October, 2016 - SUPPORT Summary of a systematic review | print this article |

Does midwife-led continuity of care improve the delivery of care to women during and after pregnancy?

Midwives are the primary providers of care for childbearing women around the world. In midwife-led continuity of care, midwives are the lead professionals in the planning, organisation and delivery of care given to women from the initial booking to the postnatal period. Non-midwife models of care includes obstetrician; family physician and shared models of care, in which responsibility for the organisation and delivery of care is shared between different health professionals.

 Key messages

  • In high-income countries, midwife-led care compared to other models of care for childbearing women and their infants:

- reduces preterm births (less than 37 weeks),

- reduces overall foetal loss and neonatal deaths,

- increases spontaneous vaginal births,

- reduces instrumental vaginal births (use of forceps or vacuum), and

- decreases the use of regional analgesia (epidural/spinal).

  • In addition, midwife-led care compared to other models of care probably reduces caesarean births and increases the number of women with an intact perineum.
  • None of the included studies were conducted in a low-income country, and the transferability of this evidence is uncertain.

 

Background

In most low- and middle-income countries, midwives are the primary providers of care for childbearing women. The philosophy behind midwife-led continuity models is normality, continuity of care, minimum interventions and being cared for by a known, trusted midwife during labour. Midwife-led continuity of care can be provided through a team of midwives who share the caseload, often called ‘team’ midwifery. Another model is ‘caseload midwifery’, which aims to ensure that the woman receives all her care from one midwife or her or his practice partner. Midwife-led continuity of care is provided in a multi-disciplinary network of consultation and referral with other care providers. In other models of care, the responsibility for the organisation and delivery of care is shared between different health professionals as obstetricians or family physicians.

 



About the systematic review underlying this summary

Review objectives: To compare midwife-led care with other models of care for childbearing women and their infants.
Type of What the review authors searched for What the review authors found
Study designs & interventions Randomised trials comparing midwife-led care to other models of care
15 randomised trials
Participants Pregnant women
17,674 pregnant women recruited from both community and hospital settings. All studies included low risk pregnancies and five studies also included high-risk pregnancies.
Settings Community or hospital
Australia (7 studies), United Kingdom (5 studies), Ireland (2 studies) and Canada (1 study).
Outcomes

Primary outcomes: Birth and immediate postpartum - regional analgesia, caesarean birth, instrumental/spontaneous vaginal birth, intact perineum; Neonatal - preterm birth, overall foetal loss and neonatal death

Secondary outcomes: complications, procedures or medication use


All primary outcomes and secondary outcomes as antenatal hospitalization, antepartum haemorrhage, induction of labour, amniotomy, augmentation/artificial oxytocin during labour, no intrapartum analgesia/anaesthesia, opiate analgesia, attendance at birth by known midwife, and episiotomy.
Date of most recent search: January 2016
Limitations: This is well-conducted systematic review with only minor limitations.
Sandall J, Soltani H, Gates S, et al. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD004667.

Summary of findings

Midwife-led care compared to other models of care for childbearing women and their infants:

  • reduces preterm births (less than 37 weeks),
  • reduces overall foetal loss and neonatal deaths,
  • increases spontaneous vaginal births,
  • reduces instrumental vaginal births (use of forceps or vacuum), and
  • decreases the use of regional analgesia (epidural/spinal).

The certainty of this evidence is high.

Midwife-led care compared to other models of care for childbearing women and their infants probably:

  • reduces caesarean births and
  • increases the number of women with an intact perineum.

The certainty of this evidence is moderate.

Midwife-led continuity models versus other models of care for childbearing women and their infants

People            Pregnant women
Settings
:         Community or hospital
Intervention   Midwife-led continuity models of care
Comparison    Other models of care

Outcome

Absolute effect (margin of error)*

Relative effect (95% CI) Certainty of the evidence (GRADE)

Other models of care

Midwife-led care

Preterm birth (less than 37 weeks)

63 per 1000

48 per 1000

RR 0.76

(0.64 to 0.91)

High

13 fewer per 1000

(22 to 5 fewer per 1000)

Overall foetal loss and neonatal death

34 per 1000

29 per 1000

RR 0.84

(0.71 to 0.99)

High

4 fewer per 1000

(11 to 1 fewer per 1000)

Spontaneous vaginal birth (as defined by trial authors)

658 per 1000

691 per 1000

RR 1.05

(1.03 to 01.07)

