A systematic review comparing continuity of midwifery care with standard maternity services

'There is no other option': Exploring health care providers' experiences implementing regional multisite midwifery model of care in South Australia

INTRODUCTION

In the past 30 years, 60% of South Australia's rural maternity units have closed. Evidence demonstrates midwifery models of care offer regional Australia sustainable birthing services. Five birthing sites within the York and Northern Region of South Australia, designed in collaboration with key stakeholders, offered a new all-risk midwifery continuity of care model (MMoC). All pregnant women in the region were allocated to a known midwife once pregnancy was confirmed. In July 2019, the pilot program was implemented and an evaluation undertaken.

OBJECTIVE

The study aimed to evaluate the effectiveness, acceptability, and sustainability of the new midwifery model of care from the perspective of health care providers.

DESIGN

The evaluation utilised a mixed methods design using focus groups and surveys to explore experiences of health care providers impacted by the implementation of the MMoC. This paper reports on midwives, doctors and nurses experiences at different time points, to gain insight into the model of care from the care providers impacted by the change to services.

FINDINGS

The first round of focus groups included 14 midwives, 6 hospital nurses/midwives and 5 doctors with the overarching theme that the 'MMoC was working well.' The second round of focus groups were undertaken across the five sites with 10 midwives, 9 hospital nurses/midwives and 5 doctors. The overarching theme captured all participants commitment to the MMoC, with agreement that 'there is no other option - it has to work'.

DISCUSSION

All participants reported positive outcomes and a strong commitment to navigate the changes required to implement the new model of care. Collaboration and communication was expressed as key elements for success. Specific challenges and complexities were evident including a need to clarify expectations and the workload for midwives, and for nurses who were accustomed to having midwives 24 hours a day in hospitals.

CONCLUSION

This innovative model responds to challenges in providing rural maternity care and offers a sustainable model for maternity services and workforce. There is an overwhelming commitment and consensus that there is 'no other option-it has to work'.

A systematic review of the cost-effectiveness of maternity models of care

OBJECTIVES

In this systematic review, we aimed to identify the full extent of cost-effectiveness evidence available for evaluating alternative Maternity Models of Care (MMC) and to summarize findings narratively.

METHODS

Articles that included a decision tree or state-based (Markov) model to explore the cost-effectiveness of an MMC, and at least one comparator MMC, were identified from a systematic literature review. The MEDLINE, Embase, Web of Science, CINAHL and Google Scholar databases were searched for papers published in English, Arabic, and French. A narrative synthesis was conducted to analyse results.

RESULTS

Three studies were included; all using cost-effectiveness decision tree models with data sourced from a combination of trials, databases, and the literature. Study quality was fair to poor. Each study compared midwife-led or doula-assisted care to obstetrician- or physician-led care. The findings from these studies indicate that midwife and doula led MMCs may provide value.

CONCLUSION

The findings of these studies indicate weak evidence that midwife and doula models of care may be a cost-effective or cost-saving alternative to standard care. However, the poor quality of evidence, lack of standardised MMC classifications, and the dearth of research conducted in this area are barriers to conclusive evaluation and highlight the need for more research incorporating appropriate models and population diversity.

Partners' expectations and experiences of the project 'Midwife All the Way': A qualitative study

INTRODUCTION

Continuity models of midwifery care are significant factors in facilitating a positive childbirth experience for birthing women. A knowledge gap exists regarding partners' experiences of continuity of midwifery care during pregnancy, birth, and after birth, although it is essential to understand the experiences of both parents in relation to continuity of care. Thus, the aim of this study was to highlight partners' expectations and experiences of having participated in a continuity of midwifery care project.

METHODS

A qualitative interview study using thematic analysis was carried out. Thirty-six partners in a rural area in northern Sweden were recruited after the closure of the local labor ward. Interviews were conducted in October 2019 and in May 2020.

RESULTS

An overarching theme: 'A partner-midwife relationship facilitated a sense of security'; and two themes 'The concept of availability' and 'The midwife's competence and professionalism' reflect partners' expectations and experiences after participating in a continuity of midwifery care project.

CONCLUSIONS

Professionalism was most highly valued, but establishing a relationship with a known midwife facilitated a sense of security. When birthing women feel safe with the known midwife, the partners also feel safe. Having to travel a long-distance to a labor ward caused concern for the partners. This highlights the importance of an organization that supports families to gain access to continuity models of midwifery care and to have a possibility to give birth closer to their residence. The results of this qualitative study further strengthen the growing evidence of the positive effects of continuity models of midwifery care.

How can human resources for health interventions contribute to sexual, reproductive, maternal, and newborn healthcare quality across the continuum in low- and lower-middle-income countries? A systematic review

BACKGROUND

Well-trained, competent, and motivated human resources for health (HRH) are crucial to delivering quality service provision across the sexual, reproductive, maternal, and newborn health (SRMNH) care continuum to achieve the 2030 Sustainable Development Goals (SDGs) maternal and neonatal health targets. This review aimed to identify HRH interventions to support lay and/or skilled personnel to improve SRMNH care quality along the continuum in low- and lower-middle-income countries (LLMICs).

METHODS

A structured search of CINAHL, Cochrane Library/trials, EMBASE, PubMed, SCOPUS, Web of Science, and HRH Global Resource Centre databases was undertaken, guided by the PRISMA framework. The inclusion criteria sought to identify papers with a focus on 1. HRH management, leadership, partnership, finance, education, and/or policy interventions; 2. HRH interventions' impact on two or more quality SRMNH care packages across the continuum from preconception to pregnancy, intrapartum and postnatal care; 3. Skilled and/or lay personnel; and 4. Reported primary research in English from LLMICs. A deductive qualitative content analysis was employed using the World Health Organization-HRH action framework.

RESULTS

Out of identified 2157 studies, 24 intervention studies were included in the review. Studies where ≥ 4 HRH interventions had been combined to target various healthcare system components, were more effective than those implementing ≤ 3 HRH interventions. In primary care, HRH interventions involving skilled and lay personnel were more productive than those involving either skilled or lay personnel alone. Results-based financing (RBF) and its policy improved the quality of targeted maternity services but had no impact on client satisfaction. Local budgeting, administration, and policy to deliver financial incentives to health workers and improve operational activities were more efficacious than donor-driven initiatives. Community-based recruitment, training, deployment, empowerment, supportive supervision, access to m-Health technology, and modest financial and non-financial incentives for community health workers (CHWs) improved the quality of care continuum. Skills-based, regular, short, focused, onsite, and clinical simulation, and/or mobile phone-assisted in-service training of skilled personnel were more productive than knowledge-based, irregular, and donor-funded training. Facility-based maternal and perinatal death reviews, coupled with training and certification of skilled personnel, positively affected SRMNH care quality across the continuum. Preconception care, an essential component of the SRMNH care continuum, lacks studies and services in LLMICs.

