December 05, 2012
Volume 7 - Issue 49     

DynaMed Weekly Update

For the week ending November 30, 2012

Last week 457 articles were evaluated via DynaMed's Systematic Literature Surveillance and 250 were added to DynaMed content.   


Based on the editors' criteria of selecting "articles most likely to change clinical practice," one article of significant interest was selected for the DynaMed Weekly Update.

Feature Article

Primary Midwife Care Reduces Cesarean Deliveries in Low-Risk Women 


Cesarean delivery may increase the risks of maternal and neonatal morbidity and mortality (BMJ 2007 Nov 17;335(7628):1025,  Lancet 2010 Feb 6;375(9713):490). Nevertheless, rates of cesarean deliveries have been on the rise over the past 2 decades in the United States and world-wide, due in large part to an increase in planned, elective  cesareans. Midwife care has previously been associated with reduced rates of episiotomy and instrumental vaginal delivery, reduced use of analgesia during labor, and increased maternal satisfaction. The COSMOS trial in Australia recently investigated the effect of primary midwife care on cesarean rates in women with low obstetric risk in early pregnancy.


A total of 2,324 women with singleton pregnancy < 24 weeks gestational age were randomized to one-to-one primary midwife care vs. usual care through the postpartum period. In the primary midwife care group, the majority of care for each women was provided by a single midwife to insure continuity (with care by back-up midwives as necessary due to scheduling conflicts). Any complications were managed by collaboration between the primary midwife and an obstetrician or other care provider. In the usual care group, women had the option of midwife team care (without one-to-one relationship between midwife and patient), care by an obstetric trainee, or combined care by community-based general practitioner and hospital staff, with care provided by on-duty midwives and doctors for labor, birth, and postnatal care. Most women in the usual care group (78%) received midwife team care. All women in each group saw an obstetrician at booking, at 36 weeks gestation, and at postdates if required. Women were excluded from the trial for conditions putting them at high obstetric risk, including previous cesarean section, history of obstetric complications, cardiac disease, diabetes, and obesity. The trial was conducted at a single hospital in Melbourne, Australia.


The overall rate of cesarean deliveries was significantly lower with primary midwife care (19.4%) than with usual care (24.9%) (p = 0.001, NNT 19) (level 1 [likely reliable] evidence). Cesarean rates were also lower in a subgroup analysis of 1,595 primiparous women (24.9% vs. 32.4%, p < 0.001, NNT 14). There were no significant differences in the rate of planned cesarean sections (3.1% vs. 3.5%) or in overall cesarean sections in a subgroup of multiparous women (6.2% vs. 8%).


Primary midwife care was also associated with significantly higher rates of spontaneous vaginal birth (63% vs. 55.7%, p < 0.001, NNT 14), and with lower rates of epidural analgesia use (30.5% vs. 34.6%, p = 0.04, NNT 25) and episiotomy (23.1% vs. 29.4%, p = 0.003, NNT 16). Infant admissions to special or neonatal intensive care were also lower with primary midwife care (4% vs. 6.4% of live births, p = 0.01, NNT 42) (BJOG 2012 Nov;119(12):1483). 


A number of issues may limit the generalizability of these findings. From these data, it cannot be determined whether midwife care specifically or, more generally, continuous care from a single provider is the factor responsible for the results. Furthermore, cesarean rates differ around the world and may even differ among institutions in the same area. The authors note that the baseline cesarean rate at the study hospital was relatively high. The effects of midwife care are likely to depend on a number of demographic and cultural variables.


For more information, see the Overview of labor and delivery topic in DynaMed.

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New Topics added to DynaMed this Week 

Fragile X tremor/ataxia syndrome (FXTAS)
Hereditary episodic ataxia

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Venous thromboembolism in pregnancy

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About DynaMed Weekly Update

Prepared by the clinician members of the DynaMed Editorial Team, DynaMed Weekly Update is a compilation of one to five articles selected from DynaMed's Systematic Literature Surveillance as articles most likely to change clinical practice.

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CME Information


0.25 AMA PRA Category I Credit(s)™
Family Physicians: 0.25 Prescribed credits
Nurse Practitioners: 0.25 Contact hours
Release Date: December 05, 2012
Expiration Date: December 05, 2013
Estimated Completion Time:
15 minutes
There is no fee for this activity.

To Receive Credit 
In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.

Program Overview

Learning Objectives


Upon successful completion of this educational program, the reader should be able to:


1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.


Faculty Information
Alan Ehrlich, MD - Assistant Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company

Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.


No commercial support has been received for this activity.

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AAFP: Enduring Material activity, DynaMed Weekly Update, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 7, 2012. Term of approval is for one year from this date with the option of yearly renewal. Each Weekly Update is worth .25 Prescribed credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.


AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners.


Program ID: 1210392N

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