Randomised, controlled trial of efficacy of midwife-managed care

doi:10.1016/S0140-6736(95)11207-3

The Lancet

Volume 348, Issue 9022, 27 July 1996, Pages 213-218

https://doi.org/10.1016/S0140-6736(95)11207-3 Get rights and content

Summary

Background

Midwife-managed programmes of care are being widely implemented although there has been little investigation of their efficacy. We have compared midwife-managed care with shared care (ie, care divided among midwives, hospital doctors, and general practitioners) in terms of clinical efficacy and women's satisfaction.

Methods

We carried out a randomised controlled trial of 1 299 pregnant women who had no adverse characteristics at booking (consent rate 81·9%). 648 women were assigned midwife-managed care and 651 shared care. The research hypothesis was that compared with shared care, midwife-managed care would produce fewer interventions, similar (or more favourable) outcomes, similar complications, and greater satisfaction with care. Data were collected by retrospective review of case records and self-report questionnaires. Analysis was by intention to treat.

Findings

Interventions were similar in the two groups or lower with midwife-managed care. For example, women in the midwife-managed group were less likely than women in shared care to have induction of labour (146 [23·9%] vs 199 [33·3%]; 95% CI for difference 4·4–14·5). Women in the midwife-managed group were more likely to have an intact perineum and less likely to have had an episiotomy (p=0·02), with no significant difference in perineal tears. Complication rates were similar. Overall, 32·8% of women were permanently transferred from midwife-managed care (28·7% for clinical reasons, 3·7% for non-clinical reasons). Women in both groups reported satisfaction with their care but the midwife-managed group were significantly more satisfied with their antenatal (difference in mean scores 0·48 [95% CI 0·41–0·55]), intrapartum (0·28 [0·18–0·37]), hospital-based postnatal care (0·57 [0·45–0·70]), and home-based postnatal care (0·33 [0·25–0·42]).

Interpretation

We conclude that midwife-managed care for healthy women, integrated within existing services, is clinically effective and enhances women's satisfaction with maternity care.

Introduction

The movement to implement change in maternity services so that the individual needs of women are more central to the provision of care has gathered pace in several western countries during the 1990s.1, 2, 3, 4, 5 In the UK, the predominant model of shared care–divided among midwives, hospital doctors, and general practitioners (family physicians)—has been called into question.1, 2, 3 The UK initiatives call for a lead role and greater responsibility for midwives, and support the development of programmes of care in which midwives hold their own caseloads and provide care throughout the antenatal, intrapartum, and postnatal periods. Such programmes are currently being implemented,6, 7 but there have been few randomised controlled trials of their efficacy.⁸ Published trials have concentrated on the intrapartum⁹ or antenatal and intrapartum periods.¹⁰

The Midwifery Development Unit (MDU) project at Glasgow Royal Maternity Hospital aimed to address this issue by implementing and assessing a midwife-managed programme of care for healthy women. Care was provided by a group of 20 midwives who volunteered to join the unit from the hospital's existing complement of midwives.¹¹ Each pregnant woman had a named midwife whom she met at the first antenatal visit and who aimed to provide the majority of planned episodes of care from booking to discharge to the health visitor. When the named midwife was unavailable, the woman was cared for by an associate midwife from the MDU team; women were referred to the obstetric medical team when there was deviation from normal, rather than at routinely specified times. The programme of care and its comparison with shared care have been described in detail elsewhere12, 13 (available from the MDU).

Since alternative models of maternity care are being widely implemented, they must be subjected to rigorous evaluation. The aim of this study was to compare midwife-managed care and shared care in terms of clinical efficacy and women's satisfaction. The randomised controlled trial was designed to address the hypothesis that compared with shared care, midwife-managed care would result in fewer interventions, similar (or more favourable) outcomes, similar complications, plus greater satisfaction with care and enhanced continuity of care and carer.

