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Meta-Analysis
. 2016 Apr 28;4(4):CD004667.
doi: 10.1002/14651858.CD004667.pub5.

Midwife-led continuity models versus other models of care for childbearing women

Jane Sandall  1 , Hora Soltani, Simon Gates, Andrew Shennan, Declan Devane
Affiliations
Meta-Analysis

Midwife-led continuity models versus other models of care for childbearing women

Jane Sandall et al. Cochrane Database Syst Rev. .

Abstract

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 (25 January 2016) 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Selection criteria: All published and unpublished trials in which pregnant women are randomly allocated to midwife-led continuity models of care or other models of care during pregnancy and birth.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: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach.

Main results: We included 15 trials involving 17,674 women. We assessed the quality of the trial evidence for all primary outcomes (i.e. regional analgesia (epidural/spinal), caesarean birth, instrumental vaginal birth (forceps/vacuum), spontaneous vaginal birth, intact perineum, preterm birth (less than 37 weeks) and all fetal loss before and after 24 weeks plus neonatal death using the GRADE methodology: all primary outcomes were graded as of high quality.For the primary outcomes, women who had midwife-led continuity models of care were less likely to experience regional analgesia (average risk ratio (RR) 0.85, 95% confidence interval (CI) 0.78 to 0.92; participants = 17,674; studies = 14; high quality), instrumental vaginal birth (average RR 0.90, 95% CI 0.83 to 0.97; participants = 17,501; studies = 13; high quality), preterm birth less than 37 weeks (average RR 0.76, 95% CI 0.64 to 0.91; participants = 13,238; studies = eight; high quality) and less all fetal loss before and after 24 weeks plus neonatal death (average RR 0.84, 95% CI 0.71 to 0.99; participants = 17,561; studies = 13; high quality evidence). Women who had midwife-led continuity models of care were more likely to experience spontaneous vaginal birth (average RR 1.05, 95% CI 1.03 to 1.07; participants = 16,687; studies = 12; high quality). There were no differences between groups for caesarean births or intact perineum.For the secondary outcomes, women who had midwife-led continuity models of care were less likely to experience amniotomy (average RR 0.80, 95% CI 0.66 to 0.98; participants = 3253; studies = four), episiotomy (average RR 0.84, 95% CI 0.77 to 0.92; participants = 17,674; studies = 14) and fetal loss less than 24 weeks and neonatal death (average RR 0.81, 95% CI 0.67 to 0.98; participants = 15,645; studies = 11). Women who had midwife-led continuity models of care were more likely to experience no intrapartum analgesia/anaesthesia (average RR 1.21, 95% CI 1.06 to 1.37; participants = 10,499; studies = seven), have a longer mean length of labour (hours) (mean difference (MD) 0.50, 95% CI 0.27 to 0.74; participants = 3328; studies = three) and more likely to be attended at birth by a known midwife (average RR 7.04, 95% CI 4.48 to 11.08; participants = 6917; studies = seven). There were no differences between groups for fetal loss equal to/after 24 weeks and neonatal death, induction of labour, antenatal hospitalisation, antepartum haemorrhage, augmentation/artificial oxytocin during labour, opiate analgesia, perineal laceration requiring suturing, postpartum haemorrhage, breastfeeding initiation, low birthweight infant, five-minute Apgar score less than or equal to seven, neonatal convulsions, admission of infant to special care or neonatal intensive care unit(s) or in mean length of neonatal hospital stay (days).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 midwife-led continuity models of care. Similarly, there was a trend towards a cost-saving effect for midwife-led continuity care compared to other care models.

Authors' conclusions: This review suggests 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.Further research is needed to explore findings of fewer preterm births and fewer fetal deaths less than 24 weeks, and all fetal loss/neonatal death associated with midwife-led continuity models of care.

PubMed Disclaimer

Conflict of interest statement

Declan Devane is a co‐author in one of the included trials in this review (Begley 2011). Jane Sandall was and is principal investigator for two studies evaluating models of midwife‐led continuity of care (Sandall 2001), and co‐investigator on the 'Birthplace in England Research Programme', an integrated programme of research designed to compare outcomes of births for women planned at home, in different types of midwifery units, and in hospital units with obstetric services. Declan and Jane were not involved in assessing or data extraction for these studies.

