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Midwife-led continuity models versus other models of care for childbearing women

Sandall J, Soltani H, Gates S, Shennan A, Devane D
Published Online: 
21 August 2013

In many parts of the world, midwives are the main providers of care for childbearing women. Elsewhere, it may be obstetricians or family physicians that have the main responsibility for care; or the responsibility may be shared. The philosophy behind midwife-led continuity models is normality, continuity of care and being cared for by a known, trusted midwife during labour. The emphasis is on the natural ability of women to experience birth with minimum intervention. 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. This contrasts with medical-led models of care where an obstetrician or family physician is primarily responsible for care. In shared-care models, responsibility is shared between different healthcare professionals.

In this review we included models of care where midwives provided care throughout the pregnancy, and during labour and after birth. We identified 13 studies involving 16,242 women both at low and increased risk of complications. Midwife-led continuity of care was associated with several benefits for mothers and babies, and had no identified adverse effects compared with models of medical-led care and shared care. The main benefits were a reduction in the use of epidurals, with fewer episiotomies or instrumental births. Women's chances of being cared for in labour by a midwife she had got to know, and having a spontaneous vaginal birth were also increased. There was no difference in the number of caesarean births. Women who received midwife-led continuity of care were less likely to experience preterm birth, or lose their baby before 24 weeks' gestation, although there were no differences in the risk of losing the baby after 24 weeks, or overall. All trials included licensed midwives, and none included lay or traditional midwives. No trial included models of care that offered out of hospital birth.

The review concludes that most women should be offered midwife-led continuity models of care, although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.