There has been much research in recent years into midwifery-led models of maternity care, and this has produced considerable evidence that it can significantly improve outcomes for mothers and their babies. Continuity of care has been shown to reduce obstetric intervention, which interferes with physiological birth; reduce women's need for pain relief by improving her confidence and ability to deal with normal labour pain; and through both of these factors has been shown to improve outcomes, reduce physical and psychological morbidity, and improve satisfaction with birth (McLachlan et al, 2015; Rayment-Jones et al, 2015; Wong et al, 2015; Sandall et al, 2016; Homer et al, 2017) (Figure 1). In addition, despite concerns around increasing hours and reduced work-life balance, continuity of care models can provide midwives with a sense of fulfilment with their role, and greater autonomy and flexibility, thereby providing a better work-life balance, and protecting against psychological stress and burnout (Dahlen and Caplice, 2014; Dawson et al, 2018; Fenwick et al, 2018).
Midwife-led models of care aim to optimise continuity of care, and include team midwifery (where women are looked after by a group of midwives) and caseload midwifery (where women are looked after by the same midwife throughout the antenatal, intrapartum, and early postpartum periods) (Forster et al, 2016; Homer, 2016; Sandall et al, 2016). The aim is for the woman to develop a trusting relationship with her midwife or midwives, who, importantly, will be there for her during the intrapartum period.
This article will discuss the outcomes that can be improved by midwifery-led continuity of care, the many advantages for women of this type of care, and how it might work for midwives. It will also aim to disentangle how this complex phenomenon works in relation to specific populations and outcomes, and to elucidate how it may be important for the long-term health and wellbeing of women and their families—perhaps even our society as a whole.
Benefits for women
That being seen by the same midwife throughout the antenatal, intrapartum, and postpartum period—a seemingly simple intervention—can improve such a vast array of outcomes for women and their families is astounding and difficult to ignore. Outcomes that have consistently been found to be improved include (Table 1) reduced rates of induction of labour, reduced need for intrapartum pain relief, particularly epidural analgesia, reduced use of amniotomy and episiotomy, reduced rates of instrumental and caesarean birth, reduced preterm birth, less neonatal intensive care admission, and reduced perinatal mortality (McLachlan et al 2015; Rayment-Jones et al, 2015; Wong et al, 2015; Sandall et al, 2016; Homer et al, 2017). Women experiencing midwiferyled continuity of care are also more likely to experience a spontaneous labour and birth without the need for analgesia, to experience a physiological third stage, and to initiate and exclusively breastfeed their babies (Rayment-Jones et al, 2015; Wong et al, 2015; Sandall et al, 2016; Homer et al, 2017). In addition, women are more likely to feel in control during their labour, and satisfaction with care and with birth experience is improved (McLachlan et al, 2015; Forster et al, 2016; Sandall et al, 2016). These outcomes are extremely important amid widespread concerns of decreasing rates of physiological birth, the increasing use of obstetric intervention in childbirth, and associated physical and psychological morbidity (Leap et al, 2010; Butler, 2017; Page and Mander, 2014).
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How does continuity improve outcomes?
It has been difficult to establish which aspects of continuity matter most to women, and clarify which aspects provide the improvements seen when women experience continuity of midwifery care (Forster et al, 2016; Sandall et al, 2016). Improved outcomes could be due to being seen by the same midwife; to the midwife-mother relationship that develops as a result; to the shared philosophy of midwives who practice continuity of care; or to the consistency of advice and content of care given. Improvements could in fact result from each of these factors, which will influence care and outcomes to varying degrees for each individual woman, depending on her specific needs and circumstances (Table 2).
| Continuity of carer | Philosophy of midwife | Mother-midwife relationship |
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It is thought that it is the relationship that develops between the midwife and mother as a result of continuity, and the nature of this relationship (due to the philosophy of the midwife), that is particularly important in improving outcomes (Browne et al, 2014; Allen et al, 2016; Boyle et al, 2016; Tickle et al, 2016; Perriman et al, 2018). In many of the studies carried out into midwifeled continuity (McLachlan et al, 2015; Forster et al, 2016; Dawson et al, 2018), midwives self-selected into the role, and it is therefore likely that these midwives have certain characteristics, including a philosophy of care that ties in with this way of working and that attracts them to this model of care (Newton et al, 2014; McLachlan et al, 2015; Dawson et al, 2018).
