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Continuing midwife care trumps doctor-led and shared care approaches

Fewer premature births and labour problems, shows Cochrane review

Caroline White

Wednesday, 21 August 2013

Women who receive continuing midwifery care throughout their pregnancy and labour have a lower rate of premature birth and complications than those receiving shared care or doctor-led care, indicates a systematic review published in The Cochrane Library.

Women who received continuing care from a small group of midwives fared better than those whose care was shared between different obstetricians, GPs, and midwives.

In many countries, including the UK and Australia, midwives act as the main providers of care for women throughout pregnancy, labour and birth.

In midwife-led care, there is an emphasis on normality, continuity of care, and being cared for by a known, trusted midwife during labour. Midwife-led continuity of care is provided in a multidisciplinary network of consultation and referral with other care providers.

Doctor-led models of care give primary responsibility to the obstetrician or family doctor, while shared care approaches parcel out responsibility among different healthcare professionals. There has been some debate about whether the midwife-led model of care is more effective.

The researchers reviewed data from 13 trials involving 16,242 women. Eight trials included women at low risk of complications and five included women at high risk of complications.

They compared outcomes for mothers and babies when midwives were the main providers of care, compared with doctor-led or shared care models.

When midwives were the main providers of care throughout pregnancy and labour, women were less likely to give birth before 37 weeks or lose their babies before 24 weeks. Women were also happier with the care they received, had fewer epidurals, fewer assisted births, and fewer episiotomies to reduce the risk of a tear.

While women who received midwife-led care were no more likely to have a caesarean birth than women receiving other types of care, they were in labour for about half an hour longer on average.

Based on these results, the researchers conclude that all women should be offered midwife-led continuity of care unless they have serious medical or obstetric complications.

“Women should be encouraged to ask for this option,” said lead researcher Jane Sandall of the Division of Women’s Health at King’s College London in London. “Policymakers in areas of the world where health systems do not provide midwife-led care should consider the importance of midwives in improving maternity care and how financing of midwife-led services can be reviewed to support this.”

Five studies considered the cost of midwife-led compared with shared care. While care provided by midwives was more cost-effective during labour, the results for postnatal care were inconclusive. “There was a lack of consistency in the way that maternity care cost was estimated in the studies, but there seemed to be a trend towards a cost-saving effect of midwife-led care,” said Sandall.

DOI: 10.1002/14651858.CD004667.pub3

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