct obstetric complications [2]. The involvement of a skilled midwifery professional plays an important role in preventing maternal deaths from these causes [3]. Notably, in Iran, 99% of births are currently attended by skilled healthcare providers such as midwives [4].

Globally, midwives administer various models of maternal care in practice, such as the individual caseload model, partnership, one-to-one and continuous care. The continuous care model particularly emphasizes maintaining continuity of care throughout pregnancy and childbirth [5, 6].

Globally, the management of low-risk pregnancies by midwives often results in a more natural childbirth process, leading to improved physical and psychological outcomes for both mother and baby [5, 7]. In Iran, midwifery is acknowledged as an independent profession. However, the healthcare system integrates it within a biomedical framework. In this country, although midwives offer comprehensive care to mothers throughout pregnancy and childbirth, gynecologists are primarily responsible for maternal health in prenatal clinics and hospitals [8]. Studies indicate that, within the expert-supervised model, the gynecologist determines the midwife’s scope of activities, and midwives lose their clinical independence and reasoning ability and they only perform routine tasks under the supervision and guidance of specialists [5, 8, 9].

In Iran, the model of maternity care varies by hospital level and midwives work under gynecologists’ supervision across all levels, but their roles differ. In level 3 hospitals, midwives primarily focus on taking medical histories and providing maternal care, while specialists or residents manage labor and delivery. In levels 1 and 2 hospitals, midwives manage the entire labor process and provide one-to-one care in “LDR¹” rooms. Generally, individual caseload and partnership model of care are not carried out in Iran due to the lack of autonomy for midwives. However, some hospitals, particularly private ones, offer continuous midwifery care for mothers with low-risk pregnancies. In these settings, midwives, known as “private midwives,” provide care throughout pregnancy and manage labor and delivery independently, with gynecologists assisting as needed.

Another type of care provided by midwives in the private sectors in Iran is a service known as “doula care” which focuses on providing continuous physical and emotional support during labor and delivery. However, in this model, doulas do not participate in prenatal or delivery care, so it is not considered continuous midwifery care [10]. Doula care has shown positive effects in studies in terms of shortening the duration of labor, early initiation of breastfeeding, reducing abnormal patterns of labor, improving neonatal health, reducing the need for induction and lowering cesarean rates [11‐13].

Evidence suggests that the model of care significantly impacts maternal and neonatal outcomes. A systematic review conducted in 2023 found that midwifery-led care enhances several key outcomes, including higher rates of normal vaginal delivery, lower rates of episiotomy and postpartum hemorrhage, and shorter neonatal stays in NICUs. The study attributes these positive effects to the strong trust between midwives and expectant mothers, and the personalized attention paid to individual needs in midwifery-led care [14]. Furthermore, a lives saved tool modelling study in 2021 indicated that universal coverage of midwife-led interventions could potentially save millions of lives each year by 2035, by preventing 67% maternal deaths, 64% of neonatal deaths, and 65% of stillbirths [15]. Consistent with these findings, several other studies have also demonstrated that midwifery-led care yields better outcomes compared to specialist-led care. These benefits include shorter labor duration, fewer childbirth complications, reduced labor pain, lower rates of labor induction, decreased use of epidural anesthesia, higher Apgar scores, and greater satisfaction with the childbirth experience [6, 16‐20].

In Iran, despite policymakers and researchers placing a strong emphasis on improving the quality of midwifery care and developing midwife-led care [21], no report has been published so far on the outcomes of midwife-led care, which here means the care provided by private midwives. Thus, this study aims to compare the maternal and neonatal outcomes of the care provided by private midwives with those of routine midwifery care.

Based on the results, the age of mothers in the RCG was 29.41 ± 5.11 years while in the PCG it was 28.38 ± 4.71 years. The result of the independent sample t-test indicated a statistically significant difference in maternal age (P = 0.003) and the level of education between the two groups (P = 0.011). However, the study found no statistically significant difference between the two groups regarding insurance coverage (Table 1) or obstetrics characteristics including the number of pregnancies, childbirth, live children, abortions, average gestational age and the type of previous childbirth (Table 2).

Regarding maternal outcomes, labor pain management was administered for 37.7% of women in the RCG and 51.9% of women in the PCG, and the chi-square test results indicated a statistically significant difference between the two groups (P < 0.001). Also, the findings revealed that 44.2% of women in the RCG and 22.9% in the PCG underwent episiotomy, and a statistically significant difference between the two groups was observed (P < 0.001). Moreover, 14.2% of women in the RCG and only 6% of women in the PCG had labor induction and this difference was statistically significant (P < 0.001). Furthermore, 1.3% of women in the RCG and 0.8% of women in the PCG delivered with forceps or vacuum. However, this difference was not statistically significant (P = 0.5) (Table 3).

In the logistic regression model, the results indicated that both maternal age (P = 0.004) and labor pain control (P < 0.001) were significantly associated with the type of care (Table 4). Specifically, as maternal age increased, the likelihood of utilizing routine care increased by 5%. Also, the likelihood of not using interventions to manage labor pain was twice as high in the RCG compared to the PCG. In other words, the chances of utilizing pain control interventions were higher in the PCG (Table 4).

