Midwife‐led versus other models of care for childbearing women

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

doi:10.1002/14651858.CD004667.pub2

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Analysis 1.1

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 1 Mean number of antenatal visits.

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Analysis 1.2

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 2 Antenatal hospitalisation.

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Analysis 1.3

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 3 Antepartum haemorrhage.

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Analysis 1.4

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 4 Fetal loss/neonatal death before 24 weeks.

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Analysis 1.5

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 5 Fetal loss/neonatal death equal to/after 24 weeks.

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Analysis 1.6

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 6 Overall fetal loss and neonatal death.

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Analysis 1.7

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 7 Amniotomy.

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Analysis 1.8

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 8 Augmentation/artificial oxytocin during labour.

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Analysis 1.9

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 9 No intrapartum analgesia/anaesthesia.

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Analysis 1.10

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 10 Regional analgesia (epidural/spinal).

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Analysis 1.11

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 11 Opiate analgesia.

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Analysis 1.12

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 12 Mean labour length.

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Analysis 1.13

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 13 Induction of labour.

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Analysis 1.14

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 14 Caesarean birth.

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Analysis 1.15

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

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Analysis 1.16

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 16 Instrumental vaginal birth (forceps/vacuum).

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Analysis 1.17

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 17 Spontaneous vaginal birth (as defined by trial authors).

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Analysis 1.18

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 18 Episiotomy.

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Analysis 1.19

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 19 Perineal laceration requiring suturing.

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Analysis 1.20

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 20 Intact perineum.

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Analysis 1.21

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 21 Postpartum haemorrhage (as defined by trial authors).

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Analysis 1.23

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 23 Duration of postnatal hospital stay (days).

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Analysis 1.24

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 24 Low birthweight (< 2500 g).

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Analysis 1.25

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 25 Preterm birth (< 37 weeks).

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Analysis 1.26

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 26 5‐minute Apgar score below or equal to 7.

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Analysis 1.27

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 27 Admission to special care nursery/neonatal intensive care unit.

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Analysis 1.28

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 28 Mean length of neonatal hospital stay (days).

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Analysis 1.29

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 29 Neonatal convulsions (as defined by trial authors).

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Analysis 1.30

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 30 Postpartum depression.

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Analysis 1.31

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 31 Breastfeeding initiation.

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Analysis 1.32

Comparison 1 Midwife‐led versus other models of care for childbearing women and their infants, Outcome 32 High perceptions of control during labour and childbirth.

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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 Fetal loss/neonatal death before 24 weeks.

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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 Fetal loss/neonatal death equal to/after 24 weeks.

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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 Overall fetal loss and neonatal death.

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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 No intrapartum analgesia/anaesthesia.

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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 Regional analgesia (epidural/spinal).

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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 Opiate analgesia.

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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 Caesarean birth.

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Analysis 2.8

Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 8 Instrumental vaginal birth (forceps/vacuum).

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Analysis 2.9

Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 9 Spontaneous vaginal birth (as defined by trial authors).

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Analysis 2.10

Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 10 5‐minute Apgar score below or equal to 7.

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Analysis 2.11

Comparison 2 Midwife‐led versus other models of care: variation in midwifery models of care (caseload/one‐to‐one or team), Outcome 11 Postpartum depression.

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Analysis 3.1

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 1 Fetal loss/neonatal death before 24 weeks.

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Analysis 3.2

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 2 Fetal loss/neonatal death equal to/after 24 weeks.

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Analysis 3.3

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

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Analysis 3.4

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 4 No intrapartum analgesia/anaesthesia.

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Analysis 3.5

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 5 Regional analgesia (epidural/spinal).

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Analysis 3.6

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 6 Opiate analgesia.

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Analysis 3.7

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 7 Caesarean birth.

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Analysis 3.8

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 8 Instrumental vaginal birth (forceps/vacuum).

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Analysis 3.9

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 9 Spontaneous vaginal birth (as defined by trial authors).

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Analysis 3.10

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 10 5‐minute Apgar score below or equal to 7.