The importance of the underpinning philosophy of the midwife is emphasised by many (Allen et al, 2016; Boyle et al, 2016; Sandall et al, 2016). This philosophy constitutes a strong belief in the ability of women to give birth physiologically without intervention; in building supportive and meaningful relationships; in fully informed choice and personalised care; in recognising psychosocial, emotional and physical needs; and in empowering women to become autonomous in their pregnancy and birth (Allen et al, 2016; Sandall et al, 2016; Tickle et al, 2016; Butler, 2017). This might lead one to question whether outcomes would be improved if midwives working in this model of care did not uphold these professional beliefs and values, or if they were unable to do so due to the organisational infrastructure in which they worked.
Benefits for specific groups of women
Women from socially disadvantaged backgrounds are at increased risk of poor pregnancy outcomes, including stillbirth, low birth weight, and preterm birth, and at increased risk of poor outcomes associated with obstetric intervention (Rayment-Jones et al, 2015). It is thought that many of these adverse effects are due to a lack of engagement with antenatal services. Caseload care has been found to improve outcomes for socially disadvantaged women by increasing access to and engagement with antenatal care, and providing greater referral to supportive services (Rayment-Jones et al, 2015). Women who experienced caseload care were more likely to attend for their booking appointment by 10 weeks' gestation, to be referred to multidisciplinary support services, to experience spontaneous labour and birth, and to use water for pain relief. They were also less likely to use epidural analgesia or to have a caesarean birth, and had fewer neonatal admissions (Rayment-Jones et al, 2015).
Adolescents are also at increased risk of adverse pregnancy outcomes, particularly preterm birth (Allen et al, 2015). In addition, pregnant adolescents are more likely to come from socially disadvantaged backgrounds, which is associated with its own psychosocial and behavioural risk factors for preterm birth, including smoking, drinking alcohol, suboptimal nutrition and increased incidence of urinary tract infections. The risk factors for pregnancy in adolescence and for preterm birth are therefore almost identical, and socioeconomic deprivation increases the prevalence of these risk factors (Allen et al, 2015; 2016) (Figure 2).
Woman receiving caseload midwifery care are less likely to experience preterm birth (Allen et al, 2015; Sandall et al, 2016; Homer et al, 2017), and the effect of models of care on preterm birth, as well as the mechanisms behind them, have been identified as a research priority (Duley et al, 2014; Sandall et al, 2016). Allen et al (2016) investigated the mechanisms through which this seemingly simple intervention could modify such an important birth outcome, specifically among young adults. They found that this might be due to enhanced antenatal engagement, which allows the early implementation of interventions targeted at modifiable risk factors (such as drug and alcohol use, and psychosocial stress). This resulted in greater emotional resilience, reduced drug and alcohol use, optimisation of gestational weight gain, and treatment of urinary tract infections (Figure 3). Both the quality of the midwife-mother relationship and the environment in which antenatal care was carried out (non-clinical group settings appeared most effective) were thought to enhance attendance and disclosure of risk factors, as well as acceptance of referral to supportive services, and willingness to follow advice (Allen et al, 2016). Furthermore, the social support provided by the midwives was found to act as a buffer, protecting against the psychosocial stresses experienced by some young women. The authors concluded that ‘optimal caseload midwifery’ developed trusting relationships and enhanced engagement with antenatal care.
Important facets of optimal caseload midwifery included the midwives' personal philosophy and attributes, as well as the appropriate institutional infrastructure and support (Figure 3). Non-clinical group settings for antenatal care were found to reduce the stigma that adolescents can often feel when attending antenatal care (Allen et al, 2016) and may be worth wider consideration, as they have frequently been found to enhance engagement with antenatal care, in addition to providing additional social support, enhancing maternal satisfaction and using midwifery time effectively (Leap et al, 2010; Boyle et al, 2016).
As well as representing a key time during which behaviours can be altered and shaped, the antenatal period is also important for setting appropriate expectations, addressing fears and building a woman's confidence in her ability for physiological birth (Avery et al, 2014; Neerland, 2018). Continuity of care is therefore frequently associated with the ability to cope with the normal pain of childbirth and with a drug-free birth (Leap et al, 2010; Tickle et al, 2016; Homer et al, 2017). This, in addition to the reduced use of unnecessary intervention, means that caseload midwifery care can lead to feelings of satisfaction, elation, strength and confidence following birth, promoting a positive start to the challenges of breastfeeding and new parenthood (Leap et al, 2010; Tracy et al, 2013; Homer et al, 2017).
