definition of case study in midwifery

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Case Study: History Taking

Jenna Robertson, MA, RM

You are meeting Edie for her history and physical appointment. She arrives to the appointment alone. She is a 32 year-old G1P0 and she presents as a cisgender, femme woman. The first section of the Ontario Perinatal Record asks for information about the pregnant person’s partner.

How can you greet Edie and ask her questions about her partner in a way that is in inclusive of 2SLGBTQI folks and also acknowledges that not every pregnant person has a partner?

“Hi Edie, welcome to our clinic. I’m going to be asking you a lot of questions today as we go through your history. Can I start by asking if you have a partner in this pregnancy?”

By asking “do you have a partner” instead of “what is your partner’s name,” the midwife is leaving space for clients who are un-partnered during pregnancy.

Edie answers that yes she has a partner.

How do you ask questions about Edie’s partner without making any assumptions about the partner’s gender?

“What is their name?” Using they/their pronouns to ask about a client’s partner until the client has identified the gender of their partner allows space for the client to name their partner’s gender without asking direct questions. Once the client names their partner, the midwife can refer to the partner by name only, avoiding pronouns until the client names the partner’s gender.

Once the client names her partner’s gender the midwife can mirror the language the client is using to refer to her partner. Asking follow-up questions about other partners can start to open the conversation toward sexual orientation and also avoids assumptions that pregnant people are monogamous and acknowledges the existence of poly relationships.

Sexual Orientation: The new version of the Ontario Perinatal Record (OPR) has space to ask about sexual orientation. Learning about a client’s sexual orientation is important in addition to gaining information about the client’s current partner. Many queer or bi women present in pregnancy in relationships with cis men. Without careful history taking their queer identity may be erased during their time in midwifery care. This erasure may lead to feelings of anxiety or depression. Midwives should avoid the assumption that clients are heterosexual, even when they present to care in heterosexual relationships. Questions like “is Viviane your only sexual partner at this time?” and follow-up questions about sexual history like, “Do you know what the term ‘sexual orientation’ means?” “Can you tell me about how you identify your sexual orientation?” “Can you tell me if you have had sexual relationships with men, women, or both?” can help the midwife to establish an accurate sexual history. Note that many people will identify as straight when asked even if they have had/are having same-sex relationships, so asking varied questions, and asking specifically about sexual history and not just sexual orientation is important.

Gender Identity: Unfortunately neither the new nor the old OPR has space for noting the gender identity of clients or their partner(s). However, midwives can be attentive to using gender-neutral language, mimicking the language and pronouns used by clients and their partners, and asking direct questions about gender identity. Midwives should avoid the assumption that midwifery clients and their partners are cisgender.

How can you ask questions about how the pregnancy was conceived without making any assumptions about the origin of the gametes?

Questions like: “Did you use any fertility treatments to conceive this pregnancy,” can get the conversation started for 2SLGBTQI clients and for straight clients alike, but if no fertility treatments were used then the midwife will need to keep asking open-ended questions in order to elicit a complete history.

External Link

Families are coming to midwifery clinics in all kinds of shapes and sizes. Midwives in Ontario should be familiar with the Bill 137, also known as “Cy & Ruby’s Law”:  http://www.ontla.on.ca/web/bills/bills_detail.do?locale=en&BillID=3554

Midwives should avoid assumptions about the gender of the people sitting in their clinic rooms and even avoid assumptions about which partner is the pregnant client. A couple may present as a straight, cis appearing couple, but the couple may include a trans man who is the pregnant client and not his cis, female partner. History taking that uses inclusive, open-ended language benefits all clients (cis & trans, queer and straight) because an open-ended approach to history taking leaves space for all clients to honestly share their stories so that as care providers, midwives get the most complete and most accurate information and also begin to build trust with clients from the first clinical encounter.

Case Study: History Taking Copyright © 2017 by Jenna Robertson, MA, RM is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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• Maternal Health Unit

Midwifery education and care

• Stillbirth prevention
• Service delivery with quality
• Maternal and perinatal death surveillance and response
• Maternal morbidity and well-being 

Midwifery is defined as “skilled, knowledgeable and compassionate care for childbearing women, newborn infants and families across the continuum from prepregnancy, pregnancy, birth, postpartum and the early weeks of life”. The evidence shows us that midwifery plays a “vital” role, and when provided by educated, trained, regulated, licensed midwives, is associated with improved quality of care and rapid and sustained reductions in maternal and newborn mortality.

All women and newborns have a right to a quality of care that enables a positive childbirth experience that includes respect and dignity, a companion of choice, clear communication by maternity staff, pain relief strategies, mobility in labour and birth position of choice. Midwives are essential to the provision of quality of care, in all settings, globally.

Midwifery education and quality of care

The evidence is clear. Strengthening midwifery education to international standards is a key step to improving quality of care and reducing maternal and newborn mortality and morbidity. The Framework for Action to Strengthen Midwifery Education is a guide to develop high-quality, sustainable pre- and in-service education to save lives. It has been developed by WHO, UNFPA, UNICEF and ICM and includes a seven-step action plan for use by all stakeholders in maternal and newborn health.

Midwifery education is a key solution to the challenge of providing universal and quality maternal and newborn care to meet our Sustainable Development Goals. While improving access to care is critical, ensuring good quality of care has an even greater impact in terms of lives saved. WHO, ICM, UNFPA and UNICEF are finalising a report and action plan for strengthening quality midwifery education to be released at the World Health Assembly, 20-28 May 2019.

Developing leadership in global midwifery

WHO is working hard to provide a solution is to transform midwifery education through the first global, in-service, evidence based interprofessional Midwifery Education Tool kit.  This tool kit brings together maternal, newborn, sexual, reproductive and mental health for life-long learning in compassionate midwifery care, including during pandemics and for use in fragile and humanitarian settings.  Focused on a midwifery model of continuity of care, putting women, newborns and their families at the center, this toolkit provides midwives with all the training required to care for healthy women and their newborns,  prevent unnecessary interventions, while ensuring lifesaving actions and enable health professionals to work effectively in a multi-disciplinary team.

Midwifery education is designed to address three strategic priorities:

• All midwives should be educated to high standards and enabled to practise to their full scope
• Midwives should be involved in education policy at the highest level
• Education processes should be coordinated and aligned

The case for midwifery

Who is a midwife?

A midwife is a person who, having been regularly admitted to a midwifery educational programme, duly recognized in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery. (ICM 2005)

maternal / neonatal

outcomes were found to be improved through midwifery practice and philosophy of care

of services can be provided by midwives, when educated to international standards

of all maternal deaths, stillbirth and newborn deaths could be averted with quality midwifery care

of reproductive age have their need for family planning met with a modern method

of pregnant women (in 75 countries with data since 2009) had at least 4 antenatal care visits

women who died of maternal causes in 2020

effective practices

within the scope of midwifery show the importance of optimizing the normal processes of childbirth

of nurses and midwives comprise nearly 50% of the world’s health workforce

all maternal deaths

occur in low and lower middle-income countries

approximately, die every day from preventable causes related to pregnancy and childbirth

Who is a skilled birth attendant?

Skilled health personnel, as referenced by SDG indicator 3.1.2, are competent maternal and newborn health (MNH) professionals educated, trained and regulated to national and international standards. They are competent to: (i) provide and promote evidence-based, human-rights based, quality, socioculturally sensitive and dignified care to women and newborns; (ii) facilitate physiological processes during labour and delivery to ensure a clean and positive childbirth experience; and (iii) identify and manage or refer women and/or newborns with complications. In addition, as part of an integrated team of MNH professionals (including midwives, nurses, obstetricians, paediatricians and anaesthetists), they perform all signal functions of emergency maternal and newborn care to optimize the health and well-being of women and newborns. Within an enabling environment, midwives trained to International Confederation of Midwives (ICM) standards can provide nearly all of the essential care needed for women and newborns. (In different countries, these competencies are held by professionals with varying occupational titles.) Reference: WHO, UNFPA, UNICEF, ICM, ICN, FIGO and IPA 2018

Key messages

When midwives are educated to international standards, and midwifery includes the provision of family planning, it  could avert more than 80% of all maternal deaths, stillbirths and neonatal deaths.  Achieving this impact also requires that midwives are licensed, regulated, fully integrated into health systems and working in interprofessional teams.

Beyond preventing maternal and newborn deaths,  quality midwifery care improves over 50 other health-related outcomes , including in sexual and reproductive health, immunization, breastfeeding, tobacco cessation in pregnancy, malaria, TB, HIV and obesity in pregnancy, early childhood development and postpartum depression.

Midwives are uniquely able to provide essential services to women and newborns in even the most difficult humanitarian, fragile and conflict-affected settings.  This means that midwives will make a significant contribution to delivering on the commitments made in the Astana Declaration on Primary Health Care and the Global Action Plan on Healthy Lives and Well-Being.

Educating midwives to international standards is a cost-effective investment  as it saves resources by reducing costly and unnecessary interventions

Yet there is a  startling lack of investment in quality midwifery education , despite the evidence of impact. Now is the time to take collective action.

Midwives can provide about 90% of the SRMNAH care needed, but they account for less than 10% of the global SRMNAH workforce. The world needs 900,000 more midwives. By 2030, the midwife shortage will be smaller ( 750,000 ), but there will still be a major gap between the number required and the workforce available in midwifery.

The gap between low-income countries and high- and middle-income countries is projected to widen by 2030, increasing inequality. To close the gap by 2030, 1.3 million new DSE worker posts (mostly midwives and mostly in Africa) need to be created in the next 10 years.

WHO is working on each of the 4 priority areas to strengthen the quality and quantity of midwives globally. The most recent resolution, WHA 64.7, gives WHO the mandate to develop and strengthen strategies such as: capacity of nursing and midwifery workforce through the provision of support to Member States on developing targets, action plans and forging strong interdisciplinary health teams as well as strengthening the dataset on nursing and midwifery.

Related links

Publications and resources

Interprofessional midwifery education toolkit

Essential Childbirth Care Course Module 1. Introduction - Facilitator's Guide

The Essential Childbirth Care Course (ECBC) is focused on the midwifery model of care, which puts women, newborns and their families at the center, ensures...

Key publications

Standards for improving the quality of care for small and sick newborns in health facilities

The standards for the care of small and sick newborns in health facilities define, standardize and mainstream inpatient care of small and sick newborns,...

Strengthening quality midwifery education for Universal Health Coverage 2030: Framework for action

The Framework for Action to Strengthen Midwifery Education is a guide to develop high-quality, sustainable pre- and in-service midwifery education...

Standards for improving quality of maternal and newborn care in health facilities

Much progress has been made during the past two decades in coverage of births in health facilities; however, reductions in maternal and neonatal mortality...

Midwifery toolkit and education modules

Strengthening midwifery toolkit

The midwife in the community Midwifery education module 1 (foundation module)

 The module begins with the story of Mrs X which shows how certain social, economic and cultural factors, combined with delays in seeking and obtaining...

The midwife in the community Midwifery education module 2

In order that students may fully understand how postpartum haemorrhage occurs, this module begins with a detailed explanation of the physiology and management...

Managing prolonged and obstructed labour Midwifery education module 3

This module begins with a review of the anatomy and physiology relevant to the management of prolonged and obstructed labour. On the basis of this, the...

Managing puerperal sepsis Midwifery education module 4

This module begins with an explanation of the problem of puerperal sepsis. The content then covers the factors which contribute to the infection, how it...

Managing eclampsia Midwifery education module 5

This module begins with an explanation of the conditions pre-eclampsia and eclampsia. The content then covers the factors which contribute to eclampsia,...

Managing incomplete abortion Midwifery education module 6

This module begins with an explanation of abortion, including the types of abortion, the effect of abortion on maternal mortality and morbidity, the prevention...

Related activities

Strengthening health systems and communities

Raising the importance of postnatal care

Making childbirth a positive experience

Promoting healthy pregnancy

Strengthening quality midwifery for all mothers and newborns

Related health topics

Maternal health

Newborn health

Nursing and midwifery

• Latest hearings

Practice environment case studies for midwifery programmes

We've set out some example case studies and further information on how midwifery students can demonstrate their proficiency in a range of clinical scenarios. 

We’ll update this with examples in different practice environments.

The following case studies are example scenarios based on people’s real experiences for the purpose of learning. All names are fictional.

Examples by practice environment

Continuity of care and carer, additional care for women and newborns with complications.

• Last updated: 23/01/2024

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Open Access

Peer-reviewed

Research Article

Midwifery continuity of care: A scoping review of where, how, by whom and for whom?

Roles Data curation, Formal analysis, Methodology, Project administration, Validation, Writing – original draft, Writing – review & editing

Affiliations Maternal, Child, and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia, Mater Research, University of Queensland, Brisbane, Queensland, Australia

Roles Data curation, Formal analysis, Validation, Writing – review & editing

Affiliations Maternal, Child, and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia

Roles Conceptualization, Funding acquisition, Methodology, Supervision, Validation, Writing – review & editing

Affiliation Department of Maternal, Newborn, Child, and Adolescent Health, World Health Organisation, Geneva, Switzerland

Roles Conceptualization, Funding acquisition, Methodology, Writing – review & editing

Roles Formal analysis, Methodology, Validation, Writing – review & editing

Affiliation Department of Women and Children’s Health, Kings College London, London, United Kingdom

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Validation, Writing – review & editing

* E-mail: [email protected]

Affiliation Maternal, Child, and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia

• Billie F. Bradford, 
• Alyce N. Wilson, 
• Anayda Portela, 
• Fran McConville, 
• Cristina Fernandez Turienzo, 
• Caroline S. E. Homer

• Published: October 5, 2022
• https://doi.org/10.1371/journal.pgph.0000935
• Peer Review
• Reader Comments

Systems of care that provide midwifery care and services through a continuity of care model have positive health outcomes for women and newborns. We conducted a scoping review to understand the global implementation of these models, asking the questions: where, how, by whom and for whom are midwifery continuity of care models implemented? Using a scoping review framework, we searched electronic and grey literature databases for reports in any language between January 2012 and January 2022, which described current and recent trials, implementation or scaling-up of midwifery continuity of care studies or initiatives in high-, middle- and low-income countries. After screening, 175 reports were included, the majority (157, 90%) from high-income countries (HICs) and fewer (18, 10%) from low- to middle-income countries (LMICs). There were 163 unique studies including eight (4.9%) randomised or quasi-randomised trials, 58 (38.5%) qualitative, 53 (32.7%) quantitative (cohort, cross sectional, descriptive, observational), 31 (19.0%) survey studies, and three (1.9%) health economics analyses. There were 10 practice-based accounts that did not include research. Midwives led almost all continuity of care models. In HICs, the most dominant model was where small groups of midwives provided care for designated women, across the antenatal, childbirth and postnatal care continuum. This was mostly known as caseload midwifery or midwifery group practice. There was more diversity of models in low- to middle-income countries. Of the 175 initiatives described, 31 (18%) were implemented for women, newborns and families from priority or vulnerable communities. With the exception of New Zealand, no countries have managed to scale-up continuity of midwifery care at a national level. Further implementation studies are needed to support countries planning to transition to midwifery continuity of care models in all countries to determine optimal model types and strategies to achieve sustainable scale-up at a national level.

