Transcript King’s College London

The contribution of midwife-led care to
the quality and safety of maternity care :
implications of findings from a Cochrane
meta-analysis
Jane Sandall
Professor of Women’s Health, King’s College London
Hatem M, Sandall, J. (Joint First Author and Contact Author) Devane D, Soltani H. Gates,S.
October 2009
Background
Maternal and neonatal morbidity and mortality together one of
the biggest challenges to public health in developing
countries.
Evidence base on patient safety, its root causes and
contributing factors, as well as on the most cost-effective
solutions to common problems is very limited.
Maternal and neonatal care in top 20 WHO Patient Safety
Programme global research priorities in low and mid income
countries.
Improving quality and
safety in maternity care
The Institute of Medicine (IOM) defines quality
of health care as “the degree to which health
services for individuals and populations
increase the likelihood of desired health
outcomes and are consistent with current
professional knowledge”.
Crossing the Quality Chasm (2001)
Dimensions of quality
Safety
Effectiveness
Patient/woman-centeredness
Timeliness
Efficiency
Equity
Institute of Medicine (2000) Crossing the Quality Chasm: A
New Health System for the 21st Century, Washington, National
Academy Press
What is the evidence?
Improving the coverage of skilled
midwifery care has been identified by
the WHO and a range of other
agencies as delivering on the above
agenda.
Cochrane review midwife-led models of care vs
other models of care
Midwife-led model of care assumes: pregnancy and birth are normal life
events and is woman-centred and includes: continuity of care;
monitoring the physical, psychological, spiritual and social well-being
of the woman and family throughout the childbearing cycle; providing
the woman with individualised education, counselling and antenatal
care; continuous attendance during labour, birth and the immediate
postpartum period; ongoing support during the postnatal period;
minimising technological interventions; and identifying and referring
women who require obstetric or other specialist attention.
Differences between midwife-led and other models of care often include
variations in philosophy, focus, relationship between the care provider
and the pregnant woman, use of interventions during labour, care
setting (home, home-from-home or acute hospital setting, and in the
goals and objectives of care.
6
What we didn’t know before
review
Clinical and cost effectiveness of the different models of
maternity care
The optimal model of care for routine antenatal, intrapartum
and postnatal care for healthy pregnant women
Synthesised information to establish whether there are
differences in morbidity and mortality, effectiveness and
psychosocial outcomes between midwife-led and other
models of care
What Is The Cochrane Library?
The Cochrane Library is the
single most reliable source for
evidence on the effects of health
care.
Health care in the 21st Century
relies not only on individual
medical skills, but also on the
best information on the
effectiveness of each
intervention being accessible to
practitioners, patients, and
policy makers. This approach is
known as “evidence-based
medicine”.
Cochrane Reviews are now
the “gold standard” for
systematic reviews in such
key publications as The
Lancet, New England Journal
of Medicine, British Medical
Journal, and the Journal of
the American Medical
Association and routinely
appear there as well as in
specialised medical journals
for various specialty areas.
Review Objectives
Primary
to compare midwife-led models of care with other
models of care for childbearing women and their infants.
Secondary
to determine whether the effects of midwife-led care are
influenced by: 1) models of midwifery care that provide
differing levels of continuity; 2) varying levels of
obstetrical risk and 3) practice setting (community or
hospital based).
10
Definition of midwife-led care
“midwife is the lead professional providing continuity in the
planning, organisation and delivery of care given to a woman
from initial booking to the postnatal period".
Some antenatal and/or intrapartum and/or postpartum care
may be provided in consultation with medical staff as
appropriate.
Midwives are lead professional with responsibility for
assessment of her needs, planning her care, referral to other
professionals as appropriate. Thus, midwife-led models of
care aim to provide care in either community or hospital
settings, normally to healthy women with uncomplicated or
'low-risk' pregnancies.
11
Models of midwife-led care
Team midwifery
Aim to provide continuity of care to a
defined group of women through a team
of midwives sharing a caseload, often
called 'team' midwifery. Thus, a woman
will receive her care from a number of
midwives in the team, the size of which
can vary.
Caseload midwifery
Aim to offer greater relationship
continuity over time, by ensuring that a
childbearing woman receives her ante,
intra and postnatal care from one
midwife or her/his practice partner.
12
Other models of care
(a) Obstetrician-provided care
Obstetricians are the primary providers of antenatal care. An
obstetrician (not necessarily the one who provides antenatal care) is
present for the birth.
(b) Family doctor-provided care
Obstetric nurses or midwives provide intrapartum and immediate
postnatal care but not at a decision making level, and a family doctor is
present for the birth.
(c) Shared models of care
Where responsibility for the organisation and delivery of care,
throughout initial booking to the postnatal period, is shared between
different health professionals.
13
Criteria for considering
studies for this review
Types of studies
All studies in which pregnant women are randomly allocated to midwifeled models of care and other models of care during pregnancy.
Types of participants
Pregnant women classified as low and mixed risk of complications.
