Midwife-led Continuity Research Articles

Exploration of preterm birth rates associated with different models of antenatal midwifery care in Scotland: Unmatched retrospective cohort analysis

Objectivespreterm birth represents a significant personal, clinical, organisational and financial burden. Strategies to reduce the preterm birth rate have had limited success. Limited evidence indicates that certain antenatal care models may offer some protection, although the causal mechanism is not understood. We sought to compare preterm birth rates for mixed-risk pregnant women accessing antenatal care organised at a freestanding midwifery unit (FMU) and mixed-risk pregnant women attending an obstetric unit (OU) with related community-based antenatal care. Methodsunmatched retrospective 4-year Scottish cohort analysis (2008–2011) of mixed-risk pregnant women accessing (i) FMU antenatal care (n=1107); (ii) combined community-based and OU antenatal care (n=7567). Data were accessed via the Information and Statistics Division of the NHS in Scotland. Aggregates analysis and binary logistic regression were used to compare the cohorts׳ rates of preterm birth; and of spontaneous labour onset, use of pharmacological analgesia, unassisted vertex birth, and low birth weight. Odds ratios were adjusted for age, parity, deprivation score and smoking status in pregnancy. Findingsafter adjustment the ‘mixed risk’ FMU cohort had a statistically significantly reduced risk of preterm birth (5.1% [n=57] versus 7.7% [n=583]; AOR 0.73 [95% CI 0.55–0.98]; p=0.034). Differences in these secondary outcome measures were also statistically significant: spontaneous labour onset (FMU 83.9% versus OU 74.6%; AOR 1.74 [95% CI 1.46–2.08]; p<0.001); minimal intrapartum analgesia (FMU 53.7% versus OU 34.4%; AOR 2.17 [95% CI 1.90–2.49]; p<0.001); spontaneous vertex delivery (FMU 71.9% versus OU 63.5%; AOR 1.46 [95% CI 1.32–1.78]; p<0.001). Incidence of low birth weight was not statistically significant after adjustment for other variables. There was no significant difference in the rate of perinatal or neonatal death. Conclusionsgiven this study׳s methodological limitations, we can only claim associations between the care model and or chosen outcomes. Although both cohorts were mixed risk, differences in risk levels could have contributed to these findings. Nevertheless, the significant difference in preterm birth rates in this study resonates with other research, including the recent Cochrane review of midwife-led continuity models. Because of the multiplicity of risk factors for preterm birth we need to explore the salient features of the FMU model which may be contributing to this apparent protective effect. Because a randomised controlled trial would necessarily restrict choice to pregnant women, we feel that this option is problematic in exploring this further. We therefore plan to conduct a prospective matched cohort analysis together with a survey of unit practices and experiences.

Professional and social support enhances maternal well-being in women with intellectual disability – A Swedish interview study

Objectiveto gain a deeper understanding of the experience of professional and social support during pregnancy and childbirth among women with intellectual disability (ID) in Sweden. Design/settingan interview study among 10 women with ID, who had given birth within seven years. Two interviews were performed with each woman and data were analysed with qualitative content analysis. Findingsthe overarching theme was: Professional and social support enhances maternal well-being in women with intellectual disability. The women described that the midwife and other caregivers contributed to their own insights and supported their mother-to-be process. They were mostly satisfied with the professional care and support during pregnancy and childbirth, based on aspects such as continuity, competence and professional experience of the midwives but also professional approach and working methods. Dissatisfaction and confusion occurred when questions were left unanswered or when the women׳s special needs were not taken into consideration. Family members, friends and colleagues could also have a supporting role and, together with the health staff, contribute to the well-being of the woman. Conclusionsif professional support and care from midwives and other caregivers is adapted to the special needs of women with ID, it contributes to new insights, enhances well-being and supports the process of becoming a mother. Midwife-led continuity of care together with continuous social support should be offered to pregnant women with ID during pregnancy and childbirth.

