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The results of a major study comparing two methods of maternity care, commissioned by the HSE and conducted by the School of Nursing and Midwifery, Trinity College Dublin, were presented to the HSE on Friday December 18th.
This study involved 1653 women having babies in the HSE North-Eastern region from 2004 to 2007, and compared the usual consultant-led maternity care with a new model of care provided by midwives in two integrated Midwifery-led Units (MLUs) in Our Lady of Lourdes Hospital, Drogheda and Cavan General Hospital. The two MLUs, the first such units in Ireland, were opened in response to recommendations made in the Kinder Report in 2001, to provide more choice in maternity care in the North East. The study was carried out with the full support and cooperation of medical and midwifery staff in both units in the region.
The 'MidU' ('Midwifery Unit') study showed that midwifery-led care, as practised in these units, is as safe as consultant-led care but uses less intervention in pregnancy and childbirth. The number of babies needing resuscitation at birth, or admission to the special care baby unit, was the same in both groups. Six out of every ten women (59%) having the usual care in the consultant-led hospitals (CLUs) had their baby's heart beat monitored continuously in labour by an electronic monitoring machine, compared with 38% of women in the MLUs.
Almost half of the women in the CLUs (49%) had their labours speeded up by either having their waters broken or having oxytocin, a hormone, given intravenously by 'drip', compared with a third (34%) of women in the MLUs.
Professor John Bonnar, Emeritus Professor of Obstetrics and Gynaecology in Trinity College Dublin and a member of the Maternity Services Taskforce set up by the HSE to oversee the implementation of the Kinder Report in the North East, welcomed the results of this study. "Midwifery-led care has potential to provide greater choice for the majority of low-risk women, better continuity of personal antenatal care and a more satisfying birth experience" he said. "Women are also in hospital for a much shorter time and then have supportive follow-up midwifery care in their homes for the first 7 days. This model of care will enable consultant obstetricians to devote more time to caring for women with pregnancy complications, so all women in Ireland gain through this initiative."
Cecily Begley, Professor of Midwifery in Trinity College Dublin and principal investigator of the project said the results demonstrated the high quality care given by both consultants and midwives in this country. "Safety is our primary concern", she said, "and this study has shown conclusively that low risk women receive safe care from both midwives and obstetricians. Midwifery-led care uses fewer interventions, however, and most women prefer that."
The model of care used in the two MLUs is one where midwives, working in partnership with the woman, are the lead professional. They provide care in pregnancy, shared with the woman's general practitioner if desired, and refer any problems to the GP or obstetrician as necessary. When the woman commences labour, she comes to the MLU, which is a separate unit within the maternity hospital, and is welcomed into her private room where she stays for the labour, birth and postnatal resting time. Each room has a bed, pull-out couch for her partner to sleep on, a birthing pool, birthing aids, television, and tea/coffee-making facilities available.
Women's satisfaction with the facilities was apparent in the study and 85% of those attending the MLUs said they would recommend the care they had received to a friend, compared with 70% of those having usual care. Although facilities in the MLUs were quite luxurious, the cost of care for each woman was €332.80 less than in the usual hospital system.
In labour, fewer women in the MLU group chose to have epidurals (19%) than did those in the CLU (25%). Other methods of pain relief chosen included immersion in warm water in a birthing pool (24% in MLU compared with 3% in CLU). Despite having fewer epidurals, 83% of women in the MLUs expressed satisfaction with their pain relief, compared with 68% of women in the CLU. "When women are supported by one-to-one midwifery care, are encouraged to labour gently at their own pace and have the pain-relieving benefits of relaxing in warm water, they are far better able to tolerate pain, and labour more effectively," said Professor Begley. At birth, women in the MLU had a higher rate of spontaneous pushing and 20% used upright positions for birthing compared with 6% in the CLU. In addition, 13% did not require any drugs to speed up the after-birth, compared with just 1 woman (0.2%) in the CLU.
The results of this study agree with those from international research, and the Cochrane review of midwifery-led care concludes that most women should be offered midwife-led models of care. A recent KPMG report on maternity care in the Greater Dublin Region also recommended the introduction of midwifery-led units, adjacent to the obstetric units, so that access to consultant care and clinical support services is immediately available if required. The KPMG report concluded that, providing that the midwives in the MLU are experienced and adhere to guidelines, MLUs can provide a safe alternative location for low risk mothers to deliver their babies in addition to the main obstetric unit.
Fionnuala Duffy, Assistant National Director, Reconfiguration, accepted the report on behalf of the HSE. She stated that this study was "a carefully implemented, randomised trial comparing midwifery-led care provided for low risk women in an integrated MLU using evidence-based policies and procedural guidelines, with consultant-led care. The results have shown that midwifery-led care, as practised in this study, is as safe as consultant-led care, results in less intervention, is viewed by women with greater satisfaction in some aspects of care and is more cost-effective. "
She said "This comprehensive MidU study provides further evidence to support the need for development and expansion of such units as an integral part of a comprehensive maternity service offering appropriate range of services for women. The results and recommendations are very relevant to the HSE in informing the planning, reconfiguration and delivery of maternity services nationally. The study findings are also relevant in informing operational policy in care provision in maternity services. The HSE will study the detail of the report, share the findings with the relevant stakeholders and consider the implications for the delivery of maternity care nationally."
A copy of the study is available here.