Midwifery Care and Patient–Provider Communication
in Maternity Decisions in the United States
Katy B. Kozhimannil • Laura B. Attanasio •
Y. Tony Yang • Melissa D. Avery • Eugene Declercq
Published online: 10 February 2015
Springer Science+Business Media New York 2015
Abstract To characterize reasons women chose midwives as prenatal care providers and to measure the relationship between midwifery care and patient–provider
communication in the U.S. context. Retrospective analysis
of data from a nationally-representative survey of women
who gave birth in 2011–2012 to a single newborn in a U.S.
hospital (n = 2,400). We used multivariate logistic
regression models to characterize women who received
prenatal care from a midwife, to describe the reasons for
this choice, and to examine the association between midwife-led prenatal care and women’s reports about communication. Preference for a female clinician and having a
particular clinician assigned was associated with higher
odds of midwifery care (AOR = 2.65, 95 % CI 1.70, 4.14
and AOR = 1.63, 95 % CI 1.04, 2.58). A woman with
midwifery care had lower odds of reporting that she held
back questions because her preference for care was different from her provider’s recommendation (AOR = 0.46,
95 % CI 0.23, 0.89) or because she did not want to be
perceived as difficult (AOR = 0.48, 95 % CI 0.28, 0.81).
Women receiving midwifery care also had lower odds of
reporting that the provider used medical words were hard
for them to understand (AOR = 0.58, 95 % CI 0.37, 0.91)
and not feeling encouraged to discuss all their concerns
(AOR = 0.54, 95 % CI 0.34, 0.89). Women whose prenatal care was provided by midwives report better communication compared with those cared for by other types of
clinicians. Systems-level interventions, such as assigning a
clinician, may improve access to midwifery care and the
associated improvements in patient–provider communication in maternity care.
Keywords Midwifery Maternal health
Communication Patient-centered care Patient choice
Introduction
Recent health care reforms and health care policy dialogues
in the U.S. have focused on achieving transformation of
health systems and care delivery in an effort to achieve (1)
the ‘‘triple aim’’ of better outcomes and higher quality at
lower costs, and (2) greater patient engagement and
patient-centeredness in care. The three components of the
triple aim are to improve individual outcomes and experiences in health care, to advance the quality of care at both
individual and population levels, and to reduce per-capita
costs of providing necessary health care services [1]. While
not an entirely new idea, the recent emphasis on patientcentered care highlights the importance of a patient’s
participation in choices about their own health and care
management as well as the importance of clinicians taking
account of the values, preferences, and contextual life
K. B. Kozhimannil (&) L. B. Attanasio
Division of Health Policy and Management, University of
Minnesota School of Public Health, 720 Delaware St. SE, MMC
729, Minneapolis, MN 55455, USA
e-mail: [email protected]
Y. T. Yang
Department of Health Administration and Policy, College of
Health and Human Services, George Mason University, Fairfax,
VA, USA
M. D. Avery
Child and Family Health Co-operative, School of Nursing,
University of Minnesota, Minneapolis, MN, USA
E. Declercq
Community Health Sciences, Boston University School of Public
Health, Boston, MA, USA
123
Matern Child Health J (2015) 19:1608–1615
DOI 10.1007/s10995-015-1671-8
circumstances of patients in collaborative discussions to
formulate plans of care [2, 3].
The midwifery model of care aligns well with both the
triple aim and the paradigm of patient-centered care. Similar
to other maternity care providers, the American College of
Nurse-Midwives philosophy of care includes providing a
woman with full information, involving her in decisions
about her care, and individualizing care to best meet her needs
[4]. American midwifery care is one example of a ‘‘working’’
maternity care model, based on criteria that include reducing
morbidity as well as mortality, being woman-centered, and
being financially viable [5]. A systematic review comparing
outcomes for midwife-led and other models of care confirms
that health outcomes are similar to obstetrician-led care and
identifies a focus on continuity of care and judicious use of
medical interventions as key components of midwifery care
across settings [6]. Midwifery is associated with less frequent
use of costly interventions when not medically necessary [6]
and with greater patient satisfaction and involvement in care
decisions [7, 8]. Midwifery-led care is also associated with
lower rates of regional (i.e. epidural) analgesia, episiotomies,
and instrumental births, and higher rates of continuity of care
and women feeling in control during labor [6, 9]. Respecting
the individuality of a woman’s family and creating a setting
that is appropriate to her needs are two central tenets of
‘‘exemplary’’ midwifery care [10].
