REVIEW

childbearing
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31 A Literature Review of Midwifery-Led Care
32
33
34
in Reducing Labor and Birth Interventions
35 Q19 Harinder Dosanjh Raipuria, Briana Lovett, Laura Lucas & Victoria Hughes
36
37
ABSTRACT: Certified nurse-midwives are usually recognized as independently practicing advanced practice registered nurses because
38 they provide maternity care to pregnant women in various states. In the United States, certified nurse-midwives are historically
39 underused. Culture favors physician-led care, with 90% of all births attended by physicians. Midwifery-led care is considered
40 high-touch/low-intervention and is guided by a philosophy of care that regards pregnancy and childbirth as normal life events for
41 most women. Evidence from the literature supports midwifery-led care as being safe, effective, and associated with fewer
42 interventions.
doi: 10.1016/j.nwh.2018.07.002 Accepted July 2018
43
44 KEYWORDS: birth outcomes, certified nurse-midwife, cesarean, labor and birth interventions, midwifery-led care, pregnancy
45
46
47 esearch findings support a strong association

R
associated with lower medical costs and reduced birth
48
Photo ª www.birthbecomesher.com

between midwifery-led care for pregnant women and interventions. CNMs are usually recognized and respected as
49 reduced labor and birth interventions (Begley et al., advanced practice registered nurses (APRNs). Greater use of
50 2011; Johantgen et al., 2012; Sutcliffe et al., 2012). Despite midwifery-led care in the United States could result in fiscal
51 this, care led by providers other than certified nurse-midwives savings, alleviation of pressure on physicians, and fewer
52 (CNMs) is predominant in U.S. clinical practice for pregnant medical interventions for women during the birthing process.
53 women of all risk statuses (Altman et al., 2017). Many other The use of CNMs not only enhances the scope of advanced
54 countries use midwives as their primary resource to deliver practice nursing but can also lead to more positive health
55 antepartum, intrapartum, and postpartum care, which is outcomes for childbearing women through the midwifery-led

nwhjournal.org ª 2018 AWHONN; doi: 10.1016/j.nwh.2018.07.002 1

REV 5.5.0 DTD
NWH207_proof
4 September 2018
8:52 pm
ce
 Literature Review of Midwifery-Led Care

56
57 CLINICAL IMPLICATIONS
58 n Midwifery-led care is strongly associated with fewer labor and
59 birth interventions, with no evidence of any greater risk for low-
60 risk pregnant women.
61 n The current birthing care model in the United States favors
62 physician-led care, with underuse of midwives, who are expert
providers of maternity care for low-risk pregnant women.
63
64 n Collaboration among certified nurse-midwives, physicians, and
nurses working in maternity care can contribute to improved
65 maternal and neonatal health outcomes and increased maternal
66 satisfaction.
67 n With the decrease in labor and birth interventions associated with
68 midwifery-led care, there is a strong possibility of reductions in
69 health care costs.
70
71 model of care. We use a global perspective of midwifery in this
72 literature review to highlight the benefits of a midwifery-led
73 care model that enhances health care provision, improves
74 maternal health outcomes, and provides women with an
Although midwifery has grown in capacity, current practice
75 alternative to physician-led care.
for the provision of maternity care in the United States gravi-
76 tates toward physicians in all settings, regardless of whether
77 the pregnancy is high or low risk. Although the number of
78 Background CNMs has increased, various factors have affected the ability
79 CNMs provide primary care services for women across the age
of CNMs to practice to their full capacity. CNMs have been
80 spectrum, including gynecologic care, family planning guid-
limited in their practice as a result of issues such as high
81 ance, preconception counseling, pregnancy care, childbirth
malpractice costs, scope of practice regulations, and other
82 and postpartum care, newborn care for the first 28 days of
legal ramifications (ACNM, 2012a, 2014). The consequences Q2