Intervention and caesarean section
While rates of physiological birth decline in the general population, intervention and caesarean rates continue to rise (Peters et al, 2018), despite evidence of the benefits of physiological birth for both mother and baby, and evidence of potential harm imposed by unnecessary obstetric intervention (Miller et al, 2016). Caesarean section rates range from 20% to over 40% of births in developed regions (Betrán et al, 2016) and while this is often attributed to increasing prevalence of indications such as obesity and diabetes, decisions often seem to be, at the very least, influenced by the culture and the intervention threshold of the institution and professionals involved (Marshall et al, 2015; Butler, 2017). In addition, caesarean section can often be the end of a cascade of interventions, where a well-intentioned decision results in the need for further intervention, and ultimately in the need for caesarean birth. While in some cases caesarean section is essential, for the mother it is associated with an increased risk of infection, haemorrhage and thrombosis, and for the neonate, an increased risk of respiratory distress syndrome, admission to special care, and difficulty breastfeeding (Marshall et al, 2015; Butler, 2017). While in high-income countries the risk of these short-term complications can be minimised, there are long-term implications associated with caesarean section, which are less frequently discussed. These include (for the mother) risks to future pregnancies, such as reduced fertility and increased risk of placenta praevia, placenta accreta, uterine rupture and stillbirth (Keag et al, 2018).
Effects of intervention on the child
For the child, interest in the long-term risks associated with caesarean section and other forms of obstetric intervention is gathering momentum, and is increasingly being associated with a number of adverse outcomes for the infant and growing child, including respiratory, immune and metabolic disorders, such as asthma; type 1 diabetes; allergies and obesity (Dahlen et al, 2014; Magne et al, 2017; Keag et al, 2018; Tribe et al, 2018). The differences between vaginal and elective caesarean birth seemingly result in changes to newborn physiology, which increases the risk of development of these chronic conditions. Several reasons for this have been proposed. As well as a differences in the timing of birth, vaginal birth and caesarean section vary in the physical and hormonal environment to which they expose the fetus. Infants born by elective caesarean section are usually born earlier than those born vaginally, and will therefore have been exposed to the hormonal changes associated with the onset and continuation of labour and birth, such as increased oestrogen and cortisol, to a lesser extent (Tribe et al, 2018). In addition to the lack of exposure to the physical forces of labour and birth, this may result in aberrant levels of hormones such as adrenaline and cortisol in the newborn. The result could be that epigenetic changes alter the development of the hypothalamic-pituitary axis (HPA), potentially leading to altered stress reactivity in the newborn and child (Tribe et al, 2018). Vaginal birth is also associated with exposure of the newborn to maternal vaginal and faecal microbiota, while caesarean section subverts this and is usually carried out with the administration of prophylactic antibiotics (Dahlen et al, 2014; Magne et al, 2017). Dahlen et al (2013) propose that physiological labour has evolved to exert a certain level of beneficial stress (‘eustress’) on the neonate. Any significant increase (as is the case with instrumental birth) or decrease (caesarean section) in stress, and thus adrenaline and cortisol levels, can result in aberrant epigenetic changes in the neonate, potentially increasing the risk of the above disorders (Figure 4).
Any non-physiological intervention, such as induction, augmentation, and epidural analgesia, may interrupt the physiological eustress that produces the normal balance of intrapartum epigenetic changes, and may result in heritable changes in the infant's genome (Dahlen et al, 2013; 2014; Peters et al, 2018). It is increasingly becoming recognised that epigenetic changes due to antenatal and postnatal stress can alter development and later life health and behaviour for the infant and developing child. It may be, however, that intrapartum events are also important regulators of the epigenome, and as these changes are heritable, intrapartum events may therefore have an impact on society as a whole (Dahlen et al, 2013; 2014).