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Analysis 3.11

Comparison 3 Midwife‐led versus other models of care: variation in risk status (low versus mixed), Outcome 11 Postpartum depression.

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Analysis 4.1

Comparison 4 Midwife‐led versus other models of care: variation in practice setting (antenatal care), Outcome 1 Fetal loss/neonatal death before 24 weeks.

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Analysis 4.2

Comparison 4 Midwife‐led versus other models of care: variation in practice setting (antenatal care), Outcome 2 Fetal loss/neonatal death equal to/after 24 weeks.

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Analysis 4.3

Comparison 4 Midwife‐led versus other models of care: variation in practice setting (antenatal care), Outcome 3 Overall loss and neonatal death.

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Analysis 4.4

Comparison 4 Midwife‐led versus other models of care: variation in practice setting (antenatal care), Outcome 4 No intrapartum analgesia/anaesthesia.

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Analysis 4.5

Comparison 4 Midwife‐led versus other models of care: variation in practice setting (antenatal care), Outcome 5 Regional analgesia (epidural/spinal).

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Analysis 4.6

Comparison 4 Midwife‐led versus other models of care: variation in practice setting (antenatal care), Outcome 6 Opiate analgesia.

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Analysis 4.7

Comparison 4 Midwife‐led versus other models of care: variation in practice setting (antenatal care), Outcome 7 Caesarean birth.

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Analysis 4.8

Comparison 4 Midwife‐led versus other models of care: variation in practice setting (antenatal care), Outcome 8 Instrumental vaginal birth (forceps/vacuum).

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Analysis 4.9

Comparison 4 Midwife‐led versus other models of care: variation in practice setting (antenatal care), Outcome 9 Spontaneous vaginal birth (as defined by trial authors).

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Analysis 4.10

Comparison 4 Midwife‐led versus other models of care: variation in practice setting (antenatal care), Outcome 10 5‐minute Apgar score below or equal to 7.

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Analysis 4.11

Comparison 4 Midwife‐led versus other models of care: variation in practice setting (antenatal care), Outcome 11 Postpartum depression.

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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 women 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.

Table 1. Women's experiences of care

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Comparison 1. Midwife‐led versus other models of care for childbearing women and their infants

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mean number of antenatal visits Show forest plot	1	405	Mean Difference (IV, Fixed, 95% CI)	1.5 [0.96, 2.04]

2 Antenatal hospitalisation Show forest plot	5	4337	Risk Ratio (M‐H, Fixed, 95% CI)	0.90 [0.81, 0.99]

3 Antepartum haemorrhage Show forest plot	4	3655	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.63, 1.17]

4 Fetal loss/neonatal death before 24 weeks Show forest plot	8	9890	Risk Ratio (M‐H, Fixed, 95% CI)	0.79 [0.65, 0.97]

5 Fetal loss/neonatal death equal to/after 24 weeks Show forest plot	9	11604	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.67, 1.53]

6 Overall fetal loss and neonatal death Show forest plot	10	11806	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.70, 1.00]

7 Amniotomy Show forest plot	3	1543	Risk Ratio (M‐H, Random, 95% CI)	0.88 [0.75, 1.04]

8 Augmentation/artificial oxytocin during labour Show forest plot	10	11709	Risk Ratio (M‐H, Random, 95% CI)	0.92 [0.81, 1.05]

9 No intrapartum analgesia/anaesthesia Show forest plot	5	7039	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [1.05, 1.29]

10 Regional analgesia (epidural/spinal) Show forest plot	11	11892	Risk Ratio (M‐H, Random, 95% CI)	0.81 [0.73, 0.91]

11 Opiate analgesia Show forest plot	9	10197	Risk Ratio (M‐H, Random, 95% CI)	0.88 [0.78, 1.00]

12 Mean labour length Show forest plot	2	1614	Mean Difference (IV, Random, 95% CI)	0.27 [‐0.18, 0.72]

13 Induction of labour Show forest plot	10	11711	Risk Ratio (M‐H, Random, 95% CI)	0.94 [0.83, 1.06]

14 Caesarean birth Show forest plot	11	11897	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.87, 1.06]

15 Attendance at birth by known midwife Show forest plot	6	5225	Risk Ratio (M‐H, Random, 95% CI)	7.84 [4.15, 14.81]

16 Instrumental vaginal birth (forceps/vacuum) Show forest plot	10	11724	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.78, 0.96]

