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

Abstract

Objective To review randomised controlled trials of alternative maternity services characterised by continuity of midwifery care.Methods A systematic review of randomised controlled trials, analysed on an intention to treat basis, in which the study intervention was characterised by a midwife or small group of midwives providing care from early pregnancy to the postnatal period (defined as that provided on the postnatal ward); and the controls by standard maternity care as practised in the place where the trial was conducted. The seven trials identified included 9148 women. Main outcome measures were interventions during labour, maternal outcomes and infant outcomes.Results The alternative models with continuity of midwifery care were associated with less use of obstetric interventions during labour (eg, induction, augmentation of labour, electronic fetal monitoring, obstetric analgesia, instrumental vaginal delivery and episiotomy). However, the caesarean section rate did not differ statistically between the trial groups (OR 0.91; 95% CI 0.78 to 1.05). The lower episiotomy rate in the alternative models of care (OR 0.69; 95% CI 0.61 to 0.77) was associated with a significantly higher rate of perineal tears in the pooled alternative groups (OR 1.15; 95% CI 1.05 to 1.26). The percentage of intact perineums was very similar for the two groups (OR 1.11; 95% CI 1.00 to 1.24). There was no maternal death, and rates of maternal complications based on unpooled estimates did not show any statistically significant differences. The proportion of babies with an Apgar score < 7 at five minutes after the birth was approximately the same in the pooled alternative groups as in the control groups (OR 1-13 95% CI 0.69 to 1.84). Admission to intensive care or special care baby unit was similar (OR 0.86; 95% CI 0.71 to 1.04). The difference in perinatal deaths was bordering on statistical significanceContinuity of midwifery care is associated with lower intervention rates than standard maternity care. No statistically significant differences were observed in maternal and infant outcomes. However, more research is necessary to make definite conclusions about safety, for the infant as well as for the mother. This review illustrates the variation in the different models of alternative and standard maternity care, and thus the problems associated with pooling data from different trials.(OR 1.60; 95% CI 0.99 to 2.59). Conclusion

Patient Safety, Adverse Healthcare Events and Near-Misses in Obstetric Care —A Systematic Literature Review

“…The findings demonstrated a significant difference in the caesarean rate between the community group and the control group. COC has been shown to reduce interventions in labour, particularly augmentation of labour, analgesic use and electronic foetal monitoring [47].…”

Collaboration in maternity care: a randomised controlled trial comparing community-based continuity of care with standard hospital care

“…The emergency caesarean reduction might be attributable to continuity of midwifery care during labour. Differences in caesarean section rates have not been demonstrated in most other trials of continuity of midwifery care, 21 although a trend to a reduction in high risk women has been reported. 7;9 A trial of 200 women in Canada did demonstrate a significant difference.…”

“…17 Similar trials have shown a small, non-statistically significant increase in perinatal deaths associated with the continuity of care models 6;9;19;22;23 and a recent systematic review cited this increase as a major concern. 21 Our study is important as it adds to the relatively small numbers available for meta analysis to this point.…”

“…Similar trials have reported mean admission rates of 6.1 per cent in continuity of care models and 8.9 per cent in standard care. 21 This suggests that a low threshold for transfer exists, possibly enhanced by the close proximity of the delivery suite to the special care nursery and by protocols which encourage transfer.…”

“…The results from this trial can be aggregated with others in a similar manner to that conducted by Waldenström and Turnbull 21 to further understand the clinical benefits associated with continuity of care in a public sector maternity service. Unrelated to the model of care received NB: Case 4 was a woman who was offered STOMP care but chose to receive standard care through the antenatal clinic…”