New global midwifery initiatives and why 2014 should be a good year for women and newborns

Global evidence demonstrates that countries which have prioritised skilled midwifery care within an enabling health systems environment, have achieved the most significant improvements in the survival of women and newborns (Graham et al., 2001). Recently, evidence from a Cochrane systematic review of midwife-led continuity of care versus other models of maternity care (Sandall et al., 2013) shows that women and newborns who receive midwife-led continuity of care experience positive maternal outcomes with fewer interventions with no statistically significant difference betweenmidwifery-led and other models of care in fetal loss or neonatal death (Sandall et al., 2013). Midwifery services are unique in that they combine public health and clinical health, combining access to professional care for all women and newborns in both the community and clinical facilities, and across the continuum of care. As such, midwifery services are extraordinarily well positioned to move forward in the post-2015 global health agendawith its evolving focus on universal access to care (UHC) (WHO, 2012). There are positive signs that the value of midwifery services, provided mainly by midwives in teams of professionals with a range of skills including advanced obstetrics and paediatrics, are increasingly being acknowledged as essential to the improvement of quality, not only coverage, of care provided to women, their newborns and families. We are in a good place. Several global initiatives are taking hold that that will progress this agenda. Firstly, a Global Midwifery symposium took place in May 2013 in Kuala Lumpur. This second symposium united midwives and key partners including government representatives, UN agencies, donors, the private sector, and the media in a focus on quality midwifery services. The main messages of the symposium were that we have more work to do before we can truly ensure that all those providing midwifery services have the skills needed, and that we must get better at defining and measuring the quality of care that women and newborns receive. The symposium closed with a strong global commitment to seven critical priorities needed to improve the quality of midwifery services. This ‘Declaration’ includes strengthening: investment; education; deployment; being women centred; regulation; support to midwives and nurses associations, and the evidence base to justify increased investment (The Second Global Midwifery Symposium, 2013). Secondly, UNFPA, WHO and the ICM are co-chairing a process that will launch the second State of the World's Midwifery (SOWMy) Report at the ICM Triennial Congress in Prague, June 2014. The first SOWMy report (UNFPA, 2011) was ground-breaking because it was the first document providing evidence about the global situation of midwifery. The absence of previous documentation on global midwifery underlies what has been a worrying lack of investment in critical midwifery services, despite the past two decades of support for reducing maternal and newborn deaths. This second report aims to go a long way to redress that imbalance. The third, much welcomed, initiative is the first ever Lancet Series on Midwifery (LSM). Due to be published in early 2014, the LSM will add to other landmark contributions to maternal and newborn health made by The Lancet including those on newborn survival, stillbirths, and nutrition. The LSM will set out a new maternal and newborn health framework centred on the needs of women and newborns and what skills are needed to provide the best quality care to women with both straightforward and complicated pregnancies. The LSM will call for significantly increased investment in research on the impact of midwives and midwifery services. This is much needed to provide the evidence on the uniqueness, and effectiveness, of midwifery services in terms of quality care. The fourth is the exciting Global ‘Every Newborn’ Action Plan (ENAP) led by WHO and UNICEF and anticipated in mid-2014. The ICM President is engaged in the process and midwives are already involved in global consultations. There is a dynamic website open to all who want to have a voice in how the role of midwives is reflected in this global document, as well as how the quality of newborn care can be improved through midwifery services at home and in facilities (http://dx.doi.org/www.everynewborn.org). The fifth initiative is all about stronger global co-ordination and financing mechanisms being applied to investing in midwifery services. The H4þ (health four ‘plus’) refers to the coming together of the key UN agencies responsible for maternal, newborn, adolescent and child health (UNFPA, UNICEF, WB and UNAIDS) ‘plus’ other partners. The H4þ is supporting the incountry development, with and through Ministries of Health, of one national plan for midwifery based within existing national

