Midwife-led versus other models of care for childbearing women

 

Abstract

Background

Midwives are primary providers of care for childbearing women around the world. However, there is a lack of synthesised information to establish whether there are differences in morbidity and mortality, effectiveness and psychosocial outcomes between midwife-led and other models of care.

Objectives

To compare midwife-led 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 (January 2008), Cochrane Effective Practice and Organisation of Care Group's Trials Register (January 2008), Current Contents (1994 to January 2008), CINAHL (1982 to August 2006), Web of Science, BIOSIS Previews, ISI Proceedings, (1990 to 2008), and the WHO Reproductive Health Library, No. 9.

Selection criteria

All published and unpublished trials in which pregnant women are randomly allocated to midwife-led or other models of care during pregnancy, and where care is provided during the ante and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

Data collection and analysis

All authors evaluated methodological quality. Two authors checked data extraction.

Main results

We included 11 trials (12,276 women). Women who had midwife-led models of care were less likely to experience antenatal hospitalisation, risk ratio (RR) 0.90, 95% confidence interval (CI) 0.81 to 0.99), regional analgesia (RR 0.81, 95% CI 0.73 to 0.91), episiotomy (RR 0.82, 95% CI 0.77 to 0.88), and instrumental delivery (RR 0.86, 95% CI 0.78 to 0.96), and were more likely to experience no intrapartum analgesia/anaesthesia (RR 1.16, 95% CI 1.05 to 1.29), spontaneous vaginal birth (RR 1.04, 95% CI 1.02 to 1.06), feeling in control during childbirth (RR 1.74, 95% CI 1.32 to 2.30), attendance at birth by a known midwife (RR 7.84, 95% CI 4.15 to 14.81) and initiate breastfeeding (RR 1.35, 95% CI 1.03 to 1.76), although there were no statistically significant differences between groups for caesarean births (RR 0.96, 95% CI 0.87 to 1.06). Women who were randomised to receive midwife-led care were less likely to experience fetal loss before 24 weeks' gestation (RR 0.79, 95% CI 0.65 to 0.97), although there were no statistically significant differences in fetal loss/neonatal death of at least 24 weeks (RR 1.01, 95% CI 0.67 to 1.53) or in fetal/neonatal death overall (RR 0.83, 95% CI 0.70 to 1.00). In addition, their babies were more likely to have a shorter length of hospital stay (mean difference -2.00, 95% CI -2.15 to -1.85).

Authors' conclusions

Most women should be offered midwife-led models of care and women should be encouraged to ask for this option although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.

 

Plain language summary

Midwife-led versus other models of care for childbearing women

Midwife-led care confers benefits for pregnant women and their babies and is recommended.

In many parts of the world, midwives are the primary providers of care for childbearing women. Elsewhere it may be medical doctors or family physicians who have the main responsibility for care, or the responsibility may be shared. The underpinning philosophy of midwife-led care is normality, continuity of care and being cared for by a known and trusted midwife during labour. There is an emphasis on the natural ability of women to experience birth with minimum intervention. Some models of midwife-led care provide a service through a team of midwives sharing a caseload, often called 'team' midwifery. Another model is 'caseload midwifery', where the aim is to offer greater continuity of caregiver throughout the episode of care. Caseload midwifery aims to ensure that the woman receives all her care from one midwife or her/his practice partner. All models of midwife-led care are provided in a multi-disciplinary network of consultation and referral with other care providers. By contrast, medical-led models of care are where an obstetrician or family physician is primarily responsible for care. In shared-care models, responsibility is shared between different healthcare professionals.

The review of midwife-led care covered midwives providing care antenatally, during labour and postnatally. This was compared with models of medical-led care and shared care, and identified 11 trials, involving 12,276 women. Midwife-led care was associated with several benefits for mothers and babies, and had no identified adverse effects.

The main benefits were a reduction in the use of regional analgesia, with fewer episiotomies or instrumental births. Midwife-led care also increased the woman's chance of being cared for in labour by a midwife she had got to know, and the chance of feeling in control during labour, having a spontaneous vaginal birth and initiating breastfeeding. However, there was no difference in caesarean birth rates.

Women who were randomised to receive midwife-led care were less likely to lose their baby before 24 weeks' gestation, although there were no differences in the risk of losing the baby after 24 weeks, or overall. In addition, babies of women who were randomised to receive midwife-led care were more likely to have a shorter length of hospital stay.

The review concluded that most women should be offered midwife-led models of care, although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.