CONCLUSIONS

We recommend maternal and perinatal death audits in all health facilities; respectful, woman-centered care as a critical criterion of RBF initiatives; local administration of health worker allowances and incentives; and integration of CHWs into the healthcare system. There is an urgent need to include preconception care in the SRMNH care continuum and studies in LLMICs.

Measuring organizational readiness for implementing change (ORIC) in a new midwifery model of care in rural South Australia

BACKGROUND

The sustainability of Australian rural maternity services is under threat due to current workforce shortages. In July 2019, a new midwifery caseload model of care was implemented in rural South Australia to provide midwifery continuity of care and promote a sustainable workforce in the area. The model is unique as it brings together five birthing sites connecting midwives, doctors, nurses and community teams. A critical precursor to successful implementation requires those working in the model be ready to adopt to the change. We surveyed clinicians at the five sites transitioning to the new model of care in order to assess their organizational readiness to implement change.

METHODS

A descriptive study assessing readiness for change was measured using the Organizational Readiness for Implementing Change scale (ORIC). The 12 item Likert scale measures a participant's commitment to change and change efficacy. All clinicians working within the model of care (midwives, nurses and doctors) were invited to complete an e-survey.

RESULTS

Overall, 55% (56/102) of clinicians participating in the model responded. The mean ORIC score was 41.5 (range 12-60) suggesting collectively, midwives, nurses and doctors began the new model of care with a sense of readiness for change. Participants were most likely to agree on the change efficacy statements, "People who work here feel confident that the organization can get people invested in implementing this change and the change commitment statements "People who work here are determined to implement this change", "People who work here want to implement this change", and "People who work here are committed to implementing this change.

CONCLUSION

Results of the ORIC survey indicate that clinicians transitioning to the new model of care were willing to embrace change and commit to the new model. The process of organizational change in health care settings is challenging and a continuous process. If readiness for change is high, organizational members invest more in the change effort and exhibit greater persistence to overcome barriers and setbacks. This is the first reported use of the instrument amongst midwives and nurses in Australia and should be considered for use in other national and international clinical implementation studies.

Role of midwife-supported psychotherapy on antenatal depression, anxiety and maternal health: A meta-analysis and literature review

The onset of depression and anxiety during the antenatal stage of pregnancy is common. Despite the conception of numerous interventions in the past decades, studies show no signs of decline in the prevalence of antenatal depression and anxiety. Recently, the use of midwife-supported psychotherapy to treat these psychosomatic disorders has garnered a lot of attention. However, no attempt to date has been made to synthesize the evidence evaluating the influence of midwife-supported psychotherapy on antenatal depression, anxiety, and overall maternal health-status. The aim of the present meta-analysis was to demonstrate the effectiveness of midwife-supported psychotherapy on depression, anxiety, and maternal health-status outcome during the antenatal stage of pregnancy. A systematic identification of literature was performed according to PRISMA guidelines on four academic databases: MEDLINE, Scopus, EMBASE and CENTRAL. A meta-analysis evaluated the influence of midwife-supported psychotherapy on depression, anxiety, and maternal health-status outcome as compared to conventional obstetric care. Of the 1,011 records, 17 articles, including 6,193 pregnant women (mean age: 28.9±2.2 years) were included in this meta-analysis. Eleven studies compared the effects of midwife-supported therapy on depression, 14 compared its effects on anxiety and 2 compared its effects on maternal health-status outcome. The meta-analysis reveals the beneficial effects of midwife-supported psychotherapy for reducing depression (Hedge's g: -0.9), anxiety (-0.8) and enhancing maternal health-status outcome (0.1), as compared to conventional obstetric care. The current systematic review and meta-analysis recommend the use of midwife-supported psychotherapy for the reduction of depression, anxiety and enhancing maternal health-status during the antenatal stage of pregnancy.

Longitudinal continuity of care during antenatal and delivery in the Volta Region of Ghana

OBJECTIVE

To determine the extent of longitudinal continuity of care (CoC) during pregnancy and delivery in the Volta Region of Ghana.

METHODS

Longitudinal data were used from the National Health Insurance Claims Dataset for the period January to December 2013 for pregnant women who sought antenatal and delivery care in the region. Pregnant women who delivered at a health facility with at least three visits were included in the study. Five CoC indices were calculated for each pregnant woman.

RESULTS

Of the 14 474 pregnant women included in the study, 58.4% had perfect CoC. Mean CoC indices were: most frequent provider continuity (MFPC) 0.82 ± 0.25; modified, modified continuity index (MMCI) 0.86 ± 0.20; continuity of care index (COCI) 0.76 ± 0.30; sequential continuity index (SECON) 0.80 ± 0.28; and place of delivery continuity (PDC) 0.68 ± 0.41.

CONCLUSION

There are relatively medium to high levels of CoC indices during pregnancy and delivery, with place of delivery CoC having the lowest score, an indication that more pregnant women switched providers during delivery. There is a need for policy to ensure CoC during pregnancy.

Two decades of Birth Centre and midwifery-led care in South Australia, 1998-2016

BACKGROUND

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).

AIM

To describe BC utilisation and the growth of midwifery-led care in SA over the past two decades.

METHODS

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.

FINDINGS

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.

CONCLUSION

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.

Why we miss fetal growth restriction: Identification of risk factors for severely growth-restricted fetuses remaining undelivered by 40 weeks gestation

BACKGROUND

Severe fetal growth restriction (FGR) is a leading cause of adverse perinatal morbidity and mortality; however, in Victoria, 35% of severely growth-restricted infants are undelivered by 40 weeks gestation.

AIMS

We aimed to identify factors associated with failure to deliver severely growth-restricted fetuses by 40 weeks gestation.

