The Midwives Model of Care

The Midwives Model of Care is based on the fact that pregnancy and birth are normal life processes.

The Midwives Model of Care includes:

The application of this woman-centered model of care has been proven to reduce the incidence of birth injury, trauma, and cesarean section.
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Midwife-led versus other models of care for childbearing women

Midwife-led care confers benefits for pregnant women and their babies and is recommended.

In many parts of the world, midwives are the primary providers of care for childbearing women. Elsewhere it may be medical doctors or family physicians who have the main responsibility for care, or the responsibility may be shared. The underpinning philosophy of midwife-led care is normality and being cared for by a known and trusted midwife during labour. There is an emphasis on the natural ability of women to experience birth with minimum intervention. Some models of midwife-led care provide a service through a team of midwives sharing a caseload, often called 'team' midwifery. Another model is 'caseload midwifery', where the aim is to offer greater continuity of caregiver throughout the episode of care. Caseload midwifery aims to ensure that the woman receives all her care from one midwife or her/his practice partner. By contrast, medical-led models of care are where an obstetrician or family physician is primarily responsible for care. In shared-care models, responsibility is shared between different healthcare professionals.

The review of midwife-led care covered midwives providing care antenatally, during labour and postnatally. This was compared with models of medical-led care and shared care, and identified 11 trials, involving 12,276 women. Midwife-led care was associated with several benefits for mothers and babies, and had no identified adverse effects. The main benefits were a reduced risk of losing a baby before 24 weeks. Also during labour, there was a reduced use of regional analgesia, with fewer episiotomies or instrumental births. Midwife-led care also increased the woman's chance of being cared for in labour by a midwife she had got to know. It also increased the chance of a spontaneous vaginal birth and initiation of breastfeeding. In addition, midwife-led care led to more women feeling they were in control during labour. There was no difference in risk of a mother losing her baby after 24 weeks. The review concluded that all women should be offered midwife-led models of care.

[Intervention Review]
Midwife-led versus other models of care for childbearing women

Marie Hatem², Jane Sandall¹, Declan Devane³, Hora Soltani⁴, Simon Gates⁵

¹Health and Social Care Research Division, King's College, London, UK. ²Département de médecine sociale et préventive, Université de Montréal, Montréal, Canada. ³School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland. ⁴Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK. ⁵Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK

Contact address: Jane Sandall, Health and Social Care Research Division, King's College, Waterloo Bridge Wing, 150 Stamford Street, London, SE1 9NH, UK. jane.sandall@kcl.ac.uk. (Editorial group: Cochrane Pregnancy and Childbirth Group.)

Cochrane Database of Systematic Reviews, Issue 2, 2009 (Status in this issue: Edited, commented)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DOI: 10.1002/14651858.CD004667.pub2
This version first published online: 8 October 2008 in Issue 4, 2008. Re-published online with edits: 15 April 2009 in Issue 2, 2009. Last assessed as up-to-date: 2 May 2008. (Help document - Dates and Statuses explained).

This record should be cited as: Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub2.

Midwives are primary providers of care for childbearing women around the world. However, there is a lack of synthesised information to establish whether there are differences in morbidity and mortality, effectiveness and psychosocial outcomes between midwife-led and other models of care.

To compare midwife-led models of care with other models of care for childbearing women and their infants.

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2008), Cochrane Effective Practice and Organisation of Care Group's Trials Register (January 2008), Current Contents (1994 to January 2008), CINAHL (1982 to August 2006), Web of Science, BIOSIS Previews, ISI Proceedings, (1990 to 2008), and the WHO Reproductive Health Library, No. 9.

All published and unpublished trials in which pregnant women are randomly allocated to midwife-led or other models of care during pregnancy, and where care is provided during the ante- and intrapartum period in the midwife-led model.

All authors evaluated methodological quality. Two authors independently checked the data extraction.

We included 11trials (12,276 women). Women who had midwife-led models of care were less likely to experience antenatal hospitalisation, risk ratio (RR) 0.90, 95% confidence interval (CI) 0.81 to 0.99), the use of regional analgesia (RR 0.81, 95% CI 0.73 to 0.91), episiotomy (RR 0.82, 95% CI 0.77 to 0.88), and instrumental delivery (RR 0.86, 95% CI 0.78 to 0.96) and were more likely to experience no intrapartum analgesia/anaesthesia (RR 1.16, 95% CI 1.05 to 1.29), spontaneous vaginal birth (RR 1.04, 95% CI 1.02 to 1.06), to feel in control during labour and childbirth (RR 1.74, 95% CI 1.32 to 2.30), attendance at birth by a known midwife (RR 7.84, 95% CI 4.15 to 14.81) and initiate breastfeeding (RR 1.35, 95% CI 1.03 to 1.76). In addition, women who were randomised to receive midwife-led care were less likely to experience fetal loss before 24 weeks' gestation (RR 0.79, 95% CI 0.65 to 0.97), and their babies were more likely to have a shorter length of hospital stay (mean difference -2.00, 95% CI -2.15 to -1.85). There were no statistically significant differences between groups for overall fetal loss/neonatal death (RR 0.83, 95% CI 0.70 to 1.00), or fetal loss/neonatal death of at least 24 weeks (RR 1.01, 95% CI 0.67 to 1.53).