Citation: Bradford BF, Wilson AN, Portela A, McConville F, Fernandez Turienzo C, Homer CSE (2022) Midwifery continuity of care: A scoping review of where, how, by whom and for whom? PLOS Glob Public Health 2(10): e0000935. https://doi.org/10.1371/journal.pgph.0000935

Editor: Ahmed Waqas, University of Liverpool, UNITED KINGDOM

Received: June 3, 2022; Accepted: September 5, 2022; Published: October 5, 2022

Copyright: © 2022 Bradford et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All data are in the Supporting information files.

Funding: This review was commissioned by the World Health Organization Department of Maternal, Newborn, Child and Adolescent Health and Ageing and funded through a grant received from Merck Sharp and Dohme Corp (MSD). CFT is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South London, a NIHR Global Health Research Group (NIHR133232) and a NIHR Development and Skills Award (NIHR301603). CSEH is supported by an Australian National Health and Medical Research Council Fellowship (APP1137745). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Continuity of care is a concept rooted in primary care involving the care of individuals (rather than populations) over time by the same care provider. It encompasses relational continuity, informational continuity and management continuity [ 1 ]. In the primary care setting, continuity of care has been shown to reduce mortality and hospitalisations, and increase patient satisfaction [ 2 ]. Continuity of care also has an important place in chronic care settings, such as palliative care [ 3 ].

In the maternal and newborn care setting, midwife-led continuity of care refers to a model whereby care is provided by the same midwife, or small team of midwives, during pregnancy, labour and birth, and the postnatal periods with referral to specialist care as needed [ 4 ]. Midwife-led also refers to a model of care which is provided there is a distinct occupational group of midwives [ 5 ] and the person is fully qualified, regulated and deployed only as a midwife. This contrasts to systems in many countries (most countries in Africa for and South East Asia for example) where nurse-midwives are rotated to either nursing or midwifery duties. Midwife-led continuity models in a small number of HICs have been associated with lower rates of preterm birth (24% reduction), and lower fetal loss before and after 24 weeks and neonatal deaths (16%) less likely to lose their babies overall (combined reduction in fetal loss and neonatal death) for women at low and mixed risk of complications compared to other models of care. In addition, women are less likely to experience interventions and more likely to report positive experiences of care [ 4 ]. A Cochrane review of reviews of interventions during pregnancy to prevent preterm birth also found that these models had clear benefit in reducing preterm birth and perinatal death [ 6 ]. Women prefer the personalised experience provided by such models, leading to trust between midwife and woman and empowerment of both women and midwives [ 7 ].

Models of care that provide continuity across the childbearing continuum are complex interventions, and the pathway of influence that produces these positive outcomes is unclear. A number of plausible hypotheses require further investigation. For example, it could be that midwives provide a mechanism that enables effective and equitable care to be provided by better coordination, navigation and referral; and/or that relational continuity and advocacy engenders trust and confidence between women and midwives, resulting in women feeling safer, less stressed and more respected [ 4 ]. Access to organisational infrastructure, innovative partnerships, and robust community networks has been found crucial to overcome barriers, address women’s, newborns’ and parents’ needs and ensure quality of care [ 8 ].

Inequity is a key driver of adverse perinatal outcome, both between and within countries. Some observational studies of midwife-led continuity of care models in socially and economically disadvantaged populations in high-income countries (HIC) have reported significant reductions in pre-term birth and caesarean sections in diverse cohorts of women in the United Kingdom [ 9 – 12 ]. In Australia, a study of maternity care during significant floods in Queensland showed that midwife-led continuity of care mitigated the social and emotional impacts of the floods [ 13 ]. Another Australian study showed reduced preterm births amongst Australian Aboriginal and Torres Strait Islander women who received midwife-led continuity of care [ 14 ]. These studies suggest that women who typically experience a greater burden of adverse perinatal outcome, may derive greater benefit from continuity of care. However, understanding how continuity per se may mitigate inequities in maternal and newborn health remains a research priority.

Despite evidence supporting midwife-led continuity of care and guidelines from the World Health Organization which recommend midwife-led continuity-of-care models for pregnant women in settings with well-functioning midwifery programmes [ 15 – 17 ] only a small proportion of women internationally have access to such care. The current evidence suggests that access to midwife-led continuity of care models is largely confined to a small number of HICs notably Australia, Canada, New Zealand and the United Kingdom [ 17 ] where a distinct occupational group of midwives has been a central part of the health systems for decades. Barriers to implementation of midwifery-led continuity of care exist across all country income levels and include a lack of local health system financing, shortage of personnel including administrative and other support staff [ 4 ]. It is not clear to what extent midwife-led continuity of care has been implemented in low- to middle-income countries (LMIC). Many LMICs have a model of predominantly nurse-midwives who are deployed to both nursing and midwifery duties, often preventing midwife-led continuity of care models. Advancing understanding around which countries have implemented continuity of care models for maternal and newborn health, how, for whom, and in what context, is crucial for successful implementation, scale-up and sustainability.

The overall aim of this review was to understand the global implementation of midwifery continuity of care, asking the questions: Where, how, by whom and for whom are midwifery continuity of care initiatives implemented?

Materials and methods

A scoping review was undertaken guided by the approach described by Arksey and O’Malley [ 18 ] and further defined by Levac and colleagues [ 19 ]. The following five steps were followed: i) identifying the research question; ii) identifying the relevant literature; iii) study selection, iv) charting the data; and v) collating, summarising and reporting the results.

We used the broad definition of midwifery from The Lancet Series on Midwifery as our starting point, that is, “skilled, knowledgeable, and compassionate care for childbearing women, newborn infants and families across the continuum from pre-pregnancy, pregnancy, birth, postpartum and the early weeks of life [ 20 ]. Midwifery continuity of care was defined as care delivered by the same known care provider or care provider team across two or more parts in the care continuum–antenatal, intrapartum, postnatal and neonatal periods. In some settings, continuity of care may be provided by cadre other than midwives, for example, nurses or physicians. Thus, eligible papers could include care providers that were midwives and non-midwives, such as, nurses, community health workers and physicians. We excluded reports on care primarily by traditional birth attendants (TBA).

Identifying the relevant literature—Search strategy and selection criteria

In order to develop the search strategy, a preliminary search of PubMed and Google scholar using the terms ‘midwifery or midwife-led continuity of care’ were used to locate key systematic and scoping reviews on the topic and identify relevant search terms for the systematic search strategy (see S1 Text for the search strategy). We then searched the following electronic databases: MEDLINE, CENTRAL, CINAHL, PsychINFO and Web of Science. A subject librarian reviewed search terms, keywords and strategies. In addition, we searched PubMed, Google Scholar, PROSPERO, Scopus and Dimensions and the WHO International Clinical Trials Registry platform. We conducted the search on the 20 February 2022 and included publications (peer reviewed studies and reports) in the past 10 years.

A key area of interest was implementation of continuity of midwifery care in LMICs but we recognised that reports of implementation may be published in formats other than peer reviewed publications. Eligible papers therefore included implementation studies or reports of implementation of midwifery continuity of care in the grey literature. We sourced grey literature through online searches on the websites of relevant professional groups, United Nations agencies and non-government organisations (NGO). We circulated a call for relevant materials through online list servs (email groups) and through midwifery contacts. The International Confederation of Midwives assisted by emailing all member associations asking for any relevant reports.

Eligible reports could report on midwifery continuity of care efforts in HICs and LMICs. Reports from implementation efforts by government programmes, private providers, professional organisations, NGOs and universities and research studies of any design were eligible for inclusion. Protocols that reported studies that were underway, but not concluded, were also eligible. Opinion pieces, editorials and other materials, which included details of midwifery continuity of care initiatives, were also eligible. Publications in any language were eligible. The search was limited to reports published in the last ten years (January 2012 to January 2022) to ensure the information was contemporary and therefore of greatest relevance to policy makers.

Reports identified through both peer-reviewed and grey literature databases were hand-searched for other potentially relevant studies. These included reference lists of relevant systematic reviews, and published conference abstracts, as well as any reports forwarded to authors in response to a call for notification of new or ongoing initiatives from key global stakeholder organisations, such as the International Confederation of Midwives.

Reports were excluded they if reported on midwifery continuity of care in general but did not report on a continuity of care practice initiative. We excluded systematic and literature reviews although their reference lists were searched for relevant primary studies.

Study selection

All reports identified through database searching were imported into Endnote referencing programme (Endnote 20, Clarivate Analytics, Philadelphia), and duplicates removed. Remaining citations (n = 5789) were uploaded into systematic review software Covidence (Covidence 2022, Veritas Health Innovations, Melbourne). Two authors independently conducted initial title and abstract screening and undertook full-text review. A third author screened a random selection of 10% of studies and discrepancies were discussed and resolved.

Charting the data

The following information was extracted for all included reports: country, income-level (as defined by the World Bank [ 21 ], study design (if applicable), setting (urban/rural and community-based or facility-based), novel or scaled-up initiative, model of care, level of continuity (antenatal and intrapartum, antenatal and postnatal, intrapartum and postnatal) and cadre of care providers, (e.g. mix of providers involved). We also collected information on the inclusion of priority population groups–these are groups of people who are persistently disadvantaged by existing systems of power with demographic features known to be associated with adverse perinatal outcomes, such as ethnic minorities, urban and remote women, socially disadvantaged, and Indigenous women. We have described these specific groups as priority rather than vulnerable populations [ 22 ]. Reporting of the scoping review findings follows the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) format (see S1 Checklist ) and reference ( Fig 1 ) [ 23 ]. Appraisal of study quality or meta-analysis was not undertaken.

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https://doi.org/10.1371/journal.pgph.0000935.g001

In total, 6595 references were identified from electronic peer-reviewed databases, 821 duplicate records were removed prior to uploading to Covidence, a further 634 duplicates were removed by automation. Of the 5136 remaining references, 4728 did not meet the inclusion criteria. A further 256 references were excluded at the full-text stage as either: they did not describe continuity of care according to our pre-determined criteria (167); did not include primary source data (42); were duplicates (41); or did not have insufficient detail regarding the model of care (6). One hundred and fifty-two (152) peer-reviewed publications were eligible based on inclusion and exclusion criteria. A further 23 reports were identified following the grey literature search, bringing the total to 175 ( Fig 1 ). Details are listed in S1 Table .

Of the 175 individual reports, 152 (86.8%) were peer reviewed publications, 18 (10.3%) were conference abstracts, and the remaining five (3%) were published or unpublished reports. Reports primarily reported on birth outcomes (n = 54, 31%), women’s (including some partners’) views and experiences (n = 47, 27%) and midwives (including doctors) views and experiences (n = 33, 19%). There were 18 reporting on the model of care more broadly, including implementation challenges (n = 18, 10%), and 14 (7%) that were focussed on the experience of midwifery students providing continuity of care as part of their education. The majority of these student-focused reports were from Australia. Fewer reports focussed on the experience of midwifery managers (n = 3, 2%), while four were cost analyses (2%).

There were 163 unique studies including eight (4.9%) randomised or quasi randomised trials, 58 (38.5%) qualitative, 53 (32.7%) quantitative (cohort, cross sectional, descriptive, observational), 31 (19.0%) survey studies, and three (1.9%) health economics analyses. There were 10 practice-based accounts that did not include research.

‘The where’: Country and setting

Of the 175 included reports, the majority (n = 157, 90%) were from HICs and 18 (10%) from LMICs ( Table 1 ). Most were from Australia, (n = 71, 41%), followed by the United Kingdom (England, Scotland, Wales) (24, 14%), Sweden (13, 8%), Canada (8, 5%), Denmark (6, 4%), New Zealand (7, 4%), Japan (5, 3%), with less than five reports described initiatives conducted in Belgium, Finland, Germany, Greece, Ireland, Netherlands, Norway, Singapore, Switzerland and the United States of America (USA). In the LMICs, three from Palestine, three from China, two each from Bangladesh and Indonesia, and one from each of the remaining countries.

https://doi.org/10.1371/journal.pgph.0000935.t001

Overall, most midwifery continuity of care models were based in urban areas (n = 126, 72%). In HIC, three-quarters of services (n = 118, 75%) were urban-based, whereas in LMICs just under half (n = 8, 44%) were urban-based. Hospital or facility-based services were most common across all income levels (n = 124, 72% overall).

‘The how’: Describing the way continuity of care is provided

There were a number of different terms used to define the model of care, and the level of continuity provided across the continuum of care varied with no single term used. Overall, the most common terms were caseload midwifery (n = 63, 36%), midwifery-led continuity (n = 60, 34%), or team/midwifery group practice (n = 40, 23%). Most described services designed so that the same providers provided care across the continuum–antenatal, intrapartum and postnatal (n = 159, 91%). There were eight which described continuity only across the antenatal and postpartum periods [ 24 – 31 ] (excluding labour and birth), and five reported [ 32 – 36 ] (including 3 unique examples) where the continuity was provided only across antenatal and intrapartum periods without postpartum care.

In HICs, the most dominant approach is where small groups of midwives provide care for designated women, known as caseload midwifery or midwifery group practice in countries like Australia [ 37 ], the United Kingdom [ 9 ], Denmark [ 38 ], Sweden [ 39 ], and Singapore [ 40 ] where the number of midwives is usually two to four. In other countries, for example, Japan [ 41 ] and Switzerland [ 42 ], the approach is also called team midwifery and the number of midwives is five or more.

The continuity of care services were located as part of the usual hospital [ 37 , 43 ], in an alongside birth centre [ 44 – 46 ] or in a free-standing birth centre [ 47 ]. Some midwife-led continuity of care services were offered through homebirth practices, either as part of the hospital system [ 48 , 49 ] or as a private service [ 50 ]. Most services were based in urban areas but there were some examples from rural areas in Australia [ 51 – 53 ], Sweden [ 54 – 56 ] and Scotland [ 57 ] ( Table 2 ).

https://doi.org/10.1371/journal.pgph.0000935.t002

Although midwife-led continuity of care was available in a number of countries, mostly high-income with a cadre of midwives, in select facilities and locations, it was generally not scaled-up nationally. The exception being New Zealand, where the Lead Maternity Carer model is national allowing to midwives provide continuity of care to all women regardless of risk, in either caseloading or small community-based group practices, under a national funding arrangement and with medical or other collaboration when required [ 58 ].

In LMICs there was greater diversity in structure of arrangements for provision of midwifery continuity of care models. Models of care included a lead midwife delivering care across the continuum [ 59 , 60 ], midwives on-call for women during labour who they had previously seen for antenatal care [ 61 ], and a midwifery continuity of care team that ran in parallel with an obstetric team [ 62 ]. An initiative in Ethiopia involved the same midwife providing antenatal, intrapartum and postnatal care to the same women [ 63 , 64 ]. An initiative in Kenya involved midwifery care across the childbearing continuum, embedded within a family planning and HIV care service [ 65 ]. One initiative in China [ 66 ] facilitated continuity of care for women wishing to have a vaginal birth, where efforts were made for women to see the same midwife for intrapartum and postnatal care. In the Palestinian initiative [ 67 – 69 ], midwives were allocated geographical areas to provide antenatal and postnatal care for between 50–100 women. One initiative in Bangladesh [ 70 ] and another in Iran [ 71 ] involved teams of midwives providing care in a private midwifery clinic associated with two local hospitals.

