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Models of Maternity Care: evidence for midwifery continuity of care
Abstract
There has been substantial reform in the past decade in the provision of maternal and child health services, and specifically regarding models of maternity care. Increasingly, midwives are working together in small groups to provide midwife-led continuity of care. This article reviews the current evidence for models of maternity care that provide midwifery continuity of care, in terms of their impact on clinical outcomes, the views of midwives and childbearing women, and health service costs. A systematic review of midwife-led continuity of care models identified benefits for women and babies, with no adverse effects. Non-randomised studies have shown benefits of midwifery continuity of care for specific groups, such as Aboriginal and Torres Strait Islander women. There are also benefits for midwives, including high levels of job satisfaction and less occupational burnout. Implementing midwifery continuity of care in public and private settings in Australia has been challenging, despite the evidence in its favour and government policy documents that support it. A reorganisation of the way maternity services are provided in Australia is required to ensure that women across the country can access this model of care. Critical to such reform is collaboration with obstetricians, general practitioners, paediatricians and other medical professionals involved in the care of pregnant women, as well as professional respect for the central role of midwives in the provision of maternity care. More research is needed into ways to ensure that all childbearing women can access midwifery continuity of care.
... Midwives, obstetricians, general practitioners, and Aboriginal and Torres Strait Islander health staff largely provide the care, and do so in the public, private, or Aboriginal community controlled sectors [3]. Many nuances exist in the way models of care are configured, depending on the location (home, birth centre, hospital), the provider of care, the sector, and the complexity of women or their babies [4]. Continuity of care is defined in this paper as 'care provided by the same provider, or small team of providers, during pregnancy, labour and birth, and the postnatal periods with referral to specialist care as needed' [5]. ...
... These findings will be used in the ongoing Midwifery Futures project as we build workforce models designed to address women and gender-diverse people's needs. A literature review published in 2016 synthesised what women wanted in relation to continuity of maternity care, but did not investigate the needs of women in other models of care [4]. We could not find a recent synthesis of what women want from Australian maternity care. ...
... Despite the evidence and considerable efforts over many years, only a small proportion of women have access to continuity of midwifery care [83], with around one third of models of care offered by health services offering continuity of care [2]. Reorganisation of maternity service provision needs to occur to increase access to continuity of care [4]. For new models to be implemented, collaboration between midwives, obstetricians, paediatricians, and general practitioners is required, with all professionals involved in provision of maternity care having professional respect for the pivotal role that midwives play [4]. ...
... Addressing these barriers is crucial for leveraging midwives' role in reducing maternal and newborn deaths. (Homer, 2016) [5] review found benefits for women and babies with no adverse effects when care is provided by midwives. It supports the need for a system-level shift to skilled care for all, highlighting the role of midwives in providing preventive and supportive care. ...
... Addressing these barriers is crucial for leveraging midwives' role in reducing maternal and newborn deaths. (Homer, 2016) [5] review found benefits for women and babies with no adverse effects when care is provided by midwives. It supports the need for a system-level shift to skilled care for all, highlighting the role of midwives in providing preventive and supportive care. ...
... Access to continuity midwifery-led care models in Australia remains limited, 36 despite a solid evidence base for (1) consumer desire and satisfaction 37 and (2) for maternal and infant safety and efficacy of this model of care over others. 36,37 Homer asks (p.373), 36 "is it ethical to withhold access to midwifery continuity of care from the majority of women in Australia, given the strength of evidence, the supporting policy documents and the demand from women?" ...
... Access to continuity midwifery-led care models in Australia remains limited, 36 despite a solid evidence base for (1) consumer desire and satisfaction 37 and (2) for maternal and infant safety and efficacy of this model of care over others. 36,37 Homer asks (p.373), 36 "is it ethical to withhold access to midwifery continuity of care from the majority of women in Australia, given the strength of evidence, the supporting policy documents and the demand from women?" ...
Background:
Woman-centered maternity service delivery is endorsed by Australian federal health policy. Despite this, little evaluation of maternity care is conducted through the lens of women. We examined the responses of women birthing in Australia to the international Babies Born Better 2018 (Version 2) open-response survey.
Methods:
An online international survey was distributed primarily by means of social media for women who had given birth in the last 5 years. In addition to closed-ended questions to describe the sample, a series of open-ended questions recorded women's experiences and satisfaction with their maternity care and place of birth.
Results:
Of 1249 women who reported birthing their most recent baby in Australia and speaking English, 84% responded to at least one open-ended evaluation question. We thematically analyzed the data to identify three related themes of safety, choice, and respect for women. Women's experiences of these were closely tied to their model of care; those birthing at home with a private midwife more so reported positive experiences than those discussing obstetric care or, to a lesser extent, midwifery-led care in a hospital. There was a strong preference and need for (1) access to affordable care with a known practitioner from early pregnancy to postpartum, and (2) individualized care with the removal of restrictive hospital policies not aligned with woman-centered practice.
Discussion:
This is the first Australian national study of women's maternity experiences and evaluations. Consistent with previous state-based research, women birthing in Australia continue to report maternity "care" that is physically and emotionally harmful. They also stated a need to address the psychosocial aspects of becoming a mother, in addition to the biological ones. Women and other birthing people must be at the center of defining quality maternity health service delivery, and services must be accountable for preventing and addressing harm, as defined by all birthing people.
... Such systems would be holistic and provide care tailored to the individual woman's needs rather than subject the woman to routine practices and protocols which only address the needs of the institution. This style of care is most often achieved in midwifery-led continuity models of care [26,27] where similarities with woman-centred care and continuity of care can be drawn. There is a strong evidence base that midwifery continuity of care (CoC) has been proven to enhance both the woman's positive childbirth experience and clinical outcomes. ...
... A surprising finding of the Delphi study was the expert panel's opinion about the place of continuity of care in woman-centred care. Generally touted in the midwifery literature as a core element of midwifery practice [26,27,33], the expert panel members expressed the view that continuity of care was not a core characteristic of woman-centred care. ...
Problem:
There is no internationally-informed understanding of how midwives perceive woman-centred care and use it in practice.
Background:
Woman-centred care is integral to the role of the midwife and to determining standards of practice. Few empirical studies have explored the meaning of woman-centred care, and those that have are limited to country specific research.
Aim:
To gain an in-depth understanding and consensus on the concept of woman-centred care from an international perspective.
Methods:
A three round Delphi study was conducted, with surveys distributed online to a group of international expert midwives to draw consensus on the topic of woman-centred care.
Findings:
A panel of 59 expert midwives representing 22 countries participated. Fifty-nine statements about woman-centred care, of which 63% of statements reached the 75% a priori agreement level, were developed and categorised under four emergent themes: defining characteristics of woman-centred care (n = 17), the role of the midwife in woman-centred care (n = 19), woman-centred care and systems of care (n = 18), woman-centred care in education and research (n = 5).
Discussion:
Participants agreed that woman-centred care should be provided by any health care professional in any health care setting. Systems of maternity care should provide holistic care tailored for the individual woman rather than subject her to routine practices and policies. Although continuity of care is important to midwifery practice, it was not reported as a core characteristic of woman-centred care.
Conclusion:
This is the first study to investigate the concept of woman-centred care as it is experienced globally by midwives. The findings of this study will be used to contribute to the development of an internationally informed evidence-based definition of woman-centred care.
... V těchto zemích jsou porodní asistentky také integrovány do systému veřejného zdravotnictví, což jim umožňuje poskytovat péči v různých prostředích, včetně domácích porodů a porodních domů (13). Ve Spojeném království je komunitní porodní asistence součástí národního zdravotnického systému (14), který zajišťuje, že porodní asistentky poskytují péči nejen v nemocnicích, ale také v komunitních prostředích a porodních centrech. Důraz je kladen na kontinuitu péče, kdy porodní asistentka provází ženu celým těhotenstvím, porodem i poporodním obdobím. ...
Introduction: Community midwifery offers an alternative approach to maternity care, focusing on individualized support for pregnant women in their natural environment. This model allows women to build a deeper relationship with their midwife and is often considered beneficial for both the mother and the newborn. However, in the Czech Republic, community midwifery is still in the developmental phase and faces many challenges, including legislative and financial constraints.
Aim: The aim of the article is to analyze the significance of community midwifery in the Czech Republic and to highlight its benefits for women and families, as well as the barriers that prevent its broader implementation within the healthcare system.
Conclusion: Community midwifery represents a significant contribution to the field of individualized care and family support. This care model enhances the trust between the woman and the midwife and supports the natural process of childbirth. However, for community midwifery to fully develop in the Czech Republic, it is essential to overcome legislative barriers and secure adequate financial support.
... Concerningly, associating midwife-led care with these traditional childbirth methods which are linked to poorer outcomes could hinder the development of midwifery in India [3]. Providing information so that women can recognise and value the midwife's role as a primary maternity care provider [20] will help women to accept this model. ...
... These findings underscore the effectiveness of such care in enhancing the functioning of primiparous women, suggesting that participants in the intervention group exhibited a greater capacity to adjust to the postpartum phase. Furthermore, these results align with the favorable outcomes reported in prior research concerning midwifery continuity of care [25,[34][35][36]. Recent studies suggest that ensuring continuity of care in midwifery may serve as a preventive strategy to reduce maternal anxiety, worries, and depressive symptoms during the perinatal period [35]. ...
Background/Objectives: New mothers face significant challenges during the postpartum period, which can impact their maternal performance. This study aimed to assess the effect of tele-continuous midwifery care on maternal functioning and neonatal perception in first-time Iranian mothers. Methods: A randomized controlled field trial was conducted from January to May 2023 on 48 first-time mothers in the postpartum ward at Arash Women’s Hospital, Tehran. Participants were randomly assigned to either an intervention or control group. The intervention group received tele-continuous care for six weeks postpartum, while the control group received standard care. The Barkin Index of Maternal Functioning (BIMF) and the Neonatal Perception Inventory (NPI) were used to collect data in the second and sixth weeks after delivery. Data were analyzed using SPSS 26. Results: The mean age was 26.2 ± 4.8 years in the intervention group and 28.0 ± 6.1 years in the control group. An independent t-test revealed a significant difference in maternal functioning (BIMF score) between the intervention and control groups by the sixth week postpartum (p < 0.0001). A significant improvement in BIMF scores was observed within the intervention group from the second to the sixth week (p = 0.007). However, the McNemar’s test on the NPI showed no significant difference in the proportions of negative and positive maternal perceptions within the intervention group (p = 0.219) and in the control group (p = 0.508). Conclusions: Tele-continuous midwifery care effectively enhances maternal functioning during the vulnerable postpartum period, highlighting the necessity of ongoing support for new mothers.
... With increasing evidence of improved clinical outcomes and care satisfaction in pregnant women, interest in midwife-led continuity models of care is growing. However, the majority of existing studies on this topic have been conducted in developed countries, limiting their generalizability to low-and middle-income contexts 21,22 . In low-and middle-income countries, the unique needs and challenges necessitate a culturally sensitive and context-specific approach when introducing new strategies 23 . ...
Midwife-led continuity of care models have been linked to better clinical outcomes in certain developed countries. However, there is a paucity of research on these models in developing nations. This quasi-experimental study was conducted on primiparous women who referred to one private midwifery center and two public hospitals in Ahvaz, Iran to evaluate the effect of team midwifery care on maternal and neonatal outcomes of pregnant women in Iran. Two hundred women were allocated either into the experimental (n = 100) or control (n = 100) groups. Women in the experimental group, received team midwifery care, while women in the control group, received routine care. Data were collected using a demographic questionnaire, Mackey questionnaire, and a checklist. Women in the team midwifery care group experienced significantly higher rates of normal vaginal birth and exclusive breastfeeding compared to women in the control group. No statistically significant difference was observed between the two groups in terms of the rate of induction of labor and postpartum hemorrhage. The duration of labor was longer in the team midwifery care compared to the control group. Women in the team midwifery care group had a significantly higher rate of exclusive breastfeeding at six weeks postpartum compared to the control group (80 vs. 61%, p = 0.001). After excluding women with ruptured membranes and prolonged pregnancies, neonates in the intervention group had significantly higher first- and fifth-minute Apgar scores (p < 0.0001), and a lower rate of admission to intensive care unit in the intervention group compared to the control group (1 vs. 9%, p = 0.04). Also, women in the team midwifery group had skin-to-skin contact significantly earlier than those in the control group (33.87 ± 66.26 min vs. 111.98 ± 247.31 min, p = 0.578). Given the positive impact of continuous team midwifery care on maternal and neonatal outcomes, its implementation in maternity care systems, particularly in countries like Iran with high cesarean section rates, is strongly recommended.
