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 reseachers 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.
Two of the results may need further consideration. Firstly, there was no difference in rates of augmentation of labour. The authors did not discuss this, but it may be because midwives in both groups were compelled to follow obstetric guidelines around time limits in labour … or it may be for other reasons, but I think it would be worth pondering. Secondly, it is a little surprising that it was the standard care group which showed a statistically significantly higher chance of having an intact perineum, and this warrants further investigation. The study authors noted that “this may be related to the levels of experience of midwives working in the two different settings but we do not have any data to support this hypothesis” (Wong et al 2015).
A few research-related issues to note are that the research team used information collected in existing databases, which may limit the nature and quality of the data that may be collected. The women in the two groups were to some extent self-selected and there were some differences between the groups to begin with. “It was not possible to determine socioeconomic status, educational level, marital status or ethnicity of the women included in this study. The mean age of women in the midwifery continuity model is statistically (though not clinically) significantly higher than that of the women receiving standard care. It is also interesting to note that the smoking rate is significantly higher in the standard care group.” (Wong et al 2015) This is a retrospective study and not a prospective trial, however “considering most outcomes were worse in the standard care group it may be unethical to conduct an RCT on models of care with such knowledge to hand” (Wong et al 2015).
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
If you’d like to discuss more of the evidence on how we can keep birth normal, I’d love to see you at one of my upcoming workshops.