Section snippets

Design and participants

The study was carried out at Glasgow Royal Maternity Hospital, a major urban teaching hospital with around 5000 deliveries per year, serving a largely disadvantaged community.¹⁴ Between Jan 11, 1993, and Feb 25, 1994, all women booking for care at routine hospital-based consultant clinics were screened for eligibility; the criteria were residence within the hospital's catchment area, booking for antenatal care within 16 completed weeks of pregnancy, and absence of medical or obstetric

Results

Of the 1586 eligible women, 1299 (81·9%) consented to take part in the study. 651 women were assigned shared care and 648 midwife-managed care. Case records were available for 635 (97·5%) of the shared-care group and 643 (99·2%) in the midwife-managed group. The baseline characteristics of women in the two study groups were similar (table 1).

Women in the midwife-managed group were more likely than those in the shared-care group to return the third-trimester questionnaire (534 [85·3%] vs 487

Discussion

Our study examined the efficacy of midwife-managed care from booking to discharge to the health visitor and women's satisfaction with such care. The study was done in an inner-city community, and about two-thirds of women were from very deprived backgrounds. The analysis was by intended care group, which makes the comparison of types of care more realistic.

We found that compared with shared care, the midwife-managed care programme resulted in similar or reduced rates of interventions, similar

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Cited by (168)

Two decades of Birth Centre and midwifery-led care in South Australia, 1998–2016
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Birth Centres (BC) are underpinned by a philosophy of woman- centred care and were pivotal in growing models of midwifery-led care in South Australia (SA).
To describe BC utilisation and the growth of midwifery-led care in SA over the past two decades.
The SA Perinatal Statistics Collection was used to describe women birthing from 1998 to 2016. Number of births through midwifery-led services from 2004 to 2016 were obtained from unit managers. Analyses are descriptive.
Women who birthed in BC in SA from 1998 to 2016 comprised approximately 6% of all births per year, and numbers have remained static. Three BC models operate in SA, all with different capacity. Proportionally, women not born in Australia are as likely to birth in BC as labour wards. The proportion of women who received midwifery-led care (whether affiliated with a BC or not), increased from 8.3% in 1998 to 19.2% of all births in 2016. Of the women who received midwifery-led care in 2016, 15.3% went on to birth in a midwifery-led model of care.
Whilst the overall number of BC births has not increased, women seeking midwifery-led care has more than doubled over the past two decades. BC encompass the midwifery philosophy, quality of care, and a physical home-like environment. The BC models in SA are managed through the three tertiary maternity units enabling women to access publicly funded midwifery care and should be more widely available.
Sustaining quality midwifery care in a pandemic and beyond
2020, Midwifery
Citation Excerpt :
The loss of key evidence-informed aspects of safe, quality care will have long-lasting consequences for individuals, families, and wider society. These aspects may include continuity of care and carer; community-based services; midwifery-led, women-centred and individualised care that takes into account the context of women's lives; provision of public health information and support; optimising normal processes; avoiding unnecessary interventions; promoting skin-to-skin contact and attachment; enabling women to breastfeed; and supporting women's mental health (Turnbull et al., 1996; Begley et al., 2011; Birthplace in England Collaborative Group, 2011; Renfrew et al., 2014; Balogun et al., 2016; Sandall et al., 2016; Jaafar, Ho and Lee, 2016; Miller et al., 2016; Moore et al., 2016; Homer et al., 2017; McFadden et al., 2017; Stuebe, 2020; Birth Companions, 2020). Mental health is already likely to be adversely affected by the anxiety and fear generated by the coronavirus, so it is especially important not to aggravate this for women, or for staff, by unnecessary and potentially adverse changes to services (Maternal Mental Health Alliance, 2020).
A comparison of midwife-led care versus obstetrician-led care for low-risk women in Japan
2014, Women and Birth
Continuity of midwife-led care is recommended in maternity care because of its various positive outcomes. In Japan, midwife-led care is receiving broad attention as well. In order to popularise midwifery care within the entire system of perinatal care in Japan, there is a need to show evidence that continuity of midwife care for women will bring about positive outcomes.
The objectives of this study were to compare the health outcomes of women and infants who received midwife-led care with obstetrician-led care in Japan.
This was an observational study using non-random purposive sampling with a survey questionnaire. Settings where midwife-led care and obstetrician-led care were chosen by purposive samples. Participants were low-risk women who received antenatal care and delivered a term-singleton-infant at the participating settings during the research period. Measurements were: Women-centred care pregnancy questionnaire, Stein's maternity blues questionnaire, and Edinburgh Postnatal Depression Scale.