... The care women receive during their childbearing journey can have profound and lasting effects on their health and well-being (O'Rourke et al., 2022). Relational care with continuity -provided by the same caregiver over time, such as midwifery-led continuity of care (MCoC) -is a well-established model of optimal maternity care (Fox et al., 2023;Homer, 2016;Tickle et al., 2022). In practice, care is usually fragmented, provided by multiple healthcare professionals, and is within a medical environment, such as a hospital (Steel et al. 2015). ...
Objective: The objective of this article was to gain a deeper understanding and insight into the training and characteristics of childbirth doulas on the maternity care team. The aim was to integrate knowledge obtained from two studies: an integrative review (IR) of doula education programs globally (Study 1) and the qualitative experiences of those training to become a doula (Study 2).
Methods: For the IR (Study 1), the modified Whittemore and Knafl (2005) framework and Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines were used. Five electronic databases were searched (CINAHL, ProQuest Education Databases, ERIC, MEDLINE, and Scopus) using doula and education/training as key terms. Nineteen papers were included in the review. For the qualitative study (Study 2), semi-structured interviews with 10 student doulas were analyzed using inductive thematic analysis.
Results: The results highlighted ambiguity around the education (review) and scope of practice (qualitative) of a childbirth doula. The review showed a variety in duration, content, learning, certificate/accreditation, and educator qualifications in doula training programs, globally. The variety in student doulas’ understanding of their role in the maternity care context emerged from the key themes: (a) what influenced the decision to become a doula, (b) personal attributes perceived as essential to be a doula, and (c) what constitutes the role of a childbirth doula.
Conclusions: This article highlights a variability in doula training legislation and accreditation, as well as program content and length. This variation may be reflected in student doulas’ understanding of their role in the maternity context. A better understanding of doula training and a defined scope of practice can fill the current gap in continuity of care and improve communication within the maternity care health team.
... 3,5 Working in midwife continuity of care teams has been seen to mitigate feelings of stress and burnout, as midwives can rely on the team dynamic for support and time off, but a general lack of midwives still remains a concern. 3, 6 Interprofessional challenges within hospital settings also present a barrier to midwife-led care. Differences in the approaches of doctors and midwives can lead to conflict between the two professions. ...
Midwifery has been publicly funded since 2009 in Alberta, Canada. However, significant barriers to accessing midwife-led care, interprofessional challenges, lack of funding, and the demanding role required of midwives raise issues regarding sustainability. The findings presented in this paper are based on in-depth interviews with 16 midwives in Alberta, Canada. This paper discusses the findings based on a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis framework. The SWOT analysis identified the following major themes: Strong connections to the profession and clients, barriers to work-life balance, strategies for sustainability, and difficult working conditions combined with limited funding. The findings highlight an urgent need to address the difficult working conditions and high levels of burnout described by Alberta midwives. The midwives' commitment to the profession and their relationships with clients run deep; however, this did not offset the challenges and barriers to having a long career working as a midwife. Our findings suggest that there are opportunities to make midwifery more sustainable, but this will require the healthcare system in Alberta to prioritize funding for midwifery services to ensure the midwives who provide this care are valued and supported.
... Reviews of the literature concerned with MCoC implementation to date tend to have a specific scope and focus, including assessing feasibility in specific contexts such as rural Australia [29], scoping where MCoC takes place globally [30], reviewing the cost effectiveness of MCoC during complex pregnancies as a possible facilitator of implementation [31], considering the role of leadership and management in effecting MCoC implementation [32], and describing midwives' perceptions of barriers and enablers to working in MCoC [28,33,34]. Other reviews make limited implementation claims in the course of a discussion of general aspects of MCoC research [35,36]. One previous review addresses MCoC implementation processes more widely using Normalisation Process Theory (NPT) [37]. ...
Background
Midwifery continuity of carer (MCoC) is a model of care in which the same midwife or small team of midwives supports women throughout pregnancy, birth and the postnatal period. The model has been prioritised by policy makers in a number of high-income countries, but widespread implementation and sustainability has proved challenging.
Methods
In this narrative review and synthesis of the global literature on the implementation and sustainability of midwifery continuity of carer, we identify barriers to, and facilitators of, this model of delivering maternity care. By mapping existing research evidence onto the Consolidated Framework for Implementation Research (CFIR), we identify factors for organisations to consider when planning and implementing midwifery continuity of carer as well as gaps in the current research evidence.
Results
Analysing international evidence using the CFIR shows that evidence around midwifery continuity of carer implementation is patchy and fragmented, and that the impetus for change is not critically examined. Existing literature pays insufficient attention to core aspects of the innovation such as the centrality of on call working arrangements and alignment with the professional values of midwifery. There is also limited attention to the political and structural contexts into which midwifery continuity of carer is introduced.
Conclusions
By synthesizing international research evidence with the CFIR, we identify factors for organisations to consider when planning and implementing midwifery continuity of carer. We also call for more systematic and contextual evidence to aid understanding of the implementation or non-implementation of midwifery continuity of carer. Existing evidence should be critically evaluated and used more cautiously in support of claims about the model of care and its implementation, especially when implementation is occurring in different settings and contexts to the research being cited.
... In addition to the prevailing standard care, the most evaluated of these models of care continuity is midwifery-led continuity of care (MLCoC There is no evidence that any specific continuity of care model has altered the rising rates of modifiable causes of iatrogenic preterm birth specifically-an increasing problem about which this Committee has previously published FIGO good practice recommendations. 28 Even when models of care have not been shown to improve birth outcomes, virtually all of them have been repeatedly shown in most studies to demonstrate higher rates of maternal 14,22,[29][30][31][32][33][34] and health professional satisfaction [35][36][37] across the continuum of prenatal and postnatal care, and for high-risk as well low-risk pregnancies, when delivered in continuity. Taken together, care continuity of existing care models in most contexts is associated with more favorable outcomes and patient and carer experience. ...
The global challenge of preterm birth persists with little or no progress being made to reduce its prevalence or mitigate its consequences, especially in low‐resource settings where health systems are less well developed. Improved delivery of respectful person‐centered care employing effective care models delivered by skilled healthcare professionals is essential for addressing these needs. These FIGO good practice recommendations provide an overview of the evidence regarding the effectiveness of the various care models for preventing and managing preterm birth across global contexts. We also highlight that continuity of care within existing, context‐appropriate care models (such as midwifery‐led care and group care), in primary as well as secondary care, is pivotal to delivering high quality care across the pregnancy continuum—prior to conception, through pregnancy and birth, and preparation for a subsequent pregnancy—to improve care to prevent and manage preterm birth.
... Midwife Group Practice Midwife Group Practice models of care are part of a suite of midwifery continuity of care models available in Australia. 26 Midwives provide antenatal, intrapartum and postpartum care. Regional, rural and remote midwives work across primary and secondary care settings, seeing women at home visits, in clinics and in hospital wards. ...
Issue Addressed
The oral glucose tolerance test is the ‘gold standard’ for detecting gestational diabetes in Australian and International guidelines. Test completion in regional, rural and remote regions may be as low as 50%. We explored challenges and enablers for regional, rural and remote antenatal clinicians providing gestational diabetes screening to better understand low oral glucose tolerance test completion.
Methods
We conducted a qualitative descriptive study using semi‐structured interviews. Participants eligible for the study were doctors or midwives providing antenatal care in regional, rural and remote Western Australia, between August 2019 and November 2020. Interviews were recorded digitally and transcribed into a Word document. We conducted a thematic analysis after initial categorisation and deduction of themes through workshops involving the research team.
Results
We found a diversity of viewpoints on oral glucose tolerance test reliability for detecting gestational diabetes. Themes that emerged were; good collaboration between antenatal clinicians is required for successful screening; screening occurs throughout pregnancy using various tests; clinicians make significant efforts to address barriers; clinicians prioritise therapeutic relationships.
Conclusions
Effective universal screening for gestational diabetes in regional, rural and remote Western Australia is difficult and more complex in practice than guidelines imply. Detecting gestational diabetes requires creative solutions, early identification of at risk women and trust and collaboration between clinicians and women.
So What?
Detection of gestational diabetes in regional, rural and remote Western Australia remains poorly completed. New strategies are required to adequately identify women at risk of adverse birth outcomes relating to hyperglycaemia in pregnancy.
... The first pregnancy is called primigravida. More than one pregnancy is called multigravida, and more than four pregnancies are called grande multigravida [24]. Primigravida pregnant women have higher levels of anxiety than multigravida pregnant women. ...
Pregnancy-related anxiety is a prevalent mental condition characterized by apprehension and fear about uncertain events. Several factors contribute to anxiety in pregnant women, including Age, education, gravidity, husband's support, and spiritual self-care. This research aims to identify the influencing factors on anxiety levels in third-trimester pregnant women facing the birthing process in Bengkulu City, utilizing a cross-sectional approach. Forty-four respondents were selected through purposive sampling, and data were analyzed using the Spearman rank correlation test. The findings reveal significant relationships between Age (p-value 0.012 < 0.05), education (p-value 0.018 < 0.05), gravidity (p-value 0.026 < 0.05), husband's support (p-value 0.038 < 0.05), and spiritual self-care (p-value 0.000 < 0.05) and anxiety levels. In conclusion, Age, gravidity, education, husband's support, and spiritual self-care are associated with the anxiety levels of third-trimester pregnant women facing the birthing process in Bengkulu City.
... (12) Observationeel onderzoek laat zien dat vrouwen in kwetsbare situaties die continue zorg van verloskundigen ontvangen minder vaak te vroeg bevallen of een te kleine baby krijgen. (19)(20)(21) ...
De tekst "Bekend maakt bemind" door prof. dr. Ank de Jonge richt zich op de toepassing van de Ubuntu-filosofie binnen de geboortezorg. Ubuntu, een Zuid-Afrikaanse filosofie, benadrukt het belang van menselijkheid en onderlinge verbondenheid: het welzijn van een individu is nauw verbonden met het welzijn van anderen. De Jonge stelt dat deze filosofie kan bijdragen aan betere relaties en daarmee betere zorguitkomsten. Ze vergelijkt deze benadering met het individualisme in Europa, waarbij zelfontplooiing centraal staat, maar wat vaak kan leiden tot eenzaamheid en ongelijkheid. De Jonge pleit voor een meer relationele benadering in de geboortezorg, waar zorgverleners niet alleen focussen op het verlagen van sterfte en ziekte, maar ook op het opbouwen van goede relaties met de vrouwen die ze ondersteunen. Ze benadrukt het belang van cultuur responsieve zorg en sociale verloskunde, waarin de leefomstandigheden van kwetsbare vrouwen worden verbeterd en ze in staat worden gesteld zelf gezonde keuzes te maken. Het doel is om zorg te bieden die niet betuttelend is, maar vrouwen in hun kracht zet en hun autonomie respecteert.
... These barriers are possibly attributed to shortages of midwifery staff, inadequate professional training and a lack of enabling environment. 58 59 The task of providing caseload continuous support may lead to intensification of human resource shortages and have implications on the organisation of shifts at the LDU. 60 Currently, the implementation of the caseload model of midwifery care in China may be limited Open access due to a shortage of midwives. ...
Objective
To investigate the status of the midwifery workforce and childbirth services in China and to identify the association between midwife staffing and childbirth outcomes.
Design
A descriptive, multicentre cross-sectional survey.
Setting
Maternity hospitals from the eastern, central and western regions of China.
Participants
Stratified sampling of maternity hospitals between 1 July and 31 December 2021.
The sample hospitals received a package of questionnaires, and the head midwives from the participating hospitals were invited to fill in the questionnaires.
