BACKGROUND: Midwives are primary providers of care for childbearing women globally and there is a need to establish whether there are differences in effectiveness between midwife continuity of care models and other models of care. This is an update of a review published in 2016.
OBJECTIVES: To compare the effects of midwife continuity of care models with other models of care for childbearing women and their infants.
SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Trials Register, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) (17 August 2022), as well as the reference lists of retrieved studies.
SELECTION CRITERIA: All published and unpublished trials in which pregnant women are randomly allocated to midwife continuity of care models or other models of care during pregnancy and birth.
DATA COLLECTION AND ANALYSIS: Two authors independently assessed studies for inclusion criteria, scientific integrity, and risk of bias, and carried out data extraction and entry. Primary outcomes were spontaneous vaginal birth, caesarean section, regional anaesthesia, intact perineum, fetal loss after 24 weeks gestation, preterm birth, and neonatal death. We used GRADE to rate the certainty of evidence.
MAIN RESULTS: We included 17 studies involving 18,533 randomised women. We assessed all studies as being at low risk of scientific integrity/trustworthiness concerns. Studies were conducted in Australia, Canada, China, Ireland, and the United Kingdom. The majority of the included studies did not include women at high risk of complications. There are three ongoing studies targeting disadvantaged women. Primary outcomes Based on control group risks observed in the studies, midwife continuity of care models, as compared to other models of care, likely increase spontaneous vaginal birth from 66% to 70% (risk ratio (RR) 1.05, 95% confidence interval (CI) 1.03 to 1.07; 15 studies, 17,864 participants; moderate-certainty evidence), likelyreduce caesarean sections from 16% to 15% (RR 0.91, 95% CI 0.84 to 0.99; 16 studies, 18,037 participants; moderate-certainty evidence), and likely result in little to no difference in intact perineum (29% in other care models and 31% in midwife continuity of care models, average RR 1.05, 95% CI 0.98 to 1.12; 12 studies, 14,268 participants; moderate-certainty evidence). There may belittle or no difference in preterm birth (< 37 weeks) (6% under both care models, average RR 0.95, 95% CI 0.78 to 1.16; 10 studies, 13,850 participants; low-certainty evidence). We arevery uncertain about the effect of midwife continuity of care models on regional analgesia (average RR 0.85, 95% CI 0.79 to 0.92; 15 studies, 17,754 participants, very low-certainty evidence), fetal loss at or after 24 weeks gestation (average RR 1.24, 95% CI 0.73 to 2.13; 12 studies, 16,122 participants; very low-certainty evidence), and neonatal death (average RR 0.85, 95% CI 0.43 to 1.71; 10 studies, 14,718 participants; very low-certainty evidence). Secondary outcomes When compared to other models of care, midwife continuity of care models likely reduce instrumental vaginal birth (forceps/vacuum) from 14% to 13% (average RR 0.89, 95% CI 0.83 to 0.96; 14 studies, 17,769 participants; moderate-certainty evidence), and may reduceepisiotomy 23% to 19% (average RR 0.83, 95% CI 0.77 to 0.91; 15 studies, 17,839 participants; low-certainty evidence). When compared to other models of care, midwife continuity of care models likelyresult in little to no difference inpostpartum haemorrhage (average RR 0.92, 95% CI 0.82 to 1.03; 11 studies, 14,407 participants; moderate-certainty evidence) and admission to special care nursery/neonatal intensive care unit (average RR 0.89, 95% CI 0.77 to 1.03; 13 studies, 16,260 participants; moderate-certainty evidence). There may be little or no difference in induction of labour (average RR 0.92, 95% CI 0.85 to 1.00; 14 studies, 17,666 participants; low-certainty evidence), breastfeeding initiation (average RR 1.06, 95% CI 1.00 to 1.12; 8 studies, 8575 participants; low-certainty evidence), and birth weight less than 2500 g (average RR 0.92, 95% CI 0.79 to 1.08; 9 studies, 12,420 participants; low-certainty evidence). We are very uncertain about the effect of midwife continuity of care models compared to other models of care onthird or fourth-degree tear (average RR 1.10, 95% CI 0.81 to 1.49; 7 studies, 9437 participants; very low-certainty evidence), maternal readmission within 28 days (average RR 1.52, 95% CI 0.78 to 2.96; 1 study, 1195 participants; very low-certainty evidence), attendance at birth by a known midwife (average RR 9.13, 95% CI 5.87 to 14.21; 11 studies, 9273 participants; very low-certainty evidence), Apgar score less than or equal to seven at five minutes (average RR 0.95, 95% CI 0.72 to 1.24; 13 studies, 12,806 participants; very low-certainty evidence) andfetal loss before 24 weeks gestation (average RR 0.82, 95% CI 0.67 to 1.01; 12 studies, 15,913 participants; very low-certainty evidence). No maternal deaths were reported across three studies. Although the observed risk of adverse events was similar between midwifery continuity of care models and other models, our confidence in the findings was limited. Our confidence in the findings was lowered by possible risks of bias, inconsistency, and imprecision of some estimates. There were no available data for the outcomes: maternal health status, neonatal readmission within 28 days, infant health status, and birth weight of 4000 g or more. Maternal experiences and cost implications are described narratively. Women receiving care from midwife continuity of care models, as opposed to other care models, generally reported more positive experiences during pregnancy, labour, and postpartum. Cost savings were noted in the antenatal and intrapartum periods in midwife continuity of care models.