Similar to HICs, continuity of care services were located as part of the usual hospital services (eg in Pakistan [ 59 , 72 ], China [ 61 ], Ethiopia [ 63 , 64 ], Palestine [ 67 – 69 ] or in community health centres or maternity clinics, for example in Bangladesh [ 60 , 70 ], Kenya [ 65 ] and Afghanistan [ 73 ]. Most services were based in urban or semi-urban areas but there were some examples from rural areas, for example, Palestine [ 67 – 69 ], Bangladesh [ 70 ], Afghanistan [ 73 ] and Indonesia [ 74 ].

Reports from China [ 62 ], Ethiopia [ 63 ], Iran [ 71 ], Kenya [ 65 ] and Pakistan [ 59 ] provided some degree of continuity of care across all antenatal, intrapartum and postnatal periods. Two reports, one from China [ 61 ] and the one from Kenya [ 65 ] provided care across antenatal and intrapartum. A study in China [ 66 ] involved the provision of midwife-led care at antenatal, intrapartum and postnatal time points, but continuity of care with the same/a known provider was only guaranteed at intrapartum and postnatal time points. S1 Table provides more details on each of the initiatives and S2 Table gives additional detail on models of care from LMICs.

The ‘by whom’: Providers of midwifery continuity of care

Midwives were the dominant provider of continuity of care across all settings. Services were mostly midwife-led with some reports including other cadre as well. Integration with existing services including systems for referral to obstetric services when needed was usual.

In HIC, almost all models of continuity of midwifery care involved care provided by midwives and/or midwifery students. A small number included midwives and other cadre. For example, programs with midwives and Aboriginal Health Workers (Indigenous health providers) [ 14 , 75 – 78 ]; collaborations with general practitioners, obstetricians or a social worker [ 44 , 79 – 81 ]. Just two examples did not include midwives; a model in Finland where continuity of care is provided by a nurse who takes care of the family from the pregnancy until the child reaches school age [ 26 , 82 ], and an example in Ireland [ 83 ], where continuity of care was provided by a privately practising obstetrician.

All except two of the continuity of care initiatives in LMICs were midwife-led. The initiative from Ghana [ 84 ] was provided by midwives, nurses and doctors while the one in Kenya [ 65 ] was provided by community based midwives who may have nursing or midwifery qualifications and other health professional with obstetric skills who reside in the community.

There were 16 reports which described midwifery students providing continuity of care, most of these were from Australia, Norway and Indonesia [ 74 , 85 – 101 ]. Midwifery students were placed with women, providing continuity of care to a defined number of women over their education program, as a way to engage them in this model of care [ 91 , 94 ].

The ‘for whom’: Priority groups for continuity of care initiatives

Of the 175 initiatives, 44 (25.5%) of these were implemented for women and newborns with risk of adverse outcomes ( Table 3 ). These included women from Indigenous communities, refugee and migrant populations, young mothers, women living in rural and remote areas, women who experience socioeconomic disadvantage, women with a history of substance abuse, chronic illness, and ethnic minority groups. The majority were from Australia [ 23 ], United Kingdom [ 9 ] and Canada [ 3 ]. There were four examples from LMICs, these were designed primarily for rural and remote communities in Palestine [ 67 – 69 ], Bangladesh [ 70 ], Afghanistan [ 73 ] and Kenya [ 84 ].

https://doi.org/10.1371/journal.pgph.0000935.t003

This scoping reviewed aimed to map where, how, by whom, and for whom are midwifery continuity of care models are being implemented globally. The majority of models identified were in HICs, largely in Australia and the United Kingdom. Notably, all countries where five or more continuity of midwifery care initiatives were identified in the last 10 years are high-income and provide free public healthcare to their citizens and have a distinct cadre of midwives which makes this possible (Australia, Canada, Denmark, Japan, New Zealand, Sweden, and United Kingdom). Only 18 initiatives were identified in LMICs.

There is a growing body of literature demonstrating beneficial effects of midwifery continuity of care [ 4 , 8 ]. Midwifery continuity of care is a complex, multi-faceted intervention and teasing out which elements impart benefit to recipients of care is difficult. We found that almost all papers included in this review, involved continuity of care initiatives led by midwives or midwifery students (with midwife supervision). This was despite casting the net wide to identify continuity of care initiatives provided by any health provider across two or parts of the maternal and newborn care continuum.

Reviews of continuity of care in maternal and newborn care have focused on midwife-led continuity of care compared with other models of care such as doctor-led and shared care models [ 4 , 102 ]. However, a previous integrative review of midwife-led care in LMICs, found that just over half of studies included in the review included only midwives, with other cadres of health professionals including nurses, nurse-midwives, doctors, traditional birth attendants and family planning workers [ 103 ]. Whilst there is scope for other non-midwife health providers to provide continuity of care, such as family physicians [ 104 ]and community health workers [ 105 ], which may particularly be of value in LMICs countries where there is a shortage of midwives [ 106 ], there are few studies or reports available about these continuity of care models and their benefits. Although other cadre are not precluded from providing continuity of care, this review has shown that in the global literature, continuity of care across the maternal and newborn continuum is reported to be almost exclusively provided by midwives and is a significant area of quality improvement and research interest for midwives.

An encouraging finding from this review was the significant proportion of initiatives in HICs which focussed on women and newborns with vulnerabilities related to social and economic determinants of health (23.2%). The evidence that such initiatives are feasible for a diverse range of priority groups across many countries could demonstrate recognition of the benefits of continuity of care in improving outcomes for those with greater social and economic barriers to good health outcomes. This has implications for future research in that previous studies exploring childbirth outcomes from midwifery continuity of care frequently involve low-risk women [ 4 ], or women who had self-selected to be part of a midwife-led care project and thus are more likely to experience a positive outcome. This review has revealed that initiatives in a range of settings involve groups acknowledged to be at increased risk of adverse outcome. Larger scale and robust studies of midwifery continuity of care initiatives involving populations who experience social and economic disadvantage, and/or are at increased obstetric risk are both feasible and desirable.

Implications for policy, practice, research

This review has revealed that most studies, or reports, on midwifery continuity of care describe models led by midwives within HICs. Despite the benefits of midwife-led continuity of care, none of these countries has managed to scale-up this approach to being the standard of care at a national level, other than New Zealand. This highlights the organisational challenges of widespread implementation and the importance of system-level reform to enable countries to transition to this model of care and to scale-up. This reform means having adequate funding, support to enable midwives to be educated, and regulated, to work to their full scope of practice including flexibility and autonomy, self-managed time, team space, telephone access, and being able to work safely in the community and having access to transport and referral services [ 8 , 107 ].

Fewer than 10% of initiatives included in this review were from LMICs and only one was a clinical trial. The greatest burden of maternal and newborn deaths and stillbirths exists in LMICs. In HICs, midwife-led continuity of care has potential to reduce preventable maternal and newborn mortality and morbidity and stillbirths, however system-level reform and ensuring an enabling environment is still key [ 44 ]. The lack of midwifery continuity of care initiatives in LMICs, highlights the need for greater investment to ensure well-functioning midwifery systems can be developed with monitoring, evaluation and research to understand the effect of different models and associated benefits and/or challenges in different contexts. Operational research that identifies the barriers, facilitators and blockages to implementing models of midwifery continuity of care is needed, including in settings where there are shortages of midwives. In order to facilitate transition to, and scale-up of, midwifery continuity of care in LMICs, key considerations include strengthening midwifery education and regulation and ensuring the presence of an enabling environment [ 66 , 73 ].

Future systematic and scoping review studies would be enhanced by clear reporting of midwifery continuity model type, implementation details (including on midwife competence, scope of practice, deployment) and degree of continuity achieved within published studies and reports. Establishment of a classification system for this purpose would also enhance implementation efforts. One example of a classification system in a country which has an identifiable cadre of midwives is the Maternity Care Classification System (MaCCS) which was developed to classify, record and report data about maternity models of care in Australia [ 108 , 109 ]. The MaCCS includes a series attributes including the target groups, profession of provider, the caseload size, the extent of planned continuity of care and the location of care to come up with 11 major model categories (see S3 Table for details) [ 110 ]. This classification system is now being included in all routine data systems in Australia so that, in the future, outcomes by model of care will be reported. While this is developed for one high-income country, an adaptation for global utility could be useful.

Measuring the extent to which continuity of care is achieved is the second key area. The health insurance industry in the USA has developed measures to assess patterns of visits to providers and therefore, the level of continuity of care [ 111 ]. The measures include the Bice-Boxerman Continuity of Care Index (measures the degree of coordination required between different providers during an episode), the Herfindahl Index (the degree of coordination required between different providers during an episode), the Usual Provider of Care (the concentration of care with a primary provider) and Sequential Continuity of Care Index (the number of handoffs of information required between providers). The Usual Provider of Care index has also been used to assess continuity of care in general practice in the UK, that is, to assess the proportion of a patient’s contacts that was with their most regularly seen doctor [ 112 ]. For example, if a patient had 10 general practitioner contacts, including six with the same doctor, then their usual provider of care index score would be 0.6. With the exception of one study, none of the papers in this review had applied such indexes. This is an important consideration for the future.

Strengths and limitations

This review provides a summary of midwifery continuity of care efforts globally. As countries look to strengthen midwifery and quality of care for women and newborns during pregnancy, childbirth and postnatal periods, understanding implementation in all resource settings is important. In this review the broad criteria for inclusion allowed for identifying the maximum number of implementation efforts in LMICs to be identified. Despite the efforts to reach out, and although no language filters were applied, search terms were in English thus we may have missed some ongoing efforts. We also did not measure, or account for, the skills and competencies in the different cadres providing care, or if they are always deployed as midwives or provide details about the profile/qualifications of the healthcare providers, the way the midwifery system function, if any affiliation to healthcare centres, support systems, health costs and coverage or safety outcome indicators as these were reported differently or not at all across the papers. Finally, in this review we were not able to reliably determine the extent to which women receiving care were able to see the same individual care provider. Relational continuity is a key element of continuity of care, and possible mechanism for beneficial effects, which requires repeat contact over time between individual care providers and recipients of care.

Conclusions

This review mapped midwifery continuity of care initiatives globally. The majority of initiatives identified were in HICs, with fewer identified in LMICs. Almost all initiatives identified in LMICs were led by midwives (some of whom worked in a model in which they were also deployed as nurses), despite our efforts to identify models led by other skilled health professionals. Almost no countries have managed to scale-up midwifery continuity of care to being the standard of care at a national level. This highlights the organisational challenges of widespread implementation and the importance of system-level reform to enable these models of care to scale-up. Nevertheless, examples of successful implementation of midwifery continuity of care in low-resource settings reported show that advances in this area are possible.

A number of initiatives identified in HICs focused on women and newborns at risk of adverse outcomes, demonstrating the value of midwifery continuity of care in populations who experience social and economic disadvantage and vulnerabilities. There is a need for further research on midwifery continuity of care models in LMICs, and strategies to facilitate transition to, and scale-up of, midwifery continuity of care initiatives globally.

Supporting information

S1 text. search strategy..

https://doi.org/10.1371/journal.pgph.0000935.s001

S1 Table. All included items.

https://doi.org/10.1371/journal.pgph.0000935.s002

S2 Table. Additional details from low- and middle-income countries.

https://doi.org/10.1371/journal.pgph.0000935.s003

S3 Table. Major model categories in MaCCS.

https://doi.org/10.1371/journal.pgph.0000935.s004

S1 Checklist. Preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews.

https://doi.org/10.1371/journal.pgph.0000935.s005

Acknowledgments

Thank you to Rana Islamiah Zahroh, PhD student and researcher at the University of Melbourne in Australia for assistance mapping the data. Thanks also to Rosemary Rowe, Subject Librarian at Faculty of Health, Victoria University of Wellington in New Zealand and to Allisyn Moran and Joao Paolo Souza (WHO) for useful feedback and advice.

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Midwifery continuity of care: A scoping review of where, how, by whom and for whom?

Billie F. Bradford

1 Maternal, Child, and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia

2 Mater Research, University of Queensland, Brisbane, Queensland, Australia

Alyce N. Wilson

3 Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia

Anayda Portela

4 Department of Maternal, Newborn, Child, and Adolescent Health, World Health Organisation, Geneva, Switzerland

Fran McConville

Cristina fernandez turienzo.

5 Department of Women and Children’s Health, Kings College London, London, United Kingdom

Caroline S. E. Homer

Associated data.

All data are in the Supporting information files.

Systems of care that provide midwifery care and services through a continuity of care model have positive health outcomes for women and newborns. We conducted a scoping review to understand the global implementation of these models, asking the questions: where, how, by whom and for whom are midwifery continuity of care models implemented? Using a scoping review framework, we searched electronic and grey literature databases for reports in any language between January 2012 and January 2022, which described current and recent trials, implementation or scaling-up of midwifery continuity of care studies or initiatives in high-, middle- and low-income countries. After screening, 175 reports were included, the majority (157, 90%) from high-income countries (HICs) and fewer (18, 10%) from low- to middle-income countries (LMICs). There were 163 unique studies including eight (4.9%) randomised or quasi-randomised trials, 58 (38.5%) qualitative, 53 (32.7%) quantitative (cohort, cross sectional, descriptive, observational), 31 (19.0%) survey studies, and three (1.9%) health economics analyses. There were 10 practice-based accounts that did not include research. Midwives led almost all continuity of care models. In HICs, the most dominant model was where small groups of midwives provided care for designated women, across the antenatal, childbirth and postnatal care continuum. This was mostly known as caseload midwifery or midwifery group practice. There was more diversity of models in low- to middle-income countries. Of the 175 initiatives described, 31 (18%) were implemented for women, newborns and families from priority or vulnerable communities. With the exception of New Zealand, no countries have managed to scale-up continuity of midwifery care at a national level. Further implementation studies are needed to support countries planning to transition to midwifery continuity of care models in all countries to determine optimal model types and strategies to achieve sustainable scale-up at a national level.

Introduction

Continuity of care is a concept rooted in primary care involving the care of individuals (rather than populations) over time by the same care provider. It encompasses relational continuity, informational continuity and management continuity [ 1 ]. In the primary care setting, continuity of care has been shown to reduce mortality and hospitalisations, and increase patient satisfaction [ 2 ]. Continuity of care also has an important place in chronic care settings, such as palliative care [ 3 ].

In the maternal and newborn care setting, midwife-led continuity of care refers to a model whereby care is provided by the same midwife, or small team of midwives, during pregnancy, labour and birth, and the postnatal periods with referral to specialist care as needed [ 4 ]. Midwife-led also refers to a model of care which is provided there is a distinct occupational group of midwives [ 5 ] and the person is fully qualified, regulated and deployed only as a midwife. This contrasts to systems in many countries (most countries in Africa for and South East Asia for example) where nurse-midwives are rotated to either nursing or midwifery duties. Midwife-led continuity models in a small number of HICs have been associated with lower rates of preterm birth (24% reduction), and lower fetal loss before and after 24 weeks and neonatal deaths (16%) less likely to lose their babies overall (combined reduction in fetal loss and neonatal death) for women at low and mixed risk of complications compared to other models of care. In addition, women are less likely to experience interventions and more likely to report positive experiences of care [ 4 ]. A Cochrane review of reviews of interventions during pregnancy to prevent preterm birth also found that these models had clear benefit in reducing preterm birth and perinatal death [ 6 ]. Women prefer the personalised experience provided by such models, leading to trust between midwife and woman and empowerment of both women and midwives [ 7 ].