17 Spontaneous vaginal birth (as defined by trial authors) Show forest plot	9	10926	Risk Ratio (M‐H, Fixed, 95% CI)	1.04 [1.02, 1.06]

18 Episiotomy Show forest plot	11	11872	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.77, 0.88]

19 Perineal laceration requiring suturing Show forest plot	7	9349	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.94, 1.03]

20 Intact perineum Show forest plot	8	9706	Risk Ratio (M‐H, Random, 95% CI)	1.05 [0.95, 1.16]

21 Postpartum haemorrhage (as defined by trial authors) Show forest plot	7	8454	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.84, 1.23]

22 Maternal death	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
23 Duration of postnatal hospital stay (days) Show forest plot	2	1944	Mean Difference (IV, Fixed, 95% CI)	‐0.14 [‐0.33, 0.04]

24 Low birthweight (< 2500 g) Show forest plot	5	8009	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.83, 1.17]

25 Preterm birth (< 37 weeks) Show forest plot	5	7516	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.73, 1.04]

26 5‐minute Apgar score below or equal to 7 Show forest plot	8	6780	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.79, 1.41]

27 Admission to special care nursery/neonatal intensive care unit Show forest plot	10	11782	Risk Ratio (M‐H, Fixed, 95% CI)	0.92 [0.81, 1.05]

28 Mean length of neonatal hospital stay (days) Show forest plot	2	259	Mean Difference (IV, Random, 95% CI)	‐2.00 [‐2.15, ‐1.85]

29 Neonatal convulsions (as defined by trial authors) Show forest plot	1	1216	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 8.03]

30 Postpartum depression Show forest plot	1	1213	Risk Ratio (M‐H, Fixed, 95% CI)	1.94 [0.18, 21.32]

31 Breastfeeding initiation Show forest plot	1	405	Risk Ratio (M‐H, Random, 95% CI)	1.35 [1.03, 1.76]

32 High perceptions of control during labour and childbirth Show forest plot	1	471	Risk Ratio (M‐H, Fixed, 95% CI)	1.74 [1.32, 2.30]

Comparison 1. Midwife‐led versus other models of care for childbearing women and their infants

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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 Fetal loss/neonatal death before 24 weeks Show forest plot	8		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 Caseload	1	1216	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.46, 1.47]
1.2 Team models of midwifery care	7	8674	Risk Ratio (M‐H, Fixed, 95% CI)	0.79 [0.64, 0.98]
2 Fetal loss/neonatal death equal to/after 24 weeks Show forest plot	9		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.1 Caseload	2	2721	Risk Ratio (M‐H, Fixed, 95% CI)	0.48 [0.23, 1.03]
2.2 Team models of midwifery care	7	8883	Risk Ratio (M‐H, Fixed, 95% CI)	1.44 [0.86, 2.42]
3 Overall fetal loss and neonatal death Show forest plot	10		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3.1 Caseload	2	2721	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.42, 1.05]
3.2 Team	8	9085	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.72, 1.06]
4 No intrapartum analgesia/anaesthesia Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

4.1 Caseload	1	1210	Risk Ratio (M‐H, Fixed, 95% CI)	1.07 [0.79, 1.46]
4.2 Team models of midwifery care	4	5829	Risk Ratio (M‐H, Fixed, 95% CI)	1.18 [1.06, 1.31]
5 Regional analgesia (epidural/spinal) Show forest plot	11		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

5.1 Caseload	2	2715	Risk Ratio (M‐H, Random, 95% CI)	0.83 [0.61, 1.13]
5.2 Team models of midwifery care	9	9177	Risk Ratio (M‐H, Random, 95% CI)	0.81 [0.71, 0.91]
6 Opiate analgesia Show forest plot	9		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