Intervention following birth
Active management of the third stage of labour may not typically be viewed as an intervention, as it has become such a routine part of care (Begley, 2014). However, its benefit for low-risk women who have experienced a physiological labour and birth is questionable (Begley et al, 2015), and it may even do harm. Premature cord clamping, checking for signs of placental separation, and pulling at the umbilical cord (Begley, 2014) interrupt the extremely precious moments following birth that should be reserved for mother-baby bonding and attachment. In the Albany midwifery practice, a well-known model of caseload midwifery, 79% of women experienced a physiological third stage of labour, and of these women, only 5.9% had a blood loss of more than 500 ml (Homer et al, 2017). In a Cochrane systematic review comparing active management of the third stage with physiological management, there was an increased risk of blood loss over 500 ml with physiological management of the third stage (Begley et al, 2015). However, the women in this study were of mixed risk; many had received oxytocics for induction or augmentation, which would increase the risk of uterine atony due to receptor desensitisation; and often the midwives were not experienced in physiological management of the third stage. In addition, when studies included only low-risk women, there was no such increased risk of bleeding.
It should be noted, however, that there are questions around what constitutes normal blood loss during the third stage of labour (Dixon et al, 2013; Begley, 2014; Begley et al, 2015). During pregnancy there is a normal expansion and haemodilution of the circulation, which is thought to compensate, at least in part, for the blood loss that occurs following placental separation. A loss of 500-750 ml of diluted blood is said to be equivalent to that of a routine blood donation, and in healthy women with a normal haemoglobin level may not cause any adverse effects (Dixon et al, 2013; Begley et al, 2015).
Dixon et al (2013) found that when physiological management was restricted to women who had undergone a spontaneous labour and birth, and when they were cared for by midwives who were experienced in physiological third stage, there was actually less blood loss with physiological than with active management. Active management was also associated with a significantly increased need for manual removal of the placenta. In a recent study by Erickson et al (2018), women who experienced a more physiological birth had a lower risk of postpartum haemorrhage, and active management in these circumstances increased the risk of having a postpartum haemorrhage. Again, active management was found to be associated with a higher risk of having a retained placenta. In the Midwives' Expertise in Expectant Third stage management (MEET) trial, midwives described how they would use the skills they had developed to watch and wait for the birth of the placenta; to use gravity, skin-to-skin and breastfeeding to their advantage; and how, through monitoring maternal cues, there was no need to interfere during this important bonding period after birth (Begley et al, 2012). However, there is a danger that active management is becoming so routine that, for some, physiological management will become another lost skill.
The inherent benefits of optimal cord clamping (waiting until the umbilical cord has stopped pulsating and the infant has received its full volume of blood) are numerous, and include allowing for a physiological transition, increased haemoglobin and haematocrit levels, reduced risk of intraventricular haemorrhage, reduced need for transfusions, and a reduced risk of anaemia (Jelin et al, 2016; Backes et al, 2016; Hooper et al, 2016; Weeks and Bewley, 2018). This is more often experienced with physiological management of the third stage, and may be an extremely important outcome of this (Begley et al, 2012). Given that healthy women who have experienced a physiological labour and birth have no increased risk—and perhaps reduced risk—of increased blood loss, there is no reason to rush to clamp the cord and interfere with the precious moments following birth (Dixon et al, 2013; Begley, 2014).
The role of caseload midwifery
Caseload midwifery could preclude physical and psychological morbidities by reducing obstetric intervention, and through lower rates of emergency and elective caesarean section (McLachlan et al, 2015; Tracy et al, 2013). Importantly, by reducing rates of intervention, caseload midwifery may also reduce financial costs in the long term (Tracy et al, 2014). Wong et al (2015) emphasise the importance of getting the first birth right, as well as stressing the importance of caseload midwifery from the first birth, as previous caesarean section is a major contributory factor to rising caesarean rates, and because this, as well as other forms of intervention, can affect future pregnancy outcomes and choices.
There is a considerable weight of evidence to show that caseload midwifery can reduce intervention, normalise birth, and improve outcomes, including maternal satisfaction with birth. There needs to be a stronger emphasis on promoting and protecting physiological birth (Browne et al, 2014; Dahlen et al, 2014; Daemers et al, 2017; Healy et al, 2017); however, the financial and institutional infrastructure needs to support the philosophical commitments of caseload care, for midwives to work in this way, and for caseload midwifery to work (Allen et al, 2016; Sandall et al, 2016).