High

33 more per 1000

(19 to 46 more per 1000)

Caesarean birth

155 per 1000

143 per 1000

RR 0.92

(0.84 to 1.00)

Moderate

8 fewer per 1000

(25 to 0 fewer per 1000)

Instrumental vaginal birth (forceps/vacuum)

143 per 1000

129 per 1000

RR 0.90

(0.83 to 0.97)

High

14 fewer per 1000

(24 to 4 fewer per 1000)

Intact perineum

269 per 1000

279 per 1000

RR 1.04

(0.95 to 1.13)

Moderate

10 more per 1000

 (14 fewer to 35 more per 1000)

Regional analgesia

270 per 1000

229 per 1000

RR 0.85

(0.78 to 0.92)

High

41 fewer per 1000

(59 to 22 fewer per 1000)

*Margin of error = confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page)

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY
All trials included in the review were conducted in high-income countries.

The context of ‘midwifery-led care’ is quite different in low-income countries. It is likely that midwives provide care but often do not lead it, and they may not have clear referral mechanisms. It is also uncertain whether the midwives are able to provide continuous antenatal, intrapartum and postnatal care to women.

When assessing the transferability of these findings, the following factors should be considered:

− The availability and training of midwives

− The midwives’ work load

− Accessibility for childbearing women

− The baseline risk for the outcomes listed above for the current model of care

EQUITY
There was no information in the included studies regarding effects of the interventions on disadvantaged populations.

Given the scarcity of obstetricians and family physicians serving disadvantaged populations, the use of midwife-led care has the potential to reduce inequities in access to antenatal and postpartum care, provided the midwives are recruited, trained, supported and retained in under-served communities.

Consideration should be given to how the midwives are recruited, trained, supported and retained in under-served communities, including incentives and regulations encouraging this.

ECONOMIC CONSIDERATIONS

Five studies presented cost data using different economic evaluation methods.

Evidence from these studies suggests that the use of midwife-led care may reduce costs and leads to better or comparable outcomes when compared to other models of care.

Midwife-led care could be cost effective in low- income countries, but this is uncertain.
MONITORING & EVALUATION
No evidence from low-income countries was identified in this review, and the transferability of the evidence to low-income countries is uncertain.

Midwife-led continuity of care should be pilot tested and their impacts and costs monitored and evaluated prior to scaling up the use of this model in low-income countries.

*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods


 

Additional information

Related literature

Butler M, Collins R, Drennan J, et al. Hospital nurse staffing models and patient and staff-related outcomes. The Cochrane Database of Systematic Reviews 2011 (7):CD007019.

 

Thompson JB, Fullerton JT, Sawyer AJ, et al. The International Confederation of Midwives: global standards for midwifery education (2010) with companion guidelines. Midwifery 2011; 27(4):409-16.

 

Nicholls L, Webb C. What makes a good midwife? An integrative review of methodologically-diverse re-search. Journal of Advanced Nursing 2006; 56(4):414-29.

 

Muthu V, Fischbacher C. Free-standing midwife-led maternity units: a safe and effective alternative to hospital delivery for low-risk women? Evidence-Based Healthcare and Public Health 2004; 8:325-31.

 

Walsh D, Downe SM. Outcomes of free-standing, midwife-led birth centers: a structured review. Birth 2004; 31:222-29.

 

Hodnett ED, Downe S, Edwards N, Walsh D. Home-like versus conventional institutional settings for birth. Cochrane Database Systematic Reviews 2005; (1):CD000012.

 

Ciliska D, Hayward S, Thomas H, et al. A systematic overview of the effectiveness of home visiting as a delivery strategy for public health nursing interventions. Canadian Journal of Public Health 1996; 87:193-8.

 

McNaughton DB. Nurse home visits to maternal-child clients: a review of intervention research.

Public Health Nursing 2004; 21:207-19.

 

This summary was prepared by

Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Jane Sandall and Metin Gülmezoglu.

 

This review should be cited as

Sandall J, Soltani H, Gates S, et al. Midwife-led continuity models versus other models of care for

childbearing women. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD004667.  

 

The summary should be cited as

Ciapponi A. Does midwife-led continuity of care improve the delivery of care to women during and after pregnancy?  A SUPPORT Summary of a systematic review. October 2016. www.supportsummaries.org

 

Keywords

 

All Summaries:

evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care

Midwives, birth centre, task shifting, antenatal care, postpartum care, maternity. models of care,

continuity of care

 



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