6.1 Caseload	1	1210	Risk Ratio (M‐H, Random, 95% CI)	0.94 [0.83, 1.07]
6.2 Team models of midwifery care	8	8987	Risk Ratio (M‐H, Random, 95% CI)	0.87 [0.75, 1.01]
7 Caesarean birth Show forest plot	11		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

7.1 Caseload	2	2714	Risk Ratio (M‐H, Fixed, 95% CI)	1.04 [0.88, 1.25]
7.2 Team models of midwifery care	9	9183	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.82, 1.04]
8 Instrumental vaginal birth (forceps/vacuum) Show forest plot	10		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

8.1 Caseload	2	2714	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.73, 1.09]
8.2 Team models of midwifery care	8	9010	Risk Ratio (M‐H, Fixed, 95% CI)	0.85 [0.76, 0.96]
9 Spontaneous vaginal birth (as defined by trial authors) Show forest plot	9		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

9.1 Caseload	2	2714	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.96, 1.06]
9.2 Team models of midwifery care	7	8212	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [1.02, 1.08]
10 5‐minute Apgar score below or equal to 7 Show forest plot	8		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

10.1 Caseload	1	1216	Risk Ratio (M‐H, Fixed, 95% CI)	0.62 [0.38, 1.02]
10.2 Team models of midwifery care	7	5564	Risk Ratio (M‐H, Fixed, 95% CI)	1.40 [0.97, 2.01]
11 Postpartum depression Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

11.1 Caseload	1	1213	Risk Ratio (M‐H, Fixed, 95% CI)	1.94 [0.18, 21.32]
11.2 Team models of midwifery care	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

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

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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 Fetal loss/neonatal death before 24 weeks Show forest plot	8		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 Low risk	5	6881	Risk Ratio (M‐H, Fixed, 95% CI)	0.90 [0.66, 1.22]
1.2 Other risk status	3	3009	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.55, 0.94]
2 Fetal loss/neonatal death equal to/after 24 weeks Show forest plot	9		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.1 Low risk	4	6679	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.59, 1.81]
2.2 Other risk status	5	4925	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.54, 1.82]
3 Overall fetal loss and neonatal death Show forest plot	10		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3.1 Low risk	5	6881	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.71, 1.21]
3.2 Other risk status	5	4925	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.60, 0.97]
4 No intrapartum analgesia/anaesthesia Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

4.1 Low risk	3	5672	Risk Ratio (M‐H, Fixed, 95% CI)	1.21 [1.08, 1.35]
4.2 Other risk status	2	1367	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.79, 1.25]
5 Regional analgesia (epidural/spinal) Show forest plot	11		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

5.1 Low risk	6	7027	Risk Ratio (M‐H, Random, 95% CI)	0.77 [0.65, 0.93]
5.2 Other risk status	5	4865	Risk Ratio (M‐H, Random, 95% CI)	0.84 [0.75, 0.95]
6 Opiate analgesia Show forest plot	9		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

6.1 Low risk	5	6854	Risk Ratio (M‐H, Random, 95% CI)	0.90 [0.85, 0.96]
6.2 Other risk status	4	3343	Risk Ratio (M‐H, Random, 95% CI)	0.84 [0.57, 1.25]
7 Caesarean birth Show forest plot	11		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

7.1 Low risk	6	7026	Risk Ratio (M‐H, Fixed, 95% CI)	0.97 [0.83, 1.13]
7.2 Other risk status	5	4871	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.84, 1.09]
8 Instrumental vaginal birth (forceps/vacuum) Show forest plot	10		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

8.1 Low risk	5	6853	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.77, 1.01]
8.2 Other risk status	5	4871	Risk Ratio (M‐H, Fixed, 95% CI)	0.84 [0.72, 0.99]
9 Spontaneous vaginal birth (as defined by trial authors) Show forest plot	9		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