Results
A total of 180 hospitals were selected and investigated, staffed with 4159 midwives, 412 obstetric nurses and 1007 obstetricians at the labour and delivery units. The average efficiency index of annual midwifery services was 272 deliveries per midwife. In the sample hospitals, 44.9% of women had a caesarean delivery and 21.4% had an episiotomy. Improved midwife staffing was associated with reduced rates of instrumental vaginal delivery (adjusted β −0.032, 95% CI −0.115 to −0.012, p<0.05) and episiotomy (adjusted β −0.171, 95% CI −0.190 to −0.056, p<0.001).
Conclusion
The rates of childbirth interventions including the overall caesarean section in China and the episiotomy rate, especially in the central region, remain relatively high. Improved midwife staffing was associated with reduced rates of instrumental vaginal delivery and episiotomy, indicating that further investments in the midwifery workforce could produce better childbirth outcomes.
... Pressures on the maternity care system and service delivery did not facilitate the midwife-woman relationship, resulting in poorer clinical outcomes [112]. Supporting women throughout their perinatal period is essential so women and their babies are able to emerge from the experience feeling prepared, safe and satisfied [113,114]. ...
Background
Pregnant and postpartum women’s experiences of the COVID-19 pandemic, as well as the emotional and psychosocial impact of COVID-19 on perinatal health, has been well-documented across high-income countries. Increased anxiety and fear, isolation, as well as a disrupted pregnancy and postnatal period are widely described in many studies. The aim of this study was to explore, describe and synthesise studies that addressed the experiences of pregnant and postpartum women in high-income countries during the first two years of the pandemic.
Methods
A qualitative evidence synthesis of studies relating to women’s experiences in high-income countries during the pandemic were included. Two reviewers extracted the data using a thematic synthesis approach and NVivo 20 software. The GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) was used to assess confidence in review findings.
Results
Sixty-eight studies were eligible and subjected to a sampling framework to ensure data richness. In total, 36 sampled studies contributed to the development of themes, sub-themes and review findings. There were six over-arching themes: (1) dealing with public health restrictions; (2) navigating changing health policies; (3) adapting to alternative ways of receiving social support; (4) dealing with impacts on their own mental health; (5) managing the new and changing information; and (6) being resilient and optimistic. Seventeen review findings were developed under these themes with high to moderate confidence according to the GRADE-CERQual assessment.
Conclusions
The findings from this synthesis offer different strategies for practice and policy makers to better support women, babies and their families in future emergency responses. These strategies include optimising care delivery, enhancing communication, and supporting social and mental wellbeing.
... The implementation of midwifery continuity of care is highly valued by childbearing women and young parents (Homer 2016;Cummins et al. 2018). Women prefer the personalised experience, building relationships of trust through a high level of continuity of care provided by midwives (Cummins et al. 2018;Perriman et al. 2018). ...
... It emphasizes the importance of working collaboratively in interdisciplinary teams for families and navigating complications as they arise. 25 Because this major shift in the guidelines around infant feeding has only recently occurred in high-income settings, many WWH may not be aware of the current recommendations. It is essential to recognize that the previous recommendation against breastfeeding in WWH resulted in several negative consequences for some WWH, including, in some cases, the involvement of Child Protective Services. ...
... The eight recommendations presented here are already partly reflected in the priority areas within maternity settings in the UK, and outlined in key policy documents (e.g., NHS England, 2016). For example, in relation to recommendation 4, models of midwifery continuity of care are already recommended in international guidance and at the heart of maternity policy in the UK and Australia, when there are recommendations to scale up continuity models on the basis of improving high quality and safe maternity care (Australian Government Department of Health, 2019;Fernandez Turienzo et al., 2020;Homer, 2016;NHS England, 2016). In several countries, including the UK, midwives provide care for women during pregnancy and as such are gatekeepers to further care such as mental health support. ...
... A Cochrane review in 2016 by Sandall et all [56], including 15 trials involving 17,674 women, found that the majority of included studies reported higher rates of maternal satisfaction in midwife-led continuity of care models. This model is favoured in Australia [57], particularly for Aboriginal people and Torres Islanders [58]. ...
Objective
Vulnerability relates to fragile physical, psychological, and socio-environmental circumstances. Pregnant women's social vulnerability can lead to disruptions in their medical follow-ups, prematurity, and increased infant mortality rates, such that their special needs must be considered. Yet, despite different governments' ‘perinatality’ plans, international literature suggests their care can be improved. Although quantitative studies regularly evaluate these plans, few studies have assessed vulnerable pregnant women's views. This study explores the needs and expectations of vulnerable women regarding their follow-ups during pregnancy and identified strategies to improve their circumstances.
Methods
The study was a phenomenological qualitative study involving semi-structured interviews with women who gave birth in the past six months (December 2017 to June 2018) and who fulfilled at least one vulnerability criterion. The women were recruited by French midwives and general practitioners (GPs).
Findings
Concerning these vulnerable pregnant women, three phenomenological categories emerged: 1) they need to be monitored by a single trusted contact; 2) they seek medical and social support adapted to their situations that addresses their needs; and 3) they expect kind and person-centred communication skills from professionals who provide them appropriate information.
Conclusion
We identified various international recommendations to screen and care for vulnerable pregnant women, but still these women often experience numerous challenges. Finally, the implementation of recommendations for healthcare professionals based on women's real-life experiences could help optimise the identification of vulnerable pregnant women as well as their follow-up care.
... In Australia, around 300,000 women give birth each year using public or private maternity service models [1]. While a 'model of care' is frequently used in healthcare to characterise the way health services are delivered, it is poorly understood and not easily defined [2,3]. ...
Background
Pregnancy, birth, and early parenthood are significant life experiences impacting women and their families. Growing evidence suggests models of maternity care impact clinical outcomes and birth experiences. The aim of this study was to explore the strengths and limitations of different maternity models of care accessed by women in Australia who had given birth in the past 5 years.
Methods
The data analysed and presented in this paper is from the Australian Birth Experience Study (BESt), an online national survey of 133 questions that received 8,804 completed responses. There were 2,909 open-ended comments in response to the question on health care provider/s. The data was analysed using content analysis and descriptive statistics.
Results
In models of fragmented care, including standard public hospital care (SC), high-risk care (HRC), and GP Shared care (GPS), women reported feelings of frustration in being unknown and unheard by their health care providers (HCP) that included themes of exhaustion in having to repeat personal history and the difficulty in navigating conflicting medical advice. Women in continuity of care (CoC) models, including Midwifery Group Practice (MGP), Private Obstetric (POB), and Privately Practising Midwifery (PPM), reported positive experiences of healing past birth trauma and care extending for multiple births. Compared across models of care in private and public settings, comments in HRC contained the lowest percentage of strengths (11.94%) and the highest percentage of limitations (88.06%) while comments in PPM revealed the highest percentage of strengths (95.93%) and the lowest percentage of limitations (4.07%).
Conclusions
Women across models of care in public and private settings desire relational maternity care founded on their unique needs, wishes, and values. The strengths of continuity of care, specifically private midwifery, should be recognised and the limitations for women in high risk maternity care investigated and prioritised by policy makers and managers in health services.
Trial registration
The study is part of a larger project that has been retrospectively registered with OSF Registries Registration DOI https://doi.org/10.17605/OSF.IO/4KQXP.
... Existing evidence for the costs alone, or cost-effectiveness of MMCs is limited especially for team and caseload midwife-led continuity MMCs [14,15]. Studies that have examined both costs and health outcomes of various MMCs have generally not used economic modelling methods which establish a generalizable framework for future research and service evaluations. ...
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.
... 135 Developing a warm, consistent relationship with patients supports the relatedness needs of both parties, improves care practitioners' job satisfaction, and reduces burnout. 136 Providing care that results in optimal outcomes and a positive evaluation from patients satisfies the caregivers' need to feel competent and effective. There is also reason to predict a "trickle-down" effect, in that care practitioners who are provided more autonomy will in turn support autonomy in their patients (see Reeve et al. 137 for similar findings with teachers and students). ...
Women often report being dissatisfied with their childbirth experience, which in turn predicts negative outcomes for themselves and their children. Currently, there is no consensus as to what constitutes a satisfying or positive birth experience. We posit that a useful framework for addressing this question already exists in the form of Basic Psychological Needs Theory, a subtheory of Self‐Determination Theory (Deci & Ryan, Can. Psychol., 49, 2008, 182). Specifically, we argue that the degree to which maternity care practitioners support or frustrate women's needs for relatedness, competence, and autonomy predicts their childbirth satisfaction. Using this framework provides a potentially powerful lens to better understand and improve the well‐being of new mothers and their infants.
... Review paper -a caseload model of MCoC, which is often described as Midwifery Group Practices (MGP) or caseloading, where a midwife takes on a specified number of women per year (on average 35 women) per full-time equivalent (FTE) 4 . It is understood that MCoC models aim to provide women with a primary midwife and as much continuity with their primary midwife throughout their pregnancy, birth and postnatal continuum 5 . Given the international evidence supporting the benefits of MCoC models for women and infants 6,7 , national maternity care reform has called for increasing these models in Australia 8 . ...
BACKGROUND
International maternity care experts have called for expanding midwifery-led continuity of care (MCoC) models. However, the number of models need augmentation as the number of women receiving this care is small. The majority of the midwifery workforce in Australian public health systems comprises women who work part-time. This aspect of the midwifery workforce demands careful consideration when attempting to change a maternity care system and sustain new models of care. Sparse research has been undertaken to explore whether part-time factors could play a role in the growth and sustainability of MCoC in Australia. This integrative review aims to analyze the role of part-time practice arrangements in the sustainability of MCoC models in Australia.
METHODS Following a systematic search of research databases (CINAHL, ScienceDirect,Cochrane Database of Systematic Reviews, and Proquest) and screening the literature with eligibility criteria including keywords related to midwifery continuity of care, workforce arrangements and full-time equivalent (FTE), eight Australian research articles were identified for evaluation. The articles were appraised for bias using the Mixed Methods Appraisal Tool(MMAT) and data were analyzed using an integrated convergent narrative synthesis method.
RESULTS The resulting themes from the synthesis suggest that part-time MCoC rolesmay support the sustainability of the MCoC workforce without reducing quality of care to women. In various studies, midwives reported that FTE (full-time equivalent) of 0.5may not meet the job’s demands. However, this is likely influenced by local context and caseload size rather than the quantum of each midwife’s FTE. The quality of the studies is limited due to the small scale of the studies; however, the qualitative results give a depth of understanding to the strengths and challenges that part-time arrangements in MCoC add to the midwifery workforce.
CONCLUSIONS This review recommends that part-time arrangements in MCoC models in Australia be evaluated in conjunction with other routinely analyzed workforce data. Further considerations should be made by midwifery managers, leaders, stakeholders, and decision makers responsible for developing and supporting part-time job arrangements in caseload models of care in Australia.
... Continuity of care is increasingly shown to be an effective intervention to improve health outcomes. [27][28][29][30][31][32][33] It is theorized that the more often a provider can interact with a patient, the more likely they are to get to know them and their family members or caregivers regardless of the presence of a language barrier. Therefore, the purpose of this paper is to examine the relative effectiveness of both continuity of care and language concordance with skilled nursing services in home health care as alternative or complementary interventions to improve health outcomes of people with LEP. ...
Background:
Language concordance between health care practitioners and patients have recently been shown to lower the risk of adverse health events. Continuity of care also been shown to have the same impact.
Objective:
The purpose of this paper is to examine the relative effectiveness of both continuity of care and language concordance as alternative or complementary interventions to improve health outcomes of people with limited English proficiency.
Design:
A multivariable logistic regression model using rehospitalization as the dependent variable was built. The variable of interest was created to compare language concordance and continuity of care.
Participants:
The final sample included 22,103 patients from the New York City area between 2010 and 2015 who were non-English-speaking and admitted to their home health site following hospital discharge.
Measures:
The odds ratio (OR) average marginal effect (AME) of each included variable was calculated for model analysis.
Results:
When compared with low continuity of care and high language concordance, high continuity of care and high language concordance significantly decreased readmissions (OR=0.71, 95% CI: 0.62-0.80, P<0.001, AME=-4.95%), along with high continuity of care and low language concordance (OR=0.80, 95% CI: 0.74-0.86, P<0.001, AME=-3.26%). Low continuity of care and high language concordance did not significantly impact readmissions (OR=1.04, 95% CI: 0.86-1.26, P=0.672, AME=0.64%).
