The benefits of midwifery care

For years, I blogged about individual studies on this topic. We have now brought together summaries of the research that I’ve looked at into this one post, which details many of the studies carried out in this area. Click any of the links to see the original studies.

The Cochrane Review

The latest update to the Cochrane systematic review on Midwife-led continuity models versus other models of care for childbearing women, shows that “women who received midwife-led continuity models of care were less likely to experience intervention and more likely to be satisfied with their care with at least comparable adverse outcomes for women or their infants than women who received other models of care”.

We know from Cochrane reviews that women who receive continuity of care led by a midwife are

• 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

In 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.

Why do women value midwifery care?

As the studies on this page show, we have a good deal of robust evidence that continuity of midwifery care improves outcomes for women (Perriman et al 2018). And we know that women really, really like this model of care. We also suspect from experience and from the results of other kinds of research that what women really like is the relationship that they have with their midwife.

In 2018, a systematic review and meta-synthesis brought together many of the existing studies on this topic and confirmed that, “the relationship between the childbearing woman and midwife is central and through this additional benefits are realised; trust, personalised care, and empowerment.” (Perriman et al 2018).

The article is freely available and there is, of course, more depth if you’d like to read it, but the researchers’ core message is a simple one:

The woman-midwife relationship is important and of huge value.

“Employers and service providers should recognise the importance of the development of such a relationship and provide the resources and environment necessary to enable this.” (Perriman et al 2018).

Perriman N, Davis DL, Ferguson S (2018). What women value in the midwifery continuity of care model: a systematic review with meta-synthesis. Midwifery 62: 220-29. https://doi.org/10.1016/j.midw.2018.04.011

Australia (2019)

Allen et al (2019) looked at women’s perceptions of the quality of their antenatal care and the results show that caseload midwifery care “outperforms standard care” (Allen et al 2019) for all women, even those perceived to have a higher chance of problems.

This latest study was a survey which asked women to fill out a survey at 6 weeks postpartum. The survey asked about women’s experiences of their pregnancy care and the researchers found that, “women allocated to caseload midwifery perceived a higher level of quality care across every antenatal measure.” (Allen et al 2019).

Perhaps even more significantly:

“Notably, those women with identified risk factors reported higher levels of emotional support (aOR 2.52 [95% CI 1.87‐3.39]), quality care (2.94 [2.28‐3.79]), and feeling actively involved in decision‐making (3.21 [2.35‐4.37]).” (Allen et al 2019).

Allen J, Kildea S, Tracy MB et al (2019). The impact of caseload midwifery, compared with standard care, on women’s perceptions of antenatal care quality: Survey results from the M@NGO randomized controlled trial for women of any risk. Birth: Issues in Perinatal Care. https://doi.org/10.1111/birt.12436

Canada (2018)

McRae et al (2018) focused on women of low socioeconomic position. The researchers looked at three particular types of problem: having a small baby (described in the study as SGA, or small for gestational age), having a pre-term birth (PTB) and having a baby with a low birth weight (LBW).

The study was carried out in British Colombia, Canada and the researchers compared the outcomes of 4705 women who were cared for by midwives, 45114 women cared for by GPs and 8053 women cared for by obstetricians.

Women who had midwifery care had the best outcomes in all three of these areas. That is, they were less likely to have a small or low birth weight baby and less likely to have a baby born pre-term than women who received pregnancy care from GPs or obstetricians.

The authors conclude that, “Antenatal midwifery care in British Columbia, Canada, was associated with lower odds of SGA birth, PTB and LBW, for women of low socioeconomic position, compared with physician models of care. Results support the development of policy to ensure antenatal midwifery care is available and accessible for women of low socioeconomic position.” (McRae et al 2018).

As the authors of this study note, “Future research is needed to determine the underlying mechanisms linking midwifery care to better birth outcomes for women of low socioeconomic position.” (McRae et al 2018).

