Mike: Hello, I’m Mike Clarke podcast editor for the Cochrane Library. Cochrane Pregnancy and Childbirth has produced many reviews of interventions relevant to the organization and delivery of maternity care. In this podcast, two of the group’s researchers, Cristina Fernandez Turienzo and Hannah Rayment-Jones, midwives and senior research fellows at King’s College London in the UK, discuss their April 2024 update for one of these reviews, looking at the effects of midwife continuity of care models for childbearing women.

Cristina: Hello Hannah, first of all, could you introduce listeners to the concept of midwife continuity of care models and how they differ from other models of maternity care?

Hannah: Hi Cristina, yes so across the globe, there is wide variation in the organisation and delivery of maternity care for pregnant women. In a midwife continuity of care model, women receive care during their pregnancy, birth, and the early parenting period from the same midwife or a small team of midwives in collaboration with obstetric and specialist teams when required. In other models of care, women receive care from several different midwives or obstetricians or family physicians, who they may not have had the opportunity to get to know or build a relationship with.

Cristina: Our review compares the different models of care, so could you say a few words about what we were looking for and why?

Hannah: We wanted to find out how outcomes differed for women or their babies who received a midwife continuity of care model compared to other models of care, and whether this has changed since the last version of the review, in 2016. This will help policymakers and healthcare providers to use the most recent evidence to make decisions about how maternity care should be organized. It will also help researchers and funders to prioritize future research and do studies that will fill gaps in the evidence.

Cristina: So, tell us about the studies that we found?

Hannah: We’ve added three studies in this update, bringing us to a total of 17 randomised trials involving just over 18,500 women. The studies were done in Australia, Canada, China, Ireland, and the United Kingdom, in a wide variety of settings and health systems.
All the included studies involved continuity of care models from either one known midwife or a small team of midwives throughout pregnancy and birth, and sometimes into the postnatal period. Mostly, the studies focused on women with a lower risk of complications but there were some for women who were classified as mixed or high risk.
The comparison groups in the studies covered various other models of care involving obstetricians, family physicians, nurses and midwives in various organisational settings. For example, some studies had models of care that offered intrapartum care in hospitals, midwife birth centres co‐located in a maternity unit, and home birth. All studies included qualified midwives, and none included lay or traditional midwives.
None of the studies focused on women from disadvantaged backgrounds or who had social risk factors, highlighting a need for future research in these areas.

Cristina: So, what do the included studies tell us about the effectiveness of midwife continuity of care models?

Hannah: Women or their babies who received midwife continuity of care models were more likely to experience a spontaneous vaginal birth than those receiving other models of care and less likely to experience a caesarean section or instrumental vaginal delivery. They may be less likely to have an episiotomy and they also reported more positive experiences during pregnancy, labour, and postpartum. Additionally, there were cost savings in the antenatal and intrapartum period. However, there is not enough evidence to be sure about some other important outcomes, such as preterm birth, fetal loss after 24 weeks' gestation and neonatal death.

Cristina: Apart from adding the three new studies, what else has changed since the last version of the review in 2016?

Hannah: Firstly, we are using a new definition for the model of care. We have also updated our methods for assessing bias and strength of evidence and changed our primary and secondary outcomes. And, as well as adding in the data from the new studies, we’ve also been able to include new data from some of the studies that were already in the review.

Cristina: You mentioned assessing the strength of evidence. What did that tell us about the research?

Hannah: The quality of the evidence varied across the review. This means that we have high‐quality evidence for some outcomes, but others present more uncertainty. For example, the analyses for fetal loss after 24 weeks' gestation and neonatal death is based on a very small number of cases. We also lack evidence on important outcomes like maternal and infant health after birth and neonatal readmissions to hospital. There’s also an important gap in information from low resource countries and from populations with high social risks.

Cristina: Lastly, what’s the take home message from this update?

Hannah: Midwife continuity of care models are safe and effective, provide a better experience with less interventions and offer important benefits to women and their babies. However, there is still a need for more research. This should focus on measuring a core outcome set, the impact on women with social risk factors, and those with medical complications, and understanding the implementation and scaling up of midwife continuity of care models, with emphasis on low‐ and middle‐income countries.

Cristina: Thanks Hannah. If people would like to read the review, how can they get hold of it?

Hannah: Thank you, Cristina. The review is available online. If listeners go to Cochrane Library dot com and type “midwife continuity” in the search box, they’ll see our review at the top of the list.