Midwife-led care was perceived by women to be beneficial and had no adverse outcomes compared to obstetrician-led care. Main findings are: (1) Perception of Women-centred care was higher; (2) Less premature rupture of membranes, and the Apgar scores of the infants were similar; (3) Exclusively breast-feeding during hospitalisation and at one-month postpartum; (4) Stein's maternity blues scale scores was lower in women who received midwife-led care than those who received obstetrician-led care.
Continuity of midwife-led care was perceived by women to be beneficial and had no adverse outcomes. Therefore, midwife-led care in low-risk pregnancy could be applicable and recommended.
The effectiveness of a Chinese midwives' antenatal clinic service on childbirth outcomes for primipare: A randomised controlled trial
2013, International Journal of Nursing Studies
Antenatal care is an important component of maternity care. In many parts of the world, midwives are the primary caregivers for childbearing women, providing a high level of continuity of care during a normal pregnancy. While in China, obstetricians are the primary providers of antenatal care for all childbearing women; and midwives only provide intrapartum care to labouring women. Today midwifery as a profession in China has been marginalised. Pregnant women usually lack individualised continuity of care from midwives during the perinatal period. There have been few randomised controlled trials of midwifery care practice in mainland China.
(1) To develop and implement a model of Chinese midwives’ antenatal clinic service and (2) to explore its effect on childbirth outcomes, psychological state and satisfaction, for primiparae.
Two-group randomised controlled trial. One hundred and ten pregnant women were assessed for eligibility and invited to participate in either the intervention group (midwives’ antenatal clinic service) or the control group (routine antenatal care) in the Obstetrics and Gynaecology Hospital of Fudan University from September 2011 to December 2011. Baseline data were collected, and then women were randomised to individual midwives’ antenatal clinic care (intervention group) or regular antenatal clinic service by obstetricians and obstetric nurse (control group). The research hypothesis was that compared with regular obstetrician-led antenatal care, the midwives’ antenatal clinic service would decrease the caesarean section rate, produce more favourable birth outcomes and women's greater satisfaction with care. Data were collected by retrospective review of case records and self-report questionnaires. The sample size of 110 was calculated to identify a decrease in caesarean birth from 70% to 40%. Birth outcomes, satisfaction and anxiety score in the two groups were compared.
The midwives’ antenatal clinic in the Obstetrics and Gynaecology Hospital of Fudan University, Shanghai, China.
55 women, attending the midwives’ antenatal clinic (the intervention group) and 55 women, entering the control group.
Women in the intervention group were more likely than women in the control group to have a vaginal birth (35 [66.04%] versus 23 [43.40%]; 95% CI for difference 3.69–41.60). Women in the intervention group had a higher perinatal satisfaction but lower anxiety score than those in the control group. No differences were seen in neonatal Apgar score and in the amount of bleeding 2 h post partum.
The midwives’ antenatal clinic can decrease the rate of caesarean section and enhance women's satisfaction with midwifery care. Further research needs to be conducted to implement this model of care more widely. We will attempt to make midwifery care a true choice for Chinese women.
‘There is no other option’: Exploring health care providers' experiences implementing regional multisite midwifery model of care in South Australia
2024, Australian Journal of Rural Health
A Bibliometric Analysis of Research Articles on Midwifery Based on the Web of Science
2023, Journal of Multidisciplinary Healthcare

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ArticlesRandomised, controlled trial of efficacy of midwife-managed care

Summary

Background

Methods

Findings

Interpretation

Introduction

Section snippets

Design and participants

Results

Discussion

Midwifery

Midwifery

Eur J Cancer

Second report on maternity services (Winterton report)

Changing childbirth. Part 1: report of the expert maternity group

Provision of maternity services in Scotland: a policy review

Final report of the study group to review birthing services in Victoria. Having a baby in Victoria

Final report of the Ministerial Task Force on Obstetric Services in New South Wales. Maternity Services in New South Wales

Mapping team midwifery. Institute of Manpower Studies report series 242

Midwife vs medical/shared care

Midwife managed delivery unit: a randomised controlled comparison with consultant led care

BMJ

Simulated home delivery in hospital: a randomised controlled trial

Br J Obstet Gynaecol

Articles
Randomised, controlled trial of efficacy of midwife-managed care