Conclusion:
In the US home health system, enhancing continuity of care for those with language barriers may be helpful to address disparities and reduce hospital readmission rates.
... Further, MLCUs are equipped to implement emergency and family-planning measures if needed. Moreover, rates of hospitalization during the antenatal period and postnatal depression can be easily attenuated by the MLCU-centric approach [24,25]. In a Swedish questionnaire-based study involving 2,686 participants, only 26% of women reported dissatisfaction related to the time and support provided by midwives [26]. ...
The allocation of the midwife-led care unit (MLCU), a midwifery-led care model in which midwives carry out eminent roles to enrich maternal and newborn outcomes with minimal standard interventions, has appeared to be productive in furthering the quality of care and positive childbirth experiences. In the present article, we review the investments needed in MLCUs for their inclusion into the public health system by describing their advantages, the latest trends in maternal mortality, the roles of midwives, the relevant background, and the current advances in midwifery practices in India. Midwifery-led care is directed by a philosophy that considers pregnancy and childbirth as normal physiological events for women. Making use of a midwife, especially in low-risk pregnancies, extends satisfactory and cost-effective care. The Government of India has begun to introduce midwifery services to the country to improve the quality, righteousness, and worthiness in the provision of care and to offload higher-level hospitals. The year 2020 was designated as the "Year of the Nurse and the Midwife" by the WHO, highlighting the importance of nurses' and midwives' roles in sustaining quality health care. Further, the acceptability among clinicians and the public is crucial for the future advancement and implementation of MLCUs in India.
... 71 Continuity of care to pregnant women is known to be beneficial for both the pregnant woman and offspring. 72 The importance of continuity of care to pregnant women during natural disasters has been highlighted by the Queensland Flood 2011 study, which illustrated that continuity of care not only protects the women against adverse pregnancy outcomes, but also has positive effects on children's future neurodevelopment. 73 We hypothesise that vulnerable and marginalised groups who are already disproportionately affected during natural disasters (as discussed here), might also be severely impacted by disruption of continuity of care; however, this remains poorly studied. ...
Adverse environmental exposures in utero and early childhood are known to programme long-term health. Climate change, by contributing to severe heatwaves, wildfires, and other natural disasters, is plausibly associated with adverse pregnancy outcomes and an increase in the future burden of chronic diseases in both mothers and their babies. In this Personal View, we highlight the limitations of existing evidence, specifically on the effects of severe heatwave and wildfire events, and compounding syndemic events such as the COVID-19 pandemic, on the short-term and long-term physical and mental health of pregnant women and their babies, taking into account the interactions with individual and community vulnerabilities. We highlight a need for an international, interdisciplinary collaborative effort to systematically study the effects of severe climate-related environmental crises on maternal and child health. This will enable informed changes to public health policy and clinical practice necessary to safeguard the health and wellbeing of current and future generations.
... Ensuring a continuum of maternity care across these three services has become a rallying call to reduce maternal and neonatal deaths [14]. Continuous uptake of antenatal, delivery, and postnatal care is associated with reduced risk of obstetrics complications and adverse birth outcomes [15][16][17]. ...
Maternal mortality in Ethiopia was estimated to be 267 per 100,000 live births in 2020. A significant number of maternal deaths occur in the emerging regions of the country: Afar, Somali, Gambela, and Benishangul-Gumuz. Achieving the Sustainable Development Goal (SDG) target requires a dramatic increase in maternal healthcare utilisation during pregnancy, childbirth, and the postpartum period. Yet, there is a paucity of evidence on the continuum of maternity care utilisation in Ethiopia, particularly in the emerging regions. Therefore, this study aimed to assess completion and factors associated with the continuum of maternity care in the emerging regions of Ethiopia. This study used the 2019 Ethiopian Demographic and Health Survey data (n = 1431). Bivariable and multivariable logistic regression analyses were carried out to identify factors associated with the completion of the continuum of maternity care. An adjustment was made to the survey design (weight, stratification, and clustering). 9.5% (95% Confidence Interval (CI): 7.0-13.0) of women completed the continuum of maternity care (four or more antenatal care, institutional delivery, and postnatal care within 24 h). Living in Somali (adjusted Odds Ratio (aOR): 0.23, 95%CI: 0.07-0.78) and Benishangul-Gumuz (aOR 3.41, 95%CI: 1.65-7.04) regions, having a secondary and higher educational level (aOR 2.12, 95%CI: 1.13-4.00), and being in the richest wealth quintile (aOR 4.55, 95%CI: 2.04-10.15) were factors associated with completion of the continuum of maternity care. Although nearly half of the women had one antenatal care, fewer than 10% completed the continuum of maternity care. This indicates that women in these regions are not getting the maximum health benefits from maternal healthcare services, and this might contribute to the high maternal death in the regions. Moreover, the completion of the continuum of maternity care was skewed toward women who are more educated (secondary or higher education) and in the richest quintile.
... According to our findings, continuous midwifery care is a requirement for any healthcare system to improve midwifery services, especially the implementation of physiologic birth. Currently, there is compelling evidence from randomized controlled studies, descriptive and comparative analyses and qualitative studies regarding the benefits of continuous midwifery care for midwives, women and the health system [24][25][26][27]. According to studies conducted in Iran, this care model improves maternal and newborn outcomes [28]. ...
Introduction
The rate of cesarean section is on the rise in both developed and developing countries, and Iran is no exception. According to the WHO, physiologic labor is one of the main strategies for reducing cesarean section and improving the health of mothers and newborns. The aim of this qualitative study was to explain the experiences of health providers regarding implementation of the physiologic birth program in Iran.
Methods
This study is a part of a mixed-methods study, in which 22 health providers were interviewed from January 2022 to June 2022. Data analysis was performed using Graneheim and Lundman’s conventional content analysis approach and using MAXQDA10 software.
Results
Two main categories and nine subcategories emerged from the results of this study. The main categories included “the obstacles to the implementation of the physiologic birth program” and “strategies for improving implementation of the program”. The subcategories of the first category included: lack of continuous midwifery care in the healthcare system, lack of free accompanying midwives, lack of integrated healthcare and hospitals in service provision, low quality of childbirth preparation and implementation of physiologic birth classes, and lack of requirements for the implementation of physiologic birth in the maternity ward. The second category included the following subcategories: Supervising the implementation of childbirth preparation classes and physiologic childbirth, support of midwives by insurance companies, holding training courses on physiologic birth, and evaluation of program implementation.
Conclusions
The experiences of the health providers with the physiologic birth program revealed that policymakers should provide the ground for the implementation of this type of labor by removing the obstacles and providing the particular operational strategies needed in Iran. Important measures that can contribute to the implementation of the physiologic labor program in Iran include the following: Setting the stage for physiologic birth in the healthcare system, creating low- and high-risk wards in maternity hospitals, providing professional autonomy for midwifery, training childbirth providers on physiologic birth, monitoring the quality of program implementation, and providing insurance support for midwifery services.
... Thus, when organising midwifery-led healthcare for pregnant women, it is important to consider limiting the number of midwives that a woman will encounter. There is evidence that a midwifery team that follows a mother during her pregnancy and birth could have an overall positive effect on the woman's perception of care, as well as her pregnancy and birth (Homer, 2016;Sandall et al, 2016). ...
Background/Aims
Self-rated health before, during and after pregnancy is important for women's quality of life and promotes bonding between mother and child. However, diverse aspects of care models influence women's experiences during pregnancy. This study aimed to investigate low-risk women's self-rated health during the perinatal period in relation to different models of care in Sweden.
Methods
A retrospective study was conducted of computerised obstetric data from 167 523 women with low-risk pregnancies during 2010–2015. Descriptive analysis was used, as well as group comparisons and ordinal regression analysis, to establish links between self-rated health before, during and after pregnancy and sociodemographic characteristics.
Results
The majority of women, regardless of model of care, rated their health as very good or good before, during and after pregnancy. During pregnancy, primiparous women, those who attended <7 midwife visits and those followed up by a private centre were more likely to rate their health as good. Women who had more than four midwives, were under the age of 30 years or foreign-born had increased risk of rating their health as bad. Postnatally, women who used private care, primiparous women and those aged 25–29 years were at lower risk of rating their health as bad.
Conclusions
Women attending private healthcare services tended to rate their health as better. Vulnerable groups of women need special attention from healthcare authorities.
Smajdor and Rasanen (2024) argue that pregnant women are routinely denied appropriate treatment because pregnancy is seen as normal, and so they are denied ‘patient status’. They claim that formally classifying pregnancy as a disease may lead to better treatment for pregnant women. In this response, we argue that pathologising pregnancy and classifying all pregnant women as ‘diseased patients’ won’t reconfigure care in ways that benefit all women. Rather, it will likely only embolden the view that clinicians are entitled to exercise jurisdiction over pregnant women and beget the increased use of medical intervention where it is not necessarily needed.
Pregnancy hypertension is a danger sign of pregnancy that significantly contributes to maternal and fetal morbidity and mortality. The purpose of the study was to evaluate the implementation of assistance for pregnant women through ongoing midwifery assistance in cases of hypertension during pregnancy to postpartum and family planning services. The research method uses a midwifery management approach and is documented in SOAP, the respondent is a pregnant woman GIP0A0 34 weeks of gestation, who is assisted and given midwifery care from pregnancy to family planning services in Sumodikaran Village, Dander District, Bojonegoro Regency. The results showed that midwifery care was carried out continuously and based on established standards of midwifery care. Pregnant women get services of at least 10 T, normal delivery care, postpartum and family planning services safely and in accordance with procedures. Mrs D as a respondent was given prenatal care according to a minimum standard of 10 T, during pregnancy NY D had hypertension but had already received treatment. Childbirth care was carried out at Aisyiyah Hospital, Bojonegoro, lasted 12 hours, the baby was born spontaneously at 9.30 p.m, cried strongly, reddish skin, active movement, good muscle tone, female, weight 3,000 g, body length 48 cm, Apgar Score: 8-9. Midwifery care during the puerperium was carried out 4 times (2 hours post partum while at Aisyiyah Hospital and 3 times home visits). Midwifery care for newborns is carried out immediately after the baby is born which is carried out at the hospital and carried out 3 times home visits. Midwifery care for post-partum contraceptive services is carried out on 40 days post partum. The mother plans to use a 3-month injectable family planning when her baby is 3 months old. In conclusion, evaluation of the implementation of assistance for pregnant women through continuous midwifery care in cases of hypertension during pregnancy to postpartum and family planning services after proper management is carried out, namely referral to health centers, pregnancy hypertension does not progress to preeclampsia. Maternity care, postpartum, newborn and family planning services are well implemented.
Background
Midwives are primary providers of care for childbearing women globally and there is a need to establish whether there are differences in effectiveness between midwife continuity of care models and other models of care. This is an update of a review published in 2016.
Objectives
To compare the effects of midwife continuity of care models with other models of care for childbearing women and their infants.
Search methods
We searched the Cochrane Pregnancy and Childbirth Trials Register, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) (17 August 2022), as well as the reference lists of retrieved studies.
Selection criteria
All published and unpublished trials in which pregnant women are randomly allocated to midwife continuity of care models or other models of care during pregnancy and birth.
Data collection and analysis
Two authors independently assessed studies for inclusion criteria, scientific integrity, and risk of bias, and carried out data extraction and entry. Primary outcomes were spontaneous vaginal birth, caesarean section, regional anaesthesia, intact perineum, fetal loss after 24 weeks gestation, preterm birth, and neonatal death. We used GRADE to rate the certainty of evidence.
Main results
We included 17 studies involving 18,533 randomised women. We assessed all studies as being at low risk of scientific integrity/trustworthiness concerns. Studies were conducted in Australia, Canada, China, Ireland, and the United Kingdom. The majority of the included studies did not include women at high risk of complications. There are three ongoing studies targeting disadvantaged women.
