Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care

Poor-quality maternal and newborn care is associated with maternal mortality, stillbirths, and infant deaths and contributes to acute and chronic clinical and psychological morbidity for women who survive. Midwifery care can make an essential contribution to high-quality maternal and newborn services. The participation of educated, trained, motivated, and respected licensed midwives, working effectively with medical and public health colleagues, is associated with a rapid and sustained decrease in maternal and newborn mortality and an improvement in quality of care. A multimethod approach was used to assess the key concepts of quality in maternal and newborn care including safe, effective, accessible, appropriate, affordable, equitable, efficient, and woman-centered care. A framework for quality maternal and newborn care was devised, using the best evidence for effective care practices. This evidence was used to assess the potential effect of midwifery and the workforce groups best able to provide midwifery care.

Essential interlinked components of the framework were effective practices, organization of care, philosophy, and values of the care providers working in the health system and characteristics of care providers. Interdisciplinary teamwork and collaboration are inherent in implementing the framework. Women’s views and experiences show the interrelationship between the different components of quality care. Information and education are essential to allow them to learn for themselves. They need to know and understand the organization of services so they can access them in a timely fashion, services need to be provided in a respectful way by staff who generate trust and who are not abusive or cruel, and care should be personalized to their individual needs and offered by empathic and kind providers. Women want health professionals who combine clinical knowledge and skills with interpersonal and cultural competence.

Two sources within the Cochrane Library identified high-quality, current evidence on effectiveness of specific practices in maternal/newborn care. Effective practices related to categories of the framework found that 46 (38%) of the 122 effective practices were relevant for all childbearing women and infants, with 26 (21%) being first-line management for women and infants with complications. Fifty practices (41%) required the input of a medical practitioner with advanced skills in obstetrics, neonatology, or medicine. The practice categories of (1) education, information, health promotion; (2) assessment, screening care planning; (3) promotion of normal processes and preventing complications; and (4) first-line management of complications were identified as being within the scope of midwifery. Seventy-two (59%) of the 122 effective practices were within this scope. Outcomes improved by effective practices by midwives include reduced maternal and neonatal mortality and fetal loss, reduced maternal and neonatal morbidity including preterm birth, reduced use of interventions, improved psychosocial outcomes, improved public health outcomes, and improved organizational outcomes.

The 72 effective practices were examined to determine whether they portrayed the cross-cutting components of the framework. Ten (14%) of the 72 practices for all childbearing women were intended to support women’s own capabilities with information or advice that they could act on themselves. Sixty-one (85%) of the effective practices related to only 1 phase of maternal and newborn care, usually pregnancy or labor. Only 20 practices (28%) examined any aspect of care after the birth for the mother or newborn. Only midwife-led continuity models of care and community-based packages of care applied across the whole continuum. Sixty-six (92%) of the effective practices related to care of either the woman or fetus, or both; 4 examined the mother and newborn infant, and only 1 examined care of the infant.

When the characteristics and effect of midwives providing some or all components of care were examined in various studies, women who had midwife-led care were less likely to have regional analgesia, episiotomy, and instrumental birth and were more likely to have no intrapartum analgesia or anesthesia, spontaneous vaginal birth, attendance at birth by a known midwife, and a longer mean length of labor. No differences were noted between groups for cesarean births. Women receiving midwifery care were less likely to have a preterm birth and fetal loss at less than 24 weeks’ gestation. Most studies reported a higher rate of maternal satisfaction in the midwifery-led continuity care model. A cost-saving effect was noted for midwifery care compared with other models.

In 3 case studies of large countries that account for 35% of all births globally, and in which midwives are marginalized or excluded from the health system, the focus on facility-based and emergency care reduced maternal and perinatal mortality. Without the balancing effect of the full spectrum of midwifery care, this strategy led to rapidly growing numbers of unnecessary and expensive interventions and potentially iatrogenic complications and inequalities in the provision of care and outcomes.

The new evidence-based framework for high-quality maternal and newborn care incorporates the need to balance community-based preventive and supportive services for all childbearing women and newborns with the elective and emergency services needed by those with complications. The framework differentiates among what and how care is provided and who should provide it. This framework might be used to structure analyses of health system provision, plan new services, or develop an education curriculum. Future planning for maternal and newborn care systems can benefit from incorporating the quality framework into workforce development and resource allocation.