METHODS

We conducted a retrospective case-control study of term singletons born <3rd centile for gestation at a single tertiary centre (2010-2017). Infants with a planned delivery for FGR between 37.0-39.6  weeks gestation ('planned birth' group; n = 187) were compared with those undelivered by 40.0  weeks ('undelivered' group; n = 233). Variables assessed included the presence of risk factors for FGR, model of care, symphyseal-fundal height measurements and third trimester ultrasounds.

RESULTS

An equivalent proportion of women were 'high-risk' for FGR on history (31.3% vs 38.0%, P = 0.187) in the planned and undelivered groups. Women booked under low-risk models (shared care and midwifery-led care) were significantly more likely to be in the undelivered group compared to those booked under traditional collaborative models (79.8% vs 37.4%, P < 0.001). Women in the undelivered group were less likely to have received a third trimester ultrasound (93.0% vs 40.3%, P < 0.001); however, they were more likely to have had a reassuring ultrasound with an estimation of fetal weight or abdominal circumference >10th centile (78.7% vs 16.1%, P < 0.001).

CONCLUSIONS

Failure to deliver the severely growth-restricted fetus before 40.0 weeks is more likely to occur in the following situations: (i) failure to receive an indicated third trimester ultrasound; (ii) the presence of falsely reassuring third trimester ultrasound scan; and (iii) booking under a low-risk rather than traditional collaborative models of care.

Midwife-led continuity models 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 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 (25 January 2016) 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

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

We included 15 trials involving 17,674 women. We assessed the quality of the trial evidence for all primary outcomes (i.e. regional analgesia (epidural/spinal), caesarean birth, instrumental vaginal birth (forceps/vacuum), spontaneous vaginal birth, intact perineum, preterm birth (less than 37 weeks) and all fetal loss before and after 24 weeks plus neonatal death using the GRADE methodology: all primary outcomes were graded as of high quality.For the primary outcomes, women who had midwife-led continuity models of care were less likely to experience regional analgesia (average risk ratio (RR) 0.85, 95% confidence interval (CI) 0.78 to 0.92; participants = 17,674; studies = 14; high quality), instrumental vaginal birth (average RR 0.90, 95% CI 0.83 to 0.97; participants = 17,501; studies = 13; high quality), preterm birth less than 37 weeks (average RR 0.76, 95% CI 0.64 to 0.91; participants = 13,238; studies = eight; high quality) and less all fetal loss before and after 24 weeks plus neonatal death (average RR 0.84, 95% CI 0.71 to 0.99; participants = 17,561; studies = 13; high quality evidence). Women who had midwife-led continuity models of care were more likely to experience spontaneous vaginal birth (average RR 1.05, 95% CI 1.03 to 1.07; participants = 16,687; studies = 12; high quality). There were no differences between groups for caesarean births or intact perineum.For the secondary outcomes, women who had midwife-led continuity models of care were less likely to experience amniotomy (average RR 0.80, 95% CI 0.66 to 0.98; participants = 3253; studies = four), episiotomy (average RR 0.84, 95% CI 0.77 to 0.92; participants = 17,674; studies = 14) and fetal loss less than 24 weeks and neonatal death (average RR 0.81, 95% CI 0.67 to 0.98; participants = 15,645; studies = 11). Women who had midwife-led continuity models of care were more likely to experience no intrapartum analgesia/anaesthesia (average RR 1.21, 95% CI 1.06 to 1.37; participants = 10,499; studies = seven), have a longer mean length of labour (hours) (mean difference (MD) 0.50, 95% CI 0.27 to 0.74; participants = 3328; studies = three) and more likely to be attended at birth by a known midwife (average RR 7.04, 95% CI 4.48 to 11.08; participants = 6917; studies = seven). There were no differences between groups for fetal loss equal to/after 24 weeks and neonatal death, induction of labour, antenatal hospitalisation, antepartum haemorrhage, augmentation/artificial oxytocin during labour, opiate analgesia, perineal laceration requiring suturing, postpartum haemorrhage, breastfeeding initiation, low birthweight infant, five-minute Apgar score less than or equal to seven, neonatal convulsions, admission of infant to special care or neonatal intensive care unit(s) or in mean length of neonatal hospital stay (days).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 midwife-led continuity models of care. Similarly, there was a trend towards a cost-saving effect for midwife-led continuity care compared to other care models.

AUTHORS' CONCLUSIONS

This review suggests that women who received midwife-led continuity models of care were less likely to experience intervention and more likely to be satisfied with their care with at least comparable adverse outcomes for women or their infants than women who received other models of care.Further research is needed to explore findings of fewer preterm births and fewer fetal deaths less than 24 weeks, and all fetal loss/neonatal death associated with midwife-led continuity models of care.

Midwife-led continuity models 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 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 (31 May 2015) 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

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

We included 15 trials involving 17,674 women. We assessed the quality of the trial evidence for all primary outcomes (i.e., regional analgesia (epidural/spinal), caesarean birth, instrumental vaginal birth (forceps/vacuum), spontaneous vaginal birth, intact perineum, preterm birth (less than 37 weeks) and overall fetal loss and neonatal death (fetal loss was assessed by gestation using 24 weeks as the cut-off for viability in many countries) using the GRADE methodology: All primary outcomes were graded as of high quality.For the primary outcomes, women who had midwife-led continuity models of care were less likely to experience regional analgesia (average risk ratio (RR) 0.85, 95% confidence interval (CI) 0.78 to 0.92; participants = 17,674; studies = 14; high quality), instrumental vaginal birth (average RR 0.90, 95% CI 0.83 to 0.97; participants = 17,501; studies = 13; high quality), preterm birth less than 37 weeks (average RR 0.76, 95% CI 0.64 to 0.91; participants = 13,238; studies = 8; high quality) and less overall fetal/neonatal death (average RR 0.84, 95% CI 0.71 to 0.99; participants = 17,561; studies = 13; high quality evidence). Women who had midwife-led continuity models of care were more likely to experience spontaneous vaginal birth (average RR 1.05, 95% CI 1.03 to 1.07; participants = 16,687; studies = 12; high quality). There were no differences between groups for caesarean births or intact perineum.For the secondary outcomes, women who had midwife-led continuity models of care were less likely to experience amniotomy (average RR 0.80, 95% CI 0.66 to 0.98; participants = 3253; studies = 4), episiotomy (average RR 0.84, 95% CI 0.77 to 0.92; participants = 17,674; studies = 14) and fetal loss/neonatal death before 24 weeks (average RR 0.81, 95% CI 0.67 to 0.98; participants = 15,645; studies = 11). Women who had midwife-led continuity models of care were more likely to experience no intrapartum analgesia/anaesthesia (average RR 1.21, 95% CI 1.06 to 1.37; participants = 10,499; studies = 7), have a longer mean length of labour (hours) (mean difference (MD) 0.50, 95% CI 0.27 to 0.74; participants = 3328; studies = 3) and more likely to be attended at birth by a known midwife (average RR 7.04, 95% CI 4.48 to 11.08; participants = 6917; studies = 7). There were no differences between groups for fetal loss or neonatal death more than or equal to 24 weeks, induction of labour, antenatal hospitalisation, antepartum haemorrhage, augmentation/artificial oxytocin during labour, opiate analgesia, perineal laceration requiring suturing, postpartum haemorrhage, breastfeeding initiation, low birthweight infant, five-minute Apgar score less than or equal to seven, neonatal convulsions, admission of infant to special care or neonatal intensive care unit(s) or in mean length of neonatal hospital stay (days).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 midwife-led continuity models of care. Similarly, there was a trend towards a cost-saving effect for midwife-led continuity care compared to other care models.

