Midwife-led care versus other models of care

This 2008 study of 12,276 women concluded that "most women should be offered midwife-led models of care and women should be encouraged to ask for this option."

This is certainly in keeping with most other developed countries around the world, except of course in the USA where the medical model have secured a total medical monopoly; and with the WHO recommendations for maternity care.

Plain language summary

Midwife-led care confers benefits for pregnant women and their babies and is recommended.In many parts of the world, midwives are the primary providers of care for childbearing women.

Elsewhere it may be medical doctors or family physicians who have the main responsibility for care, or the responsibility may be shared.

The underpinning philosophy of midwife-led care is normality, continuity of care and being cared for by a known and trusted midwife during labour.

There is an emphasis on the natural ability of women to experience birth with minimum intervention.

Some models of midwife-led care provide a service through a team of midwives sharing a caseload, often called 'team' midwifery. Another model is 'caseload midwifery', where the aim is to offer greater continuity of caregiver throughout the episode of care. Caseload midwifery aims to ensure that the woman receives all her care from one midwife or her/his practice partner. All models of midwife-led care are provided in a multi-disciplinary network of consultation and referral with other care providers.

By contrast, medical-led models of care are where an obstetrician or family physician is primarily responsible for care. In shared-care models, responsibility is shared between different healthcare professionals.

The review of midwife-led care covered midwives providing care antenatally, during labour and postnatally. This was compared with models of medical-led care and shared care, and identified 11 trials, involving 12,276 women.

Midwife-led care was associated with several benefits for mothers and babies, and had no identified adverse effects.

The main benefits were a reduction in the use of regional analgesia, with fewer episiotomies or instrumental births.

Midwife-led care also increased the woman's chance of being cared for in labour by a midwife she had got to know, and the chance of feeling in control during labour, having a spontaneous vaginal birth and initiating breastfeeding.

However, there was no difference in caesarean birth rates.

Women who were randomised to receive midwife-led care were less likely to lose their baby before 24 weeks' gestation, although there were no differences in the risk of losing the baby after 24 weeks, or overall.

In addition, babies of women who were randomised to receive midwife-led care were more likely to have a shorter length of hospital stay.

The review concluded that most women should be offered midwife-led models of care, although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.

The Maternity Coaltion posted this press release in October, 2008
Mothers ecstatic that study backs them up

“Australian mothers who have had the opportunity to know their midwife during their pregnancy, birth and beyond are ecstatic”, said Melissa Fox, Brisbane mother of two and National Vice-President of consumer group Maternity Coalition.

“A large review from the gold-standard Cochrane Database backs up what we have long been saying – that midwives are just great for good outcomes and a satisfying birth experience”.

The combined results of 11 trials including 12,276 women found that women who had midwife-led models of care had a reduced risk of losing a baby, a reduced use of regional analgesia, fewer episiotomies or instrumental births, an increased chance of a spontaneous vaginal birth and initiation of breastfeeding and more women feeling they were in control during labour.

The review concluded that all women should be offered midwife-led models of care.Maternity Coalition, Australia’s national maternity consumer advocacy group, have long been asking for an increase in continuity of midwifery care models. In 2002 Maternity Coalition released NMAP, a National Maternity Action Plan describing the need for change and documenting the many advantages of continuous care with a known midwife.

Since then only a handful of opportunities have been developed for women to take advantage of continuity of care with a known midwife.

“We need a reorientation of the way maternity services are delivered, to ensure women have equity of access to care from a known midwife”, said Ms Fox. “Maternity Coalition advocates that maternity care funds should “follow the woman” through her pregnancy, birth and postnatal care”.

“Having a midwife who knew me, my fears and what I wanted for my birth made all the difference. She believed in normal birth and supported me to birth with minimum intervention”, said Nicole Murphy, mother of two from Toowoomba. “If having a known midwife were a drug, every woman would have it prescribed”, said Ms Murphy.

Study:Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2008, Issue 4. Hatem M, Sandall J, Devane D, Soltani H, Gates S. http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004667/frame.html