Models of care that provide continuity across the childbearing continuum are complex interventions, and the pathway of influence that produces these positive outcomes is unclear. A number of plausible hypotheses require further investigation. For example, it could be that midwives provide a mechanism that enables effective and equitable care to be provided by better coordination, navigation and referral; and/or that relational continuity and advocacy engenders trust and confidence between women and midwives, resulting in women feeling safer, less stressed and more respected [ 4 ]. Access to organisational infrastructure, innovative partnerships, and robust community networks has been found crucial to overcome barriers, address women’s, newborns’ and parents’ needs and ensure quality of care [ 8 ].

Inequity is a key driver of adverse perinatal outcome, both between and within countries. Some observational studies of midwife-led continuity of care models in socially and economically disadvantaged populations in high-income countries (HIC) have reported significant reductions in pre-term birth and caesarean sections in diverse cohorts of women in the United Kingdom [ 9 – 12 ]. In Australia, a study of maternity care during significant floods in Queensland showed that midwife-led continuity of care mitigated the social and emotional impacts of the floods [ 13 ]. Another Australian study showed reduced preterm births amongst Australian Aboriginal and Torres Strait Islander women who received midwife-led continuity of care [ 14 ]. These studies suggest that women who typically experience a greater burden of adverse perinatal outcome, may derive greater benefit from continuity of care. However, understanding how continuity per se may mitigate inequities in maternal and newborn health remains a research priority.

Despite evidence supporting midwife-led continuity of care and guidelines from the World Health Organization which recommend midwife-led continuity-of-care models for pregnant women in settings with well-functioning midwifery programmes [ 15 – 17 ] only a small proportion of women internationally have access to such care. The current evidence suggests that access to midwife-led continuity of care models is largely confined to a small number of HICs notably Australia, Canada, New Zealand and the United Kingdom [ 17 ] where a distinct occupational group of midwives has been a central part of the health systems for decades. Barriers to implementation of midwifery-led continuity of care exist across all country income levels and include a lack of local health system financing, shortage of personnel including administrative and other support staff [ 4 ]. It is not clear to what extent midwife-led continuity of care has been implemented in low- to middle-income countries (LMIC). Many LMICs have a model of predominantly nurse-midwives who are deployed to both nursing and midwifery duties, often preventing midwife-led continuity of care models. Advancing understanding around which countries have implemented continuity of care models for maternal and newborn health, how, for whom, and in what context, is crucial for successful implementation, scale-up and sustainability.

The overall aim of this review was to understand the global implementation of midwifery continuity of care, asking the questions: Where, how, by whom and for whom are midwifery continuity of care initiatives implemented?

Materials and methods

A scoping review was undertaken guided by the approach described by Arksey and O’Malley [ 18 ] and further defined by Levac and colleagues [ 19 ]. The following five steps were followed: i) identifying the research question; ii) identifying the relevant literature; iii) study selection, iv) charting the data; and v) collating, summarising and reporting the results.

We used the broad definition of midwifery from The Lancet Series on Midwifery as our starting point, that is, “skilled, knowledgeable, and compassionate care for childbearing women, newborn infants and families across the continuum from pre-pregnancy, pregnancy, birth, postpartum and the early weeks of life [ 20 ]. Midwifery continuity of care was defined as care delivered by the same known care provider or care provider team across two or more parts in the care continuum–antenatal, intrapartum, postnatal and neonatal periods. In some settings, continuity of care may be provided by cadre other than midwives, for example, nurses or physicians. Thus, eligible papers could include care providers that were midwives and non-midwives, such as, nurses, community health workers and physicians. We excluded reports on care primarily by traditional birth attendants (TBA).

Identifying the relevant literature—Search strategy and selection criteria

In order to develop the search strategy, a preliminary search of PubMed and Google scholar using the terms ‘midwifery or midwife-led continuity of care’ were used to locate key systematic and scoping reviews on the topic and identify relevant search terms for the systematic search strategy (see S1 Text for the search strategy). We then searched the following electronic databases: MEDLINE, CENTRAL, CINAHL, PsychINFO and Web of Science. A subject librarian reviewed search terms, keywords and strategies. In addition, we searched PubMed, Google Scholar, PROSPERO, Scopus and Dimensions and the WHO International Clinical Trials Registry platform. We conducted the search on the 20 February 2022 and included publications (peer reviewed studies and reports) in the past 10 years.

A key area of interest was implementation of continuity of midwifery care in LMICs but we recognised that reports of implementation may be published in formats other than peer reviewed publications. Eligible papers therefore included implementation studies or reports of implementation of midwifery continuity of care in the grey literature. We sourced grey literature through online searches on the websites of relevant professional groups, United Nations agencies and non-government organisations (NGO). We circulated a call for relevant materials through online list servs (email groups) and through midwifery contacts. The International Confederation of Midwives assisted by emailing all member associations asking for any relevant reports.

Eligible reports could report on midwifery continuity of care efforts in HICs and LMICs. Reports from implementation efforts by government programmes, private providers, professional organisations, NGOs and universities and research studies of any design were eligible for inclusion. Protocols that reported studies that were underway, but not concluded, were also eligible. Opinion pieces, editorials and other materials, which included details of midwifery continuity of care initiatives, were also eligible. Publications in any language were eligible. The search was limited to reports published in the last ten years (January 2012 to January 2022) to ensure the information was contemporary and therefore of greatest relevance to policy makers.

Reports identified through both peer-reviewed and grey literature databases were hand-searched for other potentially relevant studies. These included reference lists of relevant systematic reviews, and published conference abstracts, as well as any reports forwarded to authors in response to a call for notification of new or ongoing initiatives from key global stakeholder organisations, such as the International Confederation of Midwives.

Reports were excluded they if reported on midwifery continuity of care in general but did not report on a continuity of care practice initiative. We excluded systematic and literature reviews although their reference lists were searched for relevant primary studies.

Study selection

All reports identified through database searching were imported into Endnote referencing programme (Endnote 20, Clarivate Analytics, Philadelphia), and duplicates removed. Remaining citations (n = 5789) were uploaded into systematic review software Covidence (Covidence 2022, Veritas Health Innovations, Melbourne). Two authors independently conducted initial title and abstract screening and undertook full-text review. A third author screened a random selection of 10% of studies and discrepancies were discussed and resolved.

Charting the data

The following information was extracted for all included reports: country, income-level (as defined by the World Bank [ 21 ], study design (if applicable), setting (urban/rural and community-based or facility-based), novel or scaled-up initiative, model of care, level of continuity (antenatal and intrapartum, antenatal and postnatal, intrapartum and postnatal) and cadre of care providers, (e.g. mix of providers involved). We also collected information on the inclusion of priority population groups–these are groups of people who are persistently disadvantaged by existing systems of power with demographic features known to be associated with adverse perinatal outcomes, such as ethnic minorities, urban and remote women, socially disadvantaged, and Indigenous women. We have described these specific groups as priority rather than vulnerable populations [ 22 ]. Reporting of the scoping review findings follows the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) format (see S1 Checklist ) and reference ( Fig 1 ) [ 23 ]. Appraisal of study quality or meta-analysis was not undertaken.

In total, 6595 references were identified from electronic peer-reviewed databases, 821 duplicate records were removed prior to uploading to Covidence, a further 634 duplicates were removed by automation. Of the 5136 remaining references, 4728 did not meet the inclusion criteria. A further 256 references were excluded at the full-text stage as either: they did not describe continuity of care according to our pre-determined criteria (167); did not include primary source data (42); were duplicates (41); or did not have insufficient detail regarding the model of care (6). One hundred and fifty-two (152) peer-reviewed publications were eligible based on inclusion and exclusion criteria. A further 23 reports were identified following the grey literature search, bringing the total to 175 ( Fig 1 ). Details are listed in S1 Table .

Of the 175 individual reports, 152 (86.8%) were peer reviewed publications, 18 (10.3%) were conference abstracts, and the remaining five (3%) were published or unpublished reports. Reports primarily reported on birth outcomes (n = 54, 31%), women’s (including some partners’) views and experiences (n = 47, 27%) and midwives (including doctors) views and experiences (n = 33, 19%). There were 18 reporting on the model of care more broadly, including implementation challenges (n = 18, 10%), and 14 (7%) that were focussed on the experience of midwifery students providing continuity of care as part of their education. The majority of these student-focused reports were from Australia. Fewer reports focussed on the experience of midwifery managers (n = 3, 2%), while four were cost analyses (2%).

There were 163 unique studies including eight (4.9%) randomised or quasi randomised trials, 58 (38.5%) qualitative, 53 (32.7%) quantitative (cohort, cross sectional, descriptive, observational), 31 (19.0%) survey studies, and three (1.9%) health economics analyses. There were 10 practice-based accounts that did not include research.

‘The where’: Country and setting

Of the 175 included reports, the majority (n = 157, 90%) were from HICs and 18 (10%) from LMICs ( Table 1 ). Most were from Australia, (n = 71, 41%), followed by the United Kingdom (England, Scotland, Wales) (24, 14%), Sweden (13, 8%), Canada (8, 5%), Denmark (6, 4%), New Zealand (7, 4%), Japan (5, 3%), with less than five reports described initiatives conducted in Belgium, Finland, Germany, Greece, Ireland, Netherlands, Norway, Singapore, Switzerland and the United States of America (USA). In the LMICs, three from Palestine, three from China, two each from Bangladesh and Indonesia, and one from each of the remaining countries.

*Due to rounding, percentages may be >100%

Overall, most midwifery continuity of care models were based in urban areas (n = 126, 72%). In HIC, three-quarters of services (n = 118, 75%) were urban-based, whereas in LMICs just under half (n = 8, 44%) were urban-based. Hospital or facility-based services were most common across all income levels (n = 124, 72% overall).

‘The how’: Describing the way continuity of care is provided

There were a number of different terms used to define the model of care, and the level of continuity provided across the continuum of care varied with no single term used. Overall, the most common terms were caseload midwifery (n = 63, 36%), midwifery-led continuity (n = 60, 34%), or team/midwifery group practice (n = 40, 23%). Most described services designed so that the same providers provided care across the continuum–antenatal, intrapartum and postnatal (n = 159, 91%). There were eight which described continuity only across the antenatal and postpartum periods [ 24 – 31 ] (excluding labour and birth), and five reported [ 32 – 36 ] (including 3 unique examples) where the continuity was provided only across antenatal and intrapartum periods without postpartum care.

In HICs, the most dominant approach is where small groups of midwives provide care for designated women, known as caseload midwifery or midwifery group practice in countries like Australia [ 37 ], the United Kingdom [ 9 ], Denmark [ 38 ], Sweden [ 39 ], and Singapore [ 40 ] where the number of midwives is usually two to four. In other countries, for example, Japan [ 41 ] and Switzerland [ 42 ], the approach is also called team midwifery and the number of midwives is five or more.

The continuity of care services were located as part of the usual hospital [ 37 , 43 ], in an alongside birth centre [ 44 – 46 ] or in a free-standing birth centre [ 47 ]. Some midwife-led continuity of care services were offered through homebirth practices, either as part of the hospital system [ 48 , 49 ] or as a private service [ 50 ]. Most services were based in urban areas but there were some examples from rural areas in Australia [ 51 – 53 ], Sweden [ 54 – 56 ] and Scotland [ 57 ] ( Table 2 ).

Although midwife-led continuity of care was available in a number of countries, mostly high-income with a cadre of midwives, in select facilities and locations, it was generally not scaled-up nationally. The exception being New Zealand, where the Lead Maternity Carer model is national allowing to midwives provide continuity of care to all women regardless of risk, in either caseloading or small community-based group practices, under a national funding arrangement and with medical or other collaboration when required [ 58 ].

In LMICs there was greater diversity in structure of arrangements for provision of midwifery continuity of care models. Models of care included a lead midwife delivering care across the continuum [ 59 , 60 ], midwives on-call for women during labour who they had previously seen for antenatal care [ 61 ], and a midwifery continuity of care team that ran in parallel with an obstetric team [ 62 ]. An initiative in Ethiopia involved the same midwife providing antenatal, intrapartum and postnatal care to the same women [ 63 , 64 ]. An initiative in Kenya involved midwifery care across the childbearing continuum, embedded within a family planning and HIV care service [ 65 ]. One initiative in China [ 66 ] facilitated continuity of care for women wishing to have a vaginal birth, where efforts were made for women to see the same midwife for intrapartum and postnatal care. In the Palestinian initiative [ 67 – 69 ], midwives were allocated geographical areas to provide antenatal and postnatal care for between 50–100 women. One initiative in Bangladesh [ 70 ] and another in Iran [ 71 ] involved teams of midwives providing care in a private midwifery clinic associated with two local hospitals.

Similar to HICs, continuity of care services were located as part of the usual hospital services (eg in Pakistan [ 59 , 72 ], China [ 61 ], Ethiopia [ 63 , 64 ], Palestine [ 67 – 69 ] or in community health centres or maternity clinics, for example in Bangladesh [ 60 , 70 ], Kenya [ 65 ] and Afghanistan [ 73 ]. Most services were based in urban or semi-urban areas but there were some examples from rural areas, for example, Palestine [ 67 – 69 ], Bangladesh [ 70 ], Afghanistan [ 73 ] and Indonesia [ 74 ].

Reports from China [ 62 ], Ethiopia [ 63 ], Iran [ 71 ], Kenya [ 65 ] and Pakistan [ 59 ] provided some degree of continuity of care across all antenatal, intrapartum and postnatal periods. Two reports, one from China [ 61 ] and the one from Kenya [ 65 ] provided care across antenatal and intrapartum. A study in China [ 66 ] involved the provision of midwife-led care at antenatal, intrapartum and postnatal time points, but continuity of care with the same/a known provider was only guaranteed at intrapartum and postnatal time points. S1 Table provides more details on each of the initiatives and S2 Table gives additional detail on models of care from LMICs.

The ‘by whom’: Providers of midwifery continuity of care

Midwives were the dominant provider of continuity of care across all settings. Services were mostly midwife-led with some reports including other cadre as well. Integration with existing services including systems for referral to obstetric services when needed was usual.

In HIC, almost all models of continuity of midwifery care involved care provided by midwives and/or midwifery students. A small number included midwives and other cadre. For example, programs with midwives and Aboriginal Health Workers (Indigenous health providers) [ 14 , 75 – 78 ]; collaborations with general practitioners, obstetricians or a social worker [ 44 , 79 – 81 ]. Just two examples did not include midwives; a model in Finland where continuity of care is provided by a nurse who takes care of the family from the pregnancy until the child reaches school age [ 26 , 82 ], and an example in Ireland [ 83 ], where continuity of care was provided by a privately practising obstetrician.

All except two of the continuity of care initiatives in LMICs were midwife-led. The initiative from Ghana [ 84 ] was provided by midwives, nurses and doctors while the one in Kenya [ 65 ] was provided by community based midwives who may have nursing or midwifery qualifications and other health professional with obstetric skills who reside in the community.

There were 16 reports which described midwifery students providing continuity of care, most of these were from Australia, Norway and Indonesia [ 74 , 85 – 101 ]. Midwifery students were placed with women, providing continuity of care to a defined number of women over their education program, as a way to engage them in this model of care [ 91 , 94 ].

