Scolaris Content Display Scolaris Content Display

Cochrane Database of Systematic Reviews

Midwife‐led continuity models versus other models of care for childbearing women

This is not the most recent version

Information

DOI:
https://doi.org/10.1002/14651858.CD004667.pub3Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 21 August 2013see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Pregnancy and Childbirth Group

Copyright:
  1. Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Article metrics

Altmetric:

Cited by:

Cited 0 times via Crossref Cited-by Linking

Collapse

Authors

  • Jane Sandall

    Correspondence to: Division of Women's Health, King's College, London, Women's Health Academic Centre, King's Health Partners, London, UK

    [email protected]

  • Hora Soltani

    Centre for Health and Social Care Research Centre, Sheffield Hallam University, Sheffield, UK

  • Simon Gates

    Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, UK

  • Andrew Shennan

    Division of Women's Health, King's College, London, Women's Health Academic Centre, King's Health Partners, London, UK

  • Declan Devane

    School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland

Contributions of authors

Declan Devane (DD)

DD contributed to the protocol by contributing to the design and writing.

DD contributed to the review by contributing to the design of the review, appraising the quality of and extracting data from selected papers, contributing to the interpretation of data, writing the review and providing a methodological and clinical perspective.

Simon Gates (SG)
SG provided methodological and statistical expertise in the development of the review, and assisted with analysis of data and interpretation of results.

Jane Sandall (JS)
JS contributed to the protocol by contributing to the design and writing. JS contributed to the design, screened retrieved papers against inclusion criteria and appraised quality of papers.

JS has been the contact author for the review since July 2006 and is first author of the review. Since 2006, she has co‐ordinated the review process, written to authors for additional information, managed data for the review, re‐extracted data from papers, re‐entered data into Review Manager, re‐entered data for the included studies section, analysed and interpreted data, and provided a clinical and policy perspective. She has rewritten the Plain Language Summary, Abstract, Background, Methods, Description of studies, Methodological quality, Results, Analysis, Discussion and wrote the final draft of the review.

JS revised the review in response to feedback from referees and the editor. When making the revisions, JS updated the search and identified four new reports, and contacted authors for additional data, which were assessed by JS and DD, and which she included in the revised version.

JS in the guarantor for the review.

Andrew Shennan (AS)

AS provided specialist obstetric expertise, and assisted with interpretation of results.

Hora Soltani (HS)
HS contributed to the design and commented on the first draft of the protocol.

HS contributed to the development of the protocol and review by contributing to the design, evaluation of the quality of the articles against the inclusion/exclusion criteria, data extraction, writing to authors for clarification of original article information, data interpretation, commenting on as well as writing the review.

Sources of support

Internal sources

  • Women's Health Academic Centre, King's Health Partners, King's College, London, UK.

  • Sheffield Hallam University, Seffield, UK.

  • Health Services Executive, Dublin North East, Ireland.

  • Trinity College, Dublin, Ireland.

External sources

  • National Institute for Health Research, UK.

    NIHR Programme of centrally‐managed pregnancy and childbirth systematic reviews of priority to the NHS and users of the NHS: 10/4001/02

Declarations of interest

Declan Devane is a co‐author in one of the included trials in this review (Begley 2011) Jane Sandall was and is principal investigator for two studies evaluating models of midwife‐led continuity of care (Sandall 2001), and co‐investigator on the 'Birthplace in England Research Programme', an integrated programme of research designed to compare outcomes of births for women planned at home, in different types of midwifery units, and in hospital units with obstetric services.

Acknowledgements

We are very grateful to the investigators who provided additional information: C Homer, H McLachlan, D Forster and P Brodie.

As part of the pre‐publication editorial process, this review has been commented on by four peers (an editor and three referees who are external to the editorial team), a member of the Pregnancy and Childbirth Group's international panel of consumers and the Group's Statistical Adviser.

The National Institute for Health Research (NIHR) is the largest single funder of the Cochrane Pregnancy and Childbirth Group.  The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health.