McRae DN, Janssen PA, Vedam S et al (2018). Reduced prevalence of small-for-gestational-age and preterm birth for women of low socioeconomic position: a population-based cohort study comparing antenatal midwifery and physician models of care. BMJ Open8(10):e022220. doi: 10.1136/bmjopen-2018-022220

Australia (2016)

As Lack et al (2016) describe in their study, “Aboriginal women and babies experience higher maternal and perinatal morbidity and mortality rates than their non-Aboriginal counterparts.”

This paper evaluates the outcomes of a Midwifery Group Practice which was set up in a remote city of the Northern Territory, Australia in 2009. The results, as with many studies of this kind of care, demonstrate the value of midwife-led care given in a continuity model:

“In total, 763 women (40% of whom were Aboriginal) gave birth to 769 babies over a four year period. There were no maternal deaths and the rate of perinatal mortality was lower than that across the Northern Territory. Lower rates of preterm birth (6%) and low birth weight babies (5%) were found in comparison to population based data.”

Lack BM, Smith RM, Arundell MJ and Homer CSE (2016). Narrowing the Gap? Describing women’s outcomes in Midwifery Group Practice in remote Australia. Women and Birth, in press. doi:10.1016/j.wombi.2016.03.003

Canada (2016)

An analysis of 83,744 births occurring in women who did not have major health problems or a raised chance of complications showed that, compared to having physician-led care:

• women who had a midwife had less chance of having an episiotomy, epidural or caesarean
• babies whose mums had midwifery were less likely to be admitted to neonatal intensive care

Other important outcomes, such as postpartum haemorrhage and the need for neonatal resuscitation were the same across the groups (Thiessen et al 2016).

Thiessen K, Nickel N, Prior HJ et al (2016). Maternity Outcomes in Manitoba Women: A Comparison between Midwifery-led Care and Physician-led Care at Birth. Birth, online ahead of print. DOI: 10.1111/birt.12225

Ireland (2015)

The results of a financial analysis of the different types of care experienced by women in a randomised controlled trial carried out in Dublin, Ireland have shown that, for low-risk women, care in midwife-led units is more cost-effective than consultant-led care.

“Given the clinical findings,” the authors write, “which showed that care provided in the midwife-led units is as safe as that in the consultant-led units and results in less intervention, more midwife-led units should be incorporated into maternity care in Ireland so that scarce resources can be used more effectively.” (Kenny et al 2015).

This study was a comparison of costs analysis conducted on the outcomes from the MidU study; a randomised controlled trial which compared two types of care for low-risk women.

The results from the oiriginal MidU trial showed that there was no difference between the group of women who were randomised to receive midwife-led care and the group of women randomised to receive consultant-led care in most of the primary outcomes, including caesarean birth, induction of labour, episiotomy, instrumental birth, Apgar scores, postpartum haemorrhage, and breastfeeding initiation.  There were differences between the groups in relation to the numbers of women who experienced continuous electronic fetal monitoring and augmentation of labour, however, with women randomised to the midwife-led group receiving less intervention overall.

The cost analysis, which has been published in the journal Midwifery, shows that midwife-led care is also financially superior to consultant-led care.  The authors found that the average cost of caring for a woman allocated to the midwife-led units was €2,598, compared to €2,780 for a woman who was allocated to care in the consultant-led units.

“The ‘intention to treat’ analysis provided an overall estimate of the average cost of care of a woman in an MLU and found it to be €182 less than the average cost of care in the CLU. Given a throughput of 1,000 women per year in an MLU, the savings would be over €180,000 per year.” (Kenny et al 2015).