Types of interventions
Models of care are classified as midwife-led, other or shared care on the
basis of the lead professional in the ante and intrapartum periods, as
decisions and actions taken in pregnancy affect intrapartum events and
continuity of care a key part of model.
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Search methods for
identification of studies
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•
•
•
•
•
•
No language restrictions, published and unpublished reports
Electronic searches
Cochrane Pregnancy and Childbirth Group’s Trials Register
Cochrane Central Register of Controlled Trials (CENTRAL)
Cochrane Effective Practice and Organisation of Care Group's Trials Register
Current Contents, Medline, CINAHL Web of Science, BIOSIS, Previews, ISI Proceedings, WHO
Reproductive Health Library
Unpublished studies from the System for Information on Grey Literature In Europe (SIGLE)
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•
•
Handsearches
30 journals and proceedings of major conferences
Current awareness alerts for additional 44 journals
Details can be found in the ‘Specialized Register’ section within the editorial information about the
Cochrane Pregnancy and Childbirth Group
Details of studies
Countries
Austr alia
N
4
Types of other models of care
Shar ed car e
N
7
Canada
1
Medical-led
3
New Zealand
1
Medical-led and shar ed car e
1
UK
5
Midwife-led models
Setting for intrapartum care
Hospital homelike unit
3
Hospital labour war d
8
Midwife-led models
Setting for AN and P/ N care
All hospital based
4
Community A/ N and no community P/ N
1
Community A/ N and P/ N
3
Hospital A/ N and community P/ N
3
Risk status
Low r isk
Mixed r isk
% women attended by a
known carer
Midwife-led
Other models
6
5
6398%
0.321%
Types of Midwife-led
Models of care
Team Midwifer y
9
Caseload Midwifer y
2
11 trials involving 12,276
randomised women
Safety
Defined as ‘avoiding injuries to patients
from the care that is intended to help
them’.
Fetal loss before 24 weeks
Risk reduction of 21%
Effectiveness
Defined as ‘providing services based on
sound scientific knowledge to all who
could benefit and refraining from
providing services to those not likely to
benefit (avoiding underuse and overuse
respectively)’.
Women randomised to midwife-led
models of care were less likely to
experience
regional analgesia/anesthesia (11 trials, n = 11,892, RR
0.81, 95% CI 0.73 to 0.91) 19% less
instrumental (forceps/vacuum) birth (10 trials, n = 11,724,
RR 0.86, 95% CI 0.78 to 0.96) 14% less
episiotomy (11 trials, n = 11,872, RR 0.82, 95% CI 0.77 to
0.88) 18% less
no significant differences in the caesarean section
rate (11 trials, n = 11897, RR 0.96, 95% CI 0.87 to 1.06
Midwife-led versus other models of care for
childbearing women and their infants Instrumental birth
Study or Subgroup
Biro 2000
Flint 1989
Harvey 1996
Homer 2001
Kenny 1994
MacVicar 1993
North Stafford 2000
Rowley 1995
Turnbull 1996
Waldenstrom 2001
Total (95% CI)
Midwife-led care Other models of care
Risk Ratio
Events
Total
Events
Total Weight M-H, Fixed, 95% CI
67
56
6
71
12
187
74
29
83
78
488
479
105
594
194
2304
770
393
612
484
86
66
7
63
29
114
84
37
86
89
6423
Total events
663
661
Heterogeneity: Chi² = 8.09, df = 9 (P = 0.53); I² = 0%
Test for overall effect: Z = 2.81 (P = 0.005)
480
473
97
601
211
1206
735
405
597
496
12.4%
9.5%
1.0%
9.0%
4.0%
21.4%
12.3%
5.2%
12.5%
12.6%
0.77 [0.57, 1.03]
0.84 [0.60, 1.17]
0.79 [0.28, 2.27]
1.14 [0.83, 1.57]
0.45 [0.24, 0.86]
0.86 [0.69, 1.07]
0.84 [0.63, 1.13]
0.81 [0.51, 1.29]
0.94 [0.71, 1.25]
0.90 [0.68, 1.18]
5301 100.0%
0.86 [0.78, 0.96]
Risk reduction of 14%
Risk Ratio
M-H, Fixed, 95% CI
0.1 0.2
0.5 1
2
5 10
Favours midwifery Favours other models
Women randomized to midwife-led
models of care were more likely to
experience
no intrapartum analgesia/anesthesia (five
trials, n = 7039, RR 1.16, 95% CI 1.05 to 1.29)
a spontaneous vaginal birth (nine trials, n =
10,926, RR 1.04, 95% CI 1.02 to 1.06)
breastfeeding initiation (one trial, n = 405, RR
1.35, 95% CI 1.03 to 1.76)
Woman – centeredness
Defined as ‘providing care that is
respectful of and responsive to
individual patient preferences, needs,
and values and ensuring that patient
values guide all clinical decisions’.