AUTHORS' CONCLUSIONS: Women receiving midwife continuity of care models were less likely to experience a caesarean section and instrumental birth, and may be less likely to experience episiotomy. They were more likely to experience spontaneous vaginal birth and report a positive experience. The certainty of some findings varies due to possible risks of bias, inconsistencies, and imprecision of some estimates. Future research should focus on the impact on women with social risk factors, and those at higher risk of complications, and implementation and scaling up of midwife continuity of care models, with emphasis on low- and middle-income countries.
BACKGROUND: Management of breech presentation is controversial, particularly in regard to manipulation of the position of the fetus by external cephalic version (ECV). ECV may reduce the number of breech presentations and caesarean sections, but there also have been reports of complications with the procedure.
OBJECTIVES: The objective of this review was to assess the effects of ECV at or near term on measures of pregnancy outcome. Methods of facilitating ECV, and ECV before term are reviewed separately.
SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Trials Register (28 February 2015) and reference lists of retrieved studies.
SELECTION CRITERIA: Randomised trials of ECV at or near term (with or without tocolysis) compared with no attempt at ECV in women with breech presentation.
DATA COLLECTION AND ANALYSIS: Two review authors assessed eligibility and trial quality, and extracted the data.
MAIN RESULTS: We included eight studies, with a total of 1308 women randomised. The pooled data from these studies show a statistically significant and clinically meaningful reduction in non-cephalic presentation at birth (average risk ratio (RR) 0.42, 95% confidence interval (CI) 0.29 to 0.61, eight trials, 1305 women); vaginal cephalic birth not achieved (average RR 0.46, 95% CI 0.33 to 0.62, seven trials, 1253 women, evidence graded very low); and caesarean section (average RR 0.57, 95% CI 0.40 to 0.82, eight trials, 1305 women, evidence graded very low) when ECV was attempted in comparison to no ECV attempted. There were no significant differences in the incidence of Apgar score ratings below seven at one minute (average RR 0.67, 95% CI 0.32 to 1.37, three trials, 168 infants) or five minutes (RR 0.63, 95% CI 0.29 to 1.36, five trials, 428 infants, evidence graded very low), low umbilical vein pH levels (RR 0.65, 95% CI 0.17 to 2.44, one trial, 52 infants, evidence graded very low), neonatal admission (RR 0.80, 95% CI 0.48 to 1.34, four trials, 368 infants, evidence graded very low), perinatal death (RR 0.39, 95% CI 0.09 to 1.64, eight trials, 1305 infants, evidence graded low), nor time from enrolment to delivery (mean difference -0.25 days, 95% CI -2.81 to 2.31, two trials, 256 women).All of the trials included in this review had design limitations, and the level of evidence was graded low or very low. No studies attempted to blind the intervention, and the process of random allocation was suboptimal in several studies. Three of the eight trials had serious design limitations, however excluding these studies in a sensitivity analysis for outcomes with substantial heterogeneity did not alter the results.