Benefits for midwives
While there are concerns that working in caseload models of care involves heavy workloads, many hours on-call, and a reduced work-life balance (Fenwick et al, 2018), there is increasing evidence that this model of care can also be also be of considerable benefit to the midwife. Midwives working in caseload models of care report higher levels of professional identity, flexibility, and autonomy than midwives working in standard models of care. They also report an improved work-life balance, and less depression, anxiety, and burnout, and gain high levels of empowerment, fulfilment and satisfaction from being able to make a real difference to the women in their care (Dahlen and Caplice, 2014; Dawson et al, 2018; Fenwick et al, 2018). In contrast, midwives working in standard models of care may be at greater risk of psychological stress than caseload midwives (Fenwick et al, 2018). Midwives who changed from their usual way of working to caseload care developed more positive professional attitudes, and a more positive attitude to midwifery work (Newton et al, 2014).
Challenges for midwives
The antenatal period may represent a critical period in improving pregnancy and birth outcomes (Browne et al, 2014; Wong et al, 2015). It sets the tone for the pregnancy and birth, and can shape behaviours and expectations. It can be used to develop relationships, allow informed decision-making, and build trust, emotional resilience, empowerment and confidence to face the challenges of pregnancy, labour and birth, and new motherhood (Browne et al, 2014; Homer et al, 2017). However, for relationships to develop, and in order to focus on the physical, psychosocial and emotional needs of the woman, time is essential (Browne et al, 2014; Boyle et al, 2016). While women experiencing caseload care may receive visits that can last up to 45 minutes (Butler, 2017), women receiving standard care often describe their antenatal appointments as ‘ticking the box’—focusing on the physical, rather than the emotional and psychological needs of the woman—where relationships are not able to develop (Browne et al, 2014; Boyle et al, 2016). Time is needed to build supportive relationships, to allow antenatal care to go beyond the physical, and to get to the heart of what matters to the woman and what can be done to optimise her experience of pregnancy and birth.
In addition, midwives working in standard models of care are often constrained by the biomedical discourse and interventionist models of care of the institutions in which they work. Fear of uncertainty, risk and litigation has led to the widespread and routine use of defensive practice, which in many places has become normal. This may be seen as ‘the easy option’, as it precludes the unknown and conforms with the culture and ethos that many struggle to work against (Browne et al, 2014; Dahlen and Caplice, 2014; Page and Mander, 2014; Dahlen, 2016). As a result, midwives may lose their sense of autonomy; become medicalised by their environment, fearing uncertainty; and may lose their belief in the normality of childbirth (Browne et al, 2014; Daemers et al, 2017; Healy, et al, 2017). This focus on risk may hinder midwives' ability to aid physiological birth and may result in physical and psychological harm to women (Dahlen and Caplice, 2014; Dahlen, 2016; Butler, 2017).
A supportive infrastructure is needed, which allows for the time and resources and, importantly, the philosophical commitments, of caseload midwifery (Allen et al, 2016). Indeed, a healthy, constructive collaboration that prioritises the philosophical commitments of caseload care can allow caseload midwifery care to work, even in large obstetric units (McLachlan et al, 2015; Tracy et al, 2013; Perriman et al, 2018). Thus, midwifery care and outcomes will depend on the midwife's philosophy, as well as the model of care and institutional infrastructure within which he or she works (Dahlen and Caplice, 2014; Daemers et al, 2017) (Figure 5).
Conclusion
Midwifery-led continuity of care is a complex package of care with a belief in the inherent normality of childbirth, and the natural ability of women to achieve this, at its heart. It is increasingly evident that it can reduce intervention, increase rates of physiological childbirth, improve psychological wellbeing, and reduce morbidity and mortality for childbearing women and their families, both in the short and long term. Trusting, supportive relationships are at the centre of this and a ‘caseload philosophy’—as well as the appropriate infrastructure to develop and maintain this philosophy and relationship—is essential (Figure 6). Self-selection of midwives onto this model of care may be necessary to optimise outcomes, although it is possible that by working in this model of care, midwives will become empowered and regain their passion for promoting and protecting physiological birth. The evidence around caseload midwifery is plentiful, astounding, and would seem contemptuous to ignore, as there is a real and desperate need to bring birth back to women, and normality back to midwives.
