The contribution of midwife-led care to the quality and safety of maternity care : implications of findings from a Cochrane meta-

analysis

Jane Sandall

Professor of Women’s Health, King’s College London

Hatem M, Sandall, J. (Joint First Author and Contact Author) Devane D, Soltani H. Gates,S. October 2009

Background Maternal and neonatal morbidity and mortality

together one of the biggest challenges to public health in developing countries.

Evidence base on patient safety, its root causes and

contributing factors, as well as on the most cost-effective solutions to common problems is very limited.

Maternal and neonatal care in top 20 WHO Patient Safety Programme global research priorities in low and mid income countries.

Improving quality and safety in maternity careThe Institute of Medicine (IOM) defines

quality of health care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”. 

Crossing the Quality Chasm (2001)

Dimensions of qualitySafety

Effectiveness

Patient/woman-centeredness

Timeliness

Efficiency

Equity

Institute of Medicine (2000) Crossing the Quality Chasm: A New Health System for the 21st Century, Washington, National Academy Press

What is the evidence?

Improving the coverage of skilled midwifery care has been identified by the WHO and a range of other agencies as delivering on the above agenda.

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Cochrane review midwife-led models of care vs other models of care

Midwife-led model of care assumes: pregnancy and birth are normal life events and is woman-centred and includes: continuity of care; monitoring the physical, psychological, spiritual and social well-being of the woman and family throughout the childbearing cycle; providing the woman with individualised education, counselling and antenatal care; continuous attendance during labour, birth and the immediate postpartum period; ongoing support during the postnatal period; minimising technological interventions; and identifying and referring women who require obstetric or other specialist attention.

Differences between midwife-led and other models of care often include variations in philosophy, focus, relationship between the care provider and the pregnant woman, use of interventions during labour, care setting (home, home-from-home or acute hospital setting, and in the goals and objectives of care.

What we didn’t know before review

Clinical and cost effectiveness of the different models of maternity care

The optimal model of care for routine antenatal, intrapartum and postnatal care for healthy pregnant women

Synthesised information to establish whether there are differences in morbidity and mortality, effectiveness and psychosocial outcomes between midwife-led and other models of care

The Cochrane Library is the single most reliable source for evidence on the effects of health care.

Health care in the 21st Century relies not only on individual medical skills, but also on the best information on the effectiveness of each intervention being accessible to practitioners, patients, and policy makers. This approach is known as “evidence-based medicine”.

What Is The Cochrane Library?

Cochrane Reviews are now the “gold standard” for systematic reviews in such key publications as The Lancet, New England Journal of Medicine, British Medical Journal, and the Journal of the American Medical Association and routinely appear there as well as in specialised medical journals for various specialty areas.

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Review Objectives

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

Secondaryto determine whether the effects of midwife-led care are influenced by: 1) models of midwifery care that provide differing levels of continuity; 2) varying levels of obstetrical risk and 3) practice setting (community or hospital based).

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Definition of midwife-led care“midwife is the lead professional providing continuity in

the planning, organisation and delivery of care given to a woman from initial booking to the postnatal period".

Some antenatal and/or intrapartum and/or postpartum care may be provided in consultation with medical staff as appropriate.

Midwives are lead professional with responsibility for assessment of her needs, planning her care, referral to other professionals as appropriate. Thus, midwife-led models of care aim to provide care in either community or hospital settings, normally to healthy women with uncomplicated or 'low-risk' pregnancies.

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Models of midwife-led careTeam midwifery

Aim to provide continuity of care to a defined group of women through a team of midwives sharing a caseload, often called 'team' midwifery. Thus, a woman will receive her care from a number of midwives in the team, the size of which can vary.

Caseload midwiferyAim to offer greater relationship continuity over time, by ensuring that a childbearing woman receives her ante, intra and postnatal care from one midwife or her/his practice partner.

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Other models of care

(a) Obstetrician-provided careObstetricians are the primary providers of antenatal care. An obstetrician (not necessarily the one who provides antenatal care) is present for the birth.

(b) Family doctor-provided care Obstetric nurses or midwives provide intrapartum and immediate postnatal care but not at a decision making level, and a family doctor is present for the birth.

(c) Shared models of care Where responsibility for the organisation and delivery of care, throughout initial booking to the postnatal period, is shared between different health professionals.

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Criteria for considering studies for this review

Types of studies  All studies in which pregnant women are randomly allocated to midwife-led models of care and other models of care during pregnancy. Types of participants  Pregnant women classified as low and mixed risk of complications. Types of interventions  Models of care are classified as midwife-led, other or shared care on the basis of the lead professional in the ante and intrapartum periods, as decisions and actions taken in pregnancy affect intrapartum events and continuity of care a key part of model.