Primary outcomes
Based on control group risks observed in the studies, midwife continuity of care models, as compared to other models of care, likely increase spontaneous vaginal birth from 66% to 70% (risk ratio (RR) 1.05, 95% confidence interval (CI) 1.03 to 1.07; 15 studies, 17,864 participants; moderate‐certainty evidence), likelyreduce caesarean sections from 16% to 15% (RR 0.91, 95% CI 0.84 to 0.99; 16 studies, 18,037 participants; moderate‐certainty evidence), and likely result in little to no difference in intact perineum (29% in other care models and 31% in midwife continuity of care models, average RR 1.05, 95% CI 0.98 to 1.12; 12 studies, 14,268 participants; moderate‐certainty evidence). There may belittle or no difference in preterm birth (< 37 weeks) (6% under both care models, average RR 0.95, 95% CI 0.78 to 1.16; 10 studies, 13,850 participants; low‐certainty evidence).
We are very uncertain about the effect of midwife continuity of care models on regional analgesia (average RR 0.85, 95% CI 0.79 to 0.92; 15 studies, 17,754 participants, very low‐certainty evidence), fetal loss at or after 24 weeks gestation (average RR 1.24, 95% CI 0.73 to 2.13; 12 studies, 16,122 participants; very low‐certainty evidence), and neonatal death (average RR 0.85, 95% CI 0.43 to 1.71; 10 studies, 14,718 participants; very low‐certainty evidence).
Secondary outcomes
When compared to other models of care, midwife continuity of care models likely reduce instrumental vaginal birth (forceps/vacuum) from 14% to 13% (average RR 0.89, 95% CI 0.83 to 0.96; 14 studies, 17,769 participants; moderate‐certainty evidence), and may reduceepisiotomy 23% to 19% (average RR 0.83, 95% CI 0.77 to 0.91; 15 studies, 17,839 participants; low‐certainty evidence).
When compared to other models of care, midwife continuity of care models likelyresult in little to no difference in postpartum haemorrhage (average RR 0.92, 95% CI 0.82 to 1.03; 11 studies, 14,407 participants; moderate‐certainty evidence) and admission to special care nursery/neonatal intensive care unit (average RR 0.89, 95% CI 0.77 to 1.03; 13 studies, 16,260 participants; moderate‐certainty evidence). There may be little or no difference in induction of labour (average RR 0.92, 95% CI 0.85 to 1.00; 14 studies, 17,666 participants; low‐certainty evidence), breastfeeding initiation (average RR 1.06, 95% CI 1.00 to 1.12; 8 studies, 8575 participants; low‐certainty evidence), and birth weight less than 2500 g (average RR 0.92, 95% CI 0.79 to 1.08; 9 studies, 12,420 participants; low‐certainty evidence).
We are very uncertain about the effect of midwife continuity of care models compared to other models of care on third or fourth‐degree tear (average RR 1.10, 95% CI 0.81 to 1.49; 7 studies, 9437 participants; very low‐certainty evidence), maternal readmission within 28 days (average RR 1.52, 95% CI 0.78 to 2.96; 1 study, 1195 participants; very low‐certainty evidence), attendance at birth by a known midwife (average RR 9.13, 95% CI 5.87 to 14.21; 11 studies, 9273 participants; very low‐certainty evidence), Apgar score less than or equal to seven at five minutes (average RR 0.95, 95% CI 0.72 to 1.24; 13 studies, 12,806 participants; very low‐certainty evidence) and fetal loss before 24 weeks gestation (average RR 0.82, 95% CI 0.67 to 1.01; 12 studies, 15,913 participants; very low‐certainty evidence). No maternal deaths were reported across three studies.
Although the observed risk of adverse events was similar between midwifery continuity of care models and other models, our confidence in the findings was limited. Our confidence in the findings was lowered by possible risks of bias, inconsistency, and imprecision of some estimates.
There were no available data for the outcomes: maternal health status, neonatal readmission within 28 days, infant health status, and birth weight of 4000 g or more.
Maternal experiences and cost implications are described narratively. Women receiving care from midwife continuity of care models, as opposed to other care models, generally reported more positive experiences during pregnancy, labour, and postpartum. Cost savings were noted in the antenatal and intrapartum periods in midwife continuity of care models.
Authors' conclusions
Women receiving midwife continuity of care models were less likely to experience a caesarean section and instrumental birth, and may be less likely to experience episiotomy. They were more likely to experience spontaneous vaginal birth and report a positive experience. The certainty of some findings varies due to possible risks of bias, inconsistencies, and imprecision of some estimates.
Future research should focus on the impact on women with social risk factors, and those at higher risk of complications, and implementation and scaling up of midwife continuity of care models, with emphasis on low‐ and middle‐income countries.
Latar belakang: Kehamilan dan melahirkan merupakan masa yang paling membahagiakan dan perubahan penting menjadi ibu bagi seorang perempuan. Di sisi lain, selama persalinan dan segera setelah melahirkan merupakan kondisi yang paling rentan bagi seorang ibu dan bayi baru lahir. Hal ini dapat dilihat dengan data masih tingginya AKI dan AKB di Indonesia sampai saat ini. Bidan sebagai pemberi asuhan kebidanan berkelanjutan dalam daur kehidupan perempuan memiliki posisi strategis untuk berperan dalam upaya mengatasi masalah tersebut. Salah satunya dengan melakukan asuhan kebidanan berkelanjutan yang dapat meningkatkan kualitas asuhan kebidanan, luaran ibu dan janin serta meningkatkan kepuasan klien yang pada akhirnya diharapkan dapat berkontribusi menurunkan AKI dan AKB. Sejauh ini asuhan kebidanan berkelanjutan belum dilaksanakan secara utuh dan belum didukung dengan digital health untuk mengoptimalkan asuhan yang dapat memudahkan bidan, tenaga kesehatan yang terkait, dan klien baik dalam komunikasi, informasi, edukasi, maupun pencatatan dan pelaporan. Kabupaten Purwakarta sendiri merupakan salah satu Kabupaten di Jawa barat yang menempati urutan ke-11 dari 27 kabupaten/kota penyumbang AKI tertinggi di Jawa Barat dan menjadi wilayah pilot project untuk inisiasi dan pengembangan digital health dalam bentuk aplikasi iPosyandu. Tujuan: Untuk mengetahui pengaruh asuhan kebidanan berkelanjutan berbasis digital terhadap luaran ibu dan janin di Kabupaten Purwakarta. Metode: Penelitian ini merupakan penelitian Quasi Experimental, dengan pendekatan Posttest-Only with Non-Equivalent Groups Design yang mengukur perbedaan luaran ibu dan janin setelah mendapatkan asuhan kebidanan berkelanjutan dengan penggunaan aplikasi iPosyandu Keluarga dan asuhan kebidanan berkelanjutan tanpa penggunaan aplikasi iPosyandu Keluarga. Sampel penelitian berjumlah 30 orang ibu hamil trimester III yang mendapatkan asuhan kebidanan berkelanjutan sampai dengan akhir masa nifas, diambil secara purposive sampling berdasarkan kriteria inklusi dan eksklusi yang telah ditentukan, masing-masing kelompok terdiri atas 15 orang. Analisis data menggunakan uji Wilcoxon Signed Rank Test. Hasil: Luaran ibu dan bayi pada responden yang mendapatkan asuhan kebidanan berkelanjutan menggunakan aplikasi iPosyandu Keluarga, seluruhnya merasa sangat puas dengan pelayanan yang didapatkan (100%), hampir semua persalinan secara spontan pervaginam (93,3%), tidak terjadi kematian perinatal (100%), tidak terjadi kelahiran prematur (100%) dan tidak terjadi BBLR (100%). Pada responden yang tidak mendapatkan asuhan kebidanan berkelanjutan tanpa aplikasi iPosyandu Keluarga, sebagian besar merasa sangat puas dengan pelayanan yang didapatkan (73,3%), sebagian besar besar lahir secara sectio caesarea (66,7%), tidak terjadi kematian perinatal (100%), hampir seluruhnya tidak mengalami kelahiran prematur (93,3%), dan tidak tidak terjadi BBLR (93,3%). Terdapat pengaruh yang signifikan pada asuhan kebidanan berkelanjutan menggunakan aplikasi iPosyandu Keluarga terhadap luaran ibu (p value 0,001), maupun pada kelompok pembanding ( p value 0,000). Luaran bayi pada kelompok intevensi didapatkan p value 0,000 yang artinya terdapat pengaruh yang signifikan pada asuhan kebidanan berkelanjutan menggunakan aplikasi iPosyandu Keluarga terhadap luaran bayi maupun pada kelompok pembanding (p value 0,018). Kesimpulan: terdapat pengaruh asuhan kebidanan berkelanjutan berbasis digital terhadap luaran ibu dan janin di Kabupaten Purwakarta.
Objective:
To gain insight into the benefits, shortcomings, and practical considerations when using the peanut ball for women during labour.
Design & setting:
We used a descriptive qualitative approach using semi-structured, in-depth interviews to explore the experiences of eight midwives working in a tertiary hospital birth unit in New South Wales, Australia when using the peanut ball for women during labour.
Participants:
Participants were recruited from the birthing unit of a tertiary hospital in New South Wales. The final sample included eight midwives working in the birth unit.
Findings:
Three overarching themes were identified: 'Education and encouragement', 'benefits and disadvantages of peanut ball' and 'techniques'. The 'Education and encouragement' theme included three sub-themes: 'selling it to the woman', 'educating midwives' and 'becoming usual practice and improving confidence'. The 'Benefits and disadvantages of peanut ball' theme included two sub-themes: 'facilitates labour and birth' and 'discomfort'. The 'Techniques' theme included three subthemes: 'positioning', 'sizing' and 'using alternative techniques'. Midwives are confident in their practice with the peanut ball and acknowledge the importance of educating midwives and women to promote its use. Midwives also discussed favoured techniques when using the ball, especially relating to size and maternal positioning.
Conclusion:
Our study provides insight into midwives' experiences about using a peanut ball for women during labour. The midwives reported that the peanut ball encourages vaginal births and shortens labour times, whilst enabling women to participate actively in the birth. Education for midwives and women is vital for using peanut balls.
Implications for practice:
Peanut balls are not usual practice in birthing units in Australia and they are a novel intervention to improve labour and birthing outcomes for women, especially when using an epidural.
Australia's national maternity strategy Woman-centred care: strategic directions for Australian maternity services (the Strategy) was released by the federal government in November 2019. It was developed to provide national guidance on the effective provision of woman-centred maternity care. The Strategy is structured around four values of safety, respect, choice, and access, and underpinned by twelve principles of woman-centred care. By examining previous research, this review aims to provide a baseline understanding of how maternity care provision is being met in relation to these core values. A systematic search of Australian literature was undertaken via four databases using the Strategy's values and 41 articles met the selection criteria. Include articles were predominantly published pre-2019, providing a baseline understanding of Australian maternity care provision prior to the Strategy's publication. Findings suggest that the four values align with those of women; however, women were not always receiving care in accordance with the values, particularly among women from priority populations. Women prioritised safety for themselves and their babies, articulated the need for respectful relationships with maternity care providers, wanted autonomy to make their own decisions, and desired access to appropriate, local, maternity services. Additionally, while pockets of appropriate care do exist, these are more likely to occur at a single-service level than more broadly at a population level. This implies the Strategy is needed, and its operationalisation must be prioritised through a coordinated national response to better meet the maternity care needs of Australian women. Further research is warranted to determine the Strategy's effectiveness.
Problem:
Little is known about midwives' views and wellbeing when working in an all-risk caseload model.
Background:
Between March 2017 and December 2020 three maternity services in Victoria, Australia implemented culturally responsive caseload models for women having a First Nations baby.
Aim:
Explore the views, experiences and wellbeing of midwives working in an all-risk culturally responsive model for First Nations families compared to midwives in standard caseload models in the same services.
Methods:
A survey was sent to all midwives in the culturally responsive (CR) model six-months and two years after commencement (or on exit), and to standard caseload (SC) midwives two years after the culturally responsive model commenced. Measures used included the Midwifery Process Questionnaire and Copenhagen Burnout Inventory (CBI).