All women should be offered midwife-led models of care and women should be encouraged to ask for this option.

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What Does Breech Mean?

For those who haven't heard, babies are supposed to be born head first. Since this is the largest part of their body, this makes for the easiest birthing process- once a newborn's head and shoulders are delivered, the rest of their body generally follows pretty quickly.

A breech "presentation" simply means a baby who is not head-down. The baby can be sitting buttocks or feet first. The definition of breech is further divided into categories by which direction, mother's front or back, the baby is facing.

Possible Outcomes

Very few doctors in the United States will deliver your baby vaginally if it is breech. Most doctors are not being trained in this technique anymore, even though a generation ago, delivering a breech baby vaginally was relatively normal. The vast majority, ninety-five percent, of breech babies delivered vaginally have no complications. If assistance is needed by a medical professional, it usually consists of turning the baby in the birth canal manually or the use of forceps. At times, an episiotomy needs to be made to assist in the baby's birth.

If you are seeing a typical American OBGYN, you have very little chance of even attempting to deliver a breech baby vaginally. The doctor will insist on delivering the baby via cesarean section.One possible risk of turning a breech baby is that they may still turn back to being breech again after they have been turned.

Midwives all over the world (including the U.S.) have other ideas about breech babies, including considering this presentation a variation of normal.

10 Ways to Turn a Breech Baby

Most ideas we researched seemed far-fetched, at best, but we tried some of them. When you come to the end of your rope, you'll try anything, far-fetched or not. For the sake of relevancy, I'll start with the most reasonable and proven methods, and move to the more obscure and questionable.

External Celphalic Version

External celphalic version, or version, is the procedure used to turn a breech or side-lying baby to a head-down position before labor starts. When the attempt is successful, a version makes it possible to attempt a vaginal delivery. A version is usually attempted at 36 or 37 weeks. A version should only be attempted in a hospital by a doctor with the help of ultrasound equipment and fetal monitoring. External celiac version has a success rate of 58% and is quite painful.

Webster's Technique

The Chiropractic Journal, a publication of the World Chiropractic Alliance, reports, "The Webster Technique, discovered by Dr. Larry Webster, founder of the International Chiropractic Pediatric Association (ICPA), is a specific chiropractic adjustment for pregnant mothers. It is a chiropractic technique designed to relieve the causes of intrauterine constraint." The Webster Technique has been in practice for over 20 years. The Journal of Manipulative and Physiological Therapeutics reported in the July/August 2002 issue that 82% of doctors using the Webster Technique reported success.

This is the method that ended up working for us! The Webster Technique does require multiple attempts over about two weeks. In my case, my daughter turned over after only one visit, one day before my scheduled version attempt.

The Breech Tilt

Some women believe that you can lie at an angle, either on a board or ironing board, with your head down and feet up and help the baby to turn over this way. The theory is that this angle helps the baby tuck their head, thus making it easier for them to flip over, like doing a somersault. Supporters recommend doing this fifteen to twenty minutes two to three times a day as early as 32 weeks and until the baby turns head down.

Massage

This method can be used alone or in combination with other ideas mentioned here, such as the "breech tilt". This is simply rubbing both hands wide and flat around the belly in the direction you want the baby to turn. Both hands should stay opposite each other and move circularly, around the baby.

Yoga

Yoga is an ancient system of breathing practices, physical exercises and postures, andmeditationbelieved to unite the practitioner's body, mind, and spirit. Certain yoga poses are believed to help a breech baby turn head down. These include kneeling on all fours with shoulders against the floor and buttocks up in the air, giving more space to the abdomen and rib cage for baby to move; laying with a pillow under your pelvis to raise your hips higher than your head, as well as a variety of inverse positions.

Acupuncture

Believers in the practice of acupuncture think that the insertion of disposable needles, just under the skin, can release or balance energy in the body. If you would like to seek the avenue of acupuncture, you will need to find an experienced, licensed practitioner. Acupuncturists believe that the release of energy can help the baby find a better position by allowing the mother's body to relax so that baby can position itself properly for birth.

Cold at the Top of the Uterus

It's possible that placing an ice pack (do not place directly on your skin) or even a frozen bag of peas against the top of your uterus may cause your baby to attempt to turn it's head away from the cold temperature.

Music at the Pubic Bone

Some believe the playing music (through headphones or a small speaker) near the pubic bone may cause your baby to attempt to turn towards the music. In essence, you're showing your baby through music which way to move.

Light Near Pubic Bone

On the same note, a bright light can be shown against the skin near the pubic bone. Babies can see light, such as bright sunlight, through their mother's skin, uterus, and amniotic fluid. It's possible that they may see a point of bright light as well. Light could either be held in one place near the pubic bone, or moved repeatedly from the top to the bottom of the belly.

Visualization

This technique, of course, can be used in conjunction with any of the methods above. Some mothers find it helpful to imagine their baby in their womb and picture the baby turning over. This is best done while relaxed and with your eyes closed.

Violet ended up being born without the intervention of c-section. I credit God answering prayer and the chiropractic Webster's technique with our personal success story. My midwife and doctor were amazed at how quickly she turned to the head down position, even the chiropractor was surprised.Here's wishing you the best with your own breech baby story!