Safety of Non-Medically Led Primary Maternity Care Models: A Critical Review of the International Literature
McIntyre, Meredith J., Australian Health Review
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.6 The Royal Australian and New Zealand College of Obstetrics and Gynaecologists warns that no pregnancy or labour is without risk and that only they have the training and expertise for safe birth outcomes to be achieved.9
This critical review of the international literature was undertaken to determine whether there is convincing evidence in support of safety to mothers and babies associated with nonmedically led primary maternity models of care.
A search of research articles between 2004 and 2011 was conducted on MEDLINE and CINHAL using the following keywords: primary maternity care, birth, midwifery, birth centre, home birth, outcomes, perinatal morbidity, mortality. CINAHL is the primary resource for international research articles related to midwifery. MEDLINE is the mainstream database for international medical papers. The author confined the search to peer-reviewed articles published in English available online in full text. The review also included Australian Government publications pertinent to the proposed reform. The years 2004-11 were selected as they coincide with a series of new maternity service policies generated by Australian states and territories. Several studies have reported findings of consumer satisfaction related to models of maternity care10-15 and this work is not duplicated in this study.
Atotal of 22 Australian and international research studies met the selection criteria in addition to three systematic reviews from the Cochrane Collaboration. Studies included: midwifery-led (n = 7), birth centre (n = 8), home birth (n = 7).Asummary of the research studies including sample sizes are provided in Table 1.
Criteria for inclusion were confined to studies reporting one or more of the four chosen outcome measures. Several studies were excluded from the review as they did not report on any of these outcome measures.
Outcome measures and analysis
Four general outcome measures were examined: perinatal mortality, and morbidity (n = 15), birth intervention (n = 11) and transfer rates (n = 6). Types of measurement included: rates of perinatal morbidity and perinatal mortality in otherwise healthy term infants (baby), rates of medical intervention in labour (mother) or transfer rates (mother or baby) inclusive of clinical indications for transfer. Perinatal morbidity is defined as any term infant in the absence of congenital abnormality requiring admission to special care nursery or the neonatal intensive care unit.16
Maternal mortality and morbidity has not been included as a measurement in this paper as maternal mortality is such a rare event that comparisons do not result in useful conclusions and maternal morbidity has been reported in another study. …