The ‘for whom’: Priority groups for continuity of care initiatives

Of the 175 initiatives, 44 (25.5%) of these were implemented for women and newborns with risk of adverse outcomes ( Table 3 ). These included women from Indigenous communities, refugee and migrant populations, young mothers, women living in rural and remote areas, women who experience socioeconomic disadvantage, women with a history of substance abuse, chronic illness, and ethnic minority groups. The majority were from Australia [ 23 ], United Kingdom [ 9 ] and Canada [ 3 ]. There were four examples from LMICs, these were designed primarily for rural and remote communities in Palestine [ 67 – 69 ], Bangladesh [ 70 ], Afghanistan [ 73 ] and Kenya [ 84 ].

*as described by the authors

Note: Some country totals are more than the country count as some studies addressed more than one priority population

This scoping reviewed aimed to map where, how, by whom, and for whom are midwifery continuity of care models are being implemented globally. The majority of models identified were in HICs, largely in Australia and the United Kingdom. Notably, all countries where five or more continuity of midwifery care initiatives were identified in the last 10 years are high-income and provide free public healthcare to their citizens and have a distinct cadre of midwives which makes this possible (Australia, Canada, Denmark, Japan, New Zealand, Sweden, and United Kingdom). Only 18 initiatives were identified in LMICs.

There is a growing body of literature demonstrating beneficial effects of midwifery continuity of care [ 4 , 8 ]. Midwifery continuity of care is a complex, multi-faceted intervention and teasing out which elements impart benefit to recipients of care is difficult. We found that almost all papers included in this review, involved continuity of care initiatives led by midwives or midwifery students (with midwife supervision). This was despite casting the net wide to identify continuity of care initiatives provided by any health provider across two or parts of the maternal and newborn care continuum.

Reviews of continuity of care in maternal and newborn care have focused on midwife-led continuity of care compared with other models of care such as doctor-led and shared care models [ 4 , 102 ]. However, a previous integrative review of midwife-led care in LMICs, found that just over half of studies included in the review included only midwives, with other cadres of health professionals including nurses, nurse-midwives, doctors, traditional birth attendants and family planning workers [ 103 ]. Whilst there is scope for other non-midwife health providers to provide continuity of care, such as family physicians [ 104 ]and community health workers [ 105 ], which may particularly be of value in LMICs countries where there is a shortage of midwives [ 106 ], there are few studies or reports available about these continuity of care models and their benefits. Although other cadre are not precluded from providing continuity of care, this review has shown that in the global literature, continuity of care across the maternal and newborn continuum is reported to be almost exclusively provided by midwives and is a significant area of quality improvement and research interest for midwives.

An encouraging finding from this review was the significant proportion of initiatives in HICs which focussed on women and newborns with vulnerabilities related to social and economic determinants of health (23.2%). The evidence that such initiatives are feasible for a diverse range of priority groups across many countries could demonstrate recognition of the benefits of continuity of care in improving outcomes for those with greater social and economic barriers to good health outcomes. This has implications for future research in that previous studies exploring childbirth outcomes from midwifery continuity of care frequently involve low-risk women [ 4 ], or women who had self-selected to be part of a midwife-led care project and thus are more likely to experience a positive outcome. This review has revealed that initiatives in a range of settings involve groups acknowledged to be at increased risk of adverse outcome. Larger scale and robust studies of midwifery continuity of care initiatives involving populations who experience social and economic disadvantage, and/or are at increased obstetric risk are both feasible and desirable.

Implications for policy, practice, research

This review has revealed that most studies, or reports, on midwifery continuity of care describe models led by midwives within HICs. Despite the benefits of midwife-led continuity of care, none of these countries has managed to scale-up this approach to being the standard of care at a national level, other than New Zealand. This highlights the organisational challenges of widespread implementation and the importance of system-level reform to enable countries to transition to this model of care and to scale-up. This reform means having adequate funding, support to enable midwives to be educated, and regulated, to work to their full scope of practice including flexibility and autonomy, self-managed time, team space, telephone access, and being able to work safely in the community and having access to transport and referral services [ 8 , 107 ].

Fewer than 10% of initiatives included in this review were from LMICs and only one was a clinical trial. The greatest burden of maternal and newborn deaths and stillbirths exists in LMICs. In HICs, midwife-led continuity of care has potential to reduce preventable maternal and newborn mortality and morbidity and stillbirths, however system-level reform and ensuring an enabling environment is still key [ 44 ]. The lack of midwifery continuity of care initiatives in LMICs, highlights the need for greater investment to ensure well-functioning midwifery systems can be developed with monitoring, evaluation and research to understand the effect of different models and associated benefits and/or challenges in different contexts. Operational research that identifies the barriers, facilitators and blockages to implementing models of midwifery continuity of care is needed, including in settings where there are shortages of midwives. In order to facilitate transition to, and scale-up of, midwifery continuity of care in LMICs, key considerations include strengthening midwifery education and regulation and ensuring the presence of an enabling environment [ 66 , 73 ].

Future systematic and scoping review studies would be enhanced by clear reporting of midwifery continuity model type, implementation details (including on midwife competence, scope of practice, deployment) and degree of continuity achieved within published studies and reports. Establishment of a classification system for this purpose would also enhance implementation efforts. One example of a classification system in a country which has an identifiable cadre of midwives is the Maternity Care Classification System (MaCCS) which was developed to classify, record and report data about maternity models of care in Australia [ 108 , 109 ]. The MaCCS includes a series attributes including the target groups, profession of provider, the caseload size, the extent of planned continuity of care and the location of care to come up with 11 major model categories (see S3 Table for details) [ 110 ]. This classification system is now being included in all routine data systems in Australia so that, in the future, outcomes by model of care will be reported. While this is developed for one high-income country, an adaptation for global utility could be useful.

Measuring the extent to which continuity of care is achieved is the second key area. The health insurance industry in the USA has developed measures to assess patterns of visits to providers and therefore, the level of continuity of care [ 111 ]. The measures include the Bice-Boxerman Continuity of Care Index (measures the degree of coordination required between different providers during an episode), the Herfindahl Index (the degree of coordination required between different providers during an episode), the Usual Provider of Care (the concentration of care with a primary provider) and Sequential Continuity of Care Index (the number of handoffs of information required between providers). The Usual Provider of Care index has also been used to assess continuity of care in general practice in the UK, that is, to assess the proportion of a patient’s contacts that was with their most regularly seen doctor [ 112 ]. For example, if a patient had 10 general practitioner contacts, including six with the same doctor, then their usual provider of care index score would be 0.6. With the exception of one study, none of the papers in this review had applied such indexes. This is an important consideration for the future.

Strengths and limitations

This review provides a summary of midwifery continuity of care efforts globally. As countries look to strengthen midwifery and quality of care for women and newborns during pregnancy, childbirth and postnatal periods, understanding implementation in all resource settings is important. In this review the broad criteria for inclusion allowed for identifying the maximum number of implementation efforts in LMICs to be identified. Despite the efforts to reach out, and although no language filters were applied, search terms were in English thus we may have missed some ongoing efforts. We also did not measure, or account for, the skills and competencies in the different cadres providing care, or if they are always deployed as midwives or provide details about the profile/qualifications of the healthcare providers, the way the midwifery system function, if any affiliation to healthcare centres, support systems, health costs and coverage or safety outcome indicators as these were reported differently or not at all across the papers. Finally, in this review we were not able to reliably determine the extent to which women receiving care were able to see the same individual care provider. Relational continuity is a key element of continuity of care, and possible mechanism for beneficial effects, which requires repeat contact over time between individual care providers and recipients of care.

Conclusions

This review mapped midwifery continuity of care initiatives globally. The majority of initiatives identified were in HICs, with fewer identified in LMICs. Almost all initiatives identified in LMICs were led by midwives (some of whom worked in a model in which they were also deployed as nurses), despite our efforts to identify models led by other skilled health professionals. Almost no countries have managed to scale-up midwifery continuity of care to being the standard of care at a national level. This highlights the organisational challenges of widespread implementation and the importance of system-level reform to enable these models of care to scale-up. Nevertheless, examples of successful implementation of midwifery continuity of care in low-resource settings reported show that advances in this area are possible.

A number of initiatives identified in HICs focused on women and newborns at risk of adverse outcomes, demonstrating the value of midwifery continuity of care in populations who experience social and economic disadvantage and vulnerabilities. There is a need for further research on midwifery continuity of care models in LMICs, and strategies to facilitate transition to, and scale-up of, midwifery continuity of care initiatives globally.

Supporting information

S1 checklist, acknowledgments.

Thank you to Rana Islamiah Zahroh, PhD student and researcher at the University of Melbourne in Australia for assistance mapping the data. Thanks also to Rosemary Rowe, Subject Librarian at Faculty of Health, Victoria University of Wellington in New Zealand and to Allisyn Moran and Joao Paolo Souza (WHO) for useful feedback and advice.

Funding Statement

This review was commissioned by the World Health Organization Department of Maternal, Newborn, Child and Adolescent Health and Ageing and funded through a grant received from Merck Sharp and Dohme Corp (MSD). CFT is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South London, a NIHR Global Health Research Group (NIHR133232) and a NIHR Development and Skills Award (NIHR301603). CSEH is supported by an Australian National Health and Medical Research Council Fellowship (APP1137745). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data Availability

• PLOS Glob Public Health. 2022; 2(10): e0000935.

Decision Letter 0

19 Jul 2022

PGPH-D-22-00905

PLOS Global Public Health

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Reviewer #1: This review has been carried out well. The authors have presented all key aspects of the review process and the results.

There are a few comments for revision which are as mentioned below.

1.Line 133: Mention the last date of search based on which the review was carried out.

2.Line 179-187: The calculation of numbers of references are wrong. Example: Out of total 6595 references, removing 821 and 634 references will result is 5140 references. But, it mentioned as 5136. Similarly, the final number of items comes to 179 as per the description but it is mentioned as 175. These need to be corrected.

Reviewer #2: The topic is interesting. The role of the midwives in ensuring continuity of care and in preventing pre, per and postnatal complications should be highlighted and well recognized and adopted in the healthcare system.

I would recommend reflecting on the factors that impede the continuity of care provided by the midwives in the introduction.

Since eligible papers include care providers who are midwives and non-midwives, such as, nurses, community health workers and physicians, I would suggest changing the title to pre, per, postnatal care instead of midwifery care. Continuity of care may be provided by cadre other than midwives as per the provided definition, but this might be confusing if you want to focus on the role of the midwife per se. But it is fine if the focus is on the continuity of maternal and newborn care.

Kindly justify why the literature search was limited to the last 10 years only.

Kindly specify the percentage of the health providers per specialty. This will give an idea about who are the providers of care.

I wonder if you can provide more details about the profile/qualifications of the healthcare providers, the way the midwifery system function, if any affiliation to healthcare centres, support system, Health cost coverage, Safety, Outcome indicators, etc.

Make sure the paper is edited.

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Reviewer #1:  Yes:  DEEPANJALI BEHERA

Reviewer #2:  Yes:  Mathilde Azar

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Author response to Decision Letter 0

17 Aug 2022

Submitted filename: Response to Review Midwifery Continuity of Care R2.docx

Decision Letter 1

PGPH-D-22-00905R1

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Reviewer #2: (No Response)

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Reviewer #1: The article appears sound after revision.

Reviewer #2: The authors addressed some of the comments. The others might not have been documented to answer. But this does not affect the quality of the paper or the aim of the study. So, we can ignore them.

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• DOI: 10.12968/BJOM.2012.20.4.289
• Corpus ID: 72267061

The complexity of decision-making in midwifery: A case study

• Published 1 April 2012
• The British Journal of Midwifery

5 Citations

Decision-making in midwifery: a tripartite clinical decision, part 1: a model for evidence-based decision-making in midwifery care, a critical analysis of a tripartite clinical decision involving a student, midwife and client, examining the decision-making theories employed by nurses to diagnose a patient presenting with a rectal bleed, supporting an ethnic minority woman's choice for pain relief in labour: a reflection, 11 references, clinical decision-making by midwives: managing case complexity., clinical decision making in nursing: theoretical perspectives and their relevance to practice., nurses, information use, and clinical decision making—the real world potential for evidence-based decisions in nursing, a prospective study of women's views of factors contributing to a positive birth experience., expectations, experiences, and psychological outcomes of childbirth: a prospective study of 825 women., a problem-based learning approach to facilitate evidence-based practice in entry-level health professional education, umbilical cord prolapse. a contemporary look., risk factors and infant outcomes associated with umbilical cord prolapse: a population-based case-control study among births in washington state., managing the risks of organizational accidents, the mortality and morbidity associated with umbilical cord prolapse, related papers.

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A qualitative study of how caseload midwifery is constituted and experienced by Danish midwives

Affiliations.

• 1 University College of Northern Denmark, Selma Lagerløfs Vej 2, 9220 Aalborg Øst, Denmark; Clinical Nursing Research, Aalborg University Hospital, Sdr. Skovvej 15, 9000 Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000 Aalborg, Denmark. Electronic address: [email protected].
• 2 Clinical Nursing Research, Aalborg University Hospital, Sdr. Skovvej 15, 9000 Aalborg, Denmark; Medical Clinic, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark. Electronic address: [email protected].
• 3 Research unit for Gynaecology and Obstetrics, Institute of Clinical Research, University of Southern Denmark, Sdr Boulevard 29, 5000 Odense C, Denmark. Electronic address: [email protected].
• 4 Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Australia. Electronic address: [email protected].
• 5 Clinical Nursing Research, Aalborg University Hospital, Sdr. Skovvej 15, 9000 Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000 Aalborg, Denmark. Electronic address: [email protected].
• PMID: 27106945
• DOI: 10.1016/j.midw.2016.03.002

Objective: the aim of this study is to advance knowledge about the working and living conditions of midwives in caseload midwifery and how this model of care is embedded in a standard maternity unit. This led to two research questions: 1) What constitutes caseload midwifery from the perspectives of the midwives? 2) How do midwives experience working in caseload midwifery?

Design and setting: phenomenology of practice was the analytical approach to this qualitative study of caseload midwifery in Northern Denmark. The methodology was inspired by ethnography, and applied methods were field observations followed by interviews.

Participants: thirteen midwives working in caseloads were observed during one or two days in the antenatal clinic and were interviewed at a later occasion.

Findings: being recognised and the feeling of doing high quality care generate high job satisfaction. The obligation and pressure to perform well and the disadvantages to the midwives׳ personal lives are counterbalanced by the feeling of doing a meaningful and important job. Working in caseload midwifery creates a feeling of working in a self-governing model within the public hospital, without losing the technological benefits of a modern birth unit. Midwives in caseload midwifery worked on welcoming and including all pregnant women allocated to their care; even women/families where relationships with the midwives were challenging were recognised and respected.

Key conclusions: caseload midwifery is a work-form with an embedded and inevitable commitment and obligation that brings forward the midwife׳s desire to do her utmost and in return receive appreciation, social recognition and a meaningful job with great job satisfaction. There is a balance between the advantages of a meaningful job and the disadvantages for the personal life of the midwife, but benefits were found to outweigh disadvantages.

