Midwife-led care is safe in Ireland

Midwives magazine: Issue 1 :: 2012

Paper | Comparison of midwife-led and consultant-led care of healthy women at low risk of childbirth complications in the Republic of Ireland: a randomised trial.
Author | Begley C, Devane D, Clarke M, McCann C, Hughes P, Reilly M, Maguire R, Higgins S, Finan A, Gormally S, Doyle M.
Publication | BMC Pregnancy and Childbirth 2011; 11: 85.


In Ireland, maternity care is predominantly hospital based and consultant led; no midwifery-led units existed before 2004. The aim of this study was to compare care within midwife-led units (MLU) with care in consultant-led units (CLU) for healthy pregnant women without risk factors for labour and delivery. In Our Lady of Lourdes Hospital in Drogheda (3200 births per year) and Cavan General Hospital (1300 births per year), midwifery units were constructed, both housed within their parent hospital, close to the main labour ward. A total of 12 midwives were employed in Drogheda and seven in Cavan.

This randomised trial was conducted between July 2004 and June 2007; women randomised to CLU received standard care from midwives, overseen by consultants. Those randomised to MLU received midwife-led care provided by the same small group of midwives throughout pregnancy, birth and into the postnatal period. Antenatal care, together with assessment, was provided by midwives in the unit or in an outreach clinic, and included the GP, if desired. Where complications occurred, women were transferred to the CLU, based on agreed criteria. On discharge, MLU midwives visited women at home and/or provided telephone support, up to the seventh postnatal day, when care was transferred to the Public Health Nursing Service.

In the main study, following a pilot study, 1101 women were randomised to the MLU and 552 to the CLU. Baseline characteristics were similar. Data for five MLU women (0.5%) and three CLU women (0.5%) were incomplete because they moved house during pregnancy. A total of 24 women (2.2%) randomised to the MLU changed their minds and requested CLU care. Two women randomised to CLU opted for home births. The most common reason for women to transfer from MLU to CLU in the antenatal period was for induction of labour, followed by fetal assessment. During labour, the most common reasons for transfer were slow progress and meconium-stained amniotic fluid.

There were seven maternal and neonatal outcomes measured: caesarean birth; induction of labour; episiotomy; instrumental birth; Apgar score; postpartum haemorrhage and breastfeeding initiation. MLU women were significantly less likely to receive electronic fetal monitoring or have labour augmented by amniotomy or with oxytocin. Cord clamping was not part of the protocol of care in MLUs because it would have excluded expectant third stage management, so cord blood pH measurement could not be undertaken. Care in the MLUs was provided by the full team of midwives, so women did not necessarily have the degree of continuity of care that might be expected from caseload models of midwife-led care.

No statistically significant difference was found between the MLU and CLU in the seven key outcomes and the authors conclude that midwife-led care, as practised in their study, is as safe as consultant-led care. They consider that the strength of the study lies in its size. A great advantage is that less intervention occurred during labour and birth in the MLUs. 


Overview

MLUs and CLUs when compared, using seven key maternal and neonatal outcomes, revealed no significant differences.

Less intervention occurred in the midwife-led care.