In relation to neonatal outcomes, the study revealed no significant differences between the two groups in various measures, including infant’s birth weight (P = 0.460), fifth-minute Apgar score (P = 0.75), neonatal resuscitation (P = 0.999), skin-to-skin contact (P = 0.626), initiation of breastfeeding (P = 0.241) and admission to the NICU (P = 0.66) (Table 5).

Based on previous studies, our hypothesis was that continuous midwifery care, provided by a dedicated and trusted midwife, referred to as a private midwife in Iran, can lead to improved maternal and neonatal outcomes compared to routine midwifery services delivered by shift-working midwives in hospitals. Therefore, this study was designed and implemented to investigate this hypothesis within the context of Iran. One of the notable findings of our study was that the users of private midwifery services were young women known as Generation Z in Iran. We characterized them as a more informed, intelligent, and empowered generation due to their intellectual advancement and modern perspectives. Therefore, it is not far-fetched to conclude that these women are more aware of modern midwifery services and are more willing to utilize them. This trend, however, has also been attributed in other studies to the greater fear and anxiety young women have about natural childbirth [24‐26]. We believe that, given the changes occurring in the newer generations of Iranian society, the shift from traditional services (RCG) to modern midwifery services (PCG) is more closely related to the increased awareness and empowerment of young mothers rather than their higher fear and anxiety.

Another finding of our study was that women in the PCG had lower levels of education compared to the RCG. Although other studies have shown that lower maternal education is associated with greater fear of childbirth [27], suggesting that less educated Iranian mothers may seek private midwifery services due to greater fear of vaginal delivery, we believe another interpretation is more plausible. Younger women are more aware of new midwifery services than older women because they are more likely to search for and obtain new information on social media, which has little to do with the level of maternal education. However, we suggest that the impact of maternal general information on the greater use of modern obstetric services should be investigated in future studies.

Logistic regression analysis also indicated that the likelihood of using pain control methods in the RCG was half that in the PCG. Although PCG used more non-pharmacological pain relief methods, this aspect is not solely a negative point but can also be considered an advantage for PCG. However, as this study did not assess the mothers’ responses to the pain relief methods, it remains unclear which group of mothers was ultimately more satisfied with their pain management approaches. Therefore, further research is recommended to explore this issue. Existing studies have established a correlation between the number of previous deliveries and the experience of pain [28]. However, in this study, no significant difference was observed between the two groups regarding the number of pregnancies and deliveries. Therefore, if mothers report experiencing less pain, it is more likely attributable to the use of pain relief methods rather than the difference in the number of deliveries. In general, we believe that private midwives’ use of non-pharmacological pain control methods can be regarded as a promising form of care rather than an unnecessary intervention. The study by Buerengen et al. also found that one-to-one midwifery care during the active stage of labor can reduce the use of epidural anesthesia [29]. In conclusion, the presence of a private midwife appears to enhance a mother’s sense of security and self-control. As a result, there is less need to use pharmacological pain relief methods, which can be associated with harmful side effects for both the mother and newborn.

A comparison of RCG and PCG in terms of labor and delivery interventions, including episiotomy, labor induction, and the use of forceps and vacuum, revealed that women in the PCG group experienced fewer interventions compared to the RCG group. This suggests that PCG may be associated with a more natural childbirth experience. National data also indicate that the overall use of medical interventions during childbirth in Iran significantly exceeds World Health Organization (WHO) standards [30]. On the other hand, evidence suggests that continuous professional support from midwives can reduce the use of labor induction and significantly enhance the mother’s childbirth experience [31]. Consistent with these findings, the study by Hailemeskel et al. demonstrated that women who received midwifery-led care were more likely to have spontaneous vaginal births compared to those who received care from various staff members at different times [32]. In terms of instrumental delivery, the chi-square result showed no significant statistical difference between the RCG and PCG. Notably, in both groups, especially the PCG, the instrumental delivery rate was very low. In this regard, Fortier et al.’s study demonstrated that continuous supportive care during labor can reduce the use of vacuum and cesarean section [33].

Upon comparing neonatal outcomes, the findings showed no statistically significant difference between the two groups in terms of baby’s birth weight, fifth-minute Apgar score, neonatal resuscitation, skin to skin contact, initiation of breastfeeding and admission to the NICU. While other studies have demonstrated the positive impact of continuous midwifery care on facilitating skin-to-skin contact, promoting breastfeeding in the first hour after birth [11] and improving newborns’ general health [13, 17], the lack of significant difference between the RCG and PCG in terms of skin-to-skin contact and initiation of breastfeeding suggests a need for further investigation into the data collection process for the Iman system. Future studies should assess whether these questionable findings are indicative of inaccurate data entry within the national data collection systems or reflect the high quality of routine maternal and newborn care. We prefer to refrain from making judgments in this regard.

This retrospective cohort study highlighted that midwifery-led care emphasizes physiologic birth practices, utilizing fewer interventions such as labor induction and episiotomy, and employing more non-pharmacological pain management methods. However, no statistically significant differences in neonatal outcomes were observed between midwifery-led care and routine midwifery care, despite other studies demonstrating positive impacts of continuous midwifery care on several neonatal outcomes. Given the positive impact of midwife-led care on significant maternal outcomes, it is recommended that health policymakers establish the necessary conditions for implementing a continuous midwifery care model in both governmental and private hospitals and prenatal clinics. Furthermore, future research should explore the challenges and facilitators of this model, as well as its impact on neonatal outcomes, using quantitative, qualitative, and mixed methods research.