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.


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


METHODS
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.


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All published and unpublished trials in which pregnant women are randomly allocated to midwife-led or other models of care during pregnancy, and where care is provided during the ante- and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


METHODS
All authors evaluated methodological quality. Two authors independently checked the data extraction.


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).


CONCLUSIONS
All women should be offered midwife-led models of care and women should be encouraged to ask for this option.
Hatem
Marie
M
Département de médecine sociale et préventive, Université de Montréal, Faculté de médecine, C.P 6128, succursale Centre-ville, Montréal, Québec, Canada, H3C 3J7.
Sandall
Jane
J
Devane
Declan
D
Soltani
Hora
H
Gates
Simon
S
D003266:Continuity of Patient Care / Q000458:organization & administration; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008880:Midwifery / Q000191:economics / Q000379:methods* / Q000458:organization & administration; D017146:Models, Organizational; D018743:Perinatal Care / Q000379:methods* / Q000458:organization & administration; D011181:Postnatal Care / Q000379:methods* / Q000458:organization & administration; D011247:Pregnancy; D011295:Prenatal Care / Q000379:methods* / Q000458:organization & administration; D016032:Randomized Controlled Trials as Topic