Most women should be offered midwife-led continuity models of care

A recently updated Cochrane review showed that women who receive continuity of care led by a midwife were

  • less likely to experience regional analgesia
  • less likely to have an episiotomy
  • less likely to have an instrumental birth
  • more likely to give birth without analgesia/anaesthesia
  • more likely to have a spontaneous vaginal birth
  • more likely to be cared for during labour and birth by a midwife they knew
  • less likely to experience preterm birth
  • less likely to have a fetal loss before 24 weeks’ gestation

small_311398714In other important outcomes such as cesarean section, fetal/neonatal death over 24 weeks’ gestation and overall fetal/neonatal death rates, there was no difference.  Midwife-led continuity care models were associated with higher maternal satisfaction and lower financial cost.

The full review can be read here; abstract below.

 

Background

Midwives are primary providers of care for childbearing women around the world. However, there is a lack of synthesised information to establish whether there are differences in morbidity and mortality, effectiveness and psychosocial outcomes between midwife-led continuity models and other models of care.

Objectives

To compare midwife-led continuity models of care with other models of care for childbearing women and their infants.

Search methods

We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (28 January 2013) and reference lists of retrieved studies.

Selection criteria

All published and unpublished trials in which pregnant women are randomly allocated to midwife-led continuity models of care or other models of care during pregnancy and birth.

Data collection and analysis

All review authors evaluated methodological quality. Two review authors checked data extraction.

Main results

We included 13 trials involving 16,242 women. Women who had midwife-led continuity models of care were less likely to experience regional analgesia (average risk ratio (RR) 0.83, 95% confidence interval (CI) 0.76 to 0.90), episiotomy (average RR 0.84, 95% CI 0.76 to 0.92), and instrumental birth (average RR 0.88, 95% CI 0.81 to 0.96), and were more likely to experience no intrapartum analgesia/anaesthesia (average RR 1.16, 95% CI 1.04 to 1.31), spontaneous vaginal birth (average RR 1.05, 95% CI 1.03 to 1.08), attendance at birth by a known midwife (average RR 7.83, 95% CI 4.15 to 14.80), and a longer mean length of labour (hours) (mean difference (hours) 0.50, 95% CI 0.27 to 0.74). There were no differences between groups for caesarean births (average RR 0.93, 95% CI 0.84 to 1.02).

Women who were randomised to receive midwife-led continuity models of care were less likely to experience preterm birth (average RR 0.77, 95% CI 0.62 to 0.94) and fetal loss before 24 weeks’ gestation (average RR 0.81, 95% CI 0.66 to 0.99), although there were no differences in fetal loss/neonatal death of at least 24 weeks (average RR 1.00, 95% CI 0.67 to 1.51) or in overall fetal/neonatal death (average RR 0.84, 95% CI 0.71 to 1.00).

Due to a lack of consistency in measuring women’s satisfaction and assessing the cost of various maternity models, these outcomes were reported narratively. The majority of included studies reported a higher rate of maternal satisfaction in the midwifery-led continuity care model. Similarly there was a trend towards a cost-saving effect for midwife-led continuity care compared to other care models.

Authors’ conclusions

Most women should be offered midwife-led continuity models of care and women should be encouraged to ask for this option although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.

 

Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub3.

 

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