In early U.S. history, midwifery occupied a prominent
position in the care of women during pregnancy and
childbirth; indeed, in the early 1900s midwives attended
nearly half of all births in the nation [11]. By 1950, however, midwives attended less than 10 % of all births, and
nearly 90 % of births took place in hospitals [11]. This
trend has persisted, and today midwives attend just 8 % of
U.S. births [12], a figure that appears strikingly low, particularly since midwives are the primary care providers for
pregnant women in many areas of the world. For example,
midwives in Australia, Denmark, France, Sweden, the
Netherlands, New Zealand, and the United Kingdom attend
more than 60 % of births in their respective nations [13].
Many factors may account for these differences, including
the role of health insurance, clinical care systems, and provider networks, which may influence whether women have a
choice of maternity care provider. Very little recent research
has examined how women choose a provider for maternity
care, but research on provider choice more generally suggests variability in whether patients seek out and compare
information on multiple potential clinicians before making a
choice [14, 15]. However, an active provider search may be
more likely in pregnancy because the need for care is more
predictably timed than, for example, with an acute illness
[16]. Having an established relationship with a physician and
recommendations from members of one’s social network
appear to influence provider choice for many people [14],
including the choice of facility for childbirth [17]. More
practical factors, such as appointment availability, insurance
coverage, and the provider’s healthcare plan affiliation, also
influence these decisions [18, 19].
Once women have chosen a provider for maternity care,
the quality of that relationship is strongly influenced by
communication [20, 21]. Published studies about communication and decision-making in maternity care have largely taken place in countries other than the U.S., where a
far greater proportion of women are cared for by midwives.
Thus, no prior U.S. studies explicitly compare communication and decision-making styles between midwifery-led
care and physician-led care. Key facets of constructive
communication in maternity care include an empathetic
communication style, provider willingness to respond to
questions, and allowing enough time to discuss the
woman’s concerns [22]. Even within midwifery care, different models of care facilitate different styles of communication. Caseload care—where women are assigned to
a single midwife or small group of midwives—was found
to result in the woman asking more questions and longer
visits, as well as enhanced patient choice and control [23].
Researchers have stressed the importance of taking into
account women’s social context and potential vulnerability
in maternity care decision-making [24]. Decision aids may
be helpful in increasing the patient’s knowledge and
reducing anxiety and uncertainty about decisions [25].
Although not explicitly assessing the maternity context, a
recent study in the U.S. indicated that patient-centered
decision-making—using contextual factors in the patient’s
life to create an appropriate care plan—was associated with
better management of diabetes and hypertension [3].
The aim of this study was to characterize access to midwifery care and reasons for choosing midwifery care among
American women, and to measure the relationship between
midwifery care and patient–provider communication in a
maternity care context. We refer throughout the manuscript
to decision factors under a woman’s control as ‘‘personal’’
and those that are outside of her control as ‘‘systems’’ factors
when discussing the issues that shape the choice of maternity
care provider. Based on prior literature, we hypothesized that
women who received care from a midwife would report
greater involvement in decisions and better communication
in during pregnancy and childbirth, compared with women
who received care from other types of clinicians.
Methods
Data
Data for this analysis came from the Listening to Mothers
III survey, a nationally-representative sample of women
Matern Child Health J (2015) 19:1608–1615 1609
123
who gave birth to a singleton infant in a U.S. hospital
between July 1, 2011 and June 30, 2012 (N = 2,400).
Commissioned by Childbirth Connection and conducted by
Harris Interactive, this survey comprehensively addressed
the labor and birth experience, including women’s views
and choices about childbirth-related care and perceptions
of the experience [19]. Recent research using data from the
Listening to Mothers surveys has examined various aspects
of maternity care [26–32], but these data have not previously been used to examine midwifery care and patient–
provider relationships and communication.
The data used in this analysis were de-identified existing
records; the study was therefore granted exemption from
review by the University of Minnesota Institutional Review
Board (Study Number 1011E92983).
