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

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The contribution of midwife-led care to the
quality and safety of maternity care
implications of findings from a Cochrane
meta-analysisJane Sandall Professor of
Womens Health, Kings College LondonHatem M,
Sandall, J. (Joint First Author and Contact
Author) Devane D, Soltani H. Gates,S. October
2009
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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.

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Improving quality and safety in maternity care

• The 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)

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Dimensions of quality

• Safety
• 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
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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.

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What we didnt 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

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What Is The Cochrane Library?
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.
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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.
• Secondary
• to 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 care

• Team 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 midwifery
• Aim 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

• Obstetrician-provided care
• Obstetricians 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.

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Search methods for identification of studies

• No language restrictions, published and
  unpublished reports
• Electronic searches
• Cochrane Pregnancy and Childbirth Groups 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

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Details of studies
11 trials involving 12,276 randomised women
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Safety

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

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Fetal loss before 24 weeks
Risk reduction of 21
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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).

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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

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Midwife-led versus other models of care for
childbearing women and their infants -
Instrumental birth
Risk reduction of 14
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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)

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Woman centeredness

• Defined 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.

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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)

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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
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Efficiency

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

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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.

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Women randomized to midwife-led models of care
were less likely to experience antenatal
hospitalization
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
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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.

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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
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

• Cant generalise to
• Women with extensive medical complications
• Home birth
• Low income countries
• Lay/traditional midwives
• Midwife-led birth centres where antenatal care
  not provided

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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 Womens 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 womenimplications 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 )
  Someones rooting for you Continuity and
  Advocacy in Bureaucratic Maternal Health Care
  Systems, Social Science and Medicine,
  doi10.1016/j.socscimed.2009.07.029

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