AUTHORS' CONCLUSIONS

This review suggests that women who received midwife-led continuity models of care were less likely to experience intervention and more likely to be satisfied with their care with at least comparable adverse outcomes for women or their infants than women who received other models of care.Further research is needed to explore findings of fewer preterm births and fewer fetal deaths less than 24 weeks, and overall fetal loss/neonatal death associated with midwife-led continuity models of care.

Students' understanding of "Women-Centred Care Philosophy" in midwifery care through Continuity of Care (CoC) learning model: a quasi-experimental study

BACKGROUND

The philosophy of midwifery education is based on the 'Women-centred care' model, which provides holistic care to women. Continuity of care (CoC) is integral to the concept of holistic women-centred care and fundamental to midwifery practice. The objective of this study was to determine any differences in students' understanding of midwifery care philosophy between students who underwent the CoC learning model and those who underwent the fragmented care learning model.

METHOD

We used a quasi-experiment design. This study was conducted by all final year midwifery students at two schools of midwifery in Indonesia. Fifty four students from one school attended 6 months of clinical training using the CoC learning model. The control group was comprised of 52 students from the other school. These students used the conventional clinical training model (the fragmented care learning model). The independent T-test using SPSS was used to analyse the differences between the two groups of students in terms of understanding midwifey care philosophy in five aspects (personalized, holistic, partnership, collaborative, and evidence-based care).

RESULTS

There were no significant differences between the groups before interventon. There were significant differences between the two groups after clinical training (p < 0.01). The mean post-clinical score of students using all five aspects of the CoC clinical learning model (15.96) was higher than that of the students in the control group (10.65). The CoC clinical learning model was shown to be a unique learning opportunity for students to understand the philosophy of midwifery. Being aligned with midwifery patients and developing effective relationships with them offered the students a unique view of midwifery practice. This also promoted an increased understanding of the philosophy of women-centred care. Zero maternal mortality rate was found in the experiment group.

CONCLUSION

The results of this study suggest that clinical trainingwith a CoC learning model is more likely to increase students' understanding of midwifery care philosophy. This in turn improves the quality ofclinical care, thereby enhancing overall health benefits for women.

Women's views about maternity care: how do women conceptualise the process of continuity?

OBJECTIVE

to gain an understanding of how women conceptualise continuity of maternity care.

DESIGN

a qualitative study involving in-depth semi-structured interviews and thematic analysis.

SETTING

a range of urban and rural public hospitals in New South Wales, Australia.

PARTICIPANTS

53 women aged 18-44 years (median age 27 years) receiving maternity care in 2011-2012.

FINDINGS

responses from women suggested five concepts of continuity: continuity of staff, continuity of relationship, continuity of information, continuity across pregnancies and continuity across locations. These concepts of continuity differed by parity and location.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

continuity of maternity care has a variety of meanings to women. If health care providers are to commit to providing woman-centred maternity care it is important to recognise the diversity of women's experiences, and ensure that systems of care are flexible and appropriate to women's circumstances and needs.

Reconceptualising failure to rescue in midwifery: a concept analysis

AIM

to reconceptualise the concept of failure to rescue, distinguishing it from its current scientific usage as a surveillance strategy to recognise physiologic decline.

BACKGROUND

failure to rescue has been consistently defined as a failure to save a patient׳s life after development of complications. The term, however, carries a richer connotation when viewed within a midwifery context. Midwives have historically believed themselves to be the vanguards of normal, physiologic processes, including birth. This philosophy mandates careful consideration of what it means to promote normal birth and the consequences of failure to rescue women from processes which challenge that outcome.

DATA SOURCES

the Medline, CINAHL, PsycINFO, PubMED, Web of Science and Google Scholar databases were searched from the period of 1992-2014 using the key terms of concept analysis, failure-to-rescue, childbirth, midwifery outcomes, obstetrical outcomes, suboptimal care, and patient outcomes. English language reports were used exclusively. The search yielded 45 articles which were reviewed in this paper.

REVIEW METHOD

a critical analysis of the published literature was undertaken as a means of determining the adequacy of the concept for midwifery practice and to detail how it relates to other concepts important in development of a conceptual framework promoting normal birth processes.

FINDINGS

failure to rescue within the context of the midwifery model of care requires robust attention to a midwifery managed setting and surveillance based on a caring presence, patient protection, and midwifery partnership with patient.

CONCLUSION

clarifying the definition of failure to rescue in childbirth and defining its attributes can help inform midwifery providers throughout the world of the ethical importance of considering failure to rescue in clinical practice. Relevance to midwifery care mandates use of failure to rescue as both a process and outcome measure.

Midwife-led continuity models 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 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.

The effectiveness of a Chinese midwives' antenatal clinic service on childbirth outcomes for primipare: a randomised controlled trial

BACKGROUND

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.

OBJECTIVE

(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.

DESIGN AND METHODS

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.

SETTING

The midwives' antenatal clinic in the Obstetrics and Gynaecology Hospital of Fudan University, Shanghai, China.

PARTICIPANTS

55 women, attending the midwives' antenatal clinic (the intervention group) and 55 women, entering the control group.

RESULTS

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 2h post partum.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

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.