Kenny C, Devane D, Normand C et al (2015).  A cost comparison of midwife-led compared with consultant-led maternity care in Ireland (The MidU Study)  Midwifery, doi:10.1016/j.midw.2015.06.012

Australia (2015 – 1)

A paper from the COSMOS research team showed that:

• midwife-led antenatal care was as effective as usual (which in the case of Australia is generally obstetrician-led) care for women with low-risk pregnancy and better in relation to choice, breast feeding and women׳s experience of care
• in settings with a relatively high baseline caesarean section rate, caseload midwifery for women at low obstetric risk in early pregnancy shows promise for reducing caesarean births
• women allocated to caseload care were admitted to hospital later in labour, and earlier admission was strongly associated with birth by caesarean section, suggesting that remaining at home somewhat longer in labour may be one of the mechanisms by which caseload care was effective in reducing caesarean section in the COSMOS trial

Previous results from this research project have already (as above) shown midwife-led care to be effective in reducing the caesarean section rate. The results also show that women who experienced caseload midwifery care, “were more positive about their overall birth experience than women in the standard care group (adjusted odds ratio 1.50, 95% CI 1.22–1.84). They also felt more in control during labour, were more proud of themselves, less anxious, and more likely to have a positive experience of pain.” (McLachlan et al 2015)

McLachlan HL, Forster DA, Davey M-A et al (2015). The effect of primary midwife-led care on women’s experience of childbirth: results from the COSMOS randomised controlled trial. BJOG 123(3):465-74.  doi: 10.1111/1471-0528.13713.

Australia (2015 – 2)

A retrospective comparative cohort study which gathered information from databases held in an Australian tertiary hospital has shown that a significantly greater proportion of women who experienced a model of care based on midwifery continuity experienced normal vaginal birth, spontaneous vaginal birth and/or water birth than women who experienced standard care (Wong et al 2015).  The women who had midwifery continuity had a lower chance of an assisted vaginal birth or caesarean section than the women receiving standard care.

The researchers compared outcomes for low risk primiparous (sic) women giving birth between 1st January 2010 and 31st December 2011 and who accessed one of two different models of care.  One model of care, experienced by 426 of the women was the continuity model:

“A model of care that provides a woman with a designated midwife who provides all care in pregnancy, is ‘on call’ for and cares for her in labour and provides postnatal support for two weeks. Women accessing this model plan to give birth in the Birth Centre which (during the period of the study), was an ‘alongside’ birth centre on the ground floor with Delivery Suite situated on level three of the same building. In this model, women who develop complications in pregnancy and in labour will remain in the care of the midwives providing continuity of care with the birth taking place in Delivery Suite, as the Birth Centre is an environment for low risk women only. Women usually transfer home within 24 h with their continuity midwife providing postnatal support for a further two weeks.” (Wong et al 2015).

The other 1220 low-risk primiparous women received what the authors describe as ‘standard public care’:

“Midwives, obstetric registrars, obstetricians and general practitioners share a woman’s care, with the woman having no expectation that she will see the same midwife more than once and will not know her midwife in labour or the postnatal period. Women within this model of care plan to give birth in the Delivery Suite which is a traditional labour ward and are encouraged to transfer home 2–3 days later, with postnatal support from midwives unknown to them previously.”  (Wong et al 2015).

Other statistically significant differences between the two groups included that the women who had midwifery continuity had less chance of having induction of labour, less epidural anaesthesia and less narcotic pain relief use than the women receiving standard care. Fewer women in the midwifery continuity group had an episiotomy, but the difference was not statistically significant. Women in the midwifery continuity group were more likely to initiate breastfeeding within an hour of birth than the standard care group and they also left hospital earlier.  No differences were found in neonatal outcomes or transfers.

It’s great to be able to add this study to the growing pile of evidence attesting to the safety and superiority of midwifery-led care in relation to the standard kind of care that is currently on offer to women within systems of maternity care.  As the authors conclude, “The study contributes to the existing body of knowledge that urges the health care system to use midwifery continuity models both for improved health outcomes for women and babies and to save valuable health dollars. The global and local importance of midwifery continuity models cannot be over-emphasised. When resources are limited we need to be strategic in ensuring every primiparous woman has access to this model of care to ensure we ‘get the first birth right’.” (Wong et al 2015).