Implications for practice: In expanding caseload midwifery, it is necessary to understand that the midwives׳ personal lives need to be prepared for this work-form. The number of women per full time midwife has to be surveilled as job-satisfaction is dependent on the midwives׳ ability of fulfilling expectations of being present at women׳s births.

Keywords: Care; Caseload midwifery; Experiences; Midwives; Phenemenology of Pratice; Qualitative methods.

Copyright © 2016 Elsevier Ltd. All rights reserved.

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Stillbirth: A reflective case study

Sarah Stott

Midwife, Whiston Hospital, Liverpool

View articles

Stillbirth rates both in the UK and worldwide are extremely high. This reflective case study is centred on my first experience at caring for a bereaved couple who lost their baby boy, stillborn, at 27 weeks gestation. Whilst causes of stillbirth are often multi-factorial and unexplained, this reflection aims to explore how midwives can adopt simple measures to care for bereaved parents and how they can support themselves. Although research has focused on how improvements in research and training have contributed to a decline in stillbirth rates, this reflection also gives particular emphasis to the emotional aspects of bereavement care.

This reflective paper seeks to explore some of the issues surrounding bereavement care and the importance of sensitive and individualised care when dealing with bereaved parents. Reflection is a key concept of learning within the health and social care professions that allows us to look at our practice and understand it within the context in which it occurs ( O'Carroll and Park, 2007 ). Without reflection, midwifery care can become automatic, thereby disregarding the concept of individualised care, which is outlined in the Nursing and Midwifery Council (NMC) code of conduct (2008) . Reid (1993) described a process of reviewing experience under headings such as description, feelings, evaluation and analysis, which consequently informs and changes practice. A variety of reflective models currently exist, which involve this systematic process ( Van Manen, 1977 ; Gibbs, 1988 ; Driscoll, 2007 ). This reflective case study will adopt Borton's (1970) developmental framework, which incorporates all the core skills of reflection from these current models, yet its simplicity is useful for those inexperienced in undertaking deeper reflection ( Jasper et al, 2013 ). Through Borton's (1970) framework, the practitioner describes (what), analyses (so what) and synthesises (now what) their experience. All names have been changed to protect confidentiality, in accordance with NMC (2008) guidelines.

Amanda, a 43-year-old para 5 was admitted to hospital for medical induction of labour in view of a 27-week intrauterine fetal death. At handover for a late shift, I was asked whether I would be willing to care for Amanda, which would enable me to gain experience in this field. I had not had much exposure to bereavement care during my time as a student midwife, therefore I felt unprepared to deal with it. Instead, my training largely involved ‘catching’ babies so that I could be signed off as competent in facilitating ‘normal’ birth. Nevertheless, I reluctantly volunteered, meanwhile experiencing feelings of panic and anxiety. I had never dealt with such a situation before. What would I say? What if I said the wrong thing?

A stillbirth, as defined by the Stillbirth (Definition) Act 1992, section 1(1), is:

‘Any ‘child’ expelled or issued forth from its mother after the 24th week of pregnancy that did not breathe or show any other signs of life.’

Research has shown that almost 3 million babies worldwide are born stillborn every year ( Mullan and Horton, 2011 ). This means that every day, 11 sets of parents will suffer the pain and grief of having a stillborn baby. Despite cumulative advances in medical science and an ever developing health system ( Mullan and Horton, 2011 ), in the UK, the rate of unexplained stillbirths runs exceedingly higher, at approximately 1000 a year, than deaths from sudden infant death syndrome (SIDS), which is about 200 deaths per year ( Henley and Schott, 2010 ). Despite this wide variation, there appears to be little research conducted on why babies die unexpectedly in utero. It could be possible that the topic of stillbirth is often overlooked because of its profoundly emotive nature and complexity. While causes of stillbirth may be multifactorial, and sometimes unexplained, the highest associated modifiable factor is maternal obesity and overweight, comprising of a body mass index (BMI) above 25kg/m 2 ( Flenady et al, 2011 ).

Although a meta-analysis of 96 population-based studies by Gardosi et al (2013) observed an association between nulliparity and stillbirth, they also found a 60% increase in stillbirth risk for mothers with a parity equal to 3 or above. Gardosi and colleagues found no significant increase in the risk of stillbirth with older maternal age, however, it could be argued that this correlation was not found because congenital anomalies were excluded, which are known to be increased in older mothers. It could be argued that women of advanced childbearing age are more likely to experience infertility, therefore they may rely heavily on artificial reproductive techniques, however, the link between these and stillbirth risk is unknown ( McDonald et al, 2005 ). Substantial variations in stillbirth rates have also been found in relation to social status and ethnicity ( Gissler et al, 2009 ). This may be a result of poor accessibility to care, as well as language and cultural barriers from disadvantaged groups.

Stillbirth rates in the UK are among the highest in high income countries ( Flenady et al, 2011 ). Around one baby, out of every 200, at 22 weeks' gestation or more is stillborn. The reason for this rate remains unexplained, although a lack of awareness among health professionals has shown to be a large contributory factor ( Mullan and Horton, 2011 ). The care that families receive during this time is extremely important, yet it is influenced to a large extent by knowledge and education and the midwives' ability to provide individualised care. An analysis of mortality data collated between 2007 and 2012, found that a high uptake of accreditation training and evidence-based protocols in customised fetal growth assessment, contributed to a steep decline in stillbirth rates ( Gardosi et al, 2013 ). Nevertheless, while this is the gold standard for most midwives, it is difficult to implement when faced with a rising birth rate, increased case complexity and minimal staffing, as well as a disparity of training and local restrictions imposed by financial constraints ( Henley and Schott, 2010 ). A survey of 77 maternity units found that regular training in bereavement care was only present in less than half of the units and that, in the majority of these units, training was only optional because of pressures on staff time, training costs and the sensitivity of the subject matter ( Henley and Schott, 2010 ). Despite this, midwives are still expected to interact supportively with bereaved parents ( Cox and Briggs, 2004 ).

Specialist bereavement midwives play an invaluable role in supporting both parents and staff, however, the specialist midwife in our unit was off duty for this particular shift. Therefore, my role as a midwife was crucial in supporting and advocating for Amanda and her partner John. Luckily, as it was a quiet shift, I had the support of my shift leader who has many years of experience in bereavement care.

I first obtained an in-depth handover from the midwife who had been caring for Amanda, before I introduced myself to her and her partner, John. I was informed that a scan 3 days previously had shown a hydropic fetus with a large bowel atresia and an absent fetal heart. Shortly after, I went to see Amanda who was being cared for in one of our specialist bereavement rooms at the far end of the labour ward. The provision of these dedicated rooms has a fundamental impact on couples' experiences ( Henley and Schott, 2010 ). During introductions, my palms began to sweat and my heart beat faster as I struggled to choose the right words to say. Did I need to say anything? I had this feeling in the forefront of my mind that nothing I said could make them feel better, but that saying the wrong thing could have a massive impact on their emotional wellbeing and subsequent mental health. Having a stillborn baby has been associated with an increase in anxiety, depression, suicidal ideation, as well as substance use and marital conflict, which can persist for many years ( Cacciatore et al, 2008 ). Consequently, I felt helpless, unable to offer any form of comfort. Säflund et al (2004) found that midwives felt the need to distance themselves from bereaved parents because they felt unable to deal with the enormity of the parent's feelings of loss. I was so used to caring for women with healthy, term pregnancies and, having been present at well over a hundred births, the expected and automatic cry of a healthy baby. In healthy pregnancies and births, I would speak with couples about parenting, feeding and tending to their babies, and their expectations, yet in bereaved parents these conversations do not exist. Instead I was caring for a woman and her partner who were submerged in grief and sorrow, these parents may experience feelings of guilt as a result of the expectation of a healthy baby. They will not feel the same excitement, joy and euphoria of bringing a new life into the world.

One concern I had was the documentation, which is ever increasing due to prospect of litigation. Failure to fill in the correct form, or sending it to the wrong place will lead to an official reprimand or managerial intervention, and this presents as a genuine fear ( Kenworthy and Kirkham, 2011 ). There are forms to be filled out surrounding the birth as well as the stillbirth certificate that is a statutory obligation after 24 weeks' gestation ( Henley and Schott, 2010 ). It is understandable that feelings of anxiety and stress can impact on the accidental omission of essential paperwork ( Kenworthy and Kirkham, 2011 ). There is information that is only collected by obtaining tissue samples, such as those for cytogenics investigation, as well as a need to prepare the baby for viewing and organising mementos. I feel strongly that had I not had support from my colleagues, the burden of the documentation would have impacted negatively on my provision of care to Amanda and John. This is disconcerting at a time when we may need to console the woman and her family and provide extra support.

Throughout the shift, my priorities were to manage Amanda's pain and monitor both her vital signs and loss per vaginum, following 3-hourly administration of oral misoprostol. Following the second dose, she began to experience abdominal cramps which were somewhat relieved with intramuscular diamorphine, yet as the shift progressed her pain became more intense with increased regularity, and so she began to use Entonox frequently. I anticipated a quick birth due to Amanda's parity and previous precipitate labours, yet I did not say much, I felt like I did not need to. I mopped her brow, gave her sips of water and held her hand. This sensitive support is the most poignant aspect of bereavement care, forming many of the memories that parents will take home with them ( Henley and Schott, 2010 ). Towards the end of the shift, she ruptured her membranes and sighed in relief, expressing gratitude, thinking the worst was over. The whole situation felt so unjust, why should she be thanking us. I felt as though she was being punished in some way; questioning why she should have to endure labour with no joy or happiness at the end. With the next contraction, tears rolled down both her cheeks as the reality of the situation took hold of her. I felt so unprepared to deal with the situation, so vulnerable, but I could not let it show. I knew the upset I was feeling was so minor in comparison. Shortly after she birthed her baby. He was so peaceful and content, so still. His tiny fingers and toes, his bottom lip curled under like he too felt the sadness both his mother and father were experiencing. I gently wrapped him in a towel before asking Amanda and John whether they would like to see and hold him.

Parents often regard holding and seeing their baby as one of their most important memories and Statham et al (2001) found that, of 104 women interviewed, 81% felt they made the right decision to hold their stillborn baby. A further study on over 2000 women, found that fewer anxiety and depressive symptoms resulted if women were able to see and hold their babies following a singleton stillbirth after 20 weeks' gestation ( Cacciatore et al, 2008 ). To separate newly bereaved mothers from their dead babies in order to relieve them of the burden of holding and seeing their baby and taking any responsibility for them was the cultural norm in Britain until relatively recently (Broderick and Cochrane, 2013). We now see the error in this reasoning and know that women and their partners value this time to spend with their babies ( Statham 2001 ; Broderick and Cochrane, 2013). It has been argued that giving parents the opportunity to see and hold their stillborn baby can reduce the risk of depression and anxiety resulting from the traumatic experience (Hughes et al, 2001). Conversely, Statham (2001) found that 50% of women who chose not to hold their baby also felt they had made the right decision, whilst Trulsson and Radestad (2004) argue that forcing parents to see and hold their stillborn baby has potential to increase the risk of negative psychiatric sequelae. It is therefore important that women and their partners are treated as individuals and given the correct information to help them make informed choices—a recommendation further supported by the National Institute for Health and Care Excellence (NICE) (2007) .

‘Giving parents the opportunity to see and hold their stillborn baby can reduce the risk of depression and anxiety resulting from the traumatic experience’

Amanda was reluctant to hold her baby initially as she began to process the situation. Instead John took hold of him and closely studied his baby from head to toe. He then gradually revealed his hands and feet to Amanda before gently placing him in her arms. It was nothing a textbook could prepare you for, those shivers you feel down your spine as well as the lump in your throat as you hear a mothers' grieving sob, or the haunting silence that no guideline or policy talks about. It felt as though the world had come to a standstill. I gently took a step back to allow Amanda and John the precious time with their baby boy.

While caring for Amanda initially brought feelings of anguish and worry, I feel that it was a positive act that enabled me to confront my fears surrounding bereavement and pregnancy loss. Despite the distressing nature of the experience, the opportunity has helped me to develop my midwifery practice in order to incorporate aspects that are imperative to bereavement care. Women are coming into hospital, usually the labour ward, where there are babies and new mothers surrounding them, therefore it is important for us as professionals to prepare ourselves for the myriad of reactions that women and their families will present following pregnancy loss.

There is also an element of self-care that is not widely discussed in midwifery literature. It involves acknowledging that women should not be left alone to grieve, but also balancing this with the appreciation of the emotional burden to the midwife that is offering their support ( Kenworthy and Kirkham, 2011 ). Although some consider bereavement care as ‘part of the job’, midwives, irrespective of their professional status, will carry personal and undoubtedly painful experiences of bereavement themselves, which means support between colleagues is fundamental in order to make a positive difference to the care that women receive, and also to reduce feelings of isolation. This support may simply involve a 10-minute debrief in the midwives office, or an in-depth reflection, both of which I feel impacted positively on my ability to care for Amanda throughout this experience.

Through non-verbal communication, midwives can take cues from individual women and respond accordingly. Simply gauging women on an individual basis and bearing in mind that some will want to talk and others simply want a shoulder to cry on or a hand to hold. Furthermore, a ‘memory box’ made up of various mementos, such as hospital bands, a measuring tape, knitted blanket and photos may be offered. While some research has suggested these are unhelpful in helping parents to feel resolution following bereavement, Davies (2004) argues that they can be beneficial.

It is important to be honest and open with women in a sensitive manner without undermining their wishes or beliefs. She will remember her midwife and although she may feel that her midwife has dealt with many of women in her position, she should feel that every effort is being made to meet her individual needs. This could be achieved, in part, by referring to her baby by their name or sex, acknowledging them as a being, thus making it personal to that woman and her family. But most importantly of all, it involves being empathetic and compassionate. Simply, just letting them know you are there without having to say a word.

Conclusions

This reflective case study is centred on my experience as a midwife at caring for Amanda, and her partner John, following a stillbirth at 27 weeks' gestation. It focuses on the emotional aspects of care that are often overlooked, which during bereavement take precedent over the physical skills we easily take for granted. It highlights simple measures that can be adopted to support bereaved parents, while at the same time supporting colleagues. Stillbirth should not be a taboo subject, considering rates, both in the UK and worldwide, are at alarming levels. While a number of stillbirths are unpredictable and therefore unavoidable, pregnancy supervision for those women at risk should be increased and improvements in research and training considered. This is as well as acknowledging the importance of individualised care, sensitive communication and advocacy, all of which are fundamental principles which we are bound to by the NMC Code (2008) .