AUTHORS' CONCLUSIONS: Attempting cephalic version at term reduces the chance of non-cephalic presentation at birth, vaginal cephalic birth not achieved and caesarean section. There is not enough evidence from randomised trials to assess complications of ECV at term. Large observational studies suggest that complications are rare.
OBJECTIVES: To systematically assess (i) the effects and safety and (ii) the acceptability of using lay health workers (LHWs) to deliver vaccines and medicines to mothers and children through compact pre-filled autodisable devices (CPADs).
METHODS: We searched electronic databases and grey literature. For the systematic review of effects and safety, we sought randomised and non-randomised controlled trials, controlled before-after studies and interrupted time series studies. For the systematic review of acceptability, we sought qualitative studies. Two researchers independently carried out data extraction, study quality assessment and thematic analysis of the qualitative data.
RESULTS: No studies met our criteria for the review exploring the effects and safety of using LHWs to deliver CPADs. For the acceptability review, six qualitative studies assessed the acceptability of using LHWs to deliver hepatitis B vaccine, tetanus toxoid vaccine, gentamicin or oxytocin using Uniject™ devices. All studies took place in low- or middle-income countries and explored the perceptions of community members, LHWs, supervisors, health professionals or programme managers. Most of the studies were of low quality. Recipients generally accepted the intervention. Most health professionals were confident that LHWs could deliver the intervention with sufficient training and supervision, but some had problems delivering supervision. The LHWs perceived Uniject™ as effective and important and were motivated by positive responses from the community. However, some LHWs feared the consequences if harm should come to recipients.
CONCLUSIONS: Evidence of the effects and safety of using CPADs delivered by LHWs is lacking. Evidence regarding acceptability suggests that this intervention may be acceptable although LHWs may feel vulnerable to blame.
Objective: to synthesise qualitative research on task-shifting to and from midwives to identify barriers and facilitators to successful implementation. Design: systematic review of qualitative evidence using a 4-stage narrative synthesis approach. We searched the CINAHL, Medline and the Social Science Citation Index databases. Study quality was assessed and evidence was synthesised using a theory-informed comparative case-study approach. Setting: midwifery services in any setting in low-, middle-, and high-income countries. Participants: midwives, nurses, doctors, patients, community members, policymakers, programme managers, community health workers, doulas, traditional birth attendants and other stakeholders. Interventions: task shifting to and from midwives. Findings: thirty-seven studies were included. Findings were organised under three broad themes: (1) challenges in defining and defending the midwifery model of care during task shifting, (2) training, supervision and support challenges in midwifery task shifting, and (3) teamwork and task shifting. Key conclusions: this is the first review to report implementation factors associated with midwifery task shifting and optimisation. Though task shifting may serve as a powerful means to address the crisis in human resources for maternal and newborn health, it is also a complex intervention that generally requires careful planning, implementation and ongoing supervision and support to ensure optimal and safe impact. The unique character and history of the midwifery model of care often makes these challenges even greater. Implications for practice: evidence from the review fed into the World Health Organisation's 'Recommendations for Optimizing Health Worker Roles to Improve Access to Key Maternal and Newborn Health Interventions through Task Shifting' guideline. It is appropriate to consider task shifting interventions to ensure wider access to safe midwifery care globally. Legal protections and liabilities and the regulatory framework for task shifting should be designed to accommodate new task shifted practices.
BACKGROUND: Lay health workers (LHWs) perform functions related to healthcare delivery, receive some level of training, but have no formal professional or paraprofessional certificate or tertiary education degree. They provide care for a range of issues, including maternal and child health. For LHW programmes to be effective, we need a better understanding of the factors that influence their success and sustainability. This review addresses these issues through a synthesis of qualitative evidence and was carried out alongside the Cochrane review of the effectiveness of LHWs for maternal and child health.
OBJECTIVES: The overall aim of the review is to explore factors affecting the implementation of LHW programmes for maternal and child health.
SEARCH METHODS: We searched MEDLINE, OvidSP (searched 21 December 2011); MEDLINE Ovid In-Process & Other Non-Indexed Citations, OvidSP (searched 21 December 2011); CINAHL, EBSCO (searched 21 December 2011); British Nursing Index and Archive, OvidSP (searched 13 May 2011). We searched reference lists of included studies, contacted experts in the field, and included studies that were carried out alongside the trials from the LHW effectiveness review.