Search methods for identification of studies

• No language restrictions, published and unpublished reports• Electronic searches• Cochrane Pregnancy and Childbirth Group’s Trials Register • Cochrane Central Register of Controlled Trials (CENTRAL)• Cochrane Effective Practice and Organisation of Care Group's Trials Register • Current Contents, Medline, CINAHL Web of Science, BIOSIS, Previews, ISI Proceedings,

WHO Reproductive Health Library• Unpublished studies from the System for Information on Grey Literature In Europe

(SIGLE)

• Handsearches• 30 journals and proceedings of major conferences• Current awareness alerts for additional 44 journals

Details can be found in the ‘Specialized Register’ section within the editorial information about the Cochrane Pregnancy and Childbirth Group

Details of studiesCountries N Types of other models of care N Australia

4 Shared care 7

Canada

1 Medical-led 3

New Zealand

1 Medical-led and shared care 1

UK 5 Midwife-led models Setting for intrapartum care

Risk status Hospital homelike unit 3 Low risk 6

Hospital labour ward 8

Mixed risk 5 Midwife-led models Setting for AN and P/N care

% women attended by a known carer

All hospital based 4

Midwife-led 63-98%

Community A/N and no community P/N 1

Other models 0.3-21%

Community A/N and P/N 3

Types of Midwife-led Models of care

Hospital A/N and community P/N 3

Team Midwifery 9 Caseload Midwifery

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11 trials involving 12,276 randomised women

Safety

Defined as ‘avoiding injuries to patients from the care that is intended to help them’.

Fetal loss before 24 weeks

Risk reduction of 21%

Effectiveness

Defined as ‘providing services based on sound scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse respectively)’.

Women randomised to midwife-led models of care were less likely to experience

regional analgesia/anesthesia (11 trials, n =

11,892, RR 0.81, 95% CI 0.73 to 0.91) 19% less

instrumental (forceps/vacuum) birth (10 trials, n =

11,724, RR 0.86, 95% CI 0.78 to 0.96) 14% less

episiotomy (11 trials, n = 11,872, RR 0.82, 95% CI 0.77

to 0.88) 18% less

no significant differences in the caesarean section rate (11 trials, n = 11897, RR 0.96, 95% CI

0.87 to 1.06

Midwife-led versus other models of care for childbearing women and their infants - Instrumental birth

Study or Subgroup

Biro 2000Flint 1989Harvey 1996Homer 2001Kenny 1994MacVicar 1993North Stafford 2000Rowley 1995Turnbull 1996Waldenstrom 2001

Total (95% CI)

Total eventsHeterogeneity: Chi² = 8.09, df = 9 (P = 0.53); I² = 0%Test for overall effect: Z = 2.81 (P = 0.005)

Events

67566

7112

18774298378

663

Total

488479105594194

2304770393612484

6423

Events

8666

76329

11484378689

661

Total

480473

97601211

1206735405597496

5301

Weight

12.4%9.5%1.0%9.0%4.0%

21.4%12.3%

5.2%12.5%12.6%

100.0%

M-H, Fixed, 95% CI

0.77 [0.57, 1.03]0.84 [0.60, 1.17]0.79 [0.28, 2.27]1.14 [0.83, 1.57]0.45 [0.24, 0.86]0.86 [0.69, 1.07]0.84 [0.63, 1.13]0.81 [0.51, 1.29]0.94 [0.71, 1.25]0.90 [0.68, 1.18]

0.86 [0.78, 0.96]

Midwife-led care Other models of care Risk Ratio Risk RatioM-H, Fixed, 95% CI

0.1 0.2 0.5 1 2 5 10Favours midwifery Favours other modelsRisk reduction of 14%

Women randomized to midwife-led models of care were more likely to experience

no intrapartum analgesia/anesthesia (five trials, n = 7039, RR 1.16, 95% CI 1.05 to 1.29)

a spontaneous vaginal birth (nine trials,

n = 10,926, RR 1.04, 95% CI 1.02 to 1.06)

breastfeeding initiation (one trial, n =

405, RR 1.35, 95% CI 1.03 to 1.76)

Woman – centerednessDefined as ‘providing care that is

respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions’.

Women randomized to midwife-led models of care were more likely to experience

high perceptions of control during labour (one trial, n = 471, RR 1.74,

95% CI 1.32 to 2.30)

attendance at birth by a known midwife (six trials, n = 5525, RR 7.84,

95% CI 4.15 to 14.81)

Experience of care

Women's reported experiences of care included maternal satisfaction with information, advice, explanation, venue of delivery and preparation for labour and birth, as well as perceptions of choice for pain relief and evaluations of carer's behaviour.