Achieving a positive balance

British Journal of MidwiferyVol. 21, No. 11 BirthwriteAchieving a positive balanceCathy WarwickCathy WarwickSearch for more papers by this authorCathy WarwickPublished Online:18 Nov 2013https://doi.org/10.12968/bjom.2013.21.11.766AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References National Perinatal Epidemiology Unit (2012) The Birthplace cohort study: Key findings. www.npeu.ox.ac.uk/birthplace/results (accessed 22 October 2013) Google ScholarNational Federation of Women's Institutes and NCT (2013) Support Overdue: Women's experiences of maternity services. NCT, London Google ScholarRoyal College of Midwives (2013) Evidence to the NHS Pay Review Body for 2014. RCM, London Google ScholarRoyal College of Midwives, Birthchoice UK (2013) Trends in Freestanding Midwife-led Units in England and Wales 2001-2013. RCM, London Google ScholarSandall J, Soltani H, Gates S, Shennan A, Devane D (2013) Midwife-led continuity models versus other models of care for childbearing women. The Cochrane Library 3: CD004667 Google ScholarTracy SK, Hartz DL, Tracy MB, Allen J, Forti A, Hall B, White J, Lainchbury A, Stapleton H, Beckmann M, Bisits A, Homer C, Foureur M, Welsh A, Kildea S (2013) Caseload midwifery care versus standard maternity care for women of any risk: [email protected], a randomised controlled trial. The Lancet 382: DOI: 10.1016/s0140-6736(13)61406-3 Crossref, Google Scholar FiguresReferencesRelatedDetailsCited byPriority issues from 0–199 March 2015 | British Journal of Midwifery, Vol. 23, No. 3Joint call for addressing issues in the 0–19 health-care service16 March 2015 | British Journal of School Nursing, Vol. 10, No. 2Priority issues from 0–1920 March 2015 | Journal of Health Visiting, Vol. 3, No. 3 1 November 2013Volume 21Issue 11ISSN (print): 0969-4900ISSN (online): 2052-4307 Metrics History Published online 18 November 2013 Published in print 1 November 2013 Information© MA Healthcare LimitedPDF download

Research on midwifery continuity of care shows many advantages

British Journal of MidwiferyVol. 21, No. 10 BirthwriteResearch on midwifery continuity of care shows many advantagesLesley PageLesley PageSearch for more papers by this authorLesley PagePublished Online:30 Sep 2013https://doi.org/10.12968/bjom.2013.21.10.690AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Birthplace in England Collaborative Group (2011) Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies. The Birthplace in England national prospective cohort study. BMJ 343 Crossref, Google ScholarDevane D, Brennan M, Begley C, Clarke M, Walsh D, Sandall J, Ryan P, Revill P Normand C (2010) Socioeconomic value of the Midwife. A systematic review, meta-analysis, meta-synthesis and economic analysis of midwife-led models of care. RCM, London Google ScholarPage L (2003) One-to-one midwifery: Restoring the “with woman” relationship in midwifery. Journal of Midwifery and Women's Health 48(2): 119–25 Crossref, Google ScholarPage L (2013) We’ve become blind to the risks of having babies by caesarean. theconversation.com/weve-become-blind-to-the-risks-of-having-babies-by-caesearean-14067 (accessed 16 September 2013) Google ScholarSandall J, Soltani H, Gates S, Shennan A, Devane D (2013) Midwife-led continuity models versus other models of care for childbearing women. The Cochrane Library 3: CD004667 Google ScholarTracy S, Tracy MB, Allan I, Forti A, Hall B, White J, Lainchbury A, Stapleton H, Beckman B, Bisits A, Homer C, Foureur M, Welsh A, Kildea S (2013) Caseload midwifery care versus standard maternity care for women of any risk: [email protected], a randomised controlled trial. The Lancet 382: DOI: 10.1016/s0140-6736(13)61406-3 Crossref, Google Scholar FiguresReferencesRelatedDetailsCited byContinuity or team-teaching approach for midwifery education? An exploratory qualitative study of student and academic preferencesWomen and Birth, Vol. 30Graduating midwifery students’ preferred model of practice and first job decisions: A qualitative studyWomen and Birth, Vol. 34, No. 1The known and trusted midwife5 April 2014 | British Journal of Midwifery, Vol. 22, No. 4Taking It Into Account: Caring for Disabled Mothers During Pregnancy and Birth1 January 2014 | International Journal of Childbirth, Vol. 4, No. 4 1 October 2013Volume 21Issue 10ISSN (print): 0969-4900ISSN (online): 2052-4307 Metrics History Published online 30 September 2013 Published in print 1 October 2013 Information© MA Healthcare LimitedPDF download

Evidence-based care series 1: Birth environment

Birth environment plays a pivotal role in the experience and outcome of childbirth and therefore the decision regarding place of birth is crucial. Choosing a home birth not only affirms the normality of childbirth but also endorses midwife-led care and continuity as important ingredients of care provision. It is also, in some senses, a political decision as the historical struggle over who controls maternity care illustrates. Yet, despite good evidence as to its efficacy for women at low obstetric risk, it remains a marginalized choice within current maternity care.