Wong N, Brown J, Ferguson S et al (2015).  Getting the first birth right: A retrospective study of outcomes for low-risk primiparous women receiving standard care versus midwifery model of care in the same tertiary hospital.  Women and Birth, online ahead of publication.  doi:10.1016/j.wombi.2015.06.005

The Lancet Series on Midwifery

In 2014, medical journal The Lancet ran a series on midwifery. Here are some of the key points and findings.

“One important conclusion is that application of the evidence presented in this Series could avert more than 80% of maternal and newborn deaths, including stillbirths. Midwifery therefore has a pivotal, yet widely neglected, part to play in accelerating progress to end preventable mortality of women and children.” (Horton and Astudillo 2014).

“A frequent view is that midwifery is about assisting childbirth. It is, but it is also much more than that. As defined in this Series, midwifery is “skilled, knowledgeable, and compassionate care for childbearing women, newborn infants, and families across the continuum throughout pre-pregnancy, pregnancy, birth, post partum, and the early weeks of life”. Midwifery includes family planning and the provision of reproductive health services. The services provided by midwives are best delivered not only in hospital settings but also in communities—midwifery is not a vertical service offered as a narrow segment of the health system. Midwifery services are a core part of universal health coverage.” (Horton and Astudillo 2014)

R Horton, O Astudillo. The power of midwifery.  Lancet (2014) published online June 23. http://dx.doi.org/10.1016/S0140-6736(14)60855-2

“Women reported that information and education were essential to allow them to learn for themselves, that they needed to know and understand the organisation of services so they could access them in a timely way, that services needed to be provided in a respectful way by staff who engendered trust and who were not abusive or cruel, and that care should be personalised to their individual needs, and offered by care providers who were empathic and kind. Particularly, women wanted health professionals who combined clinical knowledge and skills with interpersonal and cultural competence. These findings were of crucial importance in identification of components of quality maternal and newborn care.” (Renfrew et al 2014)

“These findings support a system-level shift from fragmented maternal and newborn care focused on identification and treatment of pathology for the minority, to skilled care for all. Midwifery is pivotal to this approach. Future planning for maternal and newborn care systems can benefit from incorporating the quality framework into workforce development and resource allocation.” (Renfrew et al 2014)

MJ Renfrew, A McFadden, MH Bastos et al.  Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. Lancet (2014) published online June 23. http://dx.doi.org/10.1016/S0140-6736(14)60789-3

“Two “blind-spots” were identified in the Lancet Midwifery Series: respectful care and overmedicalisation.” (Stones and Arulkumaran 2014).

W Stones, A Arulkumaran.  Health-care professionals in midwifery care.  Lancet (2014). published online June 23.  http://dx.doi.org/10.1016/S0140-6736(14)60857-6

“Women’s use of midwifery services should be supported, more should be done to meet women’s needs, and improvements should be made in the quality of care received by women and newborn infants. Progress in all three areas is needed to obtain a comprehensive health gain.” (Hoope-Bender et al 2014).

P ten Hoope-Bender, L de Bernis, J Campbell et al.  Improvement of maternal and newborn health through midwifery. Lancet (2014)  http://dx.doi.org/10.1016/S0140-6736(14)60930-2

This is from a related editorial:

“The effect of continuity of midwifery carer on the health and wellbeing of women and their newborn infants has been underestimated and neglected for many years. The increased focus on mitigating risk, especially during labour, childbirth, and the first 24 h of life, has led to an increase in hospital births, where the highly individual and idiosyncratic processes of labour and delivery have to fit into hospital routines, timelines, and protocols. Such practices can lead to an increase in routine interventions and the presence of a multitude of carers working typical 8 h shifts. In such settings, women are less in control of their pregnancy, labour, and delivery, which can have adverse effects on the progress of childbirth through to early childhood.