Reflective practice groups for nurses: a consultation liaison psychiatry nursing initiative: part 2--the evaluation

This paper outlines an evaluation of reflective practice groups (RPG) involving nurses and midwives from three clinical nursing specialties at Redcliffe and Caboolture Hospitals, Queensland, Australia. The groups were facilitated by the consultation liaison psychiatry nurse and author using a process-focused, whole-of-group approach to explore clinical narrative in a supportive group setting. This was a preliminary evaluation utilizing a recently-developed tool, the Clinical Supervision Evaluation Questionnaire, along with externally-facilitated focus groups. Nurses and midwives responded favourably to RPG, reporting a positive impact on clinical practice, self-awareness, and resilience. The majority of participants considered RPG had positive implications for team functioning. The focus groups identified the importance of facilitation style and the need to address aspects of workplace culture to enable group development and enhance the capacity for reflection. Evaluation of the data indicates this style of RPG can improve reflective thinking, promote team cohesion, and provide support for nurses and midwives working in clinical settings. Following on from this study, a second phase of research has commenced, providing more detailed, longitudinal evaluation across a larger, more diverse group of nurses.

Expanding access to midwifery care: using one practice's success to create community change

Starting in 1991, Marin's County Certified Nurse-Midwife-Physician Collaborative Practice has proven to be a successful model of care for underinsured women. Functioning within the same hospital as traditional physician-led practices, the practice displayed excellent clinical outcomes and gained respect within the community. Twenty years later, the Marin obstetric community decided to restructure its programs to incorporate the care of underinsured and privately insured women into one system. The goal was to design a system that would be patient-centered, financially and professionally sustainable, and accessible to all women and would provide evidence-based care with excellent outcomes. The community agreed, based on its own experience and on current literature, that continuing and expanding the midwife-led model of care was a way to achieve these goals. Here we describe the history, practice, and outcomes of Marin's county practice and the factors that contributed to extending the availability of midwifery care to privately insured women.

Exploring implementation and sustainability of models of care: can theory help?

OBJECTIVE

Research on new models of care in health service provision is complex, as is the introduction and embedding of such models, and positive research findings are only one factor in whether a new model of care will be implemented. In order to understand why this is the case, research design must not only take account of proposed changes in the clinical encounter, but the organisational context that must sustain and normalise any changed practices. We use two case studies where new models of maternity care were implemented and evaluated via randomised controlled trials (RCTs) to discuss how (or whether) the use of theory might inform implementation and sustainability strategies. The Normalisation Process Model is proposed as a suitable theoretical framework, and a comparison made using the two case studies - one where a theoretical framework was used, the other where it was not. CONTEXT AND APPROACH: In the maternity sector there is considerable debate about which model of care provides the best outcomes for women, while being sustainable in the organisational setting. We explore why a model of maternity care--team midwifery (where women have a small group of midwives providing their care)-- that was implemented and tested in an RCT was not continued after the RCT's conclusion, despite showing the same or better outcomes for women in the intervention group compared with women allocated to usual care. We then discuss the conceptualisation and rationale leading to the use of the 'Normalisation Process Model' as an aid to exploring aspects of implementation of a caseload midwifery model (where women are allocated a primary midwife for their care) that has recently been evaluated by RCT.

DISCUSSION

We demonstrate how the Normalisation Process Model was applied in planning of the evaluation phases of the RCT as a means of exploring the implementation of the caseload model of care. We argue that a theoretical understanding of issues related to implementation and sustainability can make a valuable contribution when researching complex interventions in complex settings such as hospitals.

CONCLUSION AND IMPLICATIONS

Application of a theoretical model in the research of a complex intervention enables a greater understanding of the organisational context into which new models of care are introduced and identification of factors that promote or challenge implementation of these models of care.

A randomised controlled trial of caseload midwifery care: M@NGO (Midwives @ New Group practice Options)

BACKGROUND

Australia has an enviable record of safety for women in childbirth. There is nevertheless growing concern at the increasing level of intervention and consequent morbidity amongst childbearing women. Not only do interventions impact on the cost of services, they carry with them the potential for serious morbidities for mother and infant.Models of midwifery have proliferated in an attempt to offer women less fragmented hospital care. One of these models that is gaining widespread consumer, disciplinary and political support is caseload midwifery care. Caseload midwives manage the care of approximately 35-40 a year within a small Midwifery Group Practice (usually 4-6 midwives who plan their on call and leave within the Group Practice.) We propose to compare the outcomes and costs of caseload midwifery care compared to standard or routine hospital care through a randomised controlled trial.

METHODS/DESIGN

A two-arm RCT design will be used. Women will be recruited from tertiary women's hospitals in Sydney and Brisbane, Australia. Women allocated to the caseload intervention will receive care from a named caseload midwife within a Midwifery Group Practice. Control women will be allocated to standard or routine hospital care. Women allocated to standard care will receive their care from hospital rostered midwives, public hospital obstetric care and community based general medical practitioner care. All midwives will collaborate with obstetricians and other health professionals as necessary according to the woman's needs.

DISCUSSION

Data will be collected at recruitment, 36 weeks antenatally, six weeks and six months postpartum by web based or postal survey. With 750 women or more in each of the intervention and control arms the study is powered (based on 80% power; alpha 0.05) to detect a difference in caesarean section rates of 29.4 to 22.9%; instrumental birth rates from 11.0% to 6.8%; and rates of admission to neonatal intensive care of all neonates from 9.9% to 5.8% (requires 721 in each arm). The study is not powered to detect infant or maternal mortality, however all deaths will be reported. Other significant findings will be reported, including a comprehensive process and economic evaluation.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12609000349246.

Parents' experiences of midwifery students providing continuity of care

OBJECTIVE

the aim of this study was to gain knowledge and a deeper understanding of the value attached by parents to relational continuity provided by midwifery students to the woman and her partner during the childbearing process. The focus of the study was on the childbirth and the postnatal home visit.

DESIGN/SETTING

in this pilot project by researchers at Sør-Trøndelag University College, Norway, six midwifery students provided continuity of care to 58 women throughout their pregnancy, birth and the postnatal period. One group interview of eight women and two group interviews of five men, based on the focus group technique, were conducted at the end of the project. Qualitative data were analysed through systematic text condensation.