Findings:
35 caseload midwives (19 CR, 16 SC) participated. Both groups reported positive attitudes towards their professional role, trending towards higher median levels of satisfaction for the culturally responsive midwives. Midwives valued building close relationships with women and providing continuity of care. Around half reported difficulty maintaining work-life balance, however almost all preferred the flexible hours to shift work. All agreed that a reduced caseload is needed for an all-risk model and that supports around the model (e.g. nominated social workers, obstetricians) are important. Mean CBI scores showed no burnout in either group, with small numbers of individuals having burnout in both groups.
Discussion and conclusion:
Midwives were highly satisfied working in both caseload models, but decreased caseloads and more organisational supports are needed in all-risk models.
Introduction:
Increased rate of caesarean section (CS) without medical indication is a global concern. According to the guidelines of the World Health Organization (WHO), the physiologic birth program is one of the strategies for reducing the rate of unnecessary caesarean sections. The aim of this study is to explain women's experiences with the implementation of the physiologic birth program in Iran.
Materials and methods:
This study is a part of a mixed-method study involving 15 targeted semi-structured interviews individually conducted with women attending physiologic birth classes between January 2022 and June 2022. Interviews continued until data saturation was achieved. Data were analyzed using conventional content analysis approach based on the criteria proposed by Graneheim and Lundman, using MAXQDA10 software.
Results:
Analysis of the findings of the study led to the emergence of 2 themes, 4 categories, and 10 subcategories. The first theme was the positive experiences of the women ("satisfaction with pregnancy" and "making the childbirth process pleasant"), and the second theme was their negative experiences with physiologic birth ("challenges and limitation of physiologic birth program" and "lack of high-quality obstetric services in the public health system").
Conclusion:
The results of this study showed that childbirth preparation classes reduced women's fear and stress and enhanced their positive attitude toward vaginal delivery by preparing them for childbirth. Also, effective communication with midwives and their support along with efficient implementation of physiologic birth techniques led to successful pain management and satisfaction with the birth process. Policymakers should implement strategies to remove limitations and make this program accessible to all women.
Background:
Psychological birth trauma is recognised as a significant and ubiquitous sequelae from childbirth, with the incidence reported as up to 44%. In a subsequent pregnancy, women have reported a range of psychological distress symptoms from anxiety, panic attacks, depression, sleep difficulties and suicidal thoughts.
Aim:
To summarise evidence on optimising a positive pregnancy and birth experience for a subsequent pregnancy following a psychologically traumatic pregnancy and identify research gaps.
Methods:
This review followed the Joanna Briggs Institute methodology for scoping reviews and the PRISMA-ScR check list. Six databases were searched using key words relating to psychological birth trauma and subsequent pregnancy. Utilising agreed criteria, relevant papers were identified, and data were extracted and synthesised.
Results:
A total of 22 papers met the inclusion criteria for this review. All papers addressed different aspects of what was important to women in this cohort, summarised as women wanting to be at the centre of their care. Pathways of care were diverse ranging from free birth to elective caesarean. There was no systematic process for identifying a previously traumatic birth experience and no education to enable clinicians to understand the importance of this.
Conclusion:
For women who have experienced a previous psychologically traumatic birth, being at the centre of their care, in their subsequent pregnancy, is a priority. Embedding woman-centred pathways of care for women with this experience, as well as multidisciplinary education on the recognition and prevention of birth trauma, should be a research priority.
In this first paper in a series of four papers on midwifery, we aimed to examine, comprehensively and systematically, the contribution midwifery can make to the quality of care of women and infants globally, and the role of midwives and others in providing midwifery care. Drawing on international definitions and current practice, we mapped the scope of midwifery. We then developed a framework for quality maternal and newborn care using a mixed-methods approach including synthesis of findings from systematic reviews of women’s views and experiences, effective practices, and maternal and newborn care providers. The framework differentiates between what care is provided and how and by whom it is provided, and describes the care and services that childbearing women and newborn infants need in all settings. We identified more than 50 short-term, medium-term, and long-term outcomes that could be improved by care within the scope of midwifery; reduced maternal and neonatal mortality and morbidity, reduced stillbirth and preterm birth, decreased number of unnecessary interventions, and improved psychosocial and public health outcomes. Midwifery was associated with more efficient use of resources and improved outcomes when provided by midwives who were educated, trained, licensed, and regulated. Our findings support a system-level shift from maternal and newborn care focused on identification and treatment of pathology for the minority to skilled care for all. This change includes preventive and supportive care that works to strengthen women’s capabilities in the context of respectful relationships, is tailored to their needs, focuses on promotion of normal reproductive processes, and in which first-line management of complications and accessible emergency treatment are provided when needed. Midwifery is pivotal to this approach, which requires effective interdisciplinary teamwork and integration across facility and community settings. Future planning for maternal and newborn care systems can benefit from using the quality framework in planning workforce development and resource allocation.
Background:
A lack of standard terminology or means to identify and define models of maternity care in Australia has prevented accurate evaluations of outcomes for mothers and babies in different models of maternity care.
Objective:
As part of the Commonwealth-funded National Maternity Data Development Project, a classification system was developed utilising a data set specification that defines characteristics of models of maternity care.
Method:
The Maternity Care Classification System or MaCCS was developed using a participatory action research design that built upon the published and grey literature.
Results:
The study identified the characteristics that differentiate models of care and classifies models into eleven different Major Model Categories.
Conclusion:
The MaCCS will enable individual health services, local health districts (networks), jurisdictional and national health authorities to make better informed decisions for planning, policy development and delivery of maternity services in Australia.
Australia has prevented accurate evaluations of outcomes for mothers and babies in different models of maternity care. As part of the Commonwealth-funded National Maternity Data Development models of maternity care. using a participatory action research design that built upon the published and grey literature. The Major Model Categories. (networks), jurisdictional and national health authorities to make better informed decisions for planning, policy development and delivery of maternity services in Australia.
Background
In response to calls for increased access and availability of maternity care that offers women continuity with a known midwife, caseload midwifery (a model where women have a known midwife for pregnancy, birth and the postnatal period) has been introduced in a number of settings, particularly in the United Kingdom, New Zealand and Australia. Caseload midwifery reduces childbirth interventions and increases women¿s satisfaction with care, however, the evidence regarding the impact of caseload midwifery on midwives has been conflicting; some studies have reported higher satisfaction, but others have raised concerns about work-life balance, stress and burnout. This study explored caseload and standard care midwives¿ attitudes to their professional role and measured burnout in two newly introduced caseload midwifery models.Methods
All midwives providing maternity care at two study sites in Victoria, Australia ¿ one regional and one metropolitan hospital ¿ were sent structured questionnaires at the commencement of the caseload midwifery model (baseline) and after the model had been in operation for two years. The questionnaires examined midwives¿ attitude to their professional role using the Midwifery Process Questionnaire (MPQ); burnout using the Copenhagen Burnout Inventory (CBI); and also explored midwives¿ views of the positive and negative aspects of caseload work. Demographic data were collected at each time point. Quantitative data were summarised using frequencies, percentages and means, and the MPQ and CBI data presented as individual and group means. Content analysis was undertaken to analyse open-ended questions. Data were pooled for the two sites and comparisons made between caseload and standard care midwives.ResultsTwenty caseload midwives and 130 standard care midwives responded to the baseline survey (response fractions 88% and 41% respectively) and 22 caseload midwives and 133 standard care midwives responded to the two year survey (response fractions 95% and 45% respectively). At baseline, caseload and standard care midwives were very similar across all measures of personal characteristics, attitude to professional role and in their personal burnout and work-related burnout scores. Client-related burnout was lower for caseload midwives at baseline (12.3 vs 22.4, p¿=¿0.02). After two years, caseload midwives had higher mean scores in professional satisfaction (1.08 vs 0.76, p¿=¿0.01), professional support (1.06 vs 0.11, p <0.01) and client interaction (1.4 vs 0.09, p <0.01) and lower scores for personal burnout (35.7 vs 47.7, p¿<¿0.01), work-related burnout (27.3 vs 42.7, p <0.01), and client-related burnout (11.3 vs 21.4, p¿<¿0.01) compared to midwives in standard care. In both the attitude and burnout measures, caseload midwives demonstrated positive changes over the two year period between surveys.Conclusion
In this study, caseload midwifery was associated with lower burnout scores and higher ratings of positive attitudes to their professional role, including professional satisfaction. Positive aspects of caseload midwifery, such as working with known women, autonomy and flexibility, and structures that encourage midwives to maintain a work life balance may be influential in both protecting caseload midwives from burnout and improving satisfaction with their role. Further research should explore the longer term sustainability of the model from a workforce perspective, for example recruitment to and attrition from the model.
Objective To compare maternal and neonatal birth outcomes and morbidities associated with the intention to give birth in two freestanding midwifery units and two tertiary-level maternity units in New South Wales, Australia.
Design Prospective cohort study.
Participants 494 women who intended to give birth at freestanding midwifery units and 3157 women who intended to give birth at tertiary-level maternity units. Participants had low risk, singleton pregnancies and were at less than 28+0 weeks gestation at the time of booking.
Primary and secondary outcome measures Primary outcomes were mode of birth, Apgar score of less than 7 at 5 min and admission to the neonatal intensive care unit or special care nursery. Secondary outcomes were onset of labour, analgesia, blood loss, management of third stage of labour, perineal trauma, transfer, neonatal resuscitation, breastfeeding, gestational age at birth, birth weight, severe morbidity and mortality.
Results Women who planned to give birth at a freestanding midwifery unit were significantly more likely to have a spontaneous vaginal birth (AOR 1.57; 95% CI 1.20 to 2.06) and significantly less likely to have a caesarean section (AOR 0.65; 95% CI 0.48 to 0.88). There was no significant difference in the AOR of 5 min Apgar scores, however, babies from the freestanding midwifery unit group were significantly less likely to be admitted to neonatal intensive care or special care nursery (AOR 0.60; 95% CI 0.39 to 0.91). Analysis of secondary outcomes indicated that planning to give birth in a freestanding midwifery unit was associated with similar or reduced odds of intrapartum interventions and similar or improved odds of indicators of neonatal well-being.
Conclusions The results of this study support the provision of care in freestanding midwifery units as an alternative to tertiary-level maternity units for women with low risk pregnancies at the time of booking.
In the concluding paper of this Series about midwifery, we look at the policy implications from the framework for quality maternal and newborn care, the potential effect of life-saving interventions that fall within the scope of practice of midwives, and the historic sequence of health system changes that made a reduction in maternal mortality possible in countries that have expanded their midwifery workforce. Achievement of better health outcomes for women and newborn infants is possible, but needs improvements in the quality of reproductive, maternal, and newborn care, alongside necessary increases in universal coverage. In this report, we propose three priority research areas and outline how national investment in midwives and in their work environment, education, regulation, and management can improve quality of care. Midwifery and midwives are crucial to the achievement of national and international goals and targets in reproductive, maternal, newborn, and child health; now and beyond 2015.
In this first paper in a series of four papers on midwifery, we aimed to examine, comprehensively and systematically, the contribution midwifery can make to the quality of care of women and infants globally, and the role of midwives and others in providing midwifery care. Drawing on international definitions and current practice, we mapped the scope of midwifery. We then developed a framework for quality maternal and newborn care using a mixed-methods approach including synthesis of findings from systematic reviews of women's views and experiences, effective practices, and maternal and newborn care providers. The framework differentiates between what care is provided and how and by whom it is provided, and describes the care and services that childbearing women and newborn infants need in all settings. We identified more than 50 short-term, medium-term, and long-term outcomes that could be improved by care within the scope of midwifery; reduced maternal and neonatal mortality and morbidity, reduced stillbirth and preterm birth, decreased number of unnecessary interventions, and improved psychosocial and public health outcomes. Midwifery was associated with more efficient use of resources and improved outcomes when provided by midwives who were educated, trained, licensed, and regulated. Our findings support a system-level shift from maternal and newborn care focused on identification and treatment of pathology for the minority to skilled care for all. This change includes preventive and supportive care that works to strengthen women's capabilities in the context of respectful relationships, is tailored to their needs, focuses on promotion of normal reproductive processes, and in which first-line management of complications and accessible emergency treatment are provided when needed. Midwifery is pivotal to this approach, which requires effective interdisciplinary teamwork and integration across facility and community settings. Future planning for maternal and newborn care systems can benefit from using the quality framework in planning workforce development and resource allocation.