Figures

1
1
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
3
3
Funnel plot of comparison: 1 Midwife‐led versus other models of care for childbearing women and their infants (all), outcome: 1.1 Regional analgesia (epidural/spinal).
4
4
Funnel plot of comparison: 1 Midwife‐led versus other models of care for childbearing women and their infants (all), outcome: 1.2 Caesarean birth.
5
5
Funnel plot of comparison: 1 Midwife‐led versus other models of care for childbearing women and their infants (all), outcome: 1.16 Episiotomy.
1.1
1.1. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 1 Regional analgesia (epidural/spinal).
1.2
1.2. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 2 Caesarean birth.
1.3
1.3. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 3 Instrumental vaginal birth (forceps/vacuum).
1.4
1.4. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 4 Spontaneous vaginal birth (as defined by trial authors).
1.5
1.5. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 5 Intact perineum.
1.6
1.6. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 6 Preterm birth (< 37 weeks).
1.7
1.7. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 7 All fetal loss before and after 24 weeks plus neonatal death.
1.8
1.8. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 8 Antenatal hospitalisation.
1.9
1.9. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 9 Antepartum haemorrhage.
1.10
1.10. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 10 Induction of labour.
1.11
1.11. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 11 Amniotomy.
1.12
1.12. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 12 Augmentation/artificial oxytocin during labour.
1.13
1.13. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 13 No intrapartum analgesia/anaesthesia.
1.14
1.14. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 14 Opiate analgesia.
1.15
1.15. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 15 Attendance at birth by known midwife.
1.16
1.16. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 16 Episiotomy.
1.17
1.17. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 17 Perineal laceration requiring suturing.
1.18
1.18. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 18 Mean labour length (hrs).
1.19
1.19. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 19 Postpartum haemorrhage (as defined by trial authors).
1.20
1.20. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 20 Breastfeeding initiation.
1.21
1.21. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 21 Duration of postnatal hospital stay (days).
1.22
1.22. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 22 Low birthweight (< 2500 g).
1.23
1.23. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 23 5‐minute Apgar score below or equal to 7.
1.24
1.24. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 24 Neonatal convulsions (as defined by trial authors).
1.25
1.25. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 25 Admission to special care nursery/neonatal intensive care unit.
1.26
1.26. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 26 Mean length of neonatal hospital stay (days).
1.27
1.27. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 27 Fetal loss less than 24 weeks and neonatal death.
1.28
1.28. Analysis
Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 28 Fetal loss equal to/after 24 weeks and neonatal death.
2.1
2.1. Analysis
Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 1 Regional analgesia (epidural/spinal).
2.2
2.2. Analysis
Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 2 Caesarean birth.
2.3
2.3. Analysis
Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 3 Instrumental vaginal birth (forceps/vacuum).
2.4
2.4. Analysis
Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 4 Spontaneous vaginal birth (as defined by trial authors).
2.5
2.5. Analysis
Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 5 Intact perineum.
2.6
2.6. Analysis
Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 6 Preterm birth (< 37 weeks).
2.7
2.7. Analysis
Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 7 All fetal loss before and after 24 weeks plus neonatal death.
3.1
3.1. Analysis
Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 1 Regional analgesia (epidural/spinal).
3.2
3.2. Analysis
Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 2 Caesarean birth.
3.3
3.3. Analysis
Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 3 Instrumental vaginal birth (forceps/vacuum).
3.4
3.4. Analysis
Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 4 Spontaneous vaginal birth (as defined by trial authors).
3.5
3.5. Analysis
Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 5 Intact perineum.
3.6
3.6. Analysis
Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 6 Preterm birth (< 37 weeks).
3.7
3.7. Analysis
Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 7 All fetal loss before and after 24 weeks plus neonatal death.
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Update of

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References to ongoing studies

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References to other published versions of this review

Hatem 2008
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