Research into continuous support for women in hospital during childbirth shows a strongly positive effect on the length of labour, the use of pain drugs, Apgar scores, the number of unassisted vaginal births, and women’s satisfaction. Additionally, research into midwife-led models of care has revealed reductions in the use of regional analgesia, episiotomies, and instrumental births while women are less likely to experience preterm birth and fetal loss before 24 weeks’ gestation. The underpinning philosophy of midwife-led care is normality, continuity of care, and being cared for by a known and trusted midwife during labour. Investigators of a recent WHO study reported that high coverage of essential interventions for maternal and newborn health did not automatically imply lower maternal mortality, leading to the conclusion that the vertical, and often delayed, provision of essential interventions in isolation from comprehensive care affected the quality of care and the ability to save lives.”

Petra ten Hoope-Bender (2013)  Continuity of maternity carer for all women. The Lancet 382(9906): 1685-87. http://dx.doi.org/10.1016/S0140-6736(13)61793-6.

Midwifery-led units

Research carried out in collaboration with the Birthplace project has found that women who booked their care at the Barkantine Birth Centre rated their care more highly than women who booked at the hospital. Compared to women booked for hospital care, women who began labour care at the birth centre were also significantly more likely to

• be cared for by a midwife they had already met
• have one to one care in labour
• have the same midwife with them throughout their labour
• report that the staff were kind and understanding
• report that they were treated with respect and dignity
• report that their privacy was respected

Compared to women who started labour at the hospital, women who started labour care at the birth centre in spontaneous labour were

• more likely to use non-pharmacological methods of pain relief, most notably water
• less likely to use pethidine
• more likely to be able to move around in labour
• less likely to have their membranes ruptured
• less likely to have continuous CTG monitoring
• more likely to be told to push spontaneously when they needed to rather than experience directed pushing
• more likely to report that they had been able to choose their position for birth
• more likely to deliver in places other than the bed
• more likely to report that they had chosen whether or not to have a physiological third stage
• more likely to report skin to skin contact with their baby in the first two hours after birth

One of the women interviewed said that,

“They were so super! They discussed my progress not with numbers i.e. how many hours to go or how many centimetres I was dilated but with positive encouragement and listening to me. They were so supportive and understanding to me and to my partner. They really helped me so much and gave me such a positive attitude and encouragement the whole way through.” (Macfarlane et al 2014: 1003)

One of the things that is remarkable about the Barkantine Birth Centre, in common with the Albany Midwifery Practice which ran from 1997 to 2009 in Peckham, is its inner city London location.  You can connect with the Barkantine Birth Centre on facebook.

Macfarlane AJ, Rocca-Ihenacho L, Turner LR et al (2014).  Survey of women׳s experiences of care in a new freestanding midwifery unit in an inner city area of London, England – 1: Methods and women׳s overall ratings of care. Midwifery 30(9): 998-1008. http://dx.doi.org/10.1016/j.midw.2014.03.013

Australian midwifery units

The first prospective cohort study comparing freestanding midwifery units with tertiary units in Australia was published in 2014, and shows that the women who planned to give birth at freestanding midwifery units were significantly more likely than women who planned to give birth at tertiary-level units to have a spontaneous vaginal birth and significantly less likely to have a caesarean section.

The paper detailing the research, entitled “Evaluating Midwifery Units (EMU): a prospective cohort study of freestanding midwifery units in New South Wales, Australia” is freely available in BMJ Open.

As the authors explain, mainstream Australian maternity services are very medicalised and these birth centres are the only ones of their kind:

New South Wales’ maternity policy strongly supports tertiary-level maternity care for all women.6–11 Planning to give birth at a facility without on-site specialist medical support is largely perceived as hazardous and unsafe for women and their unborn babies.6 ,12 Consequently, there were only two freestanding midwifery units in New South Wales (and in Australia) in 2005, recording a combined total of approximately 300 births,13 ,14 compared with seven tertiary-level maternity units with 25 637 births.15 ,16 It is unknown whether the actual gains match the expected gains of concentrating all low-risk births in large tertiary hospitals.5 (Monk et al 2014).

