Midwifery-Led Care

Maternal and newborn mortality rates have reached an historical low level. However, 92% of all maternal and newborn deaths and stillbirths occur in 73 low- and middle-income countries. Significantly, in these countries, there is also chronic shortage of skilled midwives. More than 300,0000 women, 2.7 million babies and over 3 million infants around the world die each year from preventable complications which occur from pregnancy and childbirth. In addition, there are 2.6 million stillbirths.

Many of these deaths could be prevented if there were enough qualified midwives, who are skilled to provide the care that women need before, during and after pregnancy. Our blog yesterday outlined the robust research which shows the benefits to women and their babies of having midwifery-led care, regardless of country of origin, birth setting or risk profile. We want to continue to highlight why the role of the midwives is so important to women, their newborns and families. In midwifery-led care, midwives and nurse-midwives are the main carer before, during and after pregnancy, and we highlight the benefits of this model of care, whilst recognising that the quality of care and an enabling environment are key factors also.

There is a lot of evidence that both maternal and neonatal outcomes are improved when skilled birth attendance is provided by midwives. In high-income settings in which resource-use has been examined, there are indications that such midwife-led care is a more cost-effective option than medically-led care. When midwives and nurse-midwives work in collaboration as part of multidisciplinary teams, providing integrated care across community and hospital settings, they can also provide effective midwifery care for women and infants who develop complications.

In low- and middle-income countries, women should be encouraged to give birth in a healthcare facility and to be cared for by a skilled birth attendant, which in most cases is a midwife or nurse-midwife. In the UK, healthy women with straightforward pregnancies can choose to give birth whilst being cared for by midwives at home, in midwifery units not situated in a hospital (freestanding), in midwifery units in a hospital setting (alongside) or in consultant-led hospital units (obstetric units). Women with existing health problems or those who have had problems in a previous birth are usually advised to give birth in what is called an ‘obstetric unit’. The World Health Organization estimates that between 70 and 80% of all pregnant women may be considered as low-risk at the start of labour, while in the UK it is estimated that approximately 70% of pregnant women are low-risk. However, current estimates show that in the UK, only 25% of women are birthing in midwifery units. This is due to lack of access to and provision of services, overmedicalisation of birth and cultural and social barriers.

Globally, many women want to experience a physiological labour and birth as a positive experience, and to have a sense of personal achievement and control through involvement in decision-making, even when medical interventions are needed or wanted. In its recent publication Intrapartum care for a positive childbirth experience the World Health Organization recommends mobility for all women in labour, intermittent auscultation of the foetal heart and eating and drinking during labour for healthy women with straightforward pregnancies and delayed cord clamping for all births.

Katherine Robinson who manages the largest midwifery led unit in Northern Ireland states that “Midwives who support and embrace the benefits of woman-centred care need to mentor, teach and share their practice not only within their own settings for succession planning, but also nationally and globally”. She believes that innovative midwifery care, which has continuity of carer throughout pregnancy which encourages and supports all women to be active participants in their care, needs to be disseminated to become standard practice for all women. Women should be provided with information to have evidence-based discussions to help inform their decisions regarding care during their pregnancy and birth.

Midwives and nurse-midwives should nurture a culture of woman-centered care with the expectation of normal pregnancy and birth being the most likely outcome, but to be able to adapt standard midwifery care to support those women who require specialist care and ensure timely recognition of complications and refer in a timely manner. In this way, midwives and nurse/midwives can and will support all families as they begin the journey of parenthood, by giving them a good first step towards a positive pregnancy and birth. This serves to provide an experience in which their wishes and choices have been valued and where they have been the lead in all decision-making surrounding their care, not the midwife or the doctor.

Members of the midwifery team within the Centre for Maternal and Newborn Health are involved in a technical group which involves international maternal and newborn health stakeholders, in collaboration with WHO and the global Partnership for Maternal, Newborn, and Child Health (PMNCH). This technical group has identified the need for all woman across the world to be cared for by a midwife or nurse-midwife at birth as a key priority. Education for midwives and nurse-midwives should be a strengthened globally and invested in so that care provided before, during and after pregnancy is of the quality that women and their families deserve.

An example of strengthening midwifery training is our project in Kenya. The CMNH team in Kenya includes midwifery Technical Officers who have been able to spearhead and coordinate the capacity building of different health cadres through the EmONC lifesaving skills project. These midwives have been able to foster teamwork amongst doctors, midwives and other healthcare providers. Betty Sam, one of the midwives stated that ‘doctors and midwives participate in some joint training sessions now. Before it was uncommon for midwives to teach/facilitate or run courses with doctors as participants. Through this project, the CMNH technical officers (midwives) have been able to overcome barriers to multi-disciplinary training’. What a great example of midwives leading the way with quality care!

 About the author
Hannah McCauleyHannah McCauley has been practising as a dual trained nurse and midwife for over 13 years, both in the UK and in low and middle income settings. Prior to her appointment in LSTM, she was a Clinical Sister and Manager in a midwifery led unit and labour ward in Northern Ireland. She worked in Uganda with VSO as a Maternal Health Specialist for 2 years. She is passionate regarding improving the quality of care for women and their new-born babies, supporting women’s choices in pregnancy and childbirth and promoting and empowering midwives in their professional role, both in the UK and internationally.