This week, an important paper has been published (currently in draft form) in Midwifery. Titled ‘Midwifery continuity of carer in an area of high socio-economic disadvantage in London: a retrospective analysis of Albany Midwifery Practice outcomes using routine data (1997–2009)’, the freely available paper by Homer et al (2017) examines trends and outcomes for all mothers and babies who received care from the Albany Midwifery Practice from 1997–2009. This was a total of 2568 women.
There are several reasons why this paper is important, but I am going to focus on just three of them.
Firstly, this study further demonstrates the effectiveness and safety of woman-centred, individualised and choice-focused midwifery care. It’s hard for many people to understand why governments aren’t doing more to promote and support midwives and ensure that midwifery is regulated by bodies that are fit for purpose, because this and similar studies show time and time again that midwife-led care leads to lower intervention rates and safe, positive outcomes, even for women (like many of those in this study) who have complex pregnancies and perceived risk factors.
Overall, 79.8% of women had a spontaneous birth with an overall caesarean section (CS) rate of 16%. Of the 84% of women who had a vaginal birth (spontaneous and instrumental), 78% had a physiological third stage of labour with 5.9% of these women having a postpartum haemorrhage (PPH) (blood loss >500 mL). The overall PPH rate for all births was 14% (2.3% had a blood loss of 1000 – 1500 mL and 0.5% had a blood loss of >1500 mL). Two thirds of women who had a vaginal birth had no perineal trauma (62.2%).
The second key takeaway for me is that this analysis shows that midwifery care can make even more of a difference for women from Black, Asian and Minority Ethnic (BAME) communities, who comprised 57% of the women whose data were included in this study, as well as for single women. Both of these groups of women tend to have a higher perinatal mortality rate than average, and the data from this study shows that good midwifery care can make even more of a difference to these women.
It has been shown that women from BAME groups and single women are at higher risk of adverse outcomes during pregnancy and after. For example, these women are more likely to experience complications during pregnancy, an unplanned caesarean section, and having their baby cared for in a neonatal unit than those from the White British group (Raleigh et al. 2010). Babies of Black or Black British and Asian or Asian British ethnicity have also been shown to have the highest risk of extended perinatal mortality with rates of 9.8 and 8.8 per 1,000 total births respectively (Manktelow et al. 2015). These rates are considerably higher than the Albany rate of less than 2.0 per 1000 births in women from BAME groups (Table 8). In addition, in a UK survey, women in all minority ethnic groups had a poorer experience of maternity services than White women (Henderson et al., 2013) and expressed more worries about labour and birth (Redshaw and Heikkilä 2011).
This paper will also, I imagine, be important for all those who worked in the Albany Practice. These are some pretty amazing people. As the current paper details, “they negotiated the first National Health Service (NHS) contract between a local health authority and self-employed midwives. They successfully applied for NHS funding to address inequalities in health and promote long term health gain through the provision of community based, continuity of midwifery carer throughout the childbearing period (caseload practice model) to groups of women known to have poor health outcomes due to various forms of disadvantage.” (Homer et al 2017). But the practice was controversially closed by the Trust in 2009, in response to concerns about safety. The current study was carried out as an independent evaluation of the maternal and neonatal outcomes over its entire 12 and a half year span and this evaluation demonstrates that the Albany model offered safe and effective care.
Let’s hope that the weight of evidence for woman-centred midwifery care will soon tip the balance so that more women and families can experience this kind of care.
You can find more information about the Albany model here. And most of the photos included in Birth in Focus: Stories and Photos to Inform, Educate and Inspire, which I blogged about recently, were taken within this model and demonstrate elements of the midwives’ practice.