Last month’s news section reported a Cochrane review of midwife-led care (Sandall et al 2013) which broadened previous recommendations from suggesting that this model of care should be offered only to low-risk women, to suggest that midwife-led care could be suitable for most women. Hot on its heels has come more research that adds weight to the review’s findings.
The M@NGO trial (Tracy et al 2013) from Australia, a randomised controlled trial, compared caseload midwifery care with hospital care for women to assess whether the former reduced interventions, caesarean sections in particular. Importantly, the trial did not just include low-risk women, but included 1748 women irrespective of risk factors (although it did exclude those had a multiple pregnancy, or planned to have an elective caesarean) and randomised them to either caseload midwifery or hospital care: ‘The main primary outcome was the proportion of women who had a caesarean section. The other primary maternal outcomes were the proportions who had an instrumental or unassisted vaginal birth, and the proportion who had epidural analgesia during labour. Primary neonatal outcomes were Apgar scores, preterm birth, and admission to neonatal intensive care’ (Tracy et al 2013). The outcomes were analysed by intention to treat.
Neonatal outcomes did not differ between the two groups, neither did the proportion of caesarean sections, although there was a drop in the proportion of woman who had an elective caesarean section before the onset of labour in the caseload group. The proportions of instrumental birth in both groups were similar and the proportions of unassisted vaginal birth slightly less in the caseload group (487 [56%] vs 454 [52%]; p=0·08).
The most outstanding difference however, was in cost, with the total cost of care per woman being AUS$566.74 less for those who received caseload midwifery care than those who received hospital care. The overall findings: ‘Our results show that for women of any risk, caseload midwifery is safe and cost effective’ (Tracy et al 2013). This further backs the conclusions of the most recent Cochrane review (Sandall et al 2013).
The good news continued with another interesting study that examined women’s experiences of care in a midwifery-led unit in the Republic of Ireland (McNelis 2013). This was a descriptive qualitative research study that used interpretive phenomenological analysis (see Sophie King-Hill’s article on page 32 for more information on this study method) and phenomenological data analysis to explore and interpret eight women’s experiences.
Findings focused on two particular themes that emerged during analysis of in-depth interviews: the homely atmosphere, and the women’s feelings of control. Both of these contributed to women’s positive birthing experience as they reported feeling empowered, able to make their own decisions throughout labour, and giving them the freedom to do their own thing whilst feeling supported.
These women’s overwhelmingly positive experiences of midwife-led care along with mounting evidence that midwifery-led care is comparable with traditional hospital care in terms of safety, highlight the need for this type of care to move from being the exception to becoming the rule, a reflection taken up by President of the Royal College of Midwives, Lesley Page (2013), in her editorial of a recent edition of Women and Birth: the journal of the Australian College of Midwives:
‘The evidence of the effect of midwife led care has been mounting over years… Yet the provision of midwife led care remains small scale with limited access. Midwifery led care will need to move from the fringes to the mainstream with wide access to all women if we are to bring our maternity services into balance, offering women and their babies the genuine opportunity of a normal birth, reducing the intervention rate and unleashing the potential of midwifery’ (Page 2013:166).
McNelis M (2013). Women’s experiences of care during labour in a midwifery-led unit in the Republic of Ireland. British Journal of Midwifery 21(9):622-31.
Page L (2013). Midwifery in the UK: how do we move midwifery led care from fringe to mainstream? Women and Birth: the Journal of the Australian College of Midwives 26(3):165-6.
Sandall J, Soltani H, Gates S et al (2013). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, Issue 8. http://tinyurl.com/mzd9hqv [Accessed 1 October 2013].
Tracy SK, Hartz D, Tracy MB et al (2013). Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial. Lancet 17 September [online ahead of print].