Historically, during childbirth, women were cared for by known midwives within their own community (Donnison, 1988; Davison, 2020). Today, however, continuity of midwifery care has become increasingly difficult to find.
Following the move from the home to the hospital, pregnancy and childbirth have evolved into procedures that needs to be managed to reduce the ‘risks’ to mother and baby (Donnison, 1988; Jackson et al, 2012; Davis-Floyd, 2018; Davison, 2021). In this technocratic and obstetric-led model, the overuse of medical interventions has become routine and normalised (McDougal et al, 2016).
The medicalisation of birth has led to maternity care being provided within a technocratic, biomedical model, with most midwives now working in a fragmented hospital system where relationship-based care is often overlooked (Davison et al, 2015; Reed et al, 2017; Bradfield et al, 2018; Davison, 2019). This is not woman-centred care and contradictory to the advice from the World Health Organization (2016), that recommends that every childbearing woman, in settings with well-functioning midwifery programmes, is supported by a known midwife within a continuity of care model.
But what is woman-centred care? The idea of ‘woman-centred care’ can be traced back to the women's health movement during the second wave of feminism in the 1960s and 1970s (Leap, 2009; Fahy, 2012; Davison, 2019). Leap (2000) described woman-centred midwifery care as a concept that implies that midwifery:
- Focuses on the woman's individual needs, aspirations and expectations, rather than the needs of the institution or professional
- Recognises the need for women to have choice, control and continuity from a known caregiver or caregivers
- Encompasses the needs of the baby, the woman's family and other people important to the woman, as defined and negotiated by the woman herself
- Follows the woman across the interface of community and acute settings
- Addresses social, emotional, physical, psychological, spiritual and cultural needs and expectations
- Recognises the woman's expertise in decision making.
Woman-centred care principles underpin the midwifery profession and are identified in many of the midwifery professional colleges' philosophical statements (Leap, 2000; Midwives Alliance of North America, 2010; Royal College of Midwives, 2018; Australian College of Midwives, 2020; International Confederation of Midwives, 2020). Leap (2000) states: ‘Woman-centred care is now an internationally recognised concept that acknowledges that when care concentrates on the individual woman, there is the potential to create situations where the woman can become more powerful, and in turn, strengthen her family, community and society’.
Midwife means ‘with woman’ and the concept of ‘being with woman’ is described as the foundation of midwifery (Bradfield et al, 2018). Being ‘with woman’ is embedded in professional philosophy, standards of practice and relationship-based care with women (Bradfield, 2019). A recent study in Australia explored what it meant to be ‘with woman’ for midwives working in Australia (Bradfield et al, 2019; 2019a; 2019b; 2019c). Exploring three different models of maternity care, Bradfield and colleagues conducted in-depth interviews with midwives working in the private obstetric model (where care is provided by an unknown midwife during labour with a known private obstetrician attending the birth), the ‘unknown midwife’ model (where care is provided by an unknown midwife during labour and birth) and the ‘known midwife’ model (where care is provided by a known midwife during labour and birth). Midwives in all the three models, believed that being ‘with woman’ was a central theme to providing woman-centred care and all the midwives who were interviewed sought to achieve this within their midwifery practice (Bradfield et al, 2019; 2019a; 2019b; 2019c). However, midwives working within the private obstetric model and the ‘unknown’ midwife model described how they struggled at times to be ‘with woman’ due to the challenges of working within a medical model where hierarchal structures existed, and the dominant philosophy was not deemed as woman-centred (Bradfield et al, 2019a; 2019c).
‘Woman-centred care principles underpin the midwifery profession’
The third model of care was the ‘known’ midwife model, where continuity of care during labour and birth was provided by a midwife known to the woman. Central to the ‘known’ midwives' experiences of being ‘with woman’ was the trusting relationship that developed between the midwives and the women during their labour and birth (Bradfield et al, 2019b).
The evidence clearly demonstrates that continuity of midwifery care is beneficial for both women and babies. A Cochrane review including 15 randomised trials and over 17 000 women, which compared midwifery continuity of care models with medically led care or shared models, found that midwifery led care was associated with a range of improved maternal and neonatal outcomes (Sandall et al, 2016). The review found that women were more likely to experience a spontaneous labour and vaginal birth, less likely to have pharmacological pain relief, an epidural, or an assisted birth. Women were also less likely to have a baby born preterm and their babies were at lower risk of death (including death before and after 24 weeks and neonatal deaths). The conclusion of this review was that most women should be offered midwifery led continuity of care (Sandall et al, 2016).
Other international research also shows excellent outcomes for women and their babies, and demonstrates that women who had experienced continuity of midwifery carer were more satisfied with their care and were more positive about a range of factors (McLachlan et al, 2013; Tracey et al, 2013; 2014; Haines et al, 2015; Forster, 2016; Dawson et al, 2017; Fenwick et al, 2017; Perdock et al, 2018). Women experiencing continuity of midwifery carer were more likely to report that they were given the support and care they felt they needed regarding breastfeeding and caring for their babies and their own health and wellbeing following the birth (Forster, 2016; D'haenens et al, 2019).
Women reported increased satisfaction with care after the birth, both in hospital and at home. Postnatal care, often called the ‘Cinderella’ of maternity care, is consistently an area that women report dissatisfaction with. Women who experience continuity of midwifery carer report feeling empowered, nurtured, and safe during pregnancy, labour and birth, and the postnatal period (D'haenens et al, 2019). Women do not just want continuity of carer; they want to have a relationship with their midwife. Davison et al (2015) found that women who employed a privately practising midwife, developed a relationship with their caregiver which they reported strengthened the whole family. The women in this study stated that the trusting relationship that they developed with their midwife was woman-centred, individualised and based on a shared philosophy, that directly contributed to the women having a positive and empowering birth (Davison, 2014; Davison et al, 2015). Research clearly demonstrates that women place a high value on continuity of carer and the relationship they build with their midwife. Women expect to be partners in the sharing of knowledge and expect midwives to listen to them and accept their judgement and decisions.
‘They want to have a relationship with their midwife’
Woman-centred care places the woman at the centre of her experience. Providing women with a midwife throughout the journey, means that both the woman and her baby are more likely to emerge from the experience feeling safe, supported and satisfied. If woman-centred, midwifery led continuity of carer was a medication it would be prescribed to every woman. So, this brings us to ask the question, why isn't it?