SELECTION CRITERIA: Studies that used qualitative methods for data collection and analysis and that focused on the experiences and attitudes of stakeholders regarding LHW programmes for maternal or child health in a primary or community healthcare setting.
DATA COLLECTION AND ANALYSIS: We identified barriers and facilitators to LHW programme implementation using the framework thematic synthesis approach. Two review authors independently assessed study quality using a standard tool. We assessed the certainty of the review findings using the CerQual approach, an approach that we developed alongside this and related qualitative syntheses. We integrated our findings with the outcome measures included in the review of LHW programme effectiveness in a logic model. Finally, we identified hypotheses for subgroup analyses in future updates of the review of effectiveness.
MAIN RESULTS: We included 53 studies primarily describing the experiences of LHWs, programme recipients, and other health workers. LHWs in high income countries mainly offered promotion, counselling and support. In low and middle income countries, LHWs offered similar services but sometimes also distributed supplements, contraceptives and other products, and diagnosed and treated children with common childhood diseases. Some LHWs were trained to manage uncomplicated labour and to refer women with pregnancy or labour complications.
Many of the findings were based on studies from multiple settings, but with some methodological limitations. These findings were assessed as being of moderate certainty. Some findings were based on one or two studies and had some methodological limitations. These were assessed have low certainty.
Barriers and facilitators were mainly tied to programme acceptability, appropriateness and credibility; and health system constraints. Programme recipients were generally positive to the programmes, appreciating the LHWs’ skills and the similarities they saw between themselves and the LHWs. However, some recipients were concerned about confidentiality when receiving home visits. Others saw LHW services as not relevant or not sufficient, particularly when LHWs only offered promotional services. LHWs and recipients emphasised the importance of trust, respect, kindness and empathy. However, LHWs sometimes found it difficult to manage emotional relationships and boundaries with recipients. Some LHWs feared blame if care was not successful. Others felt demotivated when their services were not appreciated. Support from health systems and community leaders could give LHWs credibility, at least if the health systems and community leaders had authority and respect. Active support from family members was also important.
Health professionals often appreciated the LHWs’ contributions in reducing their workload and for their communication skills and commitment. However, some health professionals thought that LHWs added to their workload and feared a loss of authority.
LHWs were motivated by factors including altruism, social recognition, knowledge gain and career development. Some unsalaried LHWs wanted regular payment, while others were concerned that payment might threaten their social status or lead recipients to question their motives. Some salaried LHWs were dissatisfied with their pay levels. Others were frustrated when payment differed across regions or institutions. Some LHWs stated that they had few opportunities to voice complaints.
LHWs described insufficient, poor quality, irrelevant and inflexible training programmes, calling for more training in counselling and communication and in topics outside their current role, including common health problems and domestic problems. LHWs and supervisors complained about supervisors’ lack of skills, time and transportation. Some LHWs appreciated the opportunity to share experiences with fellow LHWs.
In some studies, LHWs were traditional birth attendants who had received additional training. Some health professionals were concerned that these LHWs were over-confident about their ability to manage danger signs. LHWs and recipients pointed to other problems, including women’s reluctance to be referred after bad experiences with health professionals, fear of caesarean sections, lack of transport, and cost. Some LHWs were reluctant to refer women on because of poor co-operation with health professionals.
We organised these findings and the outcome measures included in the review of LHW programme effectiveness in a logic model. Here we proposed six chains of events where specific programme components lead to specific intermediate or long-term outcomes, and where specific moderators positively or negatively affect this process. We suggest how future updates of the LHW effectiveness review could explore whether the presence of these components influences programme success.
AUTHORS' CONCLUSIONS: Rather than being seen as a lesser trained health worker, LHWs may represent a different and sometimes preferred type of health worker. The close relationship between LHWs and recipients is a programme strength. However, programme planners must consider how to achieve the benefits of closeness while minimizing the potential drawbacks. Other important facilitators may include the development of services that recipients perceive as relevant; regular and visible support from the health system and the community; and appropriate training, supervision and incentives.