Version history

Published

Title

Stage

Authors

Version

2024 Apr 10

Midwife continuity of care models versus other models of care for childbearing women

Review

Jane Sandall, Cristina Fernandez Turienzo, Declan Devane, Hora Soltani, Paddy Gillespie, Simon Gates, Leanne V Jones, Andrew H Shennan, Hannah Rayment-Jones

https://doi.org/10.1002/14651858.CD004667.pub6

2016 Apr 28

Midwife‐led continuity models versus other models of care for childbearing women

Review

Jane Sandall, Hora Soltani, Simon Gates, Andrew Shennan, Declan Devane

https://doi.org/10.1002/14651858.CD004667.pub5

2015 Sep 15

Midwife‐led continuity models versus other models of care for childbearing women

Review

Jane Sandall, Hora Soltani, Simon Gates, Andrew Shennan, Declan Devane

https://doi.org/10.1002/14651858.CD004667.pub4

2013 Aug 21

Midwife‐led continuity models versus other models of care for childbearing women

Review

Jane Sandall, Hora Soltani, Simon Gates, Andrew Shennan, Declan Devane

https://doi.org/10.1002/14651858.CD004667.pub3

2008 Oct 08

Midwife‐led versus other models of care for childbearing women

Review

Marie Hatem, Jane Sandall, Declan Devane, Hora Soltani, Simon Gates

https://doi.org/10.1002/14651858.CD004667.pub2

2004 Jan 26

Midwifery‐led versus other models of care delivery for childbearing women

Protocol

Marie Hatem, Ellen D Hodnett, Declan Devane, William D Fraser, Jane Sandall, Hora Soltani

https://doi.org/10.1002/14651858.CD004667

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figures and Tables -
Figure 1

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
Figures and Tables -
Figure 2

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

Funnel plot of comparison: 1 Midwife‐led versus other models of care for childbearing women and their infants (all), outcome: 1.1 Regional analgesia (epidural/spinal).
Figures and Tables -
Figure 3

Funnel plot of comparison: 1 Midwife‐led versus other models of care for childbearing women and their infants (all), outcome: 1.1 Regional analgesia (epidural/spinal).

Funnel plot of comparison: 1 Midwife‐led versus other models of care for childbearing women and their infants (all), outcome: 1.2 Caesarean birth.
Figures and Tables -
Figure 4

Funnel plot of comparison: 1 Midwife‐led versus other models of care for childbearing women and their infants (all), outcome: 1.2 Caesarean birth.

Funnel plot of comparison: 1 Midwife‐led versus other models of care for childbearing women and their infants (all), outcome: 1.16 Episiotomy.
Figures and Tables -
Figure 5

Funnel plot of comparison: 1 Midwife‐led versus other models of care for childbearing women and their infants (all), outcome: 1.16 Episiotomy.

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 1 Regional analgesia (epidural/spinal).
Figures and Tables -
Analysis 1.1

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 1 Regional analgesia (epidural/spinal).

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 2 Caesarean birth.
Figures and Tables -
Analysis 1.2

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 2 Caesarean birth.

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 3 Instrumental vaginal birth (forceps/vacuum).
Figures and Tables -
Analysis 1.3

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 3 Instrumental vaginal birth (forceps/vacuum).

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 4 Spontaneous vaginal birth (as defined by trial authors).
Figures and Tables -
Analysis 1.4

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 4 Spontaneous vaginal birth (as defined by trial authors).

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 5 Intact perineum.
Figures and Tables -
Analysis 1.5

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 5 Intact perineum.

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 6 Preterm birth (< 37 weeks).
Figures and Tables -
Analysis 1.6

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 6 Preterm birth (< 37 weeks).

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 7 Overall fetal loss and neonatal death.
Figures and Tables -
Analysis 1.7

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 7 Overall fetal loss and neonatal death.

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 8 Antenatal hospitalisation.
Figures and Tables -
Analysis 1.8

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 8 Antenatal hospitalisation.

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 9 Antepartum haemorrhage.
Figures and Tables -
Analysis 1.9

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 9 Antepartum haemorrhage.

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 10 Induction of labour.
Figures and Tables -
Analysis 1.10

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 10 Induction of labour.

