Severe Adverse Maternal Outcomes among Women in Midwife-Led versus Obstetrician-Led Care at the Onset of Labour in the Netherlands: A Nationwide Cohort Study

PLoS One. 2015 May 11;10(5):e0126266. doi: 10.1371/journal.pone.0126266. eCollection 2015.


Objective: To test the hypothesis that it is possible to select a group of low risk women who can start labour in midwife-led care without having increased rates of severe adverse maternal outcomes compared to women who start labour in secondary care.

Design and methods: We conducted a nationwide cohort study in the Netherlands, using data from 223 739 women with a singleton pregnancy between 37 and 42 weeks gestation without a previous caesarean section, with spontaneous onset of labour and a child in cephalic presentation. Information on all cases of severe acute maternal morbidity collected by the national study into ethnic determinants of maternal morbidity in the Netherlands (LEMMoN study), 1 August 2004 to 1 August 2006, was merged with data from the Netherlands Perinatal Registry of all births occurring during the same period. Our primary outcome was severe acute maternal morbidity (SAMM, i.e. admission to an intensive care unit, uterine rupture, eclampsia or severe HELLP, major obstetric haemorrhage, and other serious events). Secondary outcomes were postpartum haemorrhage and manual removal of placenta.

Results: Nulliparous and parous women who started labour in midwife-led care had lower rates of SAMM, postpartum haemorrhage and manual removal of placenta compared to women who started labour in secondary care. For SAMM the adjusted odds ratio's and 95% confidence intervals were for nulliparous women: 0.57 (0.45 to 0.71) and for parous women 0.47 (0.36 to 0.62).

Conclusions: Our results suggest that it is possible to identify a group of women at low risk of obstetric complications who may benefit from midwife-led care. Women can be reassured that we found no evidence that midwife-led care at the onset of labour is unsafe for women in a maternity care system with a well developed risk selection and referral system.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Cohort Studies
  • Delivery, Obstetric / statistics & numerical data*
  • Female
  • Gestational Age
  • Home Childbirth / statistics & numerical data
  • Humans
  • Labor, Obstetric*
  • Midwifery / statistics & numerical data*
  • Netherlands
  • Odds Ratio
  • Pregnancy
  • Young Adult

Grant support

The study was funded with a career grant from the Netherlands Organisation for Health Research and Development,, grant number 91611016 received by AJ. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.