ACHTERGROND: Advance gemeenschap verdeling van misoprostol voor de preventie of behandeling van postpartum bloedingen (PPH) is uitgegroeid tot een aantrekkelijke strategie om uterotonische dekking uit te breiden naar plaatsen waar de conventionele uterotonische gebruik niet mogelijk is. Echter, de waarde en de veiligheid van deze strategie nog steeds omstreden.
Doelstellingen: de effectiviteit en de veiligheid van een strategie van te voren misoprostol distributie voor PPH de preventie en behandeling bij niet-faciliteit geboorten te beoordelen.
Zoekmethoden: We zochten de Cochrane Zwangerschap en Bevalling Group Trials Register (5 oktober 2011). We hebben niet voor elke taal beperkingen.
SELECTIECRITERIA: Gerandomiseerde en quasi-gerandomiseerde gecontroleerde studies vooraf misoprostol distributie naar gezondheidswerkers of zwangere vrouwen lagen in vergelijking met de gebruikelijke zorg voor PPH preventie of behandeling in niet-faciliteit geboorten. We uitgesloten studies zonder enige vorm van willekeurig ontwerp.
Gegevensverzameling en-analyse: Twee recensie auteurs onafhankelijk beoordeeld proces in aanmerking te komen voor opname.
Belangrijkste resultaten: Het zoeken van strategieën heeft drie studies. Geen van de studies voldeden aan de inclusiecriteria.
Auteurs CONCLUSIES: Er is geen bewijs uit gerandomiseerde of quasi-gerandomiseerde studies over de voordelen en risico's van een strategie van te voren misoprostol distributie voor PPH preventie of behandeling bij niet-faciliteit geboorten. In het licht van de toenemende belangstelling op te schalen van deze strategie is er dringend behoefte aan grote en goed ontworpen gerandomiseerde trials om zijn comparatieve voordelen en risico's te evalueren.
ACHTERGROND: Prostaglandines zijn voornamelijk gebruikt voor postpartum bloedingen (PPH), wanneer andere maatregelen falen. Misoprostol, een nieuwe en goedkope prostaglandine E1 analoog, is voorgesteld als alternatief voor dagelijks beheer van de derde fase van de bevalling.
DOELSTELLINGEN: Om de effecten van profylactische prostaglandine gebruik te beoordelen in de derde fase van de arbeid.
Zoekmethoden: We zochten de Cochrane Zwangerschap en Bevalling Groep Trials Register (7 januari 2011). We bijgewerkt deze zoekopdracht op 25 mei 2012 en de resultaten toegevoegd aan de in afwachting van classificatie sectie.
SELECTIECRITERIA: Gerandomiseerde trials vergeleken een prostaglandine-agent met een andere uterotonische of geen profylactische uterotonische (niets of placebo) als onderdeel van het beheer van de derde fase van de arbeid. De primaire resultaten bloedverlies was 1000 ml of meer en het gebruik van aanvullende uterotonics.
Gegevensverzameling en-analyse: Twee beoordeling auteurs onafhankelijk beoordeeld in aanmerking te komen en het proces kwaliteit en opgehaalde gegevens.
BELANGRIJKSTE RESULTATEN: We includeerden 72 studies (52.678 vrouwen). Orale of sublinguale misoprostol in vergelijking met placebo is effectief in het verminderen van ernstige PPH (oraal: zeven trials, 6225 vrouwen, niet totaal als gevolg van significante heterogeniteit; sublinguale: relatief risico (RR) 0,66; 95% betrouwbaarheidsinterval (CI) 0,45 tot 0,98: een proef, 661 vrouwen) en bloedtransfusie (oraal: RR 0,31, 95% CI 0,10 tot 0,94; vier proeven, 3519 vrouwen).
Vergeleken met conventionele injecteerbare uterotonics, werd mondeling misoprostol geassocieerd met een hoger risico op ernstige PPH (1,33 RR; 95% BI 1,16 tot 1,52; 17 trials, 29.797 vrouwen) en het gebruik van extra uterotonics, maar met een trend om minder bloedtransfusies (RR 0,84 ; 95% CI 0,66 tot 1,06, 15 trials, 28.213 vrouwen). Extra uterotonische gegevens werden niet totaal als gevolg van heterogeniteit. Misoprostol gebruik wordt geassocieerd met een aanzienlijke stijging van rillingen en een temperatuur van 38 º Celsius in vergelijking met zowel placebo en andere uterotonics.
