In this blog for our Maternity Matters series, researchers and Cochrane authors Jane Sandall, Hora Soltani, Andrew Shennan and Declane Devane look at evidence and practice on midwife-led continuity of care. This blog is part of a series called ‘Maternity Matters’.
Page last updated 21 February 2022.
In 2016, Better Births, the report of the National Maternity Review, the Five Year Forward View for NHS maternity services in England and in 2017 Safer Maternity Care – The National Maternity Safety Strategy – Progress and Next Steps (Department of Health, 2017), sets out a vision for maternity services in England which are safe and personalised. At the heart of this vision is the ambition that women should have continuity of the person looking after them during their maternity journey, before, during and after the birth. The NHS ten-year plan also aims to ensure that 75% of women from Black, Asian and minority ethnic communities and a similar percentage of women from the most deprived groups will receive continuity of care from their midwife throughout pregnancy, labour and the postnatal period by 2024 (NHS England, 2019).
The UK is not alone. Internationally, in 2017 both the WHO antenatal and the 2018 WHO antenatal and intrapartum care guidance for a positive pregnancy and childbirth experience recommend midwife-led continuity of care (MLCC) models for pregnant women in settings with well trained midwives (WHO Reproductive Health Library, 2016; World Health Organization, 2018; World Health Organization, 2016).
So, what does the evidence say and what else do we need to find out?
Effects of midwife-led continuity of care on women and babies’ health
In 2016, we investigated the effect of women having midwife-led continuity of care (Sandall et al, 2016). In our Cochrane Review Midwife‐led continuity models versus other models of care for childbearing women (April 2016) we found 15 studies involving 17,674 mothers and babies. We defined midwife-led continuity models of care as those that provide a woman with care from the same midwife or team of midwives during the pregnancy, birth and the early parenting period with referral to specialist obstetric care as needed. This involves care co-ordination, provision and a relationship over time.
We compared this to other models of care where responsibility and care is shared between different health professionals, such as obstetrician and family doctor led care often shared with obstetric nurses or midwives, and shared models of care between all groups. Some trials involved women who were at low riskA way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as ‘the chance of falling were one in four’ (1/4 = 25%). This measure is good no matter the incidence of events i.e. common or infrequent. of complications, and some included women who were at low and higher risk of complications at the start of pregnancy. All the included trials involved professionally-qualified midwives and no trials offered home birth.
We found that women who received MLCC were more likely to be looked after in labour by midwives they already knew (63-98% vs 0.3- 21%) and were less likely to have an epidural, episiotomy or instrumental birth. Women’s chances of a spontaneous vaginal birth were increased, but there was no difference in the likelihood of having a caesarean birth. Women were less likely to experience preterm birth, fetal loss before and after 24 weeks, and neonatal death. Women were more likely to report a better experience with various aspects of care. We did not identify any harms.
Understanding more about the implementation of midwife-led continuity of care
A recent Cochrane overview of reviewsCochrane Overviews of reviews (Overviews) are intended to summarize multiple Cochrane Reviews addressing the effects of two or more potential interventions (for example a drug, surgery, or exercise) for a single condition or health problem., Interventions during pregnancy to prevent preterm birth: an overview of Cochrane systematic reviews (November 2018) found that midwife led continuity of care had clear benefit in preventing preterm birth and stillbirth (Medley et al, 2018). The key challenge is how to implement and scale up such models in a sustainable way (NHS England, 2017). Many questions are asked about what the core elements are, and what can be adapted to context to achieve the beneficial outcomesOutcomes are measures of health (for example quality of life, pain, blood sugar levels) that can be used to assess the effectiveness and safety of a treatment or other intervention (for example a drug, surgery, or exercise). In research, the outcomes considered most important are ‘primary outcomes’ and those considered less important are ‘secondary outcomes’. for women and babies in a sustainable way.
Key elements that can be pulled out from the review are as follows:
- Care was provided in hospital and community settings
- Women gave birth in obstetric units, and alongside midwife units but not at home
- Care was provided for a woman from the same midwife or team of midwives during the pregnancy, birth and the early parenting period
- Midwives referred to specialist obstetric care as needed, and continued to provide midwifery care to women in hospital and community settings if they developed complications
- Team size ranged from 4-9 whole time equivalent (WTE) midwives
- There was no evidence of a difference in outcomes between caseload and team models of care
- There was no evidence of a difference in outcomes between models that offered care to populations of women that were classified as low risk and mixed risk
What further research needs to be done on how this model works and for whom?