Variable Measurement
Midwifery Care and Reasons for Choosing a Maternity
Care Provider
Midwifery care was assessed based on whether respondents
reported having a midwife as their primary prenatal care
provider. Women were asked to choose among several
options, including an obstetrician-gynecologist, family
medicine doctor, other doctor (not sure of specialty), midwife, nurse who is not a midwife, or physician assistant. The
type or credential of midwife was not specified in the survey
question; though since the study population was limited to
hospital births, it is likely that women are referring predominantly to certified nurse-midwives. Independent variables included indicator variables for the woman’s reported
reasons for choosing a provider. We categorized these reasons as being personal or system factors. Personal reasons
were: the provider had provided care in a previous pregnancy, was recommended by a friend or family member, was
a good match for the respondent’s values, or was female.
System reasons were: the clinician provides well-woman
care, was recommended by a health professional, was highly
rated on a website, accepted the respondent’s health insurance, attended births at a hospital that the respondent liked,
or was assigned. When a specific provider was assigned or
insurance options were limited, a woman may not have
perceived a ‘‘choice,’’ but we use that language to reflect the
broad concept and question wording. Respondents could
report each reason as a major factor, minor factor, or not a
factor in choosing their provider. We coded each variable
‘‘yes’’ if it was listed as a major factor.
Patient–Provider Communication
The survey asked if respondents had never, once, or more
than once held back a question for each of three possible
reasons: the provider seemed rushed, the respondent
‘‘wanted maternity care that differed from what [the]
maternity care provider recommended,’’ or the respondent
did not want the provider to think she was being difficult.
We created a dichotomous measure for each reason for
holding back questions, which were coded 0 for never and
1 for at least once.
The survey also asked how often the provider used
medical words the respondent did not understand, spent
enough time with the respondent, answered all questions to
the respondent’s satisfaction, and encouraged the respondent to discuss all her concerns. Response choices were
never, sometimes, usually, or always. We reversed the
coding for the positive indicators. For example, for a
respondent who reported that a provider always ‘‘spent
enough time’’ was coded as never on the new variable,
‘‘provider DID NOT spend enough time.’’ We then created
dichotomous measures for each communication problem,
coded as 0 if the problem never occurred and 1 if it
occurred sometimes, usually or always.
Covariates
Socio-demographic covariates were based on women’s
self-reports and included age, race/ethnicity (white, black,
Hispanic, other/multiple race), education (high school or
less, some college or Associate’s degree, Bachelor’s
degree, graduate education/degree), 4-category census
region, nativity (foreign- or U.S.-born), marital status
(married or not), parity (first-time vs. experienced mother),
pregnancy intention (unintended pregnancy or not). Additional covariates included agreement with the statement
‘‘birth is a process that should not be interfered with unless
medically necessary,’’ rating of the quality the U.S.
maternity care system (poor/fair, good, excellent), primary
payer for maternity care (private, public, out-of-pocket),
doula support during labor, whether the woman sought
quality information to choose a maternity care provider,
typical length of prenatal visit (0–15, 16–30, 31–45, more
than 45 min), and prior cesarean delivery.
Analysis
We first examined the descriptive statistics for the overall
sample, using two-way tabulation to explore predictors,
outcomes, and covariates. We used logistic regression to
estimate the adjusted odds of midwife care, by reasons for
choosing a provider and adjusting for covariates. We also
used logistic regression to estimate the adjusted odds of
each specific communication problem by midwifery care,
controlling for reasons for choosing provider and all
covariates. Because prior experience with childbirth is a
strong predictor of future provider choices, we conducted
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123
sensitivity analyses stratified by parity and prior cesarean
delivery, and results were broadly consistent, with a few
exceptions noted herein where some findings were driven
by multiparous women. All analyses were conducted using
Stata v.12 and weighted to be nationally representative.
Results
Table 1 reports characteristics of the study population by
midwife as prenatal provider. About 8 % of women in the
sample had a midwife as their prenatal care provider. The
other options were obstetrician (78 %), family medicine
doctor (8 %), ‘‘a doctor but I’m not sure of his/her specialty’’ (3 %), a physician assistant (1 %), or ‘‘a nurse who
is not a midwife’’ (2 %). Those with midwifery care rated
the quality of the U.S. maternity care system differently
than women with other prenatal care providers. 70 % of
women with midwifery care were experienced mothers,
versus 58 % of women with other prenatal care providers
(p = 0.024). No other covariates examined differed significantly by prenatal provider type.