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 11 Amniotomy.
Figures and Tables -
Analysis 1.11

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 11 Amniotomy.

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 12 Augmentation/artificial oxytocin during labour.
Figures and Tables -
Analysis 1.12

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 12 Augmentation/artificial oxytocin during labour.

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 13 No intrapartum analgesia/anaesthesia.
Figures and Tables -
Analysis 1.13

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 13 No intrapartum analgesia/anaesthesia.

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 14 Opiate analgesia.
Figures and Tables -
Analysis 1.14

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 14 Opiate analgesia.

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 15 Attendance at birth by known midwife.
Figures and Tables -
Analysis 1.15

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 15 Attendance at birth by known midwife.

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 16 Episiotomy.
Figures and Tables -
Analysis 1.16

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 16 Episiotomy.

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 17 Perineal laceration requiring suturing.
Figures and Tables -
Analysis 1.17

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 17 Perineal laceration requiring suturing.

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 18 Mean labour length (hrs).
Figures and Tables -
Analysis 1.18

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 18 Mean labour length (hrs).

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 19 Postpartum haemorrhage (as defined by trial authors).
Figures and Tables -
Analysis 1.19

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 19 Postpartum haemorrhage (as defined by trial authors).

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 20 Breastfeeding initiation.
Figures and Tables -
Analysis 1.20

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 20 Breastfeeding initiation.

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 21 Duration of postnatal hospital stay (days).
Figures and Tables -
Analysis 1.21

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 21 Duration of postnatal hospital stay (days).

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 22 Low birthweight (< 2500 g).
Figures and Tables -
Analysis 1.22

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 22 Low birthweight (< 2500 g).

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 23 5‐minute Apgar score below or equal to 7.
Figures and Tables -
Analysis 1.23

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 23 5‐minute Apgar score below or equal to 7.

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 24 Neonatal convulsions (as defined by trial authors).
Figures and Tables -
Analysis 1.24

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 24 Neonatal convulsions (as defined by trial authors).

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 25 Admission to special care nursery/neonatal intensive care unit.
Figures and Tables -
Analysis 1.25

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 25 Admission to special care nursery/neonatal intensive care unit.

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 26 Mean length of neonatal hospital stay (days).
Figures and Tables -
Analysis 1.26

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 26 Mean length of neonatal hospital stay (days).

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 27 Fetal loss/neonatal death before 24 weeks.
Figures and Tables -
Analysis 1.27

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 27 Fetal loss/neonatal death before 24 weeks.

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 28 Fetal loss/neonatal death equal to/after 24 weeks.
Figures and Tables -
Analysis 1.28

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants (all), Outcome 28 Fetal loss/neonatal death equal to/after 24 weeks.

Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 1 Regional analgesia (epidural/spinal).
Figures and Tables -
Analysis 2.1

Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 1 Regional analgesia (epidural/spinal).

Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 2 Caesarean birth.
Figures and Tables -
Analysis 2.2

Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 2 Caesarean birth.

Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 3 Instrumental vaginal birth (forceps/vacuum).
Figures and Tables -
Analysis 2.3

Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 3 Instrumental vaginal birth (forceps/vacuum).

Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 4 Spontaneous vaginal birth (as defined by trial authors).
Figures and Tables -
Analysis 2.4

Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 4 Spontaneous vaginal birth (as defined by trial authors).

Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 5 Intact perineum.
Figures and Tables -
Analysis 2.5

Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 5 Intact perineum.

Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 6 Preterm birth (< 37 weeks).
Figures and Tables -
Analysis 2.6

Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 6 Preterm birth (< 37 weeks).

Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 7 Overall fetal loss and neonatal death.
Figures and Tables -
Analysis 2.7

Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 7 Overall fetal loss and neonatal death.

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 1 Regional analgesia (epidural/spinal).
Figures and Tables -
Analysis 3.1

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 1 Regional analgesia (epidural/spinal).

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 2 Caesarean birth.
Figures and Tables -
Analysis 3.2

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 2 Caesarean birth.

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 3 Instrumental vaginal birth (forceps/vacuum).
Figures and Tables -
Analysis 3.3

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 3 Instrumental vaginal birth (forceps/vacuum).

