Midwife-led versus other models of care for childbearing women

Cochrane Review by Hatem M, Sandall J, Devane D, Soltani H, Gates S

This record should be cited as: Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub2.

ABSTRACT

Title

Midwife-led versus other models of care for childbearing women

Background

Midwives are primary providers of care for childbearing women around the world. However, there is a lack of synthesised information to establish whether there are differences in morbidity and mortality, effectiveness and psychosocial outcomes between midwife-led and other models of care.

Objectives

To compare midwife-led models of care with other models of care for childbearing women and their infants.

Search strategy

We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (January 2008), Cochrane Effective Practice and Organisation of Care Group’s Trials Register (January 2008), Current Contents (1994 to January 2008), CINAHL (1982 to August 2006), Web of Science, BIOSIS Previews, ISI Proceedings, (1990 to 2008), and the WHO Reproductive Health Library, No. 9.

Selection criteria

All published and unpublished trials in which pregnant women are randomly allocated to midwife-led or other models of care during pregnancy, and where care is provided during the ante and intrapartum period in the midwife-led model.

Data collection and analysis

All authors evaluated methodological quality. Two authors checked data extraction.

Main results

We included 11 trials (12,276 women). Women who had midwife-led models of care were less likely to experience antenatal hospitalisation, risk ratio (RR) 0.90, 95% confidence interval (CI) 0.81 to 0.99), regional analgesia (RR 0.81, 95%CI 0.73 to 0.91), episiotomy (RR 0.82, 95% CI 0.77 to 0.88), and instrumental delivery (RR 0.86, 95% CI 0.78 to 0.96), and were more likely to experience no intrapartum analgesia/anaesthesia (RR 1.16, 95% CI 1.05 to 1.29), spontaneous vaginal birth (RR 1.04, 95% CI 1.02 to 1.06), feeling in control during childbirth (RR 1.74, 95% CI 1.32 to 2.30), attendance at birth by a known midwife (RR 7.84, 95% CI 4.15 to 14.81) and initiate breastfeeding (RR 1.35, 95% CI 1.03 to 1.76), although there were no statistically significant differences between groups for caesarean births (RR 0.96, 95% CI 0.87 to 1.06). Women who were randomised to receive midwife-led care were less likely to experience fetal loss before 24 weeks’ gestation (RR 0.79, 95% CI 0.65 to 0.97), although there were no statistically significant differences in fetal loss/neonatal death of at least 24 weeks (RR 1.01, 95% CI 0.67 to 1.53) or in fetal/neonatal death overall (RR 0.83, 95% CI 0.70 to 1.00). In addition, their babies were more likely to have a shorter length of hospital stay (mean difference -2.00, 95% CI -2.15 to -1.85).

Authors' conclusions

Most women should be offered midwife-led models of care and women should be encouraged to ask for this option although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.

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