Satisfaction in various aspects of care appeared to be higher in the midwife-led compared to the other model of care.

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Attendance at birth by a known midwife

Women nearly X8 times more likely to know midwife

Efficiency

Defined as avoiding waste, including waste of equipment, supplies, ideas and energy.

Efficiency

All trials suggest a cost-saving effect in intrapartum care.

Lack of consistency in estimating maternity care cost among the available studies; however there seemed to be a trend towards the cost-saving effect of midwife-led care in comparison with medical-led care.

Women randomized to midwife-led models of care were less likely to

experience antenatal hospitalization Study or Subgroup

Flint 1989Homer 2001Kenny 1994Rowley 1995Waldenstrom 2001

Total (95% CI)

Total eventsHeterogeneity: Chi² = 5.84, df = 4 (P = 0.21); I² = 32%Test for overall effect: Z = 2.08 (P = 0.04)

Events

1235329

114190

509

Total

484594194393484

2149

Events

1467238

135185

576

Total

475601211405496

2188

Weight

25.8%12.5%

6.4%23.3%32.0%

100.0%

M-H, Fixed, 95% CI

0.83 [0.67, 1.01]0.74 [0.53, 1.04]0.83 [0.53, 1.29]0.87 [0.71, 1.07]1.05 [0.90, 1.23]

0.90 [0.81, 0.99]

Midwife-led care Other models of care Risk Ratio Risk RatioM-H, Fixed, 95% CI

0.1 0.2 0.5 1 2 5 10Favours midwifery Favours other models

Risk reduction of 10%

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There were no statistically significant differences between groups for:

•antepartum haemorrhage •preterm birth •low birthweight infant •amniotomy•the use of opiate analgesia augmentation during labour •induction of labour •caesarean section rate •perineal laceration requiring suturing •intact perineum •five-minute Apgar score less than or equal to seven •admission of infant to special care or neonatal intensive care unit(s)•neonatal convulsions•fetal loss or neonatal death more than or equal to 24 weeks •overall fetal loss and neonatal death •duration of postnatal hospital stay •postpartum depression

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Overall fetal loss

Non-significant trend risk reduction of 17%

Summary

Women who received models of midwife-led care were nearly eight times more likely to be attended at birth by a known midwife, were 21% less likely to lose their baby before 24 weeks, 19% less likely to have regional analgesia, 14% less likely to have instrumental birth, 18% less likely to have an episiotomy, and significantly more likely to have a spontaneous vaginal birth, initiate breastfeeding, and feel in control during childbirth.

Conclusion “Every women needs a midwife and some women need a doctor too”

Most women should be offered midwife-led 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.

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Interpretation 11 trials, 12,000 women, 4 countriesof midwife-led care in pregnancy and birth

Cant generalise to

Women with extensive medical complicationsHome birthLow income countriesLay/traditional midwivesMidwife-led birth centres where antenatal care not provided

Limitatations

Some effect sizes small

Many secondary outcomes

Confounders

Midwife led unit setting & midwife led care

Continuity & midwife led care

Care pathways/protocols & midwife led care

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What do we need to find out?

•Outcomes of different models of continuity of care

•Impact of care pathways and clinical networks

•How should services be organised for women with substantial medical complications

•Impact of midwife continuity on perinatal morbidity and mortality

•Effects in middle and low incomes settings

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Publications• Sandall,J., Hatem.M., Devane,D., Soltani,H., Gates,S. (in submission)

Implications of findings from a Cochrane Review of midwife-led versus other models of care for childbearing women in what works to improve ‘normal’ birth, Jnl Midwifery & Women’s Health

• Sandall,J., Hatem.M., Devane,D., Soltani,H., Gates,S. (2009) Discussion of findings from a Cochrane Review of midwife-led versus other models of care for childbearing women, Midwifery, 25, 8-13.

• Sandall J. (2008) Midwife-led versus other models of care for childbearing women:implications of findings from a Cochrane meta-analysis. Evidence Based Midwifery 6(4): 111.

• Hatem M, Sandall, J. Article most likely to change clinical practice” DynaMed Weekly Update 270109. Hatem M, Sandall, J. (Joint First Author and Contact Author) Devane D, Soltani H. Gates,S. (2008) Midwife-led versus other models of care for childbearing women, Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No: CD004667.

• Finlay,S. Sandall,J. (in press online ) “Someone’s rooting for you”: Continuity and Advocacy in Bureaucratic Maternal Health Care Systems, Social Science and Medicine, doi:10.1016/j.socscimed.2009.07.029