Dr. Ron’s Research Review – January 1, 2014

© 2014

This week’s research review focuses on midwives.

A recent Cochrane review found that midwife led care delivers best outcomes, when compared with that delivered by a doctor led or a shared model of care in which both doctors and midwives provide care. (Sandall, Soltani et al. 2013) (McCarthy 2013)

With a midwife, they were less likely to:

undergo spinal or epidural regional analgesia (average risk ratio 0.83, 95% confidence interval 0.76 to 0.90, 13 trials, n = 15 982, Tau2 = 0.01, I2 = 48%),

have vaginal birth with instrumentation with forceps or vacuum (average risk ratio 0.88, 95% 0.81 to 0.96, 12 trials, n = 15 809), or

to give birth prematurely (average risk ratio 0.77, 95% 0.62 to 0.94, seven trials, n = 11 546, Tau2 = 0.03, I2 = 42%).

With a midwife, they were more likely to:

experience a spontaneous vaginal birth (average risk ratio 1.05, 95% 1.03 to 1.08, 11 trials, n = 14 995).

“Overall, we did not find any increased likelihood for any adverse outcome for women or their infants associated with having been randomized to a midwife led continuity model of care,” the researchers wrote.

They concluded, “Most women should be offered midwife led continuity 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.”

Dr. Ron


Articles

Midwife led care delivers best outcomes, Cochrane review finds

         (McCarthy 2013) Download

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

         (Sandall, Soltani et al. 2013) Download

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 continuity models and other models of care. OBJECTIVES: To compare midwife-led continuity models of care with other models of care for childbearing women and their infants. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2013) and reference lists of retrieved studies. SELECTION CRITERIA: All published and unpublished trials in which pregnant women are randomly allocated to midwife-led continuity models of care or other models of care during pregnancy and birth. DATA COLLECTION AND ANALYSIS: All review authors evaluated methodological quality. Two review authors checked data extraction. MAIN RESULTS: We included 13 trials involving 16,242 women. Women who had midwife-led continuity models of care were less likely to experience regional analgesia (average risk ratio (RR) 0.83, 95% confidence interval (CI) 0.76 to 0.90), episiotomy (average RR 0.84, 95% CI 0.76 to 0.92), and instrumental birth (average RR 0.88, 95% CI 0.81 to 0.96), and were more likely to experience no intrapartum analgesia/anaesthesia (average RR 1.16, 95% CI 1.04 to 1.31), spontaneous vaginal birth (average RR 1.05, 95% CI 1.03 to 1.08), attendance at birth by a known midwife (average RR 7.83, 95% CI 4.15 to 14.80), and a longer mean length of labour (hours) (mean difference (hours) 0.50, 95% CI 0.27 to 0.74). There were no differences between groups for caesarean births (average RR 0.93, 95% CI 0.84 to 1.02).Women who were randomised to receive midwife-led continuity models of care were less likely to experience preterm birth (average RR 0.77, 95% CI 0.62 to 0.94) and fetal loss before 24 weeks' gestation (average RR 0.81, 95% CI 0.66 to 0.99), although there were no differences in fetal loss/neonatal death of at least 24 weeks (average RR 1.00, 95% CI 0.67 to 1.51) or in overall fetal/neonatal death (average RR 0.84, 95% CI 0.71 to 1.00).Due to a lack of consistency in measuring women's satisfaction and assessing the cost of various maternity models, these outcomes were reported narratively. The majority of included studies reported a higher rate of maternal satisfaction in the midwifery-led continuity care model. Similarly there was a trend towards a cost-saving effect for midwife-led continuity care compared to other care models. AUTHORS' CONCLUSIONS: Most women should be offered midwife-led continuity 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.

References

McCarthy, M. (2013). "Midwife led care delivers best outcomes, Cochrane review finds." BMJ 347: f5321. [PMID: 23990636]

Sandall, J., H. Soltani, et al. (2013). "Midwife-led continuity models versus other models of care for childbearing women." Cochrane Database Syst Rev 8: CD004667. [PMID: 23963739]