Reasons for choosing the prenatal provider and communication outcomes by midwife as prenatal provider are
presented in Table 2. A larger percentage (66 %) of
women who had midwifery care reported that having a
female provider was a major reason for choosing their
provider. In both groups, about 85 % of women reported
the provider accepting their health insurance as a major
reason for their choice. Women with a midwife as their
prenatal care provider reported several communication
problems at lower rates. Only 14 % of women with midwifery care reported holding back a question because they
wanted different care, compared to nearly a quarter of
women with other types of providers (p = 0.008). Smaller
proportions of women with midwifery care than with other
provider types reported that their provider used medical
words they did not understand (40 vs. 54 %), and that the
provider did not encourage them to discuss all their questions and concerns (37 vs. 48 %).
Adjusted odds for midwifery care by reasons for
choosing a provider are shown in Table 3. After controlling
for a range of factors, women citing the desire for a female
clinician as a major factor in choosing a maternity care
provider had more than double the odds of having a midwife for prenatal care (AOR = 2.65, 95 % CI 1.70, 4.14),
compared with those for whom having a female clinician
was not a major priority. Similarly, citing the fact that a
particular clinician was assigned was associated with
greater odds of midwifery care during the prenatal period
(AOR = 1.63, 95 % CI 1.04, 2.58), compared with not
having an assigned provider as a major decision factor.
While not statistically significant at conventional levels,
this analysis also showed that women who cited high ratings on a website as a major reason for choosing a
maternity care provider were less likely to have a midwife
as the prenatal care provider (AOR = 0.64, 95 % CI 0.38,
1.07), compared with a similar woman who did not state
this as a major reason for their choice of provider
(p = 0.087).
Table 4 presents logistic regression results for communication outcomes by midwifery care, adjusted for reasons
for choosing the care provider and other socio-demographic and clinical covariates. Midwifery care was associated with lower chances of experiencing specific
communication problems. Women with midwifery care
had less than half the odds of reporting that they held back
a question because they wanted different care than the
provider was suggesting (AOR = 0.46, 95 % CI 0.23,
0.89) or because they did not want to be perceived as
difficult (AOR = 0.48, 95 % CI 0.28, 0.81), compared to
women with other provider types. Women receiving midwifery care also had about 40 % lower odds of reporting
that the provider used medical words were hard for them to
understand (AOR = 0.58, 95 % CI 0.37, 0.91), feeling that
their provider did not spend enough time with them
(AOR = 0.61, 95 % CI 0.39, 0.96), and not feeling
encouraged to discuss all their concerns (AOR = 0.55,
95 % CI 0.34, 0.89).
Discussion
Women receiving midwifery care had statistically lower
chances of experiencing problems in patient–provider
communication, compared with women who received
prenatal care from other clinicians. While these findings
are consistent with prior research on midwifery care [7, 8],
the Listening to Mothers survey data allow us to provide a
unique examination of specific types of communication
problems that can arise in prenatal care. Our results showed
that midwifery was associated with better communication
across different dimensions, including various reasons
women may be reticent to ask questions, use of medical
terminology, and time pressure. Even after accounting for
many of the personal, clinical, or socio-demographic factors that may influence women’s perception of communication, we found that women who received prenatal care
from midwives were less likely to report that they withheld
questions because they did not want to be perceived as
‘‘difficult’’ or because they had a preference for care that
was different from what their provider was recommending.