9.1 Low risk	5	6853	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [1.00, 1.06]
9.2 Other risk status	4	4073	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [1.01, 1.10]
10 5‐minute Apgar score below or equal to 7 Show forest plot	8		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

10.1 Low risk	4	3360	Risk Ratio (M‐H, Fixed, 95% CI)	0.97 [0.67, 1.40]
10.2 Other risk status	4	3420	Risk Ratio (M‐H, Fixed, 95% CI)	1.21 [0.76, 1.92]
11 Postpartum depression Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

11.1 Low risk	1	1213	Risk Ratio (M‐H, Fixed, 95% CI)	1.94 [0.18, 21.32]
11.2 Other risk status	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

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

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Comparison 4. Midwife‐led versus other models of care: variation in practice setting (antenatal care)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Fetal loss/neonatal death before 24 weeks Show forest plot	8		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 Community based	2	2421	Risk Ratio (M‐H, Fixed, 95% CI)	0.73 [0.54, 1.00]
1.2 Hospital based	6	7469	Risk Ratio (M‐H, Fixed, 95% CI)	0.84 [0.65, 1.10]
2 Fetal loss/neonatal death equal to/after 24 weeks Show forest plot	9		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.1 Community based	3	3926	Risk Ratio (M‐H, Fixed, 95% CI)	0.62 [0.32, 1.21]
2.2 Hospital based	6	7678	Risk Ratio (M‐H, Fixed, 95% CI)	1.39 [0.81, 2.40]
3 Overall loss and neonatal death Show forest plot	10		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3.1 Community based	6	5506	Risk Ratio (M‐H, Fixed, 95% CI)	0.81 [0.63, 1.04]
3.2 Hospital based	4	6300	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.67, 1.12]
4 No intrapartum analgesia/anaesthesia Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

4.1 Community based	1	1210	Risk Ratio (M‐H, Fixed, 95% CI)	1.07 [0.79, 1.46]
4.2 Hospital based	4	5829	Risk Ratio (M‐H, Fixed, 95% CI)	1.18 [1.06, 1.31]
5 Regional analgesia (epidural/spinal) Show forest plot	10		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

5.1 Community based	4	4083	Risk Ratio (M‐H, Random, 95% CI)	0.82 [0.67, 1.02]
5.2 Hospital based	6	4299	Risk Ratio (M‐H, Random, 95% CI)	0.79 [0.67, 0.93]
6 Opiate analgesia Show forest plot	9		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

6.1 Community based	2	2405	Risk Ratio (M‐H, Random, 95% CI)	1.04 [0.83, 1.31]
6.2 Hospital based	7	7792	Risk Ratio (M‐H, Random, 95% CI)	0.83 [0.71, 0.96]
7 Caesarean birth Show forest plot	11		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

7.1 Community based	4	4082	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.82, 1.10]
7.2 Hospital based	7	7815	Risk Ratio (M‐H, Fixed, 95% CI)	0.97 [0.85, 1.11]
8 Instrumental vaginal birth (forceps/vacuum) Show forest plot	10		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

8.1 Community based	3	3909	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.81, 1.14]
8.2 Hospital based	7	7815	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.72, 0.93]
9 Spontaneous vaginal birth (as defined by trial authors) Show forest plot	9		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

9.1 Community based	3	3909	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.99, 1.07]
9.2 Hospital based	6	7017	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [1.02, 1.07]
10 5‐minute Apgar score below or equal to 7 Show forest plot	8		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

10.1 Community based	2	2421	Risk Ratio (M‐H, Fixed, 95% CI)	0.70 [0.46, 1.07]
10.2 Hospital based	6	4359	Risk Ratio (M‐H, Fixed, 95% CI)	1.56 [1.03, 2.36]
11 Postpartum depression Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

11.1 Community based	1	1213	Risk Ratio (M‐H, Fixed, 95% CI)	1.94 [0.18, 21.32]
11.2 Hospital based	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 4. Midwife‐led versus other models of care: variation in practice setting (antenatal care)

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