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 4 Spontaneous vaginal birth (as defined by trial authors).
Figures and Tables -
Analysis 3.4

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 4 Spontaneous vaginal birth (as defined by trial authors).

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 5 Intact perineum.
Figures and Tables -
Analysis 3.5

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 5 Intact perineum.

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 6 Preterm birth (< 37 weeks).
Figures and Tables -
Analysis 3.6

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 6 Preterm birth (< 37 weeks).

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 7 Overall fetal loss and neonatal death.
Figures and Tables -
Analysis 3.7

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 7 Overall fetal loss and neonatal death.

Table 1. Women's experiences of care

Satisfaction

Intervention (n/N)

Control (n/N)

Relative rate

95% CI

Statistical test

P value

Flint 1989*

Staff in labour (very caring)

252/275 (92%)

208/256 (81%)

1.1

1.0‐1.2

Experience of labour (wonderful/enjoyable)

104/246 (42%)

72/223 (32%)

1.3

1.0‐1.8

Satisfaction with pain relief (very satisfied)

121/209 (58%)

104/205 (51%)

1.1

0.9‐1.4

Very well prepared for labour

144/275 (52%)

102/254 (40%)

1.3

1.0‐1.7

MacVicar 1993

N = 1663

N = 826

Difference

Very satisfied with antenatal care

52%

44%

8.3%

4.1‐12.5

Very satisfied with care during labour

73%

60%

12.9%

9.1‐16.8

Kenny 1994

N = 213

N = 233

Carer skill, attitude and communication (antenatal care)

57.1/60

47.7/60

t = 12.4

0.0001

Convenience and waiting (antenatal care)

14.8/20

10.9/20

t = 10.1

0.0001

Expectation of labour/birth (antenatal care)

9.8/18

9.3/18

t = 1.4

0.16

Asking questions (antenatal care)

8.5/12

6.9/12

t = 6.6

0.0001

Information/communication (labour and birth)

28.3/30

24.8/30

t = 7.48

0.0001

Coping with labour (labour and birth)

20.9/30

19.3/30

t = 2.83

0.005

Midwife skill/caring (labour and birth)

22.7/24

21.3/24

t = 3.44

0.0007

Help and advice (postnatal care)

21.0/24

19.7/24

t = 1.88

0.06

Midwife skill and communication (postnatal care)

16.6/18

15.4/18

t = 4.48

0.0001

Managing baby (postnatal care)

8.7/12

8.5/12

t = 0.77

0.77

Self‐rated health (postnatal care)

7.5/12

7.1/12

t = 1.67

0.10

Rowley 1995

OR

Encouraged to ask questions

N/A

4.22

2.72‐6.55

Given answers they could understand

N/A

3.03

1.33‐7.04

Able to discuss anxieties

N/A

3.60

2.28‐5.69

Always had choices explained to them

N/A

4.17

1.93‐9.18

Participation in decision making

N/A

2.95

1.22‐7.27

Midwives interested in woman as a person

N/A

7.50

4.42‐12.80

Midwives always friendly

N/A

3.48

1.92 ‐ 6.35

Turnbull 1996

n/N

n/N

Mean difference ‐ satisfaction score

Antenatal care

534/648

487/651

0.48

0.55‐0.41

Intrapartum care

445/648

380/651

0.28

0.37‐0.18

Hospital‐based postnatal care

445/648

380/651

0.57

0.70‐0.45

Home‐based postnatal care

445/648

380/651

0.33

0.42‐0.25

Waldenstrom 2001

%

%

OR

Overall antenatal care was very good (strongly agree)

58.2%

39.7%

2.22

1.66‐2.95

< 0.001

Happy with the physical aspect of intrapartum care (strongly agree)

58.6%

42.5%

1.94

1.46‐2.59

< 0.001

Happy with the emotional aspect of intrapartum care (strongly agree)

58.8%

44.0%

1.78

1.34‐2.38

< 0.001

Overall postnatal care was very good (strongly agree)

37.6%

33.2%

1.27

0.97‐1.67

0.08

Hicks 2003**

Care and sensitivity of staff (antenatal)

1.32

1.77

Mean difference?

