4 May 2021
College of Midwives Says “Follow the Data, Invest In Midwives”
5 May – International Day of the Midwife
Fewer interventions in labour, reduced maternal and neonatal morbidity (illness, injury), improved psycho-social outcomes and increased contraceptive use; these are just some of the documented positive outcomes of a midwifery-led maternity service.
These facts are supported by research which is part of the theme for this year’s International Day of the Midwife (May 5th) – follow the data, invest in midwives.
College of Midwives Chief Executive, Alison Eddy, says investing in midwives is not only about pay.
“It’s about progressing the mahi being undertaken around developing and implementing a new funding model for community-based midwives; it’s also about recognising and understanding the work midwives do and how essential they are, and it’s about appropriately resourcing the sector so midwives can do the job they are highly trained to do,” she says.
Aotearoa New Zealand’s midwifery-led maternity model is acknowledged around the world as being the very best.
The dedicated work of core midwives in hospitals and primary maternity facilities is key to the success of the New Zealand model of maternity care. Employed midwives who have specific expertise in complex pregnancy, labour and birth, and early postnatal care, support women in maternity facilities and in community teams.
The College acknowledges the work being done by the midwives’ union MERAS, as getting the best employment conditions for midwives will support them to provide optimal care to women and babies. “There are significant recruitment and retention issues for the midwifery workforce across Aotearoa. Addressing these through better remuneration and working conditions for both hospital and community-based midwives is of paramount importance” adds Eddy.
“Our continuity-of-care model leads the world,” she says. “Seeing the same midwife through your pregnancy, labour and six weeks after a baby is born, is a key part of why New Zealand outcomes are so good. However, we need an appropriately resourced midwifery-led service to be able to deliver the best outcomes,” says Ms Eddy.
UK research published late last month¹ looking at the continuity-of-care model has found, “Community-based continuity models of care may reduce stress and anxiety through familiar, less-medicalized environments that are easier to access, and enhance the strengths of community and peer support.”
“We are midwives together, working in the community and in DHBs, with women and babies at the centre of what we do. Using data, research and lived experience, let’s all work together to strengthen the midwifery-led maternity service, supporting women and their whānau on their life-changing journey,” she says.
For more information, please contact Ali Jones on 0272473112 www.midwife.org.nz
¹ Fernandez Turienzo C, Rayment-Jones H, Roe Y, et al. A realist review to explore how midwifery continuity of care may influence preterm birth in pregnant women. Birth. 2021;00:1–14. https://doi.org/10.1111/birt.12547
The case for midwifery: the potential of midwives for improving quality of care (World Health Organisation)
- 83% of all maternal deaths, stillbirths and newborn deaths could be prevented with the full package of midwifery care (including family planning);
- 62% of effective practices within the scope of midwifery show the importance of optimising the normal processes of childbirth and early life, and empowering women to care for themselves and their families;
- 56 maternal and neonatal outcomes were found to be improved through midwifery practice and philosophy of care;
- 87% of service needs can be delivered by midwives, when educated to international standards;
- 82% reduction in maternal mortality possible with universal midwifery coverage;
- Midwifery is associated with more efficient use of resources and improved outcomes when provided by midwives who are educated, trained, licenced and regulated in international standards. Midwifery is a ‘best buy’ investment:
- Midwifery is associated with reduced maternal and neonatal morbidity, reduced interventions in labour, improved psycho-social outcomes and increased birth spacing and contraceptive use;
- Community based midwives have been found to rank positively for economy, efficiency and effectiveness;
- Midwifery should be considered a core part of universal health coverage. Quality midwifery care is central to achieving national and global priorities and securing the rights of women and newborn infants;
- Quality relates to the right for women and newborns to the highest standard of health and is synonymous with women-centred care. Providing quality care is most efficient through midwifery care for all childbearing women;
- There were no adverse outcomes associated with midwife-led care but significant benefits, thus it is recommended that all women should be offered midwife-led continuity models of care;
- Case loading midwifery care is safe and cost effective;
- Midwives have the potential to provide excellent quality of care but socio-cultural, economic and professional barriers must be overcome to allow them to practice to their full potential.
Continuity of Midwifery Care and outcomes – a synopsis
Internationally, there is increasing recognition that continuity of midwifery care is best practice for all pregnant women. The evidence is clear that there are numerous health benefits for women and midwives and the cost of continuity of midwifery care is significantly less than that of standard care.
Continuity of care midwifery care is defined as where the midwife is the lead maternity professional who plans, organises and provides maternity care from the time of confirmation of pregnancy through labour and birth and into the postnatal period.
Evidence of benefit
Sandall, Soltani, Gates, Shennan, and Devane (2016) in their systematic review involving 15 trials (17,673 women) found women who had continuity of midwifery care were more likely to experience normal vaginal birth and less likely to experience regional analgesia, instrumental vaginal birth, pre term birth (less than 37 weeks) and fetal loss before and after 24 weeks gestation.