FINDINGS

the findings included two main themes: 'trusting relationship' and 'being empowered'. The sub-themes of a 'trusting relationship' were 'relational continuity' and 'presence'. For the women, relational continuity was important throughout the childbearing process, but the men valued the continuous presence during birth most highly. 'Being empowered' had two sub-themes: 'individual care' and 'coping'. For the women, individual care and coping with birth were important factors for being empowered. The fathers highlighted the individual care as necessary to feel empowered for early parenting. The home visit of the student was highly appreciated. The relationship with the midwifery student could be concluded, and they had the opportunity to review the progression of the birth with the student who had been present during the birth. During the home visit, the focus was more on the experiences of pregnancy and birth than on what lay ahead.

KEY CONCLUSIONS

when midwifery students provided continuous care during pregnancy, birth and the postnatal period, both women and men experienced a trusting relationship. Relational continuity was important for women in the entire process, but for the men this was mostly important during childbirth. Individual care and coping with birth and early parenting enhanced empowerment. The limited sample size in this study means that it cannot be generalised without caution, and further research is needed.

The effectiveness of antenatal care programmes to reduce infant mortality and preterm birth in socially disadvantaged and vulnerable women in high-income countries: a systematic review

BACKGROUND

Infant mortality has shown a steady decline in recent years but a marked socioeconomic gradient persists. Antenatal care is generally thought to be an effective method of improving pregnancy outcomes, but the effectiveness of specific antenatal care programmes as a means of reducing infant mortality in socioeconomically disadvantaged and vulnerable groups of women has not been rigorously evaluated.

METHODS

We conducted a systematic review, focusing on evidence from high income countries, to evaluate the effectiveness of alternative models of organising or delivering antenatal care to disadvantaged and vulnerable groups of women vs. standard antenatal care. We searched Medline, Embase, Cinahl, PsychINFO, HMIC, CENTRAL, DARE, MIDIRS and a number of online resources to identify relevant randomised and observational studies. We assessed effects on infant mortality and its major medical causes (preterm birth, congenital anomalies and sudden infant death syndrome (SIDS)) RESULTS: We identified 36 distinct eligible studies covering a wide range of interventions, including group antenatal care, clinic-based augmented care, teenage clinics, prenatal substance abuse programmes, home visiting programmes, maternal care coordination and nutritional programmes. Fifteen studies had adequate internal validity: of these, only one was considered to demonstrate a beneficial effect on an outcome of interest. Six interventions were considered 'promising'.

CONCLUSIONS

There was insufficient evidence of adequate quality to recommend routine implementation of any of the programmes as a means of reducing infant mortality in disadvantaged/vulnerable women. Several interventions merit further more rigorous evaluation.

'Lending the space': midwives' perceptions of birth space and clinical risk management

OBJECTIVES

to explore and describe midwives perceptions of birth space and clinical risk management and their impact on practice both before and after a move to a new facility.

DESIGN

an exploratory descriptive study utilising a modified participatory approach and observation and focus groups for data collection.

SETTING

a major metropolitan maternity hospital in Victoria, Australia.

PARTICIPANTS

18 midwives, including graduate year midwives, caseload midwives and hospital midwives working normal shifts, employed within a hospital.

FINDINGS

the major themes identified were perceptions of birth space, perceptions of risk management, influence of birth space and risk management on practice and moving but not changing: geographical space and practice. Midwives desire to create the ideal birth space was hampered by a prevailing biomedical discourse which emphasised risk. Midwives in all three groups saw themselves as the gatekeepers, 'holding the space' or 'providing a bridge' for women, often in the face of a hierarchical hospital structure with obstetricians governing practice. This situation did not differ significantly after the relocation to the new hospital. Despite a warmer, more spacious and private birth space midwives felt the care was still influenced by the old hierarchical hospital culture. Caseload midwives felt they had the best opportunity to make a difference to women's experience because they were able, through continuity of care, to build trusting relationships with women during the antenatal period.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

although the physical environment can make a marginal contribution to an optimal birth space, it has little effect on clinical risk management practices within a major public hospital and the way in which this impacts midwives' practice. The importance of place and people are the key to providing an optimal birth space, as are women centred midwifery models of care and reasonable workloads.

Childbirth embodiment: problematic aspects of current understandings

The experience of childbirth is one of the most corporeal of the human condition. Against a backdrop of profound change in the milieu of birthing over the past 30 years, especially in the developed world, a number of discourses now compete for the status of the safest, most fulfilling birth experience. Supporters of biomedical and 'natural' approaches make their respective claims to those, with obstetricians broadly aligning their professional interests with the former and midwives with the latter. There is mounting evidence that childbearing women's experiences of birth are often shaped in the uneasy space between the two. Within sociological discourse in health, embodiment is a dominant theme but, to date, research has concentrated mainly on new reproductive technologies, and there is a dearth of recent research and theorising around the act of parturition itself. This paper argues that because of this, there has been a polarising tendency in current discourses which is having a largely negative impact on women, professionals and the maternity services. A call is made for an integration of traditional childbirth embodiment theories, mediated through compassionate, relationally focused maternity care, especially when labour complications develop.

Primary birthing attendants and birth outcomes in remote Inuit communities--a natural "experiment" in Nunavik, Canada

BACKGROUND

There is a lack of data on the safety of midwife-led maternity care in remote or indigenous communities. In a de facto natural "experiment", birth outcomes were assessed by primary birthing attendant in two sets of remote Inuit communities.

METHODS

A geocoding-based retrospective birth cohort study in 14 Inuit communities of Nunavik, Canada, 1989-2000: primary birth attendants were Inuit midwives in the Hudson Bay (1529 Inuit births) vs western physicians in Ungava Bay communities (1197 Inuit births). The primary outcome was perinatal death. Secondary outcomes included stillbirth, neonatal death, post-neonatal death, preterm, small-for-gestational-age and low birthweight birth. Multilevel logistic regression was used to obtain the adjusted odds ratios (aOR) controlling for maternal age, marital status, parity, education, infant sex and plurality, community size and community-level random effects.

RESULTS

The aORs (95% confidence interval) for perinatal death comparing the Hudson Bay vs Ungava Bay communities were 1.29 (0.63 to 2.64) for all Inuit births and 1.13 (0.48 to 2.47) for Inuit births at > or =28 weeks of gestation. There were no statistically significant differences in the crude or adjusted risks of any of the outcomes examined.