0.0000

Care and sensitivity of staff (labour and delivery)

1.26

1.58

Mean difference?

0.008

Care and sensitivity of staff (postpartum at home)

1.24

1.57

Mean difference?

0.0000

Harvey 1996

Labour and Delivery Satisfaction Index +

211

185

26

18.8‐33.1

0.001

Biro 2000

Satisfaction with antenatal care (very good)

195/344 (57%)

100/287 (35%)

1.24

1.13‐1.36

0.001

Satisfaction with intrapartum care (very good)

215/241 (63%)

134/282 (47%)

1.11

1.03‐1.20

0.01

Satisfaction with postpartum care in hospital (very good)

141/344 (41%)

102/284 (31%)

0.92

0.82‐1.04

0.22

*: 99% Confidence interval (CI) for Flint study was reported
N/A: not available
**:Mean satisfaction scores are reported: lower scale indicates higher satisfaction. Satisfaction scores were calculated on a 5‐point ordinal scale in which 1 = very satisfied and 5 = very dissatisfied.

Figures and Tables -
Table 1. Women's experiences of care
Comparison 1. Midwife‐led versus other models of care for childbearing women and their infants (all)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Regional analgesia (epidural/spinal) Show forest plot

13

15982

Risk Ratio (M‐H, Random, 95% CI)

0.83 [0.76, 0.90]

2 Caesarean birth Show forest plot

13

15982

Risk Ratio (M‐H, Random, 95% CI)

0.93 [0.84, 1.02]

3 Instrumental vaginal birth (forceps/vacuum) Show forest plot

12

15809

Risk Ratio (M‐H, Random, 95% CI)

0.88 [0.81, 0.96]

4 Spontaneous vaginal birth (as defined by trial authors) Show forest plot

11

14995

Risk Ratio (M‐H, Random, 95% CI)

1.05 [1.03, 1.08]

5 Intact perineum Show forest plot

9

11494

Risk Ratio (M‐H, Random, 95% CI)

1.03 [0.94, 1.13]

6 Preterm birth (< 37 weeks) Show forest plot

7

11546

Risk Ratio (M‐H, Random, 95% CI)

0.77 [0.62, 0.94]

7 Overall fetal loss and neonatal death Show forest plot

12

15869

Risk Ratio (M‐H, Random, 95% CI)

0.84 [0.71, 1.00]

8 Antenatal hospitalisation Show forest plot

6

6039

Risk Ratio (M‐H, Random, 95% CI)

0.93 [0.83, 1.05]

9 Antepartum haemorrhage Show forest plot

4

3654

Risk Ratio (M‐H, Random, 95% CI)

0.89 [0.57, 1.40]

10 Induction of labour Show forest plot

12

15809

Risk Ratio (M‐H, Random, 95% CI)

0.95 [0.86, 1.03]

11 Amniotomy Show forest plot

4

3253

Risk Ratio (M‐H, Random, 95% CI)

0.80 [0.66, 0.98]

12 Augmentation/artificial oxytocin during labour Show forest plot

11

13502

Risk Ratio (M‐H, Random, 95% CI)

0.89 [0.79, 1.01]

13 No intrapartum analgesia/anaesthesia Show forest plot

6

8807

Risk Ratio (M‐H, Random, 95% CI)

1.16 [1.04, 1.31]

14 Opiate analgesia Show forest plot

10

11997

Risk Ratio (M‐H, Random, 95% CI)

0.90 [0.80, 1.01]

15 Attendance at birth by known midwife Show forest plot

6

5225

Risk Ratio (M‐H, Random, 95% CI)

7.83 [4.15, 14.80]

16 Episiotomy Show forest plot

13

15982

Risk Ratio (M‐H, Random, 95% CI)

0.84 [0.76, 0.92]

17 Perineal laceration requiring suturing Show forest plot

9

13412

Risk Ratio (M‐H, Random, 95% CI)

1.02 [0.95, 1.10]