AUTEURS 'CONCLUSIES: Mondeling of sublinguale misoprostol geeft veel belovende resultaten in vergelijking met placebo in het verminderen van bloedverlies na de bevalling. De marge van voordeel kan worden beïnvloed door of andere componenten van het beheer van de derde fase van de arbeid of niet worden gebruikt. Als bijwerkingen zijn dosisafhankelijk, moet onderzoek worden gericht tot oprichting van de laagste effectieve dosis voor dagelijks gebruik, en de optimale route van toediening.
Noch intramusculaire prostaglandines, noch misoprostol zijn te verkiezen boven conventionele injecteerbare uterotonics als onderdeel van het beheer van de derde fase van de arbeid in het bijzonder voor laag-risico vrouwen, maar bewijs is bouwen voor het gebruik van orale misoprostol effectief en veilig te zijn in gebieden met een lage toegang tot faciliteiten en ervaren zorgverleners en toekomstig onderzoek op misoprostol gebruik in de gemeenschap moet zich richten op implementatie vraagstukken.
ACHTERGROND: Lay gezondheidswerkers (LHWs) worden veel gebruikt om zorg te verlenen voor een breed scala aan gezondheidsproblemen. Er is weinig bekend, echter, over de effectiviteit van de LGA interventies.
Doelstellingen: de effecten van LGA interventies in het basisonderwijs en de gemeenschap gezondheidszorg op moeder-en kindzorg en het beheer van besmettelijke ziekten te beoordelen.
Zoekstrategie: Voor de huidige versie van dit onderzoek hebben we gezocht De Cochrane Central Register of Controlled Trials (inclusief citaten gedownload van de EPOC en de CCRG registers) (De Cochrane Library 2009, Issue 1 Online) (gezocht 18 February 2009), MEDLINE, Ovidius (1950 tot en met februari week 1 2009) (gezocht 17 februari 2009); MEDLINE In-Process & andere niet-geïndexeerde Citaten, Ovidius (13 februari 2009) (gezocht 17 februari 2009), EMBASE, Ovidius (1980-2009 Week 05 ) (gezocht 18 February 2009), Amed, Ovidius (1985 tot en met februari 2009) (gezocht 19 februari 2009), British Nursing Index en Archief, Ovidius (1985 tot en met februari 2009) (gezocht 17 februari 2009), CINAHL, Ebsco 1981 te presenteren (gezocht 07 februari 2010); POPLINE (gezocht 25 februari 2009); WHOLIS (gezocht 16 april 2009); Science Citation Index en de Social Sciences Citation Index (ISI Web of Science) (1975-heden) (gezocht 10 augustus 2006 en 10 februari 2010). We zochten ook naar de referentielijsten van alle opgenomen documenten en relevante reviews, en studie auteurs en onderzoekers op het gebied gecontacteerd voor bijkomende papieren.
SELECTIECRITERIA: Gerandomiseerde, gecontroleerde studies van elke interventie geleverd door LHWs (betaald of vrijwillig) in primaire of communautaire gezondheids-zorg en bedoeld om de moeder of de gezondheid van kinderen of het beheer van infectieziekten te verbeteren. Een 'lag gezondheid van de werknemers' werd gedefinieerd als elke gezondheidswerker de uitoefening van taken die verband houden met gezondheidszorg, opgeleid in een of andere manier in het kader van de interventie, en die geen formele beroeps-of paraprofessionele certificaat of een tertiaire opleiding. Er waren geen beperkingen op zorgvragers.
Gegevensverzameling en-analyse: Twee recensie auteurs onafhankelijk van elkaar verkregen gegevens met behulp van een standaardformulier en ingeschatte risico van vooringenomenheid. Studies die in grote lijnen dezelfde soorten interventies vergeleken werden gegroepeerd. Waar mogelijk werden de onderzoeksresultaten gecombineerd en een globale raming van het effect bereikt.