CONCLUSION

Risks of perinatal death were somewhat but not significantly higher in the Hudson Bay communities with midwife-led maternity care compared with the Ungava Bay communities with physician-led maternity care. These findings are inconclusive, although the results excluding extremely preterm births are more reassuring concerning the safety of midwife-led maternity care in remote indigenous communities.

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 independently checked the 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), the use of 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), to feel in control during labour and 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). In addition, 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), and their babies were more likely to have a shorter length of hospital stay (mean difference -2.00, 95% CI -2.15 to -1.85). There were no statistically significant differences between groups for overall fetal loss/neonatal death (RR 0.83, 95% CI 0.70 to 1.00), or fetal loss/neonatal death of at least 24 weeks (RR 1.01, 95% CI 0.67 to 1.53).

AUTHORS' CONCLUSIONS

All women should be offered midwife-led models of care and women should be encouraged to ask for this option.

Doing midwifery between different belief systems

Childbirth has been increasingly concentrated in large centralised hospitals, with a parallel trend toward more birth interventions in Norway. These changes have resulted in new ways of framing birth from: a normal woman's life experience to a medical event. Caring for the birthing mother in a modern centralised ward, take place between two different belief- systems: a biomedical and a phenomenological. A phenomenological account of seven midwives' descriptions of skilled midwifery in a Norwegian high-technology labour ward was carried out. The focus was on how skilled midwives experience their daily work between a biomedical and a phenomenological belief system. Three themes were identified: (1) sensing where the woman is in labour, (2) being available for but not overbearing to the women and (3) being in a room of struggle. The findings are discussed from the perspective of being between these two belief-systems, with special focus on wise midwifery judgement as a way of managing the struggle.

COSMOS: COmparing Standard Maternity care with one-to-one midwifery support: a randomised controlled trial

Background

In Australia and internationally, there is concern about the growing proportion of women giving birth by caesarean section. There is evidence of increased risk of placenta accreta and percreta in subsequent pregnancies as well as decreased fertility; and significant resource implications. Randomised controlled trials (RCTs) of continuity of midwifery care have reported reduced caesareans and other interventions in labour, as well as increased maternal satisfaction, with no statistically significant differences in perinatal morbidity or mortality. RCTs conducted in the UK and in Australia have largely measured the effect of teams of care providers (commonly 6–12 midwives) with very few testing caseload (one-to-one) midwifery care. This study aims to determine whether caseload (one-to-one) midwifery care for women at low risk of medical complications decreases the proportion of women delivering by caesarean section compared with women receiving 'standard' care. This paper presents the trial protocol in detail.

Methods/design

A two-arm RCT design will be used. Women who are identified at low medical risk will be recruited from the antenatal booking clinics of a tertiary women's hospital in Melbourne, Australia. Baseline data will be collected, then women randomised to caseload midwifery or standard low risk care. Women allocated to the caseload intervention will receive antenatal, intrapartum and postpartum care from a designated primary midwife with one or two antenatal visits conducted by a 'back-up' midwife. The midwives will collaborate with obstetricians and other health professionals as necessary. If the woman has an extended labour, or if the primary midwife is unavailable, care will be provided by the back-up midwife. For women allocated to standard care, options include midwifery-led care with varying levels of continuity, junior obstetric care and community based general medical practitioner care. Data will be collected at recruitment (self administered survey) and at 2 and 6 months postpartum by postal survey. Medical/obstetric outcomes will be abstracted from the medical record. The sample size of 2008 was calculated to identify a decrease in caesarean birth from 19 to 14% and detect a range of other significant clinical differences. Comprehensive process and economic evaluations will be conducted.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN012607000073404.

Woman and midwives: position, problems and potential

OBJECTIVE

to describe and analyse birthing models in a number of countries, particularly Samoa and China, that have been the focus of my recent research; to discuss how cultural frameworks, colonisation and ideas of what is 'modern' influence the nature, place of birth and its attendant.

IMPLICATIONS FOR PRACTICE

midwives need to reflect on their practice and consider broader health policy and how it affects health systems. They also need to understand the social, economic, historical and cultural context of practice, including the influence of gender inequality and attitudes to women and themselves as midwives.

Do we have enough evidence to judge midwife led maternity units safe? No

The UK government claims it is trying to give women more choice by converting local maternity units to midwife led services. Lesley Page believes such units improve the birth experience, but Jim Drife remains worried about the risks of delivering outside hospital

A literature review on integrated perinatal care

CONTEXT

The perinatal period is one during which health care services are in high demand. Like other health care sub-sectors, perinatal health care delivery has undergone significant changes in recent years, such as the integrative wave that has swept through the health care industry since the early 1990s.

PURPOSE

The present study aims at reviewing scholarly work on integrated perinatal care to provide support for policy decision-making.

RESULTS

Researchers interested in integrated perinatal care have, by assessing the effectiveness of individual clinical practices and intervention programs, mainly addressed issues of continuity of care and clinical and professional integration.

CONCLUSIONS

Improvements in perinatal health care delivery appear related not to structurally integrated health care delivery systems, but to organizing modalities that aim to support woman-centred care and cooperative clinical practice.

Outcomes of the first midwife-led birth centre in Italy: 5 years’ experience

OBJECTIVE

To assess the experience of the first 5 years of the first midwife-led birth centre (MLBC) in Italy.

STUDY DESIGN

Data were prospectively collected to analyse the first 5 years' experience of the MLBC. MLBC is located alongside a University hospital maternity unit and it offers care to women with a straightforward pregnancy and midwives take primary professional responsibility for care. Women with maternal diseases, complicated obstetric history, height < 150 cm, maternal age > 45, or multiple pregnancy were excluded. Transfer was request in case of antenatal, intrapartum and postpartum pathological conditions.

RESULTS

During the 5-year period (1 January 2001-31 December 2005), 1,438 low-risk women were admitted in labour to the MLBC. Of these, 203 (14.1%) were transferred during labour to consultant care (138 because of pathologies and 65 because of request of epidural analgesia). Among the transfers, the caesarean sections were 87, corresponding to 6.1% (87/1,438) of the total of women admitted to MLBC, while the operative vaginal deliveries were 14, corresponding to 1.0% (14/1,438) of the total of women admitted to MLBC. Among women who gave birth in the MLBC, episiotomy rate was 17.1%.

CONCLUSIONS

In Italy, in the passed 10 years, the caesarean section rate reached 60%, in some regions. According to our data, the first 5 years of activity of the first MLBC in Italy had been associated with a low rate of medical interventions during labour and birth, with high rates of spontaneous vaginal birth and without signs of complications. We hope that this experience could be taken as a model to improve the quality of maternity care in Italy.