18 Mean labour length (hrs) Show forest plot

3

3328

Mean Difference (IV, Random, 95% CI)

0.50 [0.27, 0.74]

19 Postpartum haemorrhage (as defined by trial authors) Show forest plot

9

12522

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.84, 1.11]

20 Breastfeeding initiation Show forest plot

2

2050

Risk Ratio (M‐H, Random, 95% CI)

1.12 [0.81, 1.53]

21 Duration of postnatal hospital stay (days) Show forest plot

3

3593

Mean Difference (IV, Random, 95% CI)

‐0.10 [‐0.29, 0.09]

22 Low birthweight (< 2500 g) Show forest plot

6

9766

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.83, 1.16]

23 5‐minute Apgar score below or equal to 7 Show forest plot

10

10854

Risk Ratio (M‐H, Random, 95% CI)

0.99 [0.70, 1.41]

24 Neonatal convulsions (as defined by trial authors) Show forest plot

2

2923

Risk Ratio (M‐H, Random, 95% CI)

0.91 [0.14, 5.74]

25 Admission to special care nursery/neonatal intensive care unit Show forest plot

12

15869

Risk Ratio (M‐H, Random, 95% CI)

0.90 [0.76, 1.06]

26 Mean length of neonatal hospital stay (days) Show forest plot

2

1979

Mean Difference (IV, Random, 95% CI)

‐3.63 [‐7.57, 0.30]

27 Fetal loss/neonatal death before 24 weeks Show forest plot

10

13953

Risk Ratio (M‐H, Random, 95% CI)

0.81 [0.66, 0.99]

28 Fetal loss/neonatal death equal to/after 24 weeks Show forest plot

11

15667

Risk Ratio (M‐H, Random, 95% CI)

1.00 [0.67, 1.51]

Figures and Tables -
Comparison 1. Midwife‐led versus other models of care for childbearing women and their infants (all)
Comparison 2. Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Regional analgesia (epidural/spinal) Show forest plot

13

15982

Risk Ratio (M‐H, Random, 95% CI)

0.83 [0.76, 0.90]

1.1 Caseload

3

5090

Risk Ratio (M‐H, Random, 95% CI)

0.88 [0.76, 1.03]

1.2 Team models of midwifery care

10

10892

Risk Ratio (M‐H, Random, 95% CI)

0.81 [0.73, 0.89]

2 Caesarean birth Show forest plot

13

15966

Risk Ratio (M‐H, Random, 95% CI)

0.93 [0.84, 1.02]

2.1 Caseload

3

5090

Risk Ratio (M‐H, Random, 95% CI)

0.93 [0.75, 1.17]

2.2 Team models of midwifery care

10

10876

Risk Ratio (M‐H, Random, 95% CI)

0.94 [0.84, 1.05]

3 Instrumental vaginal birth (forceps/vacuum) Show forest plot

12

16273

Risk Ratio (M‐H, Random, 95% CI)

0.89 [0.82, 0.96]

3.1 Caseload

3

5090

Risk Ratio (M‐H, Random, 95% CI)

0.91 [0.80, 1.04]

3.2 Team models of midwifery care

9

11183

Risk Ratio (M‐H, Random, 95% CI)

0.88 [0.79, 0.97]

4 Spontaneous vaginal birth (as defined by trial authors) Show forest plot

11

14995

Risk Ratio (M‐H, Random, 95% CI)

1.05 [1.03, 1.08]

4.1 Caseload

3

5090

Risk Ratio (M‐H, Random, 95% CI)

1.05 [0.98, 1.14]

4.2 Team models of midwifery care

8

9905

Risk Ratio (M‐H, Random, 95% CI)

1.05 [1.02, 1.07]

5 Intact perineum Show forest plot

9

11494

Risk Ratio (M‐H, Random, 95% CI)

1.03 [0.94, 1.13]

5.1 Caseload

2

2783

Risk Ratio (M‐H, Random, 95% CI)

1.12 [0.83, 1.50]

5.2 Team

7

8711

Risk Ratio (M‐H, Random, 95% CI)

1.01 [0.91, 1.13]

