Safety of Non-Medically Led Primary Maternity Care Models: A Critical Review of the International Literature
McIntyre, Meredith J., Australian Health Review
Abstract. The Australian government has announced major reforms with the move to a primary maternity care model. The direction of the reforms remains contentious; with the Australian Medical Association warning that the introduction of non-medically led services will compromise current high standards in maternity services and threaten the safety of mothers and babies. The purpose of this paper is to conduct a critical review of the literature to determine whether there is convincing evidence to support the safety of non-medically led models of primary maternity care. Twenty-two non-randomised international studies were included representing midwifery-led care, birth centre care and home birth. Comparative outcome measurements included: perinatal mortality; perinatal morbidity; rates of medical intervention in labour; and antenatal and intrapartum referral and transfer rates. Findings support those of the three Cochrane reviews, that there is sufficient international evidence to support the conclusion of no difference in outcomes associated with low risk women in midwiferyled, birth centre and home birth models compared with standard hospital or obstetric care. These findings are limited to services involving qualified midwives working within rigorous exclusion, assessment and referral guidelines, limiting the number of urgent intrapartum transfers that come with increased risk of perinatal mortality.
What is known about the topic? Systematic reviews of maternal and perinatal outcomes associated with midwifery-led care when compared to conventional intrapartum hospital care concluded that these non-medically led models of care are associated with several benefits for low risk women and their babies with no identified adverse effects.
Whatdoes this paper add? The finding of no difference in outcomes associated with midwifery-led, birth centre and home birth compared with standard hospital or obstetric care is limited to international studies involving women in the care of qualified midwives working within rigorous guidelines for practice involving inter-professionally agreed exclusion, assessment and referral criteria.
What are the implications for practitioners? Midwives caring for women in non-medically led models are urged to be vigilant to the need for early detection and prompt action in the event of unforseen complications to avoid an over emphasis on normality. This decreases the likelihood of urgent intrapartum transfers that come with an increased risk of perinatal mortality.
Additional keywords: antenatal and intrapartum transfer rates, birth centre, home birth, midwifery-led, perinatal mortality and morbidity.
Received 29 April 2011, accepted 16 August 2011, published online 25 May 2012
The Australian government has announced a major program of reform with the move to a primary maternity care model in response to the need to achieve a balance between safety and improvingwomen's experience associated with giving birth.1 It is argued that the current model of maternity care, characterised by an obstetric monopoly2 is deemed to be unnecessarily costly and associated with a negative effect on the health of women.3-5 A main driver for reform is the need to curtail the financial extravagance associated with the majority of women reasonably expected to give birth without medical intervention being allocated the same expensive resources as women who require specialist medical care to give birth safely.1 The direction of the reforms does not come with consensus agreement within the key stakeholder group.6 The agenda for change has been influenced by a strong consumer voice,7 the Australian College of Midwives (ACM) and persuasive rural alliances advocating for women's right to choose the maternity care that best suits their needs near to where they live.4,8 The Australian Medical Association (AMA) has challenged the direction of the reforms, warning that the introduction of non-medically led services will compromise current high standards in maternity services and threaten the safety of mothers and babies. …