Studies such as this are often criticised by those who profit from the idea that birth is risky and needs to be ‘managed’ in high-tech environments, but a closer look at the content shows that these authors took measures to ensure that their research was of good quality.  They analysed the outcomes according to the place where women intended to give birth, and had minimal loss to follow-up.

One specific finding that I would like to highlight relates to placental birth.  This will not be a surprise to those familiar with studies and audits of placental birth in out-of-hospital settings and with birth attendants whose approch respects and supports rather than detracts from the physiology of labour and birth:

Despite the significantly higher odds of physiological management of the third stage of labour among women from the freestanding midwifery unit group (AOR 15.03; 95% CI 11.05 to 20.43), they were significantly more likely to experience blood loss of less than 500 mL (AOR 1.37; 95% CI 1.03 to 1.82) and significantly less likely to experience blood loss of 500–999 mL (AOR 0.70; 95% CI 0.51 to 0.97). There was no significant difference in major postpartum haemorrhage of greater than 1000 mL (AOR 0.88; 95% CI 0.52 to 1.47; table 4).(Monk et al 2014)

An element that will almost certainly be further debated as more Australian birth centres are set up is the transfer rate, which in this study appears to be higher than in the Birthplace study and Danish research, at 51%.  But the authors point out that this figure includes a high rate of antenatal transfers, at 34%, whereas the intrapartum transfer rate is similar to those in the aforementioned studies.  The authors also note that “women and midwives are encouraged to err on the side of caution and transfer antenatally whenever there is a possibility that medical intervention may be required during the birth process” (Monk et al 2014).

I don’t know whether my Australian colleagues will be able to relate to this or not, but the reality in most of the birth centres which I have worked in or been associated with is that the midwives are well aware that they are under close and constant scrutiny and that there are those who will see any adverse outcome as a reason to call for the closure of such a unit.  Such scrutiny tends to have an effect on decision-making.

Birth centres are a safe option even when transfer is involved

In 2017, another study confirmed that birth centres – or freestanding midwifery units – are a safe and reasonable option for mothers and babies and that women who use them are less likely to have a caesarean section, even if transfer is involved (Monk et al 2017).

Australian researchers carried out a descriptive study to compare the maternal and neonatal birth outcomes of two different groups of women. They compared the outcomes of 256 women who planned to give birth at freestanding midwifery units but who transferred to a tertiary maternity unit with 3157 low-risk women who planned to give birth in a tertiary maternity unit.

This is an important study because, although we have lots of research showing that out-of-hospital birth is safe and may be better than hospital birth in some dimensions for healthy women and babies, the rates of transfer from these units to tertiary care is quite high in some areas, and we don’t have much data about how the outcomes of the women and babies who transfer compare to those who booked in tertiary care in the first place. In this study, 168 (65.6%) of the women who were transferred did so during the antenatal period, 65 (25.4%) transferred during the intrapartum period and 18 (7.0%) transferred during the postnatal period. Timing of transfer was unknown for 5 women (2.0%).

The results of the study showed that proportionally fewer of the women who were originally planing to birth in the freestanding midwifery unit experienced a caesarean section than in the group of women who planned to birth at the tertiary unit – 16.1% versus 24.8% respectively.

Other outcomes were comparable between both groups and, although larger studies of various designs are needed to further expand our understanding of this area, the authors conclude that their results support the provision of care in freestanding, midwifery units as an alternative to tertiary maternity units for women who have low risk pregnancies at the time of booking (Monk et al 2017).

Monk AR, Grigg CP, Foureur M et al (2017). Freestanding midwifery units: Maternal and neonatal outcomes following transfer. Midwifery, In Press, Accepted Manuscript.  http://dx.doi.org/10.1016/j.midw.2017.01.006

There will always be those who claim that birth is risky, no matter what the evidence says, because they benefit from the worry and sense of just-in-caseness that this claim generates.  What matters is the sea of evidence and experience reminding us that women can give birth, just as they have done for millennia..

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