6 Preterm birth (< 37 weeks) Show forest plot

7

11546

Risk Ratio (M‐H, Random, 95% CI)

0.77 [0.62, 0.94]

6.1 Caseload

2

3585

Risk Ratio (M‐H, Random, 95% CI)

0.65 [0.47, 0.90]

6.2 Team

5

7961

Risk Ratio (M‐H, Random, 95% CI)

0.81 [0.62, 1.07]

7 Overall fetal loss and neonatal death Show forest plot

12

15835

Risk Ratio (M‐H, Random, 95% CI)

0.84 [0.70, 1.00]

7.1 Caseload

3

5090

Risk Ratio (M‐H, Random, 95% CI)

0.65 [0.43, 0.99]

7.2 Team

9

10745

Risk Ratio (M‐H, Random, 95% CI)

0.89 [0.73, 1.07]

Figures and Tables -
Comparison 2. Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team)
Comparison 3. Midwife‐led versus other models of care: variation in risk status (low versus mixed)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Regional analgesia (epidural/spinal) Show forest plot

13

15982

Risk Ratio (M‐H, Random, 95% CI)

0.83 [0.76, 0.90]

1.1 Low risk

8

11096

Risk Ratio (M‐H, Random, 95% CI)

0.82 [0.73, 0.92]

1.2 Mixed risk

5

4886

Risk Ratio (M‐H, Random, 95% CI)

0.84 [0.75, 0.95]

2 Caesarean birth Show forest plot

13

15982

Risk Ratio (M‐H, Random, 95% CI)

0.93 [0.84, 1.02]

2.1 Low risk

8

11096

Risk Ratio (M‐H, Random, 95% CI)

0.91 [0.79, 1.06]

2.2 Mixed risk

5

4886

Risk Ratio (M‐H, Random, 95% CI)

0.96 [0.84, 1.09]

3 Instrumental vaginal birth (forceps/vacuum) Show forest plot

12

15809

Risk Ratio (M‐H, Random, 95% CI)

0.88 [0.81, 0.96]

3.1 Low risk

7

10923

Risk Ratio (M‐H, Random, 95% CI)

0.89 [0.81, 0.99]

3.2 Mixed risk

5

4886

Risk Ratio (M‐H, Random, 95% CI)

0.82 [0.65, 1.03]

4 Spontaneous vaginal birth (as defined by trial authors) Show forest plot

11

14995

Risk Ratio (M‐H, Random, 95% CI)

1.05 [1.03, 1.08]

4.1 Low risk

7

10923

Risk Ratio (M‐H, Random, 95% CI)

1.05 [1.02, 1.08]

4.2 Mixed risk

4

4072

Risk Ratio (M‐H, Random, 95% CI)

1.06 [1.01, 1.10]

5 Intact perineum Show forest plot

9

11494

Risk Ratio (M‐H, Random, 95% CI)

1.03 [0.94, 1.13]

5.1 Low risk

6

8616

Risk Ratio (M‐H, Random, 95% CI)

1.06 [0.93, 1.21]

5.2 Mixed risk

3

2878

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.90, 1.07]

6 Preterm birth (< 37 weeks) Show forest plot

7

11546

Risk Ratio (M‐H, Random, 95% CI)

0.77 [0.62, 0.94]

6.1 Low risk

5

9726

Risk Ratio (M‐H, Random, 95% CI)

0.71 [0.54, 0.92]

6.2 Mixed risk

2

1820

Risk Ratio (M‐H, Random, 95% CI)

0.92 [0.70, 1.21]

7 Overall fetal loss and neonatal death Show forest plot

12

15835

Risk Ratio (M‐H, Random, 95% CI)

0.84 [0.70, 1.00]

7.1 Low risk

7

10895

Risk Ratio (M‐H, Random, 95% CI)

0.94 [0.73, 1.20]

7.2 Mixed risk

5

4940

Risk Ratio (M‐H, Random, 95% CI)

0.76 [0.59, 0.97]

Figures and Tables -
Comparison 3. Midwife‐led versus other models of care: variation in risk status (low versus mixed)