In many countries midwives act as the main providers of care for women throughout pregnancy, labour and birth. In our large public teaching hospital in Australia we restructured the way midwifery care is offered and introduced caseload midwifery for one third of women booked at the hospital. We then compared the costs and birth outcomes associated with caseload midwifery compared to the two existing models of care, standard hospital care and private obstetric care.
We undertook a cross sectional study examining the risk profile, birth outcomes and cost of care for women booked into one of the three available models of care in a tertiary teaching hospital in Australia between July 1st 2009 December 31st 2010. To control for differences in population or case mix we described the outcomes for a cohort of low risk first time mothers known as the 'standard primipara'.
Amongst the 1,379 women defined as 'standard primipara' there were significant differences in birth outcome. These first time 'low risk' mothers who received caseload care were more likely to have a spontaneous onset of labour and an unassisted vaginal birth 58.5% in MGP compared to 48.2% for Standard hospital care and 30.8% with Private obstetric care (p < 0.001). They were also significantly less likely to have an elective caesarean section 1.6% with MGP versus 5.3% with Standard care and 17.2% with private obstetric care (p < 0.001). From the public hospital perspective, over one financial year the average cost of care for the standard primipara in MGP was 1375.45 less per woman than those receiving Private obstetric care and $1590.91 less than Standard hospital care per woman (p < 0.001). Similar differences in cost were found in favour of MGP for all women in the study who received caseload care.
Cost reduction appears to be achieved through reorganising the way care is delivered in the public hospital system with the introduction of Midwifery Group Practice or caseload care. The study also highlights the unexplained clinical variation that exists between the three models of care in Australia.
The way in which maternity care is provided affects perinatal outcomes for pregnant adolescents; including the likelihood of preterm birth. The study purpose was to assess the feasibility of recruiting pregnant adolescents into a randomised controlled trial, in order to inform the design of an adequately powered trial which could test the effect of caseload midwifery on preterm birth for pregnant adolescents.
We recruited pregnant adolescents into a feasibility study of a prospective, un-blinded, two-arm, randomised controlled trial of caseload midwifery compared to standard care. We recorded and analysed recruitment data in order to provide estimates to be used in the design of a larger study.
The proportion of women aged 15--17 years who were eligible for the study was 34% (n=10), however the proportion who agreed to be randomised was only 11% (n = 1). Barriers to recruitment were restrictive eligibility criteria, unwillingness of hospital staff to assist with recruitment, and unwillingness of pregnant adolescents to have their choice of maternity carer removed through randomisation.
A randomised controlled trial of caseload midwifery care for pregnant adolescents would not be feasible in this setting without modifications to the research protocol. The recruitment plan should maximise opportunities for participation by increasing the upper age limit and enabling women to be recruited at a later gestation. Strategies to engage the support of hospital-employed staff are essential and would require substantial, and ongoing, work. A Zelen method of post-randomisation consent, monetary incentives and 'peer recruiters' could also be considered.
Women at low risk of pregnancy complications benefit from continuity of midwifery care, but no trial evidence exists for women with identified risk factors. We aimed to assess the clinical and cost outcomes of caseload midwifery care for women irrespective of risk factors.
In this unblinded, randomised, controlled, parallel-group trial, pregnant women at two metropolitan teaching hospitals in Australia were randomly assigned to either caseload midwifery care or standard maternity care by a telephone-based computer randomisation service. Women aged 18 years and older were eligible if they were less than 24 weeks pregnant at the first booking visit. Those who booked with another care provider, had a multiple pregnancy, or planned to have an elective caesarean section were excluded. Women allocated to caseload care received antenatal, intrapartum, and postnatal care from a named caseload midwife (or back-up caseload midwife). Controls received standard care with rostered midwives in discrete wards or clinics. The participant and the clinician were not masked to assignment. The main primary outcome was the proportion of women who had a caesarean section. The other primary maternal outcomes were the proportions who had an instrumental or unassisted vaginal birth, and the proportion who had epidural analgesia during labour. Primary neonatal outcomes were Apgar scores, preterm birth, and admission to neonatal intensive care. We analysed all outcomes by intention to treat. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12609000349246.
Publicly insured women were screened at the participating hospitals between Dec 8, 2008, and May 31, 2011. 1748 pregnant women were randomly assigned, 871 to caseload and 877 to standard care. The proportion of caesarean sections did not differ between the groups (183 [21%] in the caseload group vs 204 [23%] in the standard care group; odds ratio [OR] 0·88, 95% CI 0·70-1·10; p=0·26). The proportion of women who had elective caesarean sections (before onset of labour) differed significantly between caseload and standard care (69 [8%] vs 94 [11%]; OR 0·72, 95% CI 0·52-0·99; p=0·05). Proportions of instrumental birth were similar (172 [20%] vs 171 [19%]; p=0·90), as were the proportions of unassisted vaginal births (487 [56%] vs 454 [52%]; p=0·08) and epidural use (314 [36%] vs 304 [35%]; p=0·54). Neonatal outcomes did not differ between the groups. Total cost of care per woman was AUS$566·74 (95% 106·17-1027·30; p=0·02) less for caseload midwifery than for standard maternity care.
Our results show that for women of any risk, caseload midwifery is safe and cost effective.
National Health and Medical Research Council (Australia).
To report maternal and neonatal outcomes for Australian women planning a publicly funded homebirth from 2005 to 2010.
Retrospective analysis of data on women who planned a homebirth and on their babies. Data for 2005-2010 (or from the commencement of a program to 2010) were requested from the 12 publicly funded homebirth programs in place at the time.
Maternal outcomes (mortality; place and mode of birth; perineal trauma; type of management of the third stage of labour; postpartum haemorrhage; transfer to hospital); and neonatal outcomes (early mortality; Apgar score at 5 minutes; birthweight; breastfeeding initially and at 6 weeks; significant morbidity; transfer to hospital; admission to a special care nursery).
Nine publicly funded homebirth programs in Australia provided data accounting for 97% of births in these programs during the period studied. Of the 1807 women who intended to give birth at home at the onset of labour, 1521 (84%) did so. 315 (17%) were transferred to hospital during labour or within one week of giving birth. The rate of stillbirth and early neonatal death was 3.3 per 1000 births; when deaths because of expected fetal anomalies were excluded it was 1.7 per 1000 births. The rate of normal vaginal birth was 90%.
This study provides the first national evaluation of a significant proportion of women choosing publicly funded homebirth in Australia; however, the sample size does not have sufficient power to draw a conclusion about safety. More research is warranted into the safety of alternative places of birth within Australia.
The current Australian national maternity reform agenda focuses on improving access to maternity care for women and their families while preserving safety and quality. The caseload midwifery model of care offers the level of access to continuity of care proposed in the reforms however the introduction of these models in Australia continues to meet with strong resistance. In many places access to caseload midwifery care is offered as a token, usually restricted to well women, within limited metropolitan and regional facilities and where available, places for women are very small as a proportion of the total service provided. This case study outlines a major clinical redesign of midwifery care at a metropolitan tertiary referral maternity hospital in Sydney. Caseload midwifery care was introduced under randomised trial conditions to provide midwifery care to 1500 women of all risk resulting in half of the publicly insured women receiving midwifery group practice care. The paper describes the organisational quality and safety tools that were utilised to facilitate the process while discussing the factors that facilitated the process and the barriers that were encountered within the workforce, operational and political context.
The Australian government has announced major reforms with the move to a primary maternity care model. The direction of the reforms remains contentious; with the Australian Medical Association warning that the introduction of non-medically led services will compromise current high standards in maternity services and threaten the safety of mothers and babies. The purpose of this paper is to conduct a critical review of the literature to determine whether there is convincing evidence to support the safety of non-medically led models of primary maternity care. Twenty-two non-randomised international studies were included representing midwifery-led care, birth centre care and home birth. Comparative outcome measurements included: perinatal mortality; perinatal morbidity; rates of medical intervention in labour; and antenatal and intrapartum referral and transfer rates. Findings support those of the three Cochrane reviews, that there is sufficient international evidence to support the conclusion of no difference in outcomes associated with low risk women in midwifery-led, birth centre and home birth models compared with standard hospital or obstetric care. These findings are limited to services involving qualified midwives working within rigorous exclusion, assessment and referral guidelines, limiting the number of urgent intrapartum transfers that come with increased risk of perinatal mortality.
to evaluate mothers' satisfaction with a caseload-midwifery scheme, and whether this varied according to the extent of continuity of care provided.
mothers' satisfaction with care was assessed using a postal survey, which was linked with their clinical outcomes data.
the Wollongong Hospital, the major public hospital in the Illawarra region, New South Wales, Australia.
174 women gave birth during the evaluation period of a pilot midwifery group practice (MGP) programme at the Wollongong Hospital between 5 July 2004 and 30 April 2005. This group included 87 primiparous and 87 multiparous women, all of whom met the Australian College of Midwives' criteria for low-risk pregnancies.
the MGP was staffed by six midwives working in two groups of three. Each midwife took on a primary caseload of 40 women per year, and provided support as a secondary midwife to women cared for by colleagues.
mothers' satisfaction with care and adjustment to motherhood were assessed with self-completed questionnaires. Survey responses were linked with clinical data, allowing examination of the relationship between maternal satisfaction and continuity of care.
the MGP achieved high levels of continuity of care, both objectively (based on birth records) and from mothers' perspectives. Overall, mothers' evaluations of their care were very positive. Women indicated that their relationships with their midwives were genuinely caring and a valued source of reassurance and comfort during pregnancy, labour and early motherhood. Although continuity of care did not predict summary scores for maternal satisfaction, it was related to some individual items on the satisfaction scales. Satisfaction with control and communication was predicted by parity and the level of intervention during labour and birth.
continuous care appears to facilitate the development of supportive relationships between women and their midwives. Women's perceptions about continuous and respectful treatment were related to objectively measured continuity of care. The qualitative data confirm the importance of less tangible benefits, such as the quality of relationships between women and their caregivers.
the viability of caseload-midwifery-led care for low-risk pregnancies depends, in part, on the model's acceptability to consumers. This study demonstrated that the caseload model is associated with high levels of maternal satisfaction. Supportive relationships with midwives in a caseload scheme are highly valued by women.
To test whether a new community-based model of continuity of care provided by midwives and obstetricians improved maternal clinical outcomes, in particular a reduced caesarean section rate.
Randomised controlled trial.
A public teaching hospital in metropolitan Sydney, Australia. Sample 1089 women randomised to either the community-based model (n = 550) or standard hospital-based care (n = 539) prior to their first antenatal booking visit at an Australian metropolitan public hospital.
Data were collected on onset and outcomes of labour, antenatal, intrapartum and postnatal complications, antenatal admissions to hospital and neonatal mortality and morbidity.
There was a significant difference in the caesarean section rate between the groups, 13.3% (73/550) in the community-based group and 17.8% in the control group (96/539). This difference was maintained after controlling for known contributing factors to caesarean section (OR = 0.6, 95% CI 0.4-0.9, P = 0.02). There were no other significant differences in the events during labour and birth. Eighty babies (14.5%) from the community-based group and 102 (18.9%) from the control group were admitted to the special care nursery, but this difference was not significant (OR 0.75, 95% CI 0.5-1.1, P = 0.12). Eight infants died during the perinatal period (four from each group), for an overall perinatal mortality rate of 7.3 per 1000 births.
Community-based continuity of maternity care provided by midwives and obstetricians resulted in a significantly reduced caesarean section rate. There were no other differences in clinical outcomes.
Contemporary health care systems are constantly challenged to revise traditional methods of health care delivery. These challenges are multifaceted and stem from: (1) novel pharmacological and non-pharmacological treatments; (2) changes in consumer demands and expectations; (3) fiscal and resource constraints; (4) changes in societal demographics in particular the ageing of society; (5) an increasing burden of chronic disease; (6) documentation of limitations in traditional health care delivery; (7) increased emphasis on transparency, accountability, evidence-based practice (EBP) and clinical governance structures; and (8) the increasing cultural diversity of the community. These challenges provoke discussion of potential alternative models of care, with scant reference to defining what constitutes a model of care.