McRae et al. (2018) et al in their review of 57,872 women in British Columbia found lower odds of pre term birth, low birth weight and small for gestational age babies in women of low socioeconomic groups who had continuity of midwifery care. Rayment-Jones, Murrells, and Sandall (2015) also compared birth details for 194 women with complex social factors between women with midwifery care and those with standard maternity care in the UK. They found that women who had continuity of midwifery care were more likely to experience normal vaginal birth, use water for pain relief, and birth in a midwife-led birthing centre. In addition, more women were referred to multi-disciplinary services including psychiatry and domestic violence advocacy. There were also fewer antenatal admissions and neonatal admissions for women who had continuity of midwifery care.
Kildea et al. (2018) reviewed women’s stress and emotional reactions (depression and anxiety) following a sudden onset flood in a severely affected area of Queensland Australia. They examined the differences between continuity of care and standard care, finding that women who received continuity of care had low depression scores and objective and subjective stress scores. Similar results were seen with anxiety scores at 6 weeks post-partum. They conclude that continuity of midwifery care appeared to provide a protective or mediating effect on the woman’s emotional health. Simcock et al. (2018) explored the outcomes for the babies of 115 women who were affected by the sudden onset flood during pregnancy. They found that women who received continuity of midwifery care had infants with significantly better outcomes developmentally at 6 months when compared to women with standard care. These positive effects on the infant’s neurodevelopment were important and suggest that continuity of care can mediate the stress involved in sudden disasters for both the woman and her baby.
Women’s satisfaction with care
Allen et al. (2019) in their Australian randomised controlled trial found that women reported higher levels of emotional support, quality of care and felt actively involved in decision making when they had continuity of midwifery care. Similarly, Mortensen et al. (2019) examined the midwifery led continuity of care model in a low-middle income country finding that there was an association between receiving continuity of care and increased satisfaction with care through the continuum of pregnancy, intrapartum and postnatal care, improved the woman’s satisfaction with her care. They also found an increased duration of breastfeeding.
Callander et al. (2019) assessed the cost effectiveness of three different interventions known to reduce caesarean section rates when comparted to standard care. Using a Markov microsimulation model which looked at costs and quality adjusted life years (QALY), they found that continuity of midwifery care (caseload) would produce the greatest cost saving if implemented for all low risk nulliparous women in Australia and that caseload midwifery provided the best value for reducing caesarean section rates. This was a similar finding to that of Tracy et al. (2013)in an Australian RCT involving 1748 women. This study found that maternity outcomes were similar except for the proportion of women having an elective caesarean section which was lower for women having midwifery continuity of care, with the cost of care per woman significantly lower than standard care.
Allen, J., Kildea, S., Tracey, M., Hartz, D. L., Welsh, A., & Tracey, S. (2019). The impact of caseload midwifery, compared with standard care, on women’s perceptions of antenatal care quality: Survey results from the M@NGO randomized controlled trial for women of any risk. Birth. doi:https://doi.org/10.1111/birt.12436
Callander, E. J., Creedy, D. K., Gamble, J., Fox, H., Toohill, J., Sneddon, A., & Ellwood, D. (2019). Reducing caesarean delivery: An economic evaluation of routine induction of labour at 39 weeks in low-risk nulliparous women. Paediatr Perinat Epidemiol. doi:10.1111/ppe.12621
Kildea, S., Simcock, G., Liu, A., Elgbeili, G., Laplante, D. P., Kahler, A., . . . King, S. (2018). Continuity of midwifery carer moderates the effects of prenatal maternal stress on postnatal maternal wellbeing: the Queensland flood study. Arch Womens Ment Health, 21(2), 203-214. doi:10.1007/s00737-017-0781-2
McRae, D., Janssen, P., Vedam, S., Mayhew, M., Mpofu, D., Teucher, U., & Muharjarine, N. (2018). Reduced prevalence of small for gesttional age and preterm birth for women of low socioeconomic position: a population-based cohort study comparing antenatal midwifery and physician models of care. BMJ Open, 8(e022220). doi:10.1136/bmjopen-2018-022220
Mortensen, B., Diep, L. M., Lukasse, M., Lieng, M., Dwekat, I., Elias, D., & Fosse, E. (2019). Women’s satisfaction with midwife-led continuity of care: an observational study in Palestine. BMJ Open, 9(11), e030324. doi:10.1136/bmjopen-2019-030324
Rayment-Jones, H., Murrells, T., & Sandall, J. (2015). An investigation of the relationship between the caseload model of midwifery for socially disadvantaged women and childbirth outcomes using routine data – A retrospective, observational study. Midwifery, 31(4), 409-417. doi:10.1016/j.midw.2015.01.003
Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women (Review). Cochrane Database of Systematic Reviews. doi:https://doi.org/10.1002/14651858.CD004667.pub5
Simcock, G., Kildea, S., Kruske, S., Laplante, D. P., Elgbeili, G., & King, S. (2018). Disaster in pregnancy: midwifery continuity positively impacts infant neurodevelopment, QF2011 study. BMC Pregnancy and Childbirth, 18(1), 309. doi:10.1186/s12884-018-1944-5
Tracy, S. K., Hartz, D. L., Tracy, M. B., Allen, J., Forti, A., Hall, B., . . . Kildea, S. (2013). Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial. The Lancet, 382(9906), 1723-1732. doi:http://dx.doi.org/10.1016/S0140-6736(13)61406-3