Additionally, women receiving care from midwives were
less likely to say that their provider used medical terminology they did not understand, did not spend enough time
with them, or did not encourage them to talk about all of
Matern Child Health J (2015) 19:1608–1615 1611
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Table 1 Characteristics of
study population by midwife as
prenatal provider (N = 2,400)
Ns and percentages are
weighted
* Significant with p value0.05
Midwife as prenatal provider p value
Yes No
n = 184 n = 2,216
Key covariates
Belief that childbirth is a process that should only
be interfered with if medically necessary
67.8 57.6 0.053
Doula support 3.2 6.2 0.121
Quality of care in U.S. maternity system
Poor or fair 26.0 16.7
Good 35.2 47.5
Excellent 38.8 35.8 0.027*
Sought quality information 48.1 48.6 0.933
Primary payer for maternity care
Private 45.3 46.8
Public 47.7 46.5
Out-of-pocket or missing 7.0 8.1 0.916
Length of prenatal appointments (min)
0–15 15.7 23.0
16–30 48.2 44.4
31–45 18.8 17.6
More than 45 17.3 15.0 0.448
Socio–demographic characteristics
Age category
18–24 26.6 32.2
25–29 37.3 27.6
30–34 25.8 24.7
35? 10.3 15.5 0.108
Race
White 61.7 53.9
Black 12.6 15.6
Hispanic 16.9 23.7
Other/multiple race 8.8 6.9 0.294
Marital status at time of birth
Not married, no partner reported 8.1 7.9
Unmarried with partner 23.2 32.3
Married 68.7 59.8 0.230
Education
H.S. or less 40.4 42.4
Some college/associate’s degree 28.3 28.6
Bachelor’s degree 15.2 18.1
Graduate education/degree 16.0 11.0 0.363
Region
Northeast 13.1 15.4
Midwest 21.2 22.8
South 36.2 40.0
West 29.5 21.9 0.395
Foreign born (vs. U.S. born) 9.6 6.8 0.362
Experienced mother (vs. first time mother) 69.6 58.4 0.024*
Unintended pregnancy (vs. intended pregnancy) 37.3 35.2 0.688
1612 Matern Child Health J (2015) 19:1608–1615
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their questions and concerns. In an era of increased attention to patient engagement in health care decisions, this
finding is both important and actionable.
We also found that the reasons that women chose midwives included both personal and systems level factors, but
the factors in this survey that had the strongest effect were
a preference for a female provider, and—on the systems
level—having an assigned provider. Women who wanted
female providers or who had an assigned provider were
more likely to see a midwife for prenatal care. In our
sensitivity models stratified by parity, we found that the
association between being assigned a provider and choosing midwifery care was largely driven by experienced
mothers, while wanting a female provider was related to
choosing a midwife regardless of parity. Interestingly, a
predictor of midwifery in other settings internationally—
belief that birth is a process not to be interfered with unless
medically necessary—was not an independent predictor of
midwifery care in this national sample of U.S. women,
perhaps indicating a more constrained choice set for
maternity care clinicians, limited by health insurance
coverage, provider networks, and healthcare delivery systems. There are immediate and actionable steps that health
care providers, payers, and systems administrators can take
based on these findings to expand access to care associated
with a higher degree of patient engagement and patient–
provider communication.
We also found suggestive evidence that women for
whom web-based quality or ratings data is a major reason
for their choice of maternity provider are less likely to have
a midwife (controlling for their specific socio-demographic
and clinical characteristics). This implies that information
about midwives and the quality of care they provide may
either be presented less frequently or not at all to women
who seek it. Pregnant women cite a range of sources of
web-based information on maternity care including
Table 2 Unadjusted outcomes and reasons for choosing provider by
midwife as prenatal provider (N = 2,400)
Midwife as prenatal
provider
p value
Yes No
n = 184 n = 2,216
Reasons for choosing provider
Interpersonal
Provided care in previous
pregnancy
No 28.0 21.8
Yes 41.6 36.6 0.645
N/A (nulliparous) – –
Recommended by friend/family
member
39.8 44.6 0.384
Good match for values 67.2 69.3 0.682
Is female 65.6 47.5 0.001*
System
Highly rated on website 32.9 39.5 0.229
Provided well-woman care 52.6 60.2 0.149
Recommended by health
professional
41.7 47.5 0.297
Accepts my health insurance 84.6 85.2 0.875
Attends births at a hospital I
like
68.5 67.8 0.877

Provider DID NOT spend
enough time with you
48.1 57.2 0.087
Provider DID NOT answer all
your questions
45.2 42.2 0.586
Provider DID NOT encourage
you to talk about all questions
and concerns
36.7 47.7 0.046*
Ns and percentages are weighted
* Significant with p value 0.05
Table 3 Adjusted odds for midwifery care, by reasons for choosing
provider and other covariates (N = 2,400)
AOR 95 % CI p value
Reasons for choosing provider
Interpersonal
Provided care in previous pregnancy 0.97 0.52–1.82 0.924
Recommended by friend/family
member
0.84 0.53–1.35 0.478
Good match for values 0.93 0.55–1.57 0.796
Is female 2.65 1.70–4.14 0.001*
System
Highly rated on website 0.64 0.38–1.07 0.087