Women randomized to midwife-led
models of care were more likely to
experience
high perceptions of control during labour
(one trial, n = 471, RR 1.74, 95% CI 1.32 to
2.30)
attendance at birth by a known midwife
(six trials, n = 5525, RR 7.84, 95% CI 4.15 to
14.81)
Experience of care
Women's reported experiences of care included
maternal satisfaction with information, advice,
explanation, venue of delivery and preparation for
labour and birth, as well as perceptions of choice for
pain relief and evaluations of carer's behaviour.
Satisfaction in various aspects of care appeared to be
higher in the midwife-led compared to the other
model of care.
Attendance at birth by a
known midwife
Women nearly X8 times more likely to know midwife
26
Efficiency
Defined as avoiding waste, including
waste of equipment, supplies, ideas and
energy.
Efficiency
All trials suggest a cost-saving effect in
intrapartum care.
Lack of consistency in estimating maternity
care cost among the available studies;
however there seemed to be a trend towards
the cost-saving effect of midwife-led care in
comparison with medical-led care.
Women randomized to midwife-led models
of care were less likely to experience
antenatal hospitalization
Midwife-led care Other models of care
Risk Ratio
Study or Subgroup Events Total
Events
Total Weight M-H, Fixed, 95% CI
Flint 1989
Homer 2001
Kenny 1994
Rowley 1995
Waldenstrom 2001
Total (95% CI)
123
53
29
114
190
484
594
194
393
484
146
72
38
135
185
2149
475
601
211
405
496
25.8%
12.5%
6.4%
23.3%
32.0%
0.83 [0.67, 1.01]
0.74 [0.53, 1.04]
0.83 [0.53, 1.29]
0.87 [0.71, 1.07]
1.05 [0.90, 1.23]
2188 100.0%
0.90 [0.81, 0.99]
Total events
509
576
Heterogeneity: Chi² = 5.84, df = 4 (P = 0.21); I² = 32%
Test for overall effect: Z = 2.08 (P = 0.04)
Risk Ratio
M-H, Fixed, 95% CI
0.1 0.2 0.5 1 2
5 10
Favours midwifery Favours other models
Risk reduction of 10%
There were no statistically significant
differences between groups for:
•antepartum haemorrhage
•preterm birth
•low birthweight infant
•amniotomy
•the use of opiate analgesia augmentation during labour
•induction of labour
•caesarean section rate
•perineal laceration requiring suturing
•intact perineum
•five-minute Apgar score less than or equal to seven
•admission of infant to special care or neonatal intensive care unit(s)
•neonatal convulsions
•fetal loss or neonatal death more than or equal to 24 weeks
•overall fetal loss and neonatal death
•duration of postnatal hospital stay
•postpartum depression
30
Overall fetal loss
Non-significant trend risk reduction of 17%
31
Summary
Women who received models of midwife-led care were
nearly eight times more likely to be attended at birth
by a known midwife, were 21% less likely to lose their
baby before 24 weeks, 19% less likely to have
regional analgesia, 14% less likely to have
instrumental birth, 18% less likely to have an
episiotomy, and significantly more likely to have a
spontaneous vaginal birth, initiate breastfeeding, and
feel in control during childbirth.
Conclusion
“Every women needs a midwife and some
women need a doctor too”
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.
Interpretation
11 trials, 12,000 women, 4 countries
of midwife-led care in pregnancy and birth
Cant generalise to
Limitatations
Women with extensive
medical complications
Some effect sizes small
Home birth
Low income countries
Lay/traditional midwives
Midwife-led birth centres
where antenatal care not
provided
Confounders
34
Many secondary outcomes
Midwife led unit setting &
midwife led care
Continuity & midwife led care
Care pathways/protocols &
midwife led care
What do we need to find
out?
•Outcomes of different models of continuity of care
•Impact of care pathways and clinical networks
•How should services be organised for women with
substantial medical complications
•Impact of midwife continuity on perinatal morbidity
and mortality
•Effects in middle and low incomes settings
35
Publications
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•
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Sandall,J., Hatem.M., Devane,D., Soltani,H., Gates,S. (in submission) Implications
of findings from a Cochrane Review of midwife-led versus other models of care for
childbearing women in what works to improve ‘normal’ birth, Jnl Midwifery &
Women’s Health
Sandall,J., Hatem.M., Devane,D., Soltani,H., Gates,S. (2009) Discussion of
findings from a Cochrane Review of midwife-led versus other models of care for
childbearing women, Midwifery, 25, 8-13.
Sandall J. (2008) Midwife-led versus other models of care for childbearing
women:implications of findings from a Cochrane meta-analysis. Evidence Based
Midwifery 6(4): 111.
Hatem M, Sandall, J. Article most likely to change clinical practice” DynaMed
Weekly Update 270109. Hatem M, Sandall, J. (Joint First Author and Contact
Author) Devane D, Soltani H. Gates,S. (2008) Midwife-led versus other models of
care for childbearing women, Cochrane Database of Systematic Reviews 2008,
Issue 4. Art. No: CD004667.
Finlay,S. Sandall,J. (in press online ) “Someone’s rooting for you”: Continuity and
Advocacy in Bureaucratic Maternal Health Care Systems, Social Science and
Medicine, doi:10.1016/j.socscimed.2009.07.029