SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
October, 2016 - SUPPORT Summary of a systematic review | print this article | download PDF
Midwives are the primary providers of care for childbearing women around the world. In midwife-led continuity of care, midwives are the lead professionals in the planning, organisation and delivery of care given to women from the initial booking to the postnatal period. Non-midwife models of care includes obstetrician; family physician and shared models of care, in which responsibility for the organisation and delivery of care is shared between different health professionals.
Key messages
- reduces preterm births (less than 37 weeks),
- reduces overall foetal loss and neonatal deaths,
- increases spontaneous vaginal births,
- reduces instrumental vaginal births (use of forceps or vacuum), and
- decreases the use of regional analgesia (epidural/spinal).
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
In most low- and middle-income countries, midwives are the primary providers of care for childbearing women. The philosophy behind midwife-led continuity models is normality, continuity of care, minimum interventions and being cared for by a known, trusted midwife during labour. Midwife-led continuity of care can be provided through a team of midwives who share the caseload, often called ‘team’ midwifery. Another model is ‘caseload midwifery’, which aims to ensure that the woman receives all her care from one midwife or her or his practice partner. Midwife-led continuity of care is provided in a multi-disciplinary network of consultation and referral with other care providers. In other models of care, the responsibility for the organisation and delivery of care is shared between different health professionals as obstetricians or family physicians.
| Review objectives: To compare midwife-led care with other models of care for childbearing women and their infants. | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomised trials comparing midwife-led care to other models of care |
15 randomised trials |
| Participants | Pregnant women |
17,674 pregnant women recruited from both community and hospital settings. All studies included low risk pregnancies and five studies also included high-risk pregnancies. |
| Settings | Community or hospital |
Australia (7 studies), United Kingdom (5 studies), Ireland (2 studies) and Canada (1 study). |
| Outcomes |
Primary outcomes: Birth and immediate postpartum - regional analgesia, caesarean birth, instrumental/spontaneous vaginal birth, intact perineum; Neonatal - preterm birth, overall foetal loss and neonatal death Secondary outcomes: complications, procedures or medication use |
All primary outcomes and secondary outcomes as antenatal hospitalization, antepartum haemorrhage, induction of labour, amniotomy, augmentation/artificial oxytocin during labour, no intrapartum analgesia/anaesthesia, opiate analgesia, attendance at birth by known midwife, and episiotomy. |
| Date of most recent search: January 2016 | ||
| Limitations: This is well-conducted systematic review with only minor limitations. | ||
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
Midwife-led care compared to other models of care for childbearing women and their infants:
The certainty of this evidence is high.
Midwife-led care compared to other models of care for childbearing women and their infants probably:
The certainty of this evidence is moderate.
Midwife-led continuity models versus other models of care for childbearing women and their infants |
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|
People Pregnant women |
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| Outcome |
Absolute effect (margin of error)* |
Relative effect (95% CI) | Certainty of the evidence (GRADE) | |||
|
Other models of care |
Midwife-led care |
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|
Preterm birth (less than 37 weeks) |
63 per 1000 |
48 per 1000 |
RR 0.76 (0.64 to 0.91) |
High |
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|
13 fewer per 1000 (22 to 5 fewer per 1000) |
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|
Overall foetal loss and neonatal death |
34 per 1000 |
29 per 1000 |
RR 0.84 (0.71 to 0.99) |
High |
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|
4 fewer per 1000 (11 to 1 fewer per 1000) |
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|
Spontaneous vaginal birth (as defined by trial authors) |
658 per 1000 |
691 per 1000 |
RR 1.05 (1.03 to 01.07) |
High |
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|
33 more per 1000 (19 to 46 more per 1000) |
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|
Caesarean birth |
155 per 1000 |
143 per 1000 |
RR 0.92 (0.84 to 1.00) |
Moderate |
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|
8 fewer per 1000 (25 to 0 fewer per 1000) |
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|
Instrumental vaginal birth (forceps/vacuum) |
143 per 1000 |
129 per 1000 |
RR 0.90 (0.83 to 0.97) |
High |
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|
14 fewer per 1000 (24 to 4 fewer per 1000) |
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|
Intact perineum |
269 per 1000 |
279 per 1000 |
RR 1.04 (0.95 to 1.13) |
Moderate |
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|
10 more per 1000 (14 fewer to 35 more per 1000) |
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|
Regional analgesia |
270 per 1000 |
229 per 1000 |
RR 0.85 (0.78 to 0.92) |
High |
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|
41 fewer per 1000 (59 to 22 fewer per 1000) |
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*Margin of error = confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page) |
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| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
| All trials included in the review were conducted in high-income countries. |
The context of ‘midwifery-led care’ is quite different in low-income countries. It is likely that midwives provide care but often do not lead it, and they may not have clear referral mechanisms. It is also uncertain whether the midwives are able to provide continuous antenatal, intrapartum and postnatal care to women. When assessing the transferability of these findings, the following factors should be considered: − The availability and training of midwives − The midwives’ work load − Accessibility for childbearing women − The baseline risk for the outcomes listed above for the current model of care |
| EQUITY | |
| There was no information in the included studies regarding effects of the interventions on disadvantaged populations. |
Given the scarcity of obstetricians and family physicians serving disadvantaged populations, the use of midwife-led care has the potential to reduce inequities in access to antenatal and postpartum care, provided the midwives are recruited, trained, supported and retained in under-served communities. Consideration should be given to how the midwives are recruited, trained, supported and retained in under-served communities, including incentives and regulations encouraging this. |
| ECONOMIC CONSIDERATIONS | |
|
Five studies presented cost data using different economic evaluation methods. Evidence from these studies suggests that the use of midwife-led care may reduce costs and leads to better or comparable outcomes when compared to other models of care. |
Midwife-led care could be cost effective in low- income countries, but this is uncertain. |
| MONITORING & EVALUATION | |
| No evidence from low-income countries was identified in this review, and the transferability of the evidence to low-income countries is uncertain. |
Midwife-led continuity of care should be pilot tested and their impacts and costs monitored and evaluated prior to scaling up the use of this model in low-income countries. |
|
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods |
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Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Jane Sandall and Metin Gülmezoglu.
Sandall J, Soltani H, Gates S, et al. Midwife-led continuity models versus other models of care for
childbearing women. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD004667.
Ciapponi A. Does midwife-led continuity of care improve the delivery of care to women during and after pregnancy? A SUPPORT Summary of a systematic review. October 2016. www.supportsummaries.org
Keywords
All Summaries:
evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care
Midwives, birth centre, task shifting, antenatal care, postpartum care, maternity. models of care,
continuity of care