Provided well-woman care 0.65 0.38–1.09 0.101
Recommended by health
professional
0.79 0.51–1.21 0.279
Accepts my health insurance 0.79 0.40–1.55 0.490
Attends births at a hospital I like 1.22 0.76–1.94 0.405
Was assigned to me 1.63 1.04–2.58 0.035*
Model controls for birth attitudes, doula support, perceived quality of
U.S. maternity care, whether quality information was sought when
choosing a provider, primary payer for maternity care, age, race/
ethnicity, partnership status at the time of the birth, education level,
census region, nativity, parity, unintended pregnancy, and prior
cesarean
* Significant with p value 0.05
Matern Child Health J (2015) 19:1608–1615 1613
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websites from hospitals, clinics, health care providers,
health insurers or health plans, social media (including
Facebook), news media, and blogs [19, 33, 34]. Facilitating
a stronger web presence for midwifery care could include
greater use of marketing and attention to outreach and
advertisement. In addition, broad efforts to improve
maternity care quality measurement and data transparency
ought to include information on midwifery as an integral
part of this work [35]. This is particularly important since
midwifery care is not consistently recorded or reported in
administrative data [36].
The assignment of a provider was identified as a facilitator of midwifery care, perhaps signaling an opportunity
for health care delivery systems to consider collaborative
care models that include midwifery or family physician
care as the norm for routine, low-risk pregnancy care with
referral systems to obstetricians or maternal fetal medicine
specialists for complications that require higher acuity care
[37, 38]. To meet the potential demand for such a model,
policy makers could enhance the availability of midwifery
services by supporting the training of midwives in decisions related to federal appropriations for health provider
education.
Although it provides valuable national data on patient–
provider relationships and includes information about
midwifery care, the survey data we used for this analysis
have certain limitations that warrant discussion. These data
are based on retrospective self-reports, leaving room for
potential recall bias and social desirability bias. Although
the survey contained information about communication
from the perspective of a woman who gave birth, similar
information was not available from clinicians and would be
valuable for greater understanding of the relational
dynamics between patients and providers in the maternity
care context.
Conclusions
Women who have a midwife as their prenatal care provider
report fewer communications problems than women who
had care from other types of clinicians, suggesting that this
model of care results in better patient-clinician communication. Our analysis also revealed that factors under the
control of the health care delivery system or payer, such as
assigning a clinician and providing web-based ratings, can
influence whether women receive care from midwives.
Midwifery is a care model with demonstrated effectiveness, satisfaction, and lower costs. It is consistent with
the triple aim and is underutilized in the U.S., especially as
it appears to support broader health care policy goals of
increased patient engagement.
Acknowledgments This research was supported by a grant from the
Eunice Kennedy Shriver National Institutes of Child Health and
Human Development (NICHD; Grant Number R03HD070868) and
the Building Interdisciplinary Research Careers in Women’s Health
Grant (Grant Number K12HD055887) from NICHD, the Office of
Research on Women’s Health, and the National Institute on Aging, at
the National Institutes of Health, administered by the University of
Minnesota Deborah E. Powell Center for Women’s Health. The
content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of
Health.
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Table 4 Adjusted odds for communication outcomes, by midwifery
care
Midwifery care p value
AOR 95 % CI
Specific communication problems
Held back a question because
felt rushed
0.65 0.38–1.10 0.108
Held back a question because
wanted different care
0.46 0.23–0.89 0.022*
Held back a question because
didn’t want to be difficult
0.48 0.28–0.81 0.006*
Provider used medical words
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Provider did not spend enough
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Provider did not answer all
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1.11 0.70–1.74 0.663
Provider did not encourage you
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questions and concerns
0.54 0.34–0.89 0.016*
Models control for reasons for choosing prenatal care provider, birth
attitudes, doula support, perceived quality of U.S. maternity care,
whether quality information was sought when choosing a provider,
primary payer for maternity care, age, race/ethnicity, partnership
status at the time of the birth, education level, census region, nativity,
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* Significant with p value 0.05
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