SANDALL, J.; SOLTANI, H.; GATES, S. et al. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD004667. DOI:10.1002/14651858.CD004667.pub5.
Background Midwives are primar y providers of care for childbearing women around the world. However, th ere is a lack of synthesised informationto establish wheth er there are differences in morbidity and mortality, effectiveness and psychosocial outcomes between midwife-ledcontinuity models and othe r models of care.ObjectivesTo compare midwife-led continuity models of care with other models of care for childbearing women and their infants.Search methodsWe searched the Cochrane Pregnancy and Childbirth Gr oup’s Trials Register (25 January 2016) and reference lists of retrieved studies.Selection criteriaAll published and unpublished trials in which pregnant women are randomly al located to midwife-led continuity models of care orother model s of care during pregnancy and birth.Data collection and analysisTwo review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them f or accuracy. Thequality of the evidence was assessed using the GRADE approach.Main resultsWe included 15 trials involving 17,674 women. We assessed th e quality of the trial evidence for all primary outcomes (i.e. regionalanalgesia (e pidural/spinal), caesarean birth, instrumental vaginal birth (forceps/vacuum), spontaneous vaginal birth, intact perineum,preterm birth (less than 37 weeks) and all fetal loss before and afte r 24 weeks plus neonatal death using the GRADE methodology: allprimary outcomes were graded as of high quality.For the primary outcomes, women who had midwife-led continuity model s of care were less likely to experience regional analgesia(average risk ratio (RR) 0.85, 95% conﬁdence interval (CI) 0.78 to 0.92; participants = 17,674; studies = 14; high quality), instrumental vaginal birth (average RR 0.90, 95% CI 0.83 to 0.97; participants = 17,501; studies = 13; high quality), preterm birth less than 37weeks (average RR 0.76, 95% CI 0.64 to 0.91; participants = 13,238; studies = eight; high quality) and less all fetal loss before andafter 24 weeks plus neonatal death (average RR 0.84, 95% CI 0.71 to 0.99; participants = 17,561; studies = 13; high quality evidence).Women who had midwife-led continuity models of care were more likely to experience spontaneous vaginal birth (average RR 1.05,95% CI 1.03 to 1.07; par ticipants = 16,687; studies = 12; high quality). There were no diffe rences between groups for caesarean birthsor intact perineum.For the secondary outcomes, women who had midwife-led continuity models of care were less likely to experience amniotomy (averageRR 0.80, 95% CI 0.66 to 0.98; participants = 3253; studies = four), e pisiotomy (average RR 0.84, 95% CI 0.77 to 0.92; participants= 17,674; studies = 14) and fetal loss less than 24 weeks and neonatal death (average RR 0.81, 95% CI 0.67 to 0.98; participants =15,645; studies = 11). Women who had midwife-led continuity models of care were more likely to experience no intrapartum analgesia/anaesthesia (average RR 1.21, 95% CI 1.06 to 1.37; participants = 10,499; studies = se ven), have a longer mean le ngth of labour(hours) (mean difference (MD) 0.50, 95% CI 0.27 to 0.74; participants = 3328; studies = three) and more likely to be attended atbirth by a known midwife (average RR 7.04, 95% CI 4.48 to 11.08; participants = 6917; studies = seven). The re were no differencesbetween groups for fetal loss equal to/after 24 weeks and neonatal death, induction of l abour, antenatal hospitalisation, antepartumhaemorrhage, augmentation/artiﬁcial oxytocin during labour, opiate analgesia, perineal laceration requiring suturing, postpartumhaemorrhage, breastfeeding initiation, l ow birthweight infant, ﬁve-minute Apgar score less th an or equal to seven, neonatal convulsions,admission of infant to special care or neonatal intensive care unit(s) or in mean length of neonatal hospital stay (days).Due to a lack of consistency in measuring women’s satisfaction and assessing the cost of various maternity models, these outcomes wererepor ted narratively. The majority of included studies reported a higher rate of maternal satisfaction in midwife-le d continuity modelsof care. Similarly, there was a trend towards a cost-saving effect for midwife-led continuity care compared to othe r care models.Authors’ conclusionsThis review suggests that women who received midwife-led continuity models of care were less likely to experience intervention andmore likely to be satisﬁed with their care with at least comparable adverse outcomes for women or their infants than women whoreceived other models of care.Further research is needed to explore ﬁndings of fewer preterm births and fewer fetal de ath s less than 24 weeks, and all fetal loss/neonatal death associated with midwife-led continuity model s of care.
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