‘There is a collective myth… that getting pregnant, staying pregnant, giving birth to a live baby… is simple, despite clear evidence that this is not the case’

• Open access
• Published: 28 August 2024

Facilitators and barriers of midwife-led model of care at public health institutions of dire Dawa city, Eastern Ethiopia, 2022: a qualitative study

• Mickiale Hailu 1 ,
• Aminu Mohammed 1 ,
• Daniel Tadesse 1 ,
• Neil Abdurashid 1 ,
• Legesse Abera 1 ,
• Samrawit Ali 2 ,
• Yesuneh Dejene 2 ,
• Tadesse Weldeamaniel 1 ,
• Meklit Girma 3 ,
• Tekleberhan Hailemariam 1 ,
• Netsanet Melkamu 1 ,
• Tewodros Getnet 1 ,
• Yibekal Manaye 1 ,
• Tariku Derese 1 ,
• Muluken Yigezu 1 ,
• Natnael Dechasa 1 &
• Anteneh Atle 1  

BMC Health Services Research volume  24 , Article number:  998 ( 2024 ) Cite this article

Metrics details

The midwife-led model of care is woman-centered and based on the premise that pregnancy and childbirth are normal life events, and the midwife plays a fundamental role in coordinating care for women and linking with other health care professionals as required. Worldwide, this model of care has made a great contribution to the reduction of maternal and child mortality. For example, the global under-5 mortality rate fell from 42 deaths per 1,000 live births in 2015 to 39 in 2018. The neonatal mortality rate fell from 31 deaths per 1,000 live births in 2000 to 18 deaths per 1,000 in 2018. Even if this model of care has a pivotal role in the reduction of maternal and newborn mortality, in recent years it has faced many challenges.

To explore facilitators and barriers to a midwife-led model of care at a public health institution in Dire Dawa, Eastern Ethiopia, in 2021.

Methodology

: A qualitative approach was conducted at Dire Dawa public health institution from March 1–April 30, 2022. Data was collected using a semi-structured, in-depth interview tool guide, focused group discussions, and key informant interviews. A convenience sampling method was implemented to select study participants, and the data were analyzed thematically using computer-assisted qualitative data analysis software Atlas.ti7. The thematic analysis with an inductive approach goes through six steps: familiarization, coding, generating themes, reviewing themes, defining and naming themes, and writing up.

Two major themes were driven from facilitators of the midwife-led model of care (professional pride and good team spirit), and seven major themes were driven from barriers to the midwife-led model of care (lack of professional development, shortage of resources, unfair risk or hazard payment, limited organizational power of midwives, feeling of demoralization absence of recognition from superiors, lack of work-related security).

The midwifery-led model of care is facing considerable challenges, both pertaining to the management of the healthcare service locally and nationally. A multidisciplinary and collaborative effort is needed to solve those challenges.

Peer Review reports

Introduction

A midwife-led model of care is defined as care where “the midwife is the lead professional in the planning, organization, and delivery of care given to a woman from the initial booking to the postnatal period“ [ 1 ]. Within these models, midwives are, however, in partnership with the woman, the lead professional with responsibility for the assessment of her needs, planning her care, referring her to other professionals as appropriate, and ensuring the provision of maternity services. Most industrialized countries with the lowest mortality and morbidity rates of mothers and infants are those in which midwifery is a valued and integral pillar of the maternity care system [ 2 , 3 , 4 , 5 ].

Over the past 20 years, midwife-led model of care (MLC) has significantly lowered mother and infant mortality across the globe. In 2018, there were 39 deaths for every 1,000 live births worldwide, down from 42 in 2015. From 31 deaths per 1,000 live births in 2000 to 18 deaths per 1,000 in 2018, the neonatal mortality rate (NMR) decreased. The midwifery-led care approach is regarded as the gold standard of care for expectant women in many industrialized nations, including Canada, Australia, the United Kingdom, Sweden, the Netherlands, Norway, and Denmark. Evidence from those nations demonstrates that women and babies who get midwife-led care, as opposed to alternative types of care, experience favorable maternal outcomes, fewer interventions, and lower rates of fetal loss or neonatal death [ 6 , 7 , 8 ].

In Pakistan, the MLC was accompanied by many challenges. Some of the challenges were political threats, a lack of diversity (midwives had no opportunities for collaborating with other midwives outside their institutions), long duty hours and low remuneration, a lack of a career ladder, and a lack of socialization (the health centers are isolated from other parts of the country due to relative geographical inaccessibility, transportation issues, and a lack of infrastructure). Currently, in Pakistan, 276 women die for every 100,000 live births, and the infant mortality rate is 74/1000. But the majority of these deaths are preventable through the midwife-led care model [ 7 ].

The MLC in African countries has faced many challenges. Shortages of resources, work overload, low inter-professional collaboration between health facilities, lack of personal development, lack of a well-functioning referral system, societal challenges, family life troubles, low professional autonomy, and unmanageable workloads are the main challenges [ 8 ].

Due to the aforementioned challenges, Sub Saharan Africa (SSA) is currently experiencing the highest rate of infant mortality (1 in 13) and is responsible for 86% of all maternal fatalities worldwide. As a result, it is imperative to look at the MLC issues in low-income countries, which continue to be responsible for 99% of all maternal and newborn deaths worldwide [ 8 , 9 ].

Ethiopia’s has a Maternal mortality rate (MMR) and NMR of 412 per 100,000 live births and 33 per 1000 live births, respectively, remain high, making Ethiopia one of the largest contributors to the global burden of maternal and newborn deaths, placed 4th and 6th, although MLC could prevent a total of 83% of all neonatal and maternal fatalities in an environment that supports it. The MMR & infant mortality rate (IMR) in the research area were indistinguishable from that, at 150 per 100,000 live births and 67 fatalities per 1,000 live births, respectively [ 10 , 11 , 12 , 13 ].

Since the Federal Ministry of Health is currently viewing midwifery-led care as an essential tool in reducing the maternal mortality ratio and ending preventable deaths of newborns, exploring the facilitators and barriers of MLC may have a great contribution to make in reducing maternal and newborn mortality [ 14 ]. Since there has been no study done in Ethiopia or the study area regarding the facilitators and barriers of MLC, the aim of this research was to explore the facilitators and barriers of MLC in Dire Dawa City public health institutions.

In so doing, the research attempted to address the following research questions:

What were the facilitators for a midwife-led model of care at the Dire Dawa city public health institution?

What were the barriers to a midwife-led model of care at the Dire Dawa city public health institution?

Study setting and design

Institutional based qualitative study was conducted from March 01-April 30, 2022 in Dire Dawa city. Dire Dawa city is one of the federal city administrations in Ethiopia which is located at the distance of 515killo meters away from Addis Ababa (the capital city) to the east. The city administration has 9 urban and 38 rural kebeles (kebeles are the smallest administrative unit in Ethiopia). There are 2 government hospitals, 5 private hospitals, 15 health centers, and 33 health posts. The current metro area population of Dire Dawa city is 426,129.Of which 49.8% of them are males and 50.2% females. The total number of women in reproductive age group (15–49 years) is 52,673 which account 15.4% of the total population. It has hot temperature with a mean of 25 degree centigrade [ 15 ].

Study population and sampling procedure

The source population for this study included all midwives who worked at Dire Dawa City public health facilities as well as key informants from appropriate organizations (the focal person for the Ethiopian Midwives Association and maternal and child health (MCH) team leaders). The study encompassed basically 41 healthcare professionals who worked in Dire Dawa public health institutions in total, and the final sample size was decided based on the saturation of the data or information.

From the total 15 Health centers and 2 Governmental Hospitals found in Dire Dawa city administration, 8 Health centers and 2 Governmental Hospitals were selected by non-probability purposive sampling method. In addition to that a non-probability convenience sampling method was used to select midwives who were working in Dire Dawa city public health institutions and key informants from the relevant organization such as Ethiopian midwives association focal person and MCH team leaders. Midwives who were working for at least six months in the institution were taken as inclusion criteria while those who were working as a free service were excluded from the study.

Data collection tool and procedures

Focus groups, in-depth interviews, and key informant interviews were used in collecting data. A voice recorder, a keynote-keeping, and a semi-structured interview tool were all used to conduct the interviews. Voluntary informed written consent was obtained from the study participant’s before they participated in the study. Then an in-depth interview and focus group discussion were held with midwives chosen from various healthcare organizations. The MCH department heads and the Dire Dawa branch of the Ethiopian Midwife Association served as the key informants. In-depth interview (IDI) and key informant interviews (KII) with participants took place only once and lasted for roughly 50–60 min. In the midwives’ duty room, the interview was held. Six to eight people participated in focus group discussions (FGD), which lasted 90 to 100 min. Two midwives with experience in gathering qualitative data gathered the information.

Data quality control

The qualitative design is prone for bias but open-ended questions were used to avoid acquiescence and 2 day proper training was given for the data collector regarding taking keynotes and recording using a tape recorder. For consistency and possible modification, a pretest was done in one FGD and In-depth interviews at non selected health institutions of Dire Dawa city administrations. A detailed explanation was given for the study participants about the objectives of the study prior to the actual data collections. All (FGDs, key informant interview and In-depth interviews) were taken in a silent place.

Data analysis

Atlas.ti7, a qualitative data analysis program, was used for analyzing the data thematically. An inductive approach to thematic analysis involves six steps: familiarization, coding, generation of themes, review of themes, defining and naming of themes, and writing up. By listening to the taped interview again, the data was transcribed. The participants’ well-spoken verbatim was used to extract and describe the inductive meanings of the statements. The data was then coded after that. Each code describes the concept or emotion made clear in that passage of text. Then we look at the codes we’ve made, search for commonalities, and begin to develop themes. To ensure the data’s accuracy and representation, the generated themes were reviewed. Themes were defined and named, and then the analysis of the data was written up.

Trustworthiness of data

Meeting standards of trustworthiness by addressing credibility, conformability, and transferability ensures the quality of qualitative research. Data triangulation, data collection from various sites and study participants, the use of multiple data collection techniques (IDI, KII, and FGD), multiple peer reviews of the proposal, and the involvement of more than two researchers in the coding, analysis, and interpretation decisions are all instances of the methods that were used in order to fulfill the criteria for credibility. To increase its transferability to various contexts, the study gave details of the context, sample size and sampling method, eligibility criteria, and interview processes. To ensure conformability, the research paths were maintained throughout the study in accordance with the work plan [ 16 , 17 ].

Background characteristics of the study participants

In this study, a total of 41 health care providers who are working in Dire Dawa public health facilities participated in the three FGDs, six KIIs, and fifteen IDIs. The years of experience of study participants range from one year to 12 years. The participants represented a wide age range (30–39 years), and the educational status of the respondents ranged from diploma to master’s degree. (Table  1 )

As shown in Table  2 , from the qualitative analysis of the data, two major themes were driven from facilitators of MLC, and seven major themes were driven from barriers to MLC. (Table  2 ).

Facilitators of midwife-led model of care at a public health institution of Dire Dawa city, Eastern Ethiopia, in 2021

Professional pride.

This study found that saving the lives of mothers and newborns was a strong facilitator. Specifically, it was motivational to have skills within the midwifery domain, such as managing the full continuum of care during pregnancy and labour, supporting women in having normal physiologic births, being able to handle complications, and building relationships with the women and the community, as mentioned below by one of the IDI participants.

“I am so proud since I am a midwife; nothing is more satisfying than seeing a pregnant mother give birth almost without complications. I always see their smile and happiness on their faces , especially in the postpartum period , and they warmly thank me and say , “Here is your child; he or she is yours.” They bless me a lot. Even sometimes , when they sew me in the transport area , cafeteria , or other area , they thank me warmly , and some of them also want to invite me to something else. The sum total of those things motivates me to be in this profession or to provide midwifery care.“ IDI participants.

This finding is also supported by other participants in FGD.

“We have learned and promised to work as midwives. We are proud of our profession , to help women and children’s health. The greatest motivation is that we are midwives , we love the profession , and we are contributing a great role in decreasing maternal and child mortality….” FGD discussant.

Good teamwork

The research revealed that good midwifery teamwork and good social interaction within the staff have become facilitators of MLC. FGD participants share their experiences of working in a team.

“In our facility , all the midwives have good teamwork; we have good communication , and we share client information accurately and timely. In case a severe complication happens , we manage it as a team , and we try to cover the gap if some of our staff are absent. Further from that , we do have good social interactions in the case of weeding , funeral ceremonies , and other social activities. We do have good team spirit; we work as a team in the clinical area , and we also have good social relationships. “If some of our staff gets sick or if she or he has other social issues , the other free staff will cover her or his task.” FGD discussant.

Another participant from IDI also shared the same experience regarding their good teamwork and their social interactions.

“As a maternal and child health team , we do have a good team spirit , not only with midwives but also with other professions. We are not restricted by the ward that we assign. If there is a caseload in any unit , some midwives will volunteer to help the other team. Most of the time in the night , we admit more than 3 or 4 labouring mothers at the same time. Since in our health center only one midwife is assigned in the night , we always call nurses to help us. This is our routine experience.” IDI participants.

Barriers of midwife-led model of care at a public health institution of Dire Dawa city, Eastern Ethiopia, in 2021

Lack of professional development.

This study revealed that insufficient opportunities for further education and updated training were the main barriers for MLC. Even the few trainings and update courses that were actually arranged were unavailable to them, either because they did not meet the criteria seated or because the people who work in administration were selected. Even though opportunities are not arranged for them to upgrade themselves through self-sponsored. One of the participants from IDI narrates her opinion about opportunities for further education as follows:

“Training and updates are not sufficient; currently we are almost working with almost old science. For example , the new obstetrics management protocol for 2021 has been released from the ministry of health , and many things have changed there. But we did not receive any training or even announcements. Even the few trainings and update courses that were truly organized and turned in to us are unavailable since the selection criteria are not fair. As a result , we miss those trainings either because we did not meet the selection criteria or because those who work in administration are prioritized.” IDI participant.

FGD discussants also support this idea. She mentioned that even though opportunities are not arranged for them to upgrade themselves through self-sponsorship,

“There is almost no educational opportunity in our institution. Every year , one or two midwives may get institutional sponsorship. Midwives that will be selected for this opportunity are those who have served for more than five to ten years. Imagine that to get this chance , every midwife is expected to serve five or more years. Not only this , even if staff want to learn or upgrade at governmental or private colleges through self-sponsored programmes , whether at night or in an extension programme , they are not cooperative. Let me share with you my personal experience. Before two years , I personally started my MSc degree at Dire Dawa University in a weekend programme , and I have repeatedly asked the management bodies to let me free on weekends and to compensate me at night or any time from Monday to Friday. Since they refuse to accept my concern , I withdraw from the programme.“ FGD discussant.

Shortage of resource

The finding indicates that a shortage of equipment, staff, and rooms or wards was a challenge for MLC. Midwives claimed they were working with few staff, insufficient essential supplies, and advanced materials. This lack of equipment endangers both the midwives and their patients. One of the participants from IDI narrates her opinion about the shortage of resources as follows:

“Of course there is a shortage of resources in our hospital , like gloves and personal protective devices. Even the few types of medical equipment available , like the autoclave , forceps , vacuum delivery couch , and BP apparatus , are outdated , and some of them are unfunctional. If you see the Bp apparatus we used in ANC , it is digital but full of false positives. When I worked in the ANC , I did not trust it and always brought the analogue one from other wards. This is the routine experience of every staff member.“ IDI participants.

Another participant from IDI also shared the same experience regarding the crowdedness of rooms or wards.

“In our health center , there are no adequate wards or rooms. For example , the delivery ward and postnatal ward are almost in one room. Postnatal mothers and neonates did not get enough rest and sleep because of the sound of laboring mothers. Not only is this , but even the antenatal care and midwifery duty rooms are also very narrow.“ IDI participants.

The study also revealed midwifery staff were pressured to work long hours because they were understaffed, which in turn affected the quality of midwifery care. The experience of a certain midwife is shared as follows:

“I did not think that the management bodies understood the risk and stress that we midwives face. They did not want to consider the risk of midwives even equal to that of other disciplines but lower than the others. For example , in our health centre , during the night , only one midwife is assigned for the next 12 hours , but if you see in the nurse department , two or more nurses are assigned at night in the emergency ward.” IDI participants.

