One-to-One Midwifery: Restoring the "With Woman" Relationship in Midwifery

Lesley Page, MSc

Disclosures

J Midwifery Womens Health. 2003;48(2) 

In This Article

Literature Review: Outcomes of Continuity of Carer

It has always been hypothesized that continuity of carer will improve women's satisfaction with their care, give midwives greater job satisfaction, increase their autonomy, and reduce intervention rates. The evaluation of One-to-One Midwifery practice is the only study to have evaluated all of these outcomes within one program.[] The evaluation of complex organizational change requires appropriate methods and the dominant paradigm in research; the randomized controlled trial (RCT) is not always the most appropriate methodology for this purpose.

Two early studies of team midwifery, including the Know Your Midwife project and an Australian study, were evaluated by randomized controlled trial. The Know Your Midwife project was the first study of a midwifery project that provided continuity of carer. Four midwives working in a maternity service in London provided care from the beginning to the end of pregnancy and birth and the puerperium until up to 28 days after the birth. The RCT compared the outcomes of this form of care, that is, continuity of care by midwives with routine care by multiple caregivers.[9] Similarly, the study of team midwifery in a maternity service in Australia compared continuity of care by midwives with routine care by multiple caregivers.[10] These are the only two studies included in the metanalysis of continuity of caregiver in pregnancy and birth in the Cochrane Library.[11] Differences in clinical outcomes included a significant reduction in the rate of epidural anesthesia and analgesia.

A "structured" review of the evidence was published in 1998. Of the seven studies reviewed, only two aimed to provide continuity of carer. This included the first evaluation of One-to-One Midwifery and the Know Your Midwife study.[5] The results of recently published evaluations of changes in the organization of care have been summarized in a recent article.[12] Of three later studies of programs in the United Kingdom where a high level of continuity of carer was achieved, all demonstrated a reduction in the use of epidural and analgesia.[] and two (including the One-to-One Midwifery program under discussion here) demonstrated an increase in the number of normal births[12,13] and one a reduction in the caesarean birth rate.[12]

Psychological outcomes, including a positive experience of pregnancy and birth and of care, enhanced confidence in parenting, and positive emotional well-being following birth, are as important as physical outcomes such as a reduction in the rate of unnecessary operative interventions. Broad measures of concepts such as satisfaction with care only provide a crude and sometimes inaccurate measure of women's experience of pregnancy and birth and of health care. Sometimes women will describe satisfaction with care when more detailed and individual exploration through interviews, open-ended responses or focus groups will illustrate profound dissatisfaction. Randomized controlled trials can only compare fixed responses to the question of satisfaction with care, rather than the richer descriptions and responses elicited through qualitative methods. Not only will these responses illustrate the individuality of women's experience but may help us understand why some structures of care are associated with more positive experiences and psychological outcomes than others. Continuity of carer means that women and midwives are able to develop a close relationship. This relationship is not just instrumental, for example, to increase trust between the two or to increase confidence, but is seen as important in itself. Women's responses to One-to-One care as well as other author's studies[] have described the importance of the special relationship that may develop and how the relationship is important to women. Wilkins,[20] in particular, in her exploration of the nature of the relationships between women and their community midwives, describes how the special relationship that may develop between women and their midwives is seen as important in itself. Until recently, the published evaluations of continuity of carer have not included the outcomes of studies using appropriate methods such as qualitative research to elicit and describe the nature of the relationship that may develop. Such research is painstaking, slow, and very costly. Only now are the results of a number of studies that have used the appropriate research methodology available.[6,16,17,18,19] The effect and importance of "continuity of carer" on the outcomes of birth and women's satisfaction was thus discounted prematurely.[5] The second evaluation of One-to-One Midwifery is, as far as we know, the only program evaluation that has been done after the program was well established. This is a complex study that has included both quantitative and qualitative methods. Another recent evaluation of the Albany Practice, a long-standing independent practice in South London that has been contracted into the Health Service and that provides continuity of carer, also demonstrates a lower intervention rate, a higher vaginal birth rate, a lower caesarean birth rate, and a higher intact perineum rate.[21]

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