title: Midwife-led continuity models versus other models of care for childbearing women.
abstract: 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.
  
  
  OBJECTIVE
  To compare midwife-led continuity 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 (31 May 2015) and reference lists of retrieved studies.
  
  
  METHODS
  All published and unpublished trials in which pregnant women are randomly allocated to midwife-led continuity models of care or other models of care during pregnancy and birth.
  
  
  METHODS
  Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.
  
  
  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.
  
  
  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.
authors.affiliation: Division of Women's Health, King's College, London, Women's Health Academic Centre, King's Health Partners, 10th Floor, North Wing, St. Thomas' Hospital, Westminster Bridge Road, London, UK, SE1 7EH.
authors.forename: Jane
authors.initials: J
authors.lastname: Sandall
authors.forename: Hora
authors.initials: H
authors.lastname: Soltani
authors.forename: Simon
authors.initials: S
authors.lastname: Gates
authors.forename: Andrew
authors.initials: A
authors.lastname: Shennan
authors.forename: Declan
authors.initials: D
authors.lastname: Devane
mesh_terms: D000650:Amnion / Q000601:surgery; D016362:Analgesia, Obstetrical / Q000706:statistics & numerical data; D002585:Cesarean Section / Q000706:statistics & numerical data; D003266:Continuity of Patient Care / Q000458:organization & administration*; D004841:Episiotomy / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008880:Midwifery / Q000191:economics / Q000379:methods* / Q000458:organization & administration; D017146:Models, Organizational; D017060:Patient Satisfaction; 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