This paper aims to define what is meant by the term 'model of care' and document the pragmatic systems and processes necessary to develop, plan, implement and evaluate novel models of care delivery.
Searches of electronic databases, the reference lists of published materials, policy documents and the Internet were conducted using key words including 'model*', 'framework*', 'models, theoretical' and 'nursing models, theoretical'. The collated material was then analysed and synthesised into this review.
This review determined that in addition to key conceptual and theoretical perspectives, quality improvement theory (eg. collaborative methodology), project management methods and change management theory inform both pragmatic and conceptual elements of a model of care. Crucial elements in changing health care delivery through the development of innovative models of care include the planning, development, implementation, evaluation and assessment of the sustainability of the new model. Regardless of whether change in health care delivery is attempted on a micro basis (eg. ward level) or macro basis (eg. national or state system) in order to achieve sustainable, effective and efficient changes a well-planned, systematic process is essential.
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.
Background:
In Australia, Aboriginal women and babies experience higher maternal and perinatal morbidity and mortality rates than their non-Aboriginal counterparts. Whilst midwifery led continuity of care has been shown to be safe for women and their babies, with benefits including reducing the preterm birth rate, access to this model of care in remote areas remains limited. A Midwifery Group Practice was established in 2009 in a remote city of the Northern Territory, Australia, with the aim of improving outcomes and access to midwifery continuity of care.
Aim:
The aim of this paper is to describe the maternal and newborn outcomes for women accessing midwifery continuity of care in a remote context in Australia.
Methods:
A retrospective descriptive design using data from two existing electronic databases was undertaken and analysed descriptively.
Findings:
In total, 763 women (40% of whom were Aboriginal) gave birth to 769 babies over a four year period. There were no maternal deaths and the rate of perinatal mortality was lower than that across the Northern Territory. Lower rates of preterm birth (6%) and low birth weight babies (5%) were found in comparison to population based data.
Conclusion:
Continuity of Midwifery Care can be effectively provided to remote dwelling Aboriginal women and appears to improve outcomes for women and their infants.
Objective To test whether a new community-based model of continuity of care provided by midwives and obstetricians improved maternal clinical outcomes, in particular a reduced caesarean section rate. Design Randomised controlled trial. Setting A public teaching hospital in metropolitan Sydney, Australia. Sample 1039 women randomised to either the community-based model (n = 550) or standard hospital-based care (n = 539) prior to their first antenatal booking visit at an Australian metropolitan public hospital. Main outcome measures Data were collected on onset and outcomes of labour, antenatal, intrapartum and postnatal complications, antenatal admissions to hospital and neonatal mortality and morbidity. Results There was a significant difference in the caesarean section rate between the groups, 13.3% (73/550) in the community-based group and 17.8% in the control group (96/539). This difference was maintained after controlling for known contributing factors to caesarean section (OR = 0.6, 95% CI 0.4-0.9, P = 0.02). There were no other significant differences in the events during labour and birth. Eighty babies (14.5%) from the community-based group and 102 (18.9%) from the control group were admitted to the special care nursery, but this difference was not significant (OR 0.75, 95% CI 0.5-1.1, P = 0.12). Eight infants died during the perinatal period (four from each group), for an overall perinatal mortality rate of 7.3 per 1000 births. Conclusion Community-based continuity of maternity care provided by midwives and obstetricians resulted in a significantly reduced caesarean section rate. There were no ether differences in clinical outcomes.
Aim(s):
This study explores the views of midwifery managers and key stakeholders, regarding the facilitators and barriers to employing new graduate midwives in midwifery continuity of care models.
Background:
Maternity services in Australia are shifting towards midwifery continuity of care models, where midwives work in small group practices, requiring a change to the management of staff. Public policy in Australia supports maternity services to be reconfigured in this way. Historically, experienced midwives work in these models, as demand grows; new graduates are employed to staff the models.
Method(s):
A qualitative descriptive approach exploring the manager's experience of employing new graduate's in the models. Managers, clinical educators and hospital midwifery consultants (n = 15) were recruited by purposeful sampling.
Results:
Drivers, enablers, facilitators and barriers to employing new graduates in the models were identified. Visionary leadership enabled the managers to employ new graduates in the models through initial and ongoing support. Managing the myths stemming from fear of employing new graduates to work in midwifery continuity of care models was challenging.
Conclusion:
Managers and other key stakeholders provide initial and ongoing support through orientation and providing a reduced workload.
Implications for nursing management:
Visionary leadership can be seen as critical to supporting new graduates into midwifery continuity of care models. The challenges for management to overcome include managing the myths stemming from fear of employing new graduates to work in a flexible way around the needs of the women within an organisation culture.
Background:
Caseload midwifery models are becoming more common in Australian maternity care. Little is known about how caseload midwifery compares with mainstream models of midwifery care in terms of both the organisation of the work and the meaning of the work for caseload midwives.
Aim:
To explore caseload and standard care midwives' views and experiences of midwifery work in two new caseload models in Victoria, Australia.
Methods:
A mixed-methods approach was used. Quantitative data were collected using two cross-sectional surveys of midwives at the two study sites at the commencement of the caseload model and after two years. Qualitative data were collected using in-depth interviews with caseload midwives six months and two years after commencing in the role. Content analysis was used to analyse open-ended survey questions, and interview data were analysed thematically. Themes arising from these data sources were then considered using Normalization Process Theory.
Findings:
Two themes emerged from the data. Caseload midwifery was a 'different' way of working, involving activity-based work, working on-call, fluid navigation between work and personal time and avoiding burnout. Working in caseload was also perceived by caseload midwives to be 'real' midwifery, facilitating relationships with women, and requiring responsibility, accountability, autonomy and legitimacy in their practice. Perceptions of caseload work were influenced by understanding these differences in caseload work compared to mainstream maternity care.
Conclusion:
Increased understanding of the differences between caseload work and mainstream maternity models, and introducing opportunities to be exposed to caseload work may contribute to sustainability of caseload models.
Background:
The benefits of caseload midwifery care are clearly documented, and many policy documents in Australia support its expansion. Despite this, little is known about the availability of caseload across Australia, nor about what proportion of women have access to a caseload model. This paper describes caseload midwifery in the public maternity system in Australia; its prevalence, and factors associated with implementation and sustainability.
Methods:
A cross-sectional online survey of maternity managers of public hospitals that provide birthing services throughout Australia.
Findings:
Sixty-three percent (149/235) of eligible participants responded. Respondents were from all states and territories, metropolitan, regional and remote areas, and from hospitals with very small to very large birth numbers. Only 31% reported that their hospital offers caseload midwifery, and an estimated eight percent of women received caseload care at the time of the survey, most of whom were considered to be of 'low obstetric risk'. Many respondents were planning to implement or expand caseload. Key factors associated with the implementation of caseload were funding to establish the model, the interest and availability of staff to work in the model, organisational support and perceived consumer demand.
Conclusion:
This is the first study to explore caseload implementation at a national level. Although the number of services offering caseload midwifery care has increased nationally, access remains relatively limited. Women who live in metropolitan areas and who are considered at 'low obstetric risk' are most likely to be able to access this model. Funding and support for establishing new models are the main barriers to implementation.
Adolescent pregnancy is associated with adverse outcomes including preterm birth, admission to the neonatal intensive care unit, low birth weight infants, and artificial feeding.
To determine if caseload midwifery or young women's clinic are associated with improved perinatal outcomes when compared to standard care.
A retrospective cohort study.
A tertiary Australian hospital where routine maternity care is delivered alongside two community-based maternity care models specifically for young women aged 21 years or less: caseload midwifery (known midwife) and young women's clinic (rostered midwife).
All pregnant women aged 21 years or less, with a singleton pregnancy, who attended a minimum of two antenatal visits, and who birthed a baby (without congenital abnormality) at the study hospital during May 2008 to December 2012.
Caseload midwifery and young women's clinic were each compared to standard maternity care, but not with each other, for four primary outcomes: preterm birth (<37 weeks gestation), low birth weight infants (<2500g), neonatal intensive care unit admission, and breastfeeding initiation. Two analyses were performed on the primary outcomes to examine potential associations between maternity care type and perinatal outcomes: intention-to-treat (model of care at booking) and treatment-received (model of care on admission for labour/birth).
1908 births were analysed by intention-to-treat and treatment-received analyses. Young women allocated to caseload care at booking, compared to standard care, were less likely to have a preterm birth (adjusted odds ratio 0.59 (0.38-0.90, p=0.014)) or a neonatal intensive care unit admission adjusted odds ratio 0.42 (0.22-0.82, p=0.010). Rates of low birth weight infants and breastfeeding initiation were similar between caseload and standard care participants. Participants allocated to young women's clinic at booking, compared to standard care, were less likely to have a low birth weight infant adjusted odds ratio 0.49 (0.24-1.00, p=0.049), however when analysed by treatment-received, this finding was not significant. There was no difference in the other primary outcomes.
Young women who were allocated to caseload midwifery at booking, and/or were receiving caseload midwifery at the time of admission for birth, were less likely to experience preterm birth and neonatal intensive care unit admission.
Copyright © 2015 Elsevier Ltd. All rights reserved.
This paper focuses on midwives’ experiences of working with a case load and what it meant to them, both professionally and as individuals. Four themes emerged that summed up the midwives’ experiences of working with a case load. These were role and time, holistic practice, relationships with women, and ‘orientation’ in relation to their sense of autonomy and responsibility. Midwives found case load practice rewarding in terms of control of their time, in their relationships with the women they looked after, and the personal and professional development they achieved. As a result, they felt like ‘real midwives’ in a way they had not done before.
midwifery continuity of care has been shown to be beneficial to women through reducing interventions and other maternal and neonatal morbidity. In Australia, numerous government reports recognise the importance of midwifery models of care that provide continuity. Given the benefits, midwives, including new graduate midwives, should have the opportunity to work in these models of care. Historically, new graduates have been required to have a number of years׳ experience before they are able to work in these models of care although a small number have been able to move into these models as new graduates.
to explore the experiences of the new graduate midwives who have worked in midwifery continuity of care, in particular, the support they received; and, to establish the facilitators and barriers to the expansion of new graduate positions in midwifery continuity of care models.
a qualitative descriptive study was undertaken framed by the concept of continuity of care.
the new graduate midwives valued the relationship with the women and with the group of midwives they worked alongside. The ability to develop trusting relationships, consolidate skills and knowledge, be supported by the group and finally feeling prepared to work in midwifery continuity of care from their degree were all sub-themes. All of these factors led to the participants feeling as though they were 'becoming a real midwife'.
this is the first study to demonstrate that new graduate midwives value working in midwifery continuity of care - they felt well prepared to work in this way from their degree and were supported by midwives they worked alongside. The participants reported having more confidence to practice when they have a relationship with the woman, as occurs in these models.
Copyright © 2015 Elsevier Ltd. All rights reserved.
Objectives
In Australia, models of maternity care that offer women continuity of care with a known midwife have been promoted. Little is known about the intentions of the future midwifery workforce to work in such models. This study aimed to explore midwifery students’ views and experiences of caseload midwifery and their work intentions in relation to the caseload model following graduation.
Design
Cross-sectional survey.
Setting
Victoria, Australia.
Participants
129 midwifery students representing all midwifery course pathways (Post Graduate Diploma, Bachelor of Midwifery, Bachelor of Nursing/Bachelor of Midwifery) in Victoria.
Findings
Midwifery students from all course pathways considered that continuity of care is important to women and indicated that exposure to continuity models during their course was very positive. Two thirds of the students (67%) considered that the continuity experiences made them want to work in a caseload model; only 5% reported that their experiences had discouraged them from continuity of care work in the future. Most wanted a period of consolidation to gain experience as a midwife prior to commencing in the caseload model. Perceived barriers to caseload work were being on-call, and challenges in regard to work/life balance and family commitments.
Key conclusions and implications for practice
Midwifery students in this study were very positive about caseload midwifery and most would consider working in caseload after a period of consolidation. Continuity of care experiences during students’ midwifery education programs appeared to provide students with insight and understanding of continuity of care for both women and midwives. Further research should explore what factors influence students’ future midwifery work, whether or not their plans are fulfilled, and whether or not the caseload midwifery workforce can be sustained.