 

摘要

背景

助產士主導方式與其他產婦照護模式的比較

助產士是全世界上孕婦照護的主要提供者，不過，缺乏確認助產士主導方式與其他產婦照護模式之間發病率和死亡率、成效與心理社會結果是否有差異的綜合資訊。

目標

比較助產士主導方式與其他產婦及嬰兒照護模式。

搜尋策略

我們搜尋Cochrane Pregnancy和Childbirth Group's Trials Register (2008年1月)、Cochrane Effective Practice和Organisation of Care Group's Trials Register(2008年1月)、Current Contents(1994年2008年1月)、CINAHL(1982年2006年8月)、Web of Science、BIOSIS Previews、ISI Proceedings(1990年2008年)以及WHO Reproductive Health Library, No 。

選擇標準

孕婦隨機分組接受助產士主導方式或其他照護模式的已發表和未發表試驗，以及比較助產士主導模式中產前與生產中提供的照護。

資料收集與分析

所有作者評估試驗方法的品質，2位作者獨立檢查資料選用。

主要結論

納入11個試驗(12,276名婦女)。助產士主導模式的孕婦比較少產前住院(風險比(RR)為0.90, 95% 信賴區間為0.81 – 0.99)、使用局部麻醉(風險比(RR)為0.81, 95% 信賴區間為0.73 – 0.91)、外陰切開術(episiotomy)(風險比(RR)為0.82, 95% 信賴區間為0.77 – 0.88)、使用器械生產(風險比(RR)為0.86, 95% 信賴區間為0.78 – 0.96)，比較不需要分娩期間麻醉/止痛(風險比(RR)為1.16, 95% 信賴區間為1.05 – 1.29)、比較常自然產(風險比(RR)為1.04, 95% 信賴區間為1.02 – 1.06)、生產和分娩時感到可掌控(風險比(RR)為1.74, 95% 信賴區間為1.32 – 2.30)、由認識的助產士陪同生產(風險比(RR)為7.84, 95% 信賴區間為4.15 – 14.81)以及接受母乳哺餵(風險比(RR)為1.35, 95% 信賴區間為1.03 – 1.76)。此外，隨機分派接受助產士主導模式的孕婦比較少發生妊娠24週前流產(風險比(RR)為0.79, 95% 信賴區間為0.65 – 0.97)，她們的嬰兒的住院天數也比較短(平均差為 2.00, 95% 信賴區間為 2.15至 −1.85)。整體流產/新生兒死亡(風險比(RR)為0.83, 95% 信賴區間為0.70 – 1.00)和24週後的流產/新生兒死亡(風險比(RR)為1.01, 95% 信賴區間為0.67 – 1.53)並無統計上的顯著差異。

作者結論

應提供所有婦女助產士主導的照護模式並鼓勵婦女要求此一方式。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

助產士主導方式與其他產婦照護模式的比較：助產士主導的照護對孕婦和她們的嬰兒有幫助，建議採用此模式。世界上有許多地區助產士是孕婦的主要照護提供者。在其他地方，內科醫師或家庭醫師負責主要的照護責任或者一起分擔照護責任。助產士主導方式的基本觀念是自然常態並由認識且信任的助產士在生產時提供照護，強調婦女在最少外力介入下自然生產的能力。有些助產士照護模式是由一個助產士團隊提供以分擔工作量，通常稱為「團隊助產」。另一個模式是「工作量助產」，目的是由照護者提供較連續的照護，「工作量助產」目標是確保婦女接受同一助產士或其執業夥伴的照護。相反的，醫師主導照護模式是由產科或家庭醫師為主要的照護提供者，而在分擔照護模式中，各個健康照護專業人員分擔照護責任。助產士主導照護模式的文獻回顧包括產前、生產時與產後照護，將此模式和醫師主導照護模式與分擔照護模式進行比較，找出11個試驗共12,276名婦女。助產士主導照護模式對母嬰有許多好處，且未發現有不良影響。主要的好處是降低24週前流產的風險，此外，在生產時可減少使用局部麻醉且較少需要外陰切開術或器械補助生產。助產士主導照護模式也可增加婦女在生產時由已經認識的助產士提供照護的機會，也增加了自然產和開始哺餵母乳的機會。此外，助產士主導照護模式讓比較多婦女感覺到可以掌控生產過程。24週後流產的風險並無差異。此文獻回顧結論認為應提供所有婦女助產士主導的照護模式。