The importance of reciprocity in relationships between community-based midwives and mothers

OBJECTIVE

to explore the emotion work experiences of community-based midwives, focusing on their relationships with clients.

DESIGN

a qualitative study using an ethnographic approach. Data were collected via observation, interview and focus groups.

SETTING

a National Health Service (NHS) Trust in South Wales, UK.

PARTICIPANTS

a purposive sample of 19 NHS community-based midwives, working in different teams and with differing lengths of clinical experience.

FINDINGS

relationships between midwives and women varied considerably, and could be the source of emotion work for midwives. A model of midwife-woman relationships is proposed, based on the concept of reciprocity. Four key situations are identified: balanced exchanges, rejected exchanges, reversed exchanges and unsustainable exchanges. Balanced exchanges occur when there is 'give and take' on both sides; these are emotionally rewarding for the midwife. The other exchanges are out of balance, and require emotion work by the midwife.

KEY CONCLUSIONS

the concept of reciprocity is a useful analytical tool that enhances understanding of midwife-woman relationships and the emotion work that these may generate. Increased understanding of these issues is important, given the current national and international policy recommendations for health-care professionals to work in partnership with clients.

IMPLICATIONS FOR PRACTICE

the midwife-woman relationship and the factors that affect it need to be explicitly addressed within educational settings, in order to further develop interpersonal and communication skills. In turn, this should enhance the emotional well-being of midwives and the quality of care that women receive. Additional research is needed to further develop and refine the model.

Safety and Community: The Maternity Care Needs of Rural Parturient Women

OBJECTIVE

To investigate rural parturient women's experiences of obstetric care in the context of the social and economic realities of life in rural, remote, and small urban communities.

METHODS

Data collection for this exploratory qualitative study was carried out in 7 rural communities chosen to represent diversity of size, distance to hospital with Caesarean section capability and distance to secondary hospital, usual conditions for transport and access, and cultural and ethnic subpopulations. We interviewed 44 women who had given birth up to 24 months before the study began.

RESULTS

When asked about their experiences of giving birth in rural communities, many participants spoke of unmet needs and their associated anxieties. Self-identified needs were largely congruent with the deficit categories of Maslow's hierarchy of needs, which recognizes the contingency and interdependence of physiological needs, the need for safety and security, the need for community and belonging, self-esteem needs, and the need for self-actualization. For many women, community was critical to meeting psychosocial needs, and women from communities that currently have (or have recently had) access to local maternity care said that being able to give birth in their own community or in a nearby community was necessary if their obstetric needs were to be met.

CONCLUSION

Removing maternity care from a community creates significant psychosocial consequences that are imperfectly understood but that probably have physiological implications for women, babies, and families. Further research into rural women's maternity care that considers the loss of local maternity care from multiple perspectives is needed.

Safety of birth centre care: perinatal mortality over a 10-year period

OBJECTIVE

To study perinatal mortality in women booked for birth centre care during pregnancy.

DESIGN

Retrospective cohort study.

SETTING

In-hospital birth centre and standard maternity care in Stockholm.

POPULATION

Two thousand and five hundred and thirty-four women (3256 pregnancies) admitted to an in-hospital birth centre over 10 years (1989-2000) and 126818 women (180380 pregnancies) who gave birth in standard care during the same period and who met the same medical inclusion criteria as in the birth centre. Multiple pregnancies were excluded.

METHODS

Data were collected from the Swedish Medical Birth Register. Information on all cases of perinatal death in the birth centre group was retrieved from the medical records.

MAIN OUTCOME MEASURE

Perinatal mortality.

RESULTS

No statistically significant difference in the overall perinatal mortality rate was observed between the birth centre group and the standard care group (odds ratio [OR] 1.5, 95% CI 0.9-2.4), but infants of primiparas were at greater risk (OR 2.2, 95% CI 1.3-3.9). Infants of multiparas tended to be at lower risk, but this difference was not statistically significant (OR 0.7, 95% CI 0.3-1.9). These figures were adjusted for maternal age and gestation in multiple regression analyses.

CONCLUSION

Birth centre care may be less safe for infants of first-time mothers.

Risk and risk assessment in pregnancy – do we scare because we care?

OBJECTIVE

To assess whether being labelled 'high-risk' affects women's psychosocial state in pregnancy.

DESIGN

Prospective, cross-sectional, non-experimental, case-control study.

SETTING

a large city in Germany.

PARTICIPANTS

Women between 22 and 41 weeks gestation were identified at antenatal classes and invited to participate in the study. Of the 147 women who were given a questionnaire, 82% (122) responded but only 75% (111) were eligible for inclusion in the study. Of these 111 women, 57 were classified as 'labelled high-risk' and 54 as 'no-risk' according to the risks documented in their antenatal records.

MEASUREMENTS

Women's psychosocial state was assessed using a validated, anonymous, self-completed questionnaire, the Abbreviated Scale for the Assessment of Psychosocial State in Pregnancy (Goldenberg et al. 1997). Analysis of covariance (ANCOVA) was performed to test the effect of the risk label on psychosocial state. The effect of other variables, such as parity or education, was also tested.

FINDINGS

The effect of the risk label on psychosocial state after adjusting for age was statistically significant (R(2)=0.07, F=7.59, df=1, p=0.001). No significant differences were found for the other independent variables. The data showed that a large number of women had one or more risk factors and that 71% were booked for obstetrician-led care. A high variability in obstetrician's documentation of women's risk factors was also found.

CONCLUSION

The data suggest that labelling women to be 'at risk' may negatively affect their psychosocial state. The findings highlight the need to re-evaluate the risk catalogue in the German antenatal record (Mutterpass) as well as the German maternity guidelines (Mutterschaftsrichtlinien). Although this study was conducted within the German system of antenatal care, the findings raise questions about the effects of risk labelling in maternity care wherever it is practised. Further research is needed to assess women's psychosocial state in a more representative sample, to explore women's experiences and satisfaction with the practice of risk assessment and to investigate the reasons for the high variability in documenting women's risk factors.

Continuity of care: a multidisciplinary review

The concept—and reality—of continuity of care crosses disciplinary and organisational boundaries. The common definitions provided here should help healthcare providers evaluate continuity more rigorously and improve communication