Urgent reform needed to make midwife-led maternity care more accessible

Picture by Anna Zhu

Picture by Anna Zhu

In summary: 
  • High-level evidence shows women are better off physically and psychologically with access to the same midwife through pregnancy, birth and the postnatal period
  • Writing in the Medical Journal of Australia, UTS's Professor Caroline Homer has advocated urgent reform to deliver a better experience for more women and a better use of 21st-century midwifery education

Maternity services in Australia are in urgent need of reform to deliver a better experience for more women and a better use of 21st-century midwifery education.

High-level evidence shows women are better off physically and psychologically with access to the same midwife through pregnancy, birth and the postnatal period, said Professor Caroline Homer, from the Centre for Midwifery, Child and Family Health at UTS. Yet barely one in 10 Australian women has access to such a model of care.

At the same time, new midwives are trained in the theory and practice of such care but rarely go into a job that uses those skills.

Writing in the Medical Journal of Australia, Professor Homer said: "Midwifery continuity-of-care programs can no longer be implemented in piecemeal ways for a small proportion of women or as a pilot program – the evidence and the demand are now so strong that widespread reform is needed."

Professor Homer examined several studies, conducted over almost two decades, to determine clinical outcomes, the views of women and midwives and health service costs for maternity models that provide midwifery continuity of care.

A Cochrane Review of 15 trials (seven conducted in Australia) involving more than 17,000 mothers and their babies produced findings that showed benefits with no adverse effects.  Women who received midwife-led continuity of care were more likely to have a midwife they knew with them during labour and birth, more likely to have a spontaneous vaginal birth and less likely to had epidural analgesia, episiotomies or births involving instruments.

Other studies showed benefits for specific groups of women, such as Aboriginal and Torres Strait Islander women, including lower rates of perinatal mortality and preterm birth and higher birth weights of infants.

Professor Homer, an international midwifery leader who has led research into innovative models of midwifery care, said the impact of continuity-of-care models came from the development of relationships of trust.

Picture by Anna Zhu Picture by Anna Zhu

"This is not alternative anymore – this is mainstream care and something that all public health services should be providing," she said.

However, continuity of care under a midwife is still a niche offering in Australia – about 300,000 babies are born each year yet the model is available to only 8 per cent of women.

"If we had a drug that made a difference, from a systematic review of 15 trials, but we only gave it to 8 per cent of people who could benefit from it, wouldn't that be a problem? Because it's a model of care, it's seen as OK not to provide because it's too hard and requires organisational change," she said.

Midwifery continuity of care is usually provided in a "caseload model", delivered by a small group midwives who are on call to provide care for women during labour and birth, often with arranged times for antenatal and postnatal care. Some models are based in birth centres while others use a hospital labour ward.

Professor Homer said research showed caseload midwives had lower burnout scores and higher professional satisfaction than midwives working to standard rosters.

"At UTS, as in all universities, we educate midwives to provide continuity of care – students have to follow women through pregnancy, labour and birth and the postnatal period," said Professor Homer.

"Our midwives finish wanting to work in that way and then we send them out to work in the same old fragmented way."

Professor Homer said midwifery continuity-of-care is all about relationship building and trust.

"We all like continuity. I go to the same coffee shop every morning. I go to the same GP, the same hairdresser. We all like that people might remember us, that they have our record, that we don't have to start from scratch every time we see them.

"So why would we think it's OK that a woman in the most vulnerable moment of her life has a lot of strangers looking after her and wandering in and out of the labour ward? No. That's nonsense."

Professor Homer said reform of the system required "everybody to think differently and to trust each other differently – for doctors to respect that midwives know what they're doing and for midwives to work together effectively."

Models of Maternity Care: Evidence for midwifery continuity of care, by Professor Caroline Homer, is published in a special women's health edition of the Medical Journal of Australia.