MLCC models are complex interventions and it is unclear whether the pathway of influence that can produce these positive outcomes is the continuity of care, the midwifery philosophy of care or both. Many theories have been suggested during conversations with women, clinicians and researchers across the world. We think the following hypotheses are worthy of further investigation:
- That midwives possibly provide a trusted safetyRefers to serious adverse effects, such as those that threaten life, require or prolong hospitalization, result in permanent disability, or cause birth defects. net with midwives ‘minding the gap’?
- That more effective care may be provided by fidelity to multidisciplinary guidelines including clear transfer processes?
- That more equitable care results from fewer women falling through gaps in services due to better co-ordination/care navigation and referral which improves in-service access?
- That relational continuity and advocacy engenders trust and confidence between women and midwives?
- That women feel less stressed and secure with more opportunities for midwives to facilitate social support from families and in her local community?
- That more timely and safer care results from more opportunities for early prevention and diagnosis of complications to facilitate management and interventionA treatment, procedure or programme of health care that has the potential to change the course of events of a healthcare condition. Examples include a drug, surgery, exercise or counselling. ?
Some of our team have been working with NHS England to provide implementation support and training across England and have also been involved in publishing a practical toolkit with colleagues in Australia (Homer et al, 2019).
Where does this leave us?
We need to know more about the sustainability of scaling up MLCC models, in terms of whole system impact, cost-benefit and workforce.
We don’t know the effects of MLCC on women who are higher risk at booking. Such women often get fragmented care and miss routine midwifery care. We are currently completing a pilot trial of women at higher risk of preterm birth to see how feasible such a model is (Fernandez Turienzo et al, 2019a).
We need to find out more about whether MLCC can moderate the effects of women’s stress on the health of the mother and baby. This can build on some very exciting research in Australia, which found MLCC models mitigated the effects of high levels of stress experienced by women in the context of a natural disaster (Queensland flood) on postnatal mental health (Kildea et al, 2018).
Finally, we also need to understand more about the effects of building collaborative models of care to improve outcomes in disadvantaged diverse communities (Rayment-Jones et al, 2015; McRae et al, 2016). Pioneering research with Aboriginal communities is showing effects of a model of care integrated with family services on preterm birth (Kildea et al, 2019), and we need to think about the relevance for other settings and groups (Fernandez Turienzo et al, 2019b).
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About the authors:
Jane Sandall‘s biography appears below the blog.
Hora Soltani (Professor of Maternal and Infant Health in Sheffield Hallam University, UK) is a registered midwife and has been researching for over 20 years focusing on enhancing maternity care and reducing health inequalities for mothers and babies.
Professor Shennan is an academic obstetrician with expertise in obstetric clinical trialsClinical trials are research studies involving people who use healthcare services. They often compare a new or different treatment with the best treatment currently available. This is to test whether the new or different treatment is safe, effective and any better than what is currently used. No matter how promising a new treatment may appear during tests in a laboratory, it must go through clinical trials before its benefits and risks can really be known. including preterm birth.
Professor Devane is a midwife with expertise in trials including trials of models of maternity care.
Declarations of interest:
Jane Sandall reports that she is the lead author of the Cochrane ReviewCochrane Reviews are systematic reviews. In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. that this publication is based upon. Hora Soltani, Declan Devane and Andrew Shennan report that they are co-authors of the Cochrane Review that this publication is based upon.
It would be really interesting to know what is meant by ‘midwife they already knew’ at birth (e.g. was this met once, or who had taken several of her appointments), and as this a secondary outcome, is it considered necessary/important for some of the other outcomes such as reduced need for pain relief, reduced use of amniotomy and episiotomy? I ask as discussions around on call etc lead to ‘known midwife’ being defined as a member of the team who the woman may have quickly met, and I wonder what your thoughts are on the benefits of this. Obviously if the importance is seen to lie mainly in continuity antenatally, then this may not be so important, but if team sizes can range from 4-9, how much continuity is thought to be optimal? I ask as my thoughts would be that surely many of the intrapartum benefits would almost depend on a actually known (e.g. caseload primary midwife), but as I read the evidence again I wonder….It is very interesting! Also so important that we get this right.
What a thought provoking and important discussion.
More importantly I feel we need to look more closely at what elements make a successful and sustainable team. Unfortunately with the closure of the Albany, neighbourhood midwives and One to One it will be very difficult to carry out this research. We also need to look at how systems can support caseloading teams and the unique way in which they work. This is crucial if we don’t want better births to go the same way as changing childbirth. I would be very interested in doing this work. Give me a call!
So excited to read your article! My PhD topic is investigating factors that influence the implementation of of midwifery continuity models. I can’t wait to publish my findings and share them!
That sounds like a brilliant piece of work and so useful! Looking forward to reading it!
Have you published your findings?