Belangrijkste resultaten: Tweeëntachtig studies voldeden aan de inclusiecriteria. Deze toonden een aanzienlijke diversiteit in de doelgerichte gezondheids-probleem en de doelstellingen, inhoud, en de resultaten van interventies. De meeste werden uitgevoerd in rijke landen (n = 55), maar veel van deze gericht op een laag inkomen en minderheden. De diversiteit van de opgenomen studies beperkt meta-analyse om de resultaten voor vier werkgroepen. Deze analyses vonden bewijs van matige kwaliteit van de effectiviteit van LHWs bij het bevorderen van immunisatie jeugd opname (RR 1,22, 95% CI 1,10 tot 1,37, p = 0,0004), het bevorderen van initiatie van borstvoeding (RR = 1,36, 95% CI 1,14 tot 1,61; P <0,00001), alle borstvoeding (RR 1,24, 95% CI 1,10 tot 1,39, p = 0,0004), en exclusieve borstvoeding (RR 2,78, 95% CI 1,74 tot 4,44, P <0,0001), en het verbeteren van longtuberculose genezingspercentages ( RR 1,22 (95% CI 1,13 tot 1,31) P <0,0001), vergeleken met gebruikelijke zorg. Er was een matige kwaliteit bewijs dat LGA ondersteuning weinig of geen effect op de tbc-preventieve behandeling voltooid (RR 1,00, 95% CI 0,92 tot 1,09, P = 0,99) had. Er was ook een lage kwaliteit bewijs dat LHWs kan kind morbiditeit te verminderen (RR 0,86, 95% CI 0,75 tot 0,99, P = 0,03) en kind (RR 0,75, 95% CI 0,55 tot 1,03, P = 0,07) en neonatale (RR 0,76; 95% BI 0,57 tot 1,02, P = 0,07) sterfte en het vergroten van de kans op het inroepen van zorg voor jeugd ziekte (RR 1,33, 95% CI 0,86 tot 2,05; P = 0,20). Voor andere gezondheidsproblemen, het bewijs onvoldoende is om conclusies ten aanzien van effectiviteit te trekken, of tot de identificatie van specifieke LGA training of interventiestrategieën waarschijnlijk het meest effectief mogelijk te maken.
Auteurs CONCLUSIES: LHWs bieden veelbelovende voordelen bij het bevorderen van immunisatie opname en borstvoeding, het verbeteren van tbc-behandeling uitkomsten, en het verminderen van kind morbiditeit en mortaliteit in vergelijking met gebruikelijke zorg. Voor andere gezondheidsproblemen, het bewijs onvoldoende is om conclusies te trekken over de effecten van LHWs te trekken.
Midwives are primary providers of care for childbearing women globally and there is a need to establish whether there are differences in effectiveness between midwife continuity of care models and other models of care. This is an update of a review published in 2016.
OBJECTIVES:
To compare the effects of midwife continuity of care models with other models of care for childbearing women and their infants.
SEARCH METHODS:
We searched the Cochrane Pregnancy and Childbirth Trials Register, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) (17 August 2022), as well as the reference lists of retrieved studies.
SELECTION CRITERIA:
All published and unpublished trials in which pregnant women are randomly allocated to midwife continuity of care models or other models of care during pregnancy and birth.
DATA COLLECTION AND ANALYSIS:
Two authors independently assessed studies for inclusion criteria, scientific integrity, and risk of bias, and carried out data extraction and entry. Primary outcomes were spontaneous vaginal birth, caesarean section, regional anaesthesia, intact perineum, fetal loss after 24 weeks gestation, preterm birth, and neonatal death. We used GRADE to rate the certainty of evidence.