The discussion affirms the fact that being understaffed and not having an adequate allocation of midwife professionals on night shifts are affecting labouring mothers’ ability to get sufficient health midwifery care. The above narration is also supported by the FGD discussant.

“In our case , only one midwife is assigned to the labour ward during the night shift. I think this is the main challenge for midwives that needs attention. Let me share with you my experience that happened months before. While I was on night shift , two labouring mothers were fully dilated within three or four minutes. It was very difficult for me , to manage two labouring mothers at the same time. Immediately , I call one of my nurse friends from the emergency department to help me. If my friend was so busy , what could happen to the labouring mother and also to me? This is not only my experience but also the routine experience of other midwives.” FGD discussant.

Unfair risk or hazard payments

It is reported that the compensation amount paid for risk is lower than in other health professions. The health risks are not any less, but the remuneration system failed to capture the need to fairly compensate midwifery professionals. The narration from the FGD discussant regarding unfair payment is mentioned below.

“Only 470 ETB is paid for midwives as risk payments , which is incomparable with the risks that midwives are facing. But contrary to that , the risk payments for nurses (in emergencies) are about 1200 Ethiopian birr (ETB) , and Anesthesia is 1000 ETB. I did not want to compare my profession with other disciplines , but with the lowest cost , how the risk of midwifery cannot be equal to that of nursing and other professions. I did not know whose professionals made such types of unfair decisions and with what scientific background or base this calculation was done . ” FGD discussant.

The above finding is also supported by an IDI participant.

“………………………….Even though the midwifery profession is full of risks , with the current Ethiopian health care system , midwives are being paid the lowest risk payments compared to other disciplines…………….” IDI participants.

Limited organizational power of midwives

Midwives’ interviews reported that limited senior midwifery positions in the health system have become the challenge of midwifery care. This constrains the decision-making power and capability of midwives. This was compounded by limited opportunities for midwifery personnel to address their concerns to the responsible bodies, as stated by one of the key informants.

“Our staff has many concerns , especially professional-related concerns , which can contribute to the quality of midwifery care. Personally , as department head , I have tried to address those concerns in different management meetings at different times. But since the leadership positions are dominated by other disciplines , many of our staff concerns have not been solved yet. But let me tell you my personal prediction… If those concerns are not solved early and if this trend continues , the quality of midwifery care will be in danger.“ Participant from Key Informant.

The above finding is also supported by another IDI participant.

“In our hospital , at every hierarchal and structural level , midwives are not well represented. That is why all of our challenges or concerns have not been solved yet. For example , as a structure in the Dire Dawa Health Office (DDHO) , there is a team of management related to maternal and child health. But unfortunately , those professionals working there are not midwives. I was one of three midwives chosen to meet with Dr. X (former DDHO leader) to discuss this issue. At the time , we were reaching an agreement that two or three midwives would be represented on that team. But since a few months later the leader resigned , the issue has not gotten a solution yet.“ IDI participant.

Feeling of demoralization

One of the main concerns reported by the participants during the interviews was a feeling of demoralization induced by both their clients and their supervisors about barriers to midwifery care. They reported having been verbally abused by their patients, something that made them feel that their hard work was being undermined, as stated by an FGD participant.

“I don’t think there is any midwife who would be happy for anybody to lose their baby , or that there is any midwife who would want a woman to die. These things are accidents , but the patient and leaders will always blame the midwife.” FDG discussant.

A narration from an IDI participant also mentioned the following:

“……….If something happens , like a conflict with the patients or clients , the management is on the patient side. Not only that , the way in which they communicate with us is in an aggressive or disrespectful manner . ” IDI participant.

Absence of recognition or /motivation from superiors

This study revealed that midwives experience a loss of motivation at work due to limited support from their superiors. Their effort is used only for reporting purposes. A midwife from FGD shared her experience as follows.

“In our scenario , till the nearest time , the maternal and child health services are provided in a good way. But this was not easy; it is the cumulative effort of midwives. But unfortunately , only those in managerial positions are recognized. Nothing was done for us despite our efforts. To me , our efforts are used only for reporting purposes.” FGD discussant.

This finding was also supported by IDI participants.

“Even though we have good achievements in the MCH services , there is no motivation mechanism done to motivate midwives.” But if something or a minor mistake happens , they are on the front lines to intimidate us or write a warning letter. Generally , their concern is a report or a number issue. We are tired of such types of scenarios.” IDI participant.

Insufficient of work-related security

One of the main concerns reported by the participants during the interviews was the work related security, which has become a challenge for MLC. The midwives’ work environment was surrounded by insecurity, especially during night shifts, when midwives were facing verbal and even physical attack, as mentioned by participants.

“In the labour ward , especially at night , we face many security-related issues. The families of labouring mothers , especially those who are young , are very aggressive. Sometimes they even want to enter the delivery room. They did not hear what we told them to do , but if they hear any labour sounds from their family , they disturb the whole ward. This leads to verbal abuse , and sometimes we face physical abuse. There may be one or two security personnel at the main gate , but since the delivery ward is far from the main gate , they do not know what is happening in the delivery ward. When things become beyond our scope , we call security guards. Immediately after the security guards go back , similar things will continue. What makes it difficult to manage such situations is that only one midwife is assigned at night , and labouring mothers will not get quality midwifery care.” IDI participant.

FGD discussants also shared their experience that their working environment is full of insecurity.

“In case any complications occur , especially at night , it is very difficult to tell the labouring mother’s family or husband unless we call security personnel. It is not only swearing that we face but also that they intimidate us.” FDG discussant.

Discussions

The aim of this study was to explore facilitators’ and barriers to a midwifery-led model of care at Dire Dawa public health facilities. In this study, professional pride was the main facilitator of the midwifery-led model of care. Another qualitative study that examined the midwifery care challenges and factors that motivate them to remain in their workplace lends confirmation to this conclusion. It was found that a strong feeling of love for their work was the main facilitator’s midwifery-led model of care [ 9 ]. Having a good team spirit was also another facilitator’s midwifery-led model of care in our study. Another study’s findings confirmed this one, which emphasizes that building relationships with the midwives, women, and community was the driving force behind providing midwifery care [ 7 , 18 ].

The midwives in this study expressed a need for additional professional training, updates, and competence as part of their continuing professional development. Similar findings have been reported in the worldwide literature that midwives were struggling for survival due to a lack of limited in-service training opportunities to improve their knowledge and skills [ 19 ]. This phenomenon does not seem to differ between settings in high-, middle-, and low-income countries [ 7 , 9 , 18 ], in which midwives experienced difficult work situations due to a lack of professional development to autonomously manage work tasks, which made them feel frustrated, guilty, and inadequate. As such, this can contribute to distress and burnout, which in turn prevent midwives from being able to provide quality care and can eventually cause them to leave the profession [ 19 ].

Shortages of resources (shortage of staff, lack of physical space, and equipment) were the other reported barriers to midwifery care explored in this study. They reported that they are working in an environment with a shortage of resources, which leads to poor patient outcomes. This finding is supported by many other studies conducted around the globe [ 20 , 21 , 22 , 23 ]. Another qualitative finding, which likewise supports the aforementioned finding, which emphasizes that a shortage of resources was reported as a barrier to providing adequate midwifery care [ 19 ]. Delivery attended by skilled personnel with appropriate supplies and equipment has been found to be strongly associated with a reduction in child and maternal mortality [ 24 ].

The feeling of demoralization and lack of motivation from their superiors were other barriers to midwifery care explored in this study. This finding is concurrent with other studies conducted around the globe [ 19 , 25 , 26 , 28 ]. The above finding is also is in accord with another qualitative narration, which emphasizes that feelings of demoralization and a lack of motivation were the main challenges of midwifery care [ 22 ]. Positive support from supervisors has been demonstrated to be important for the quality of services that health workers are able to deliver. In the World Health Organization’s report on improving performance in healthcare, the WHO stresses that supportive supervision can contribute to the improved performance of health workers [ 27 ].

Unfair risk payment was the other challenge identified by the current study. Even though there is no difference in the risk they face among health professionals, the risk payment for midwives is very low compared to others. This finding was in conformity with another qualitative narration, which emphasizes that the lack of an equitable remuneration system was experienced by the DRC midwives, and it has also been confirmed to be highly problematic in other studies in low- and middle-income settings [ 7 , 8 , 22 , 28 ], leading to serious challenges. In settings where salaries are extremely low or unpredictable, proper remuneration is seen as crucial to worker motivation and the quality of midwifery care [ 29 , 30 ].

The limited organizational power of midwives was another identified challenge of MLC. This finding was in step with other studies that emphasize that limited senior midwifery positions in the health system constrain the decision-making power and capability of midwives. This was compounded by limited opportunities for midwifery personnel to address their concerns to the responsible bodies. Hence, midwives need to take control of their own situations. When midwives are included in customizing their work environments, it has proven to result in improved quality of care for women and newborns around the globe [ 8 , 15 ].

Lack of work-related security was another barrier to MLC explored in this study, in which the midwives’ work environment was surrounded by insecurity, especially during night shifts, when midwives are facing verbal and even physical attack, as mentioned by participants. This finding is supported by many other studies conducted around the globe [ 22 , 23 , 25 , 31 ]. The above finding is also in agreement with another qualitative narration, which emphasizes that the midwives’ work environment was surrounded by insecurity, especially during night shifts due to a lack of available security personnel; they often felt frightened on their way to and from work [ 7 ]. In order for midwives to provide quality care, it is crucial to create supportive work environments by ensuring sufficient pre-conditions, primarily security issues [ 31 ].

Conclusions

The study findings contribute to a better understanding of the facilitators’ and barriers of a midwifery-led model of care in the case of Dire Dawa public health facilities. Professional pride and having good team spirit were the main facilitators of midwifery-led model care. Contrary to that, insufficient professional development, shortage of resources, feeling of demoralization, lack of motivation, limited organizational power of midwives, unfair risk payment, and lack of work-related security were the main barriers to a midwifery-led model of care in the case of Dire Dawa public health facilities. Generally, midwifery care is facing considerable challenges, both pertaining to the management of the healthcare service locally and nationally.

Study implications

The findings of the study have implications for midwifery care practices in Eastern Ethiopia. Addressing these areas could potentially contribute to the reduction of IMR and MMR.

Strengths and limitations

The first strength of the study is that the participants represented different healthcare facilities, both urban and rural, thereby offering deeper and more varied experiences and reflections. A second strength is using a midwife as a moderator. She or he understood the midwives’ situation, thereby making the participants feel more comfortable and willing to share their stories. However, focusing solely on the perspective of the midwives is a limitation.

Recommendations

To overcome the barriers of midwifery care, based on the result of this study and in accordance with the 2020 Triad Statement made by the International Council of Nurses, the International Confederation of Midwives, and the World Health Organization, it is suggested that policymakers, Ethiopian federal ministry of health, Dire dawa health office, and regulators in Dire Dawa city and settings with similar conditions coordinate actions in the following:

To the Ethiopian federal ministry of health (FMOH)

Should strengthen regular and continuous educational opportunities, trainings, and updates for midwives, prioritizing and enforcing policies to include adequate and reasonable remuneration and hazard payment for midwives. Support midwifery leadership at all levels of the health system to contribute to health policy development and decision-making.

To dire Dawa health Bureau

Ensure decent working conditions and an enabling environment for midwives. This includes reasonable working hours, occupational safety, safe staffing levels, and merit-based opportunities for career progression. Special efforts must be made to ensure safe, respectful, and enabling workplaces for midwives operating on the night shift. Midwifery leaders should be involved in management bodies within an appropriate legal framework. Made regular mentorships on the functionality of different diagnostic instruments in respective health facilities.

To Dire Dawa public health facility’s

Create an arena for dialogue and implement a more supportive leadership style at the respective health facilities. Should address professional-related concerns of midwives early. Ensure midwives’ representation at the management bodies. Ensure the selection criteria for educational opportunities and different trainings are fair and inclusive. Ensure the safety and security of midwives, especially those who work night shifts. Should assign adequate staff (midwives and security guards) to the night shifts.

Ethiopian midwifery association

Should influence different stakeholders to solve midwife’s concerns like hazards payment and educational opportunity.

Data availability

All the datasets for this study are available from the corresponding author upon request.

Abbreviations

Focused group discussion

In-depth interview

Infant mortality rate

Key informant interview

Maternal and child health

Midwives led model of care

Neonatal mortality rate

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Acknowledgements

We are very grateful to Dire Dawa University for the financial support for this study and to the College of Medicine and Health for its monitoring ship. All study participants for their willingness to respond to our questionnaire.

this work has been funded by Dire Dawa University for data collection purposes. The Dire Dawa University College of Medicine and Health Sciences was involved in the project through monitoring and evaluation of the work from the beginning to the result submission. However, this organization was not involved in the design, analysis, critical review of its intellectual content, or manuscript preparation, and its budget did not include publication.

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College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia

Mickiale Hailu, Aminu Mohammed, Daniel Tadesse, Neil Abdurashid, Legesse Abera, Tadesse Weldeamaniel, Tekleberhan Hailemariam, Netsanet Melkamu, Tewodros Getnet, Yibekal Manaye, Tariku Derese, Muluken Yigezu, Natnael Dechasa & Anteneh Atle

College of Health Sciences, Wachemo University, Hossana, Ethiopia

Samrawit Ali & Yesuneh Dejene

College of Health Sciences, Mekelle University, Mekelle, Ethiopia

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Contributions

MH developed the study proposal, served as the primary lead for study implementation and data analysis/interpretation, and was a major contributor in writing and revising all drafts of the paper. AM, DT, NA, LA, and SA supported study implementation and data analysis, and contributed to writing the initial draft of the paper. YD, TW, MG, TH and, NM supported study recruitment and contributed to writing the final draft of the paper. TG, YM, TD, MY, ND and, AA conceptualized, acquired funding, and led protocol development for the study, co-led study implementation and data analysis/interpretation, and was a major contributor in writing and revising all drafts of the paper. All authors contributed to its content. All authors read and approved the final manuscript.

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Correspondence to Mickiale Hailu .

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All methods were followed in accordance with relevant guidelines and regulations. The institutional review board of Dire Dawa University has also examined and evaluated it for its methodological approach and ethical concerns. Ethical clearance was obtained from Dire Dawa University Institutional Review Board and an official letter from research affairs directorate office of Dire Dawa University was submitted to Dire Dawa health office and it was distributed to selected health institutions. Voluntary informed written consent was obtained from the study participant’s right after the objectives of the study were explained to the study participants and confidentiality of the study participants was assured throughout the study period. Participants were informed that they have the right to terminate the discussion (interview) or they can’t answer any questions they didn’t want to answer.

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Hailu, M., Mohammed, A., Tadesse, D. et al. Facilitators and barriers of midwife-led model of care at public health institutions of dire Dawa city, Eastern Ethiopia, 2022: a qualitative study. BMC Health Serv Res 24 , 998 (2024). https://doi.org/10.1186/s12913-024-11417-x

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Received : 03 September 2023

Accepted : 09 August 2024

Published : 28 August 2024

DOI : https://doi.org/10.1186/s12913-024-11417-x

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