In this blog for our Maternity Matters series, researchers and Cochrane authors Jane Sandall, Hora Soltani, Andrew Shennan and Declane Devane look at evidence and practice on midwife-led continuity of care. This blog is part of a series called ‘Maternity Matters’.
In 2016, Better Births, the report of the National Maternity Review, the Five Year Forward View for NHS maternity services in England and in 2017 Safer Maternity Care – The National Maternity Safety Strategy – Progress and Next Steps (Department of Health, 2017), sets out a vision for maternity services in England which are safe and personalised. At the heart of this vision is the ambition that women should have continuity of the person looking after them during their maternity journey, before, during and after the birth. The NHS ten-year plan also aims to ensure that 75% of women from Black, Asian and minority ethnic communities and a similar percentage of women from the most deprived groups will receive continuity of care from their midwife throughout pregnancy, labour and the postnatal period by 2024 (NHS England, 2019). The UK is not alone. Internationally, in 2017 both the WHO antenatal and the 2018 WHO antenatal and intrapartum care guidance for a positive pregnancy and childbirth experience recommend midwife-led continuity of care (MLCC) models for pregnant women in settings with well trained midwives (WHO Reproductive Health Library, 2016; World Health Organization, 2018; World Health Organization, 2016). So, what does the evidence say and what else do we need to find out?
Effects of midwife-led continuity of care on women and babies’ health
In 2016, we investigated the effect of women having midwife-led continuity of care (Sandall et al, 2016). In our Cochrane Review, we found 15 studies involving 17,674 mothers and babies. We defined midwife-led continuity models of care as those that provide a woman with care from the same midwife or team of midwives during the pregnancy, birth and the early parenting period with referral to specialist obstetric care as needed. This involves care co-ordination, provision and a relationship over time.
We compared this to other models of care where responsibility and care is shared between different health professionals, such as obstetrician and family doctor led care often shared with obstetric nurses or midwives, and shared models of care between all groups. Some trials involved women who were at low risk of complications, and some included women who were at low and higher risk of complications at the start of pregnancy. All the included trials involved professionally-qualified midwives and no trials offered home birth.
We found that women who received MLCC were more likely to be looked after in labour by midwives they already knew (63-98% vs 0.3- 21%) and were less likely to have an epidural, episiotomy or instrumental birth. Women’s chances of a spontaneous vaginal birth were increased, but there was no difference in the likelihood of having a caesarean birth. Women were less likely to experience preterm birth, fetal loss before and after 24 weeks, and neonatal death. Women were more likely to report a better experience with various aspects of care. We did not identify any harms.
Understanding more about the implementation of midwife-led continuity of care
A recent Cochrane overview of reviews of interventions during pregnancy to reduce pre-term birth found that midwife led continuity of care had clear benefit in preventing preterm birth and stillbirth (Medley et al, 2018). The key challenge is how to implement and scale up such models in a sustainable way (NHS England, 2017). Many questions are asked about what the core elements are, and what can be adapted to context to achieve the beneficial outcomes for women and babies in a sustainable way. Key elements that can be pulled out from the review are as follows:
- Care was provided in hospital and community settings
- Women gave birth in obstetric units, and alongside midwife units but not at home
- Care was provided for a woman from the same midwife or team of midwives during the pregnancy, birth and the early parenting period
- Midwives referred to specialist obstetric care as needed, and continued to provide midwifery care to women in hospital and community settings if they developed complications
- Team size ranged from 4-9 whole time equivalent (WTE) midwives
- There was no evidence of a difference in outcomes between caseload and team models of care
- There was no evidence of a difference in outcomes between models that offered care to populations of women that were classified as low risk and mixed risk
What further research needs to be done on how this model works and for whom?
MLCC models are complex interventions and it is unclear whether the pathway of influence that can produce these positive outcomes is the continuity of care, the midwifery philosophy of care or both. Many theories have been suggested during conversations with women, clinicians and researchers across the world. We think the following hypotheses are worthy of further investigation:
- That midwives possibly provide a trusted safety net with midwives ‘minding the gap’?
- That more effective care may be provided by fidelity to multidisciplinary guidelines including clear transfer processes?
- That more equitable care results from fewer women falling through gaps in services due to better co-ordination/care navigation and referral which improves in-service access?
- That relational continuity and advocacy engenders trust and confidence between women and midwives?
- That women feel less stressed and secure with more opportunities for midwives to facilitate social support from families and in her local community?
- That more timely and safer care results from more opportunities for early prevention and diagnosis of complications to facilitate management and intervention?
Some of our team have been working with NHS England to provide implementation support and training across England and have also been involved in publishing a practical toolkit with colleagues in Australia (Homer et al, 2019).
Where does this leave us?
We need to know more about the sustainability of scaling up MLCC models, in terms of whole system impact, cost-benefit and workforce.
We don’t know the effects of MLCC on women who are higher risk at booking. Such women often get fragmented care and miss routine midwifery care. We are currently completing a pilot trial of women at higher risk of preterm birth to see how feasible such a model is (Fernandez Turienzo et al, 2019a).
We need to find out more about whether MLCC can moderate the effects of women’s stress on the health of the mother and baby. This can build on some very exciting research in Australia, which found MLCC models mitigated the effects of high levels of stress experienced by women in the context of a natural disaster (Queensland flood) on postnatal mental health (Kildea et al, 2018).
Finally, we also need to understand more about the effects of building collaborative models of care to improve outcomes in disadvantaged diverse communities (Rayment-Jones et al, 2015; McRae et al, 2016). Pioneering research with Aboriginal communities is showing effects of a model of care integrated with family services on preterm birth (Kildea et al, 2019), and we need to think about the relevance for other settings and groups (Fernandez Turienzo et al, 2019b).
About the authors:
Jane Sandall‘s biography appears below the blog.
Hora Soltani (Professor of Maternal and Infant Health in Sheffield Hallam University, UK) is a registered midwife and has been researching for over 20 years focusing on enhancing maternity care and reducing health inequalities for mothers and babies.
Professor Shennan is an academic obstetrician with expertise in obstetric clinical trials including preterm birth.
Professor Devane is a midwife with expertise in trials including trials of models of maternity care.
Declarations of interest:
Jane Sandall reports that she is the lead author of the Cochrane Review that this publication is based upon. Hora Soltani, Declan Devane and Andrew Shennan report that they are co-authors of the Cochrane Review that this publication is based upon.