MAIN RESULTS:
We included 17 studies involving 18,533 randomised women. We assessed all studies as being at low risk of scientific integrity/trustworthiness concerns. Studies were conducted in Australia, Canada, China, Ireland, and the United Kingdom. The majority of the included studies did not include women at high risk of complications. There are three ongoing studies targeting disadvantaged women. Primary outcomes Based on control group risks observed in the studies, midwife continuity of care models, as compared to other models of care, likely increase spontaneous vaginal birth from 66% to 70% (risk ratio (RR) 1.05, 95% confidence interval (CI) 1.03 to 1.07; 15 studies, 17,864 participants; moderate-certainty evidence), likelyreduce caesarean sections from 16% to 15% (RR 0.91, 95% CI 0.84 to 0.99; 16 studies, 18,037 participants; moderate-certainty evidence), and likely result in little to no difference in intact perineum (29% in other care models and 31% in midwife continuity of care models, average RR 1.05, 95% CI 0.98 to 1.12; 12 studies, 14,268 participants; moderate-certainty evidence). There may belittle or no difference in preterm birth (< 37 weeks) (6% under both care models, average RR 0.95, 95% CI 0.78 to 1.16; 10 studies, 13,850 participants; low-certainty evidence). We arevery uncertain about the effect of midwife continuity of care models on regional analgesia (average RR 0.85, 95% CI 0.79 to 0.92; 15 studies, 17,754 participants, very low-certainty evidence), fetal loss at or after 24 weeks gestation (average RR 1.24, 95% CI 0.73 to 2.13; 12 studies, 16,122 participants; very low-certainty evidence), and neonatal death (average RR 0.85, 95% CI 0.43 to 1.71; 10 studies, 14,718 participants; very low-certainty evidence). Secondary outcomes When compared to other models of care, midwife continuity of care models likely reduce instrumental vaginal birth (forceps/vacuum) from 14% to 13% (average RR 0.89, 95% CI 0.83 to 0.96; 14 studies, 17,769 participants; moderate-certainty evidence), and may reduceepisiotomy 23% to 19% (average RR 0.83, 95% CI 0.77 to 0.91; 15 studies, 17,839 participants; low-certainty evidence). When compared to other models of care, midwife continuity of care models likelyresult in little to no difference inpostpartum haemorrhage (average RR 0.92, 95% CI 0.82 to 1.03; 11 studies, 14,407 participants; moderate-certainty evidence) and admission to special care nursery/neonatal intensive care unit (average RR 0.89, 95% CI 0.77 to 1.03; 13 studies, 16,260 participants; moderate-certainty evidence). There may be little or no difference in induction of labour (average RR 0.92, 95% CI 0.85 to 1.00; 14 studies, 17,666 participants; low-certainty evidence), breastfeeding initiation (average RR 1.06, 95% CI 1.00 to 1.12; 8 studies, 8575 participants; low-certainty evidence), and birth weight less than 2500 g (average RR 0.92, 95% CI 0.79 to 1.08; 9 studies, 12,420 participants; low-certainty evidence). We are very uncertain about the effect of midwife continuity of care models compared to other models of care onthird or fourth-degree tear (average RR 1.10, 95% CI 0.81 to 1.49; 7 studies, 9437 participants; very low-certainty evidence), maternal readmission within 28 days (average RR 1.52, 95% CI 0.78 to 2.96; 1 study, 1195 participants; very low-certainty evidence), attendance at birth by a known midwife (average RR 9.13, 95% CI 5.87 to 14.21; 11 studies, 9273 participants; very low-certainty evidence), Apgar score less than or equal to seven at five minutes (average RR 0.95, 95% CI 0.72 to 1.24; 13 studies, 12,806 participants; very low-certainty evidence) andfetal loss before 24 weeks gestation (average RR 0.82, 95% CI 0.67 to 1.01; 12 studies, 15,913 participants; very low-certainty evidence). No maternal deaths were reported across three studies. Although the observed risk of adverse events was similar between midwifery continuity of care models and other models, our confidence in the findings was limited. Our confidence in the findings was lowered by possible risks of bias, inconsistency, and imprecision of some estimates. There were no available data for the outcomes: maternal health status, neonatal readmission within 28 days, infant health status, and birth weight of 4000 g or more. Maternal experiences and cost implications are described narratively. Women receiving care from midwife continuity of care models, as opposed to other care models, generally reported more positive experiences during pregnancy, labour, and postpartum. Cost savings were noted in the antenatal and intrapartum periods in midwife continuity of care models.
AUTHORS' CONCLUSIONS:
Women receiving midwife continuity of care models were less likely to experience a caesarean section and instrumental birth, and may be less likely to experience episiotomy. They were more likely to experience spontaneous vaginal birth and report a positive experience. The certainty of some findings varies due to possible risks of bias, inconsistencies, and imprecision of some estimates. Future research should focus on the impact on women with social risk factors, and those at higher risk of complications, and implementation and scaling up of midwife continuity of care models, with emphasis on low- and middle-income countries.