83 life, and treatment for male sexual partners with sexually

of this are shown in an increase in the number of intrapartum
84 transmitted infections (American College of Nurse Midwives
birth interventions, including increased rates of operative
85 [ACNM], 2012a). Educated as nurses and midwives, CNMs
births (Johantgen et al., 2012). CNMs promote a woman-
86 are board certified with graduate degrees, and they attend
centered model of care, with birth deemed a reflection of
87 births in hospitals, homes, and birthing centers. In 2014,
normal healthy functioning. Greater access to midwifery-led
88 CNMs and certified midwives (CMs) collectively attended
care has vast implications for national maternal health out-
89 332,107 births; this accounts for 8.3% of all U.S. births, with
comes; however, the scope of practice for CNMs is always
90 94.2% of these taking place in hospital settings (ACNM,
state dependent, which can often create barriers to the pro-
91 2016). CMs are direct-entry midwives with master’s degrees
vision of care.
92 who do not have nursing credentials but have the same scope
93 of practice and care settings as CNMs (Vedam et al., 2018). CNMs provide primary care services
94
95
Although CMs have an identical education for midwifery as for women across the age spectrum,
CNMs, they are not considered APRNs and will not be a focus
96 for this review. Evidence-based practice supports an associ- including gynecologic care, family
97 ation between CNMs and lower rates of cesarean births, lower planning guidance, preconception
98 occurrences of labor induction and augmentation, reduced
99 incidence of third- and fourth-degree perineal tears, and
counseling, pregnancy care,
100 reduced use of regional anesthesia (ACNM, 2012b). childbirth and postpartum care,
101
newborn care for the first 28 days of
Photo ª bowdenimages / iStockphoto.com

102
103 life, and treatment for male sexual
104
105
Harinder Dosanjh Raipuria, MSN, RN, is a doctoral student and a 2017 MSN
graduate at Johns Hopkins University in Baltimore, MD. Briana Lovett, MSN,
partners with sexually transmitted
106 Q1 RN, is a 2017 MSN graduate of Johns Hopkins University in Baltimore, MD. infections
Laura Lucas, DNP, APRN-CNS, RNC-OB, C-EFM, is an assistant professor at
107
Johns Hopkins University in Baltimore, MD. Victoria Hughes, DSN, MSN,
108 CNS, is an assistant professor at Johns Hopkins University in Baltimore, MD.
109 Q18 The authors report no conflicts of interest or relevant financial relationships. The scope of the problem concerns women as a child-
110 Address correspondence to: [email protected]. bearing population and the need for procurement of

2 Volume - Issue - doi: 10.1016/j.nwh.2018.07.002

REV 5.5.0 DTD
NWH207_proof
4 September 2018
8:52 pm
ce

 Raipuria, Lovett, Lucas & Hughes

111 Nursing Theory

112 Virginia Henderson is a nursing theorist whose need theory
113 supports the use of CNMs. The 14 basic human needs—
114 ranging from breathing normally to discovering or satisfying a
115 curiosity that leads to health (Alligood, 2014)—are supported
116 by midwives and are clinically applicable to women during the
117 process of birth. Henderson identified the need for collabo-
118 ration between all health care professionals, which can be
119 applied to the laboring woman and the care she receives from
120 members of the health care team (Alligood, 2014). Another
121 important concept in Henderson’s theory is the awareness
122 and promotion of a person’s progress toward improved inde-
123 pendence. Henderson’s theory can be applied by viewing the Q4
124 laboring woman as one who needs assistance to achieve
125 completeness in her body, which is attained with the birth of
126 the newborn (see Figure 1).
127
128 CNMs promote a woman-centered
129
130
model of care, with birth deemed to
131 be a reflection of normal, healthy
132 functioning
133
134 A CNM is a health care professional who works with a
135 nurse to facilitate basic human needs and supports the
136 laboring woman through a physiologic process and the safe
137 birth of her newborn. After the birth, the midwife promotes the
138 independence of the new mother and family in their ability to
139 provide ongoing care for the newborn (Ahtisham & Jacoline,
140 2015).
141
142 Methodology
appropriate maternity care by providers who are a good fit.
143
Matching a pregnant woman’s risk level with the level of A literature search was conducted in MEDLINE/PubMed,
144
provider skill and expertise uses resources most effectively Cochrane, UpToDate, Google Scholar, Clinical Key, and the
145
and has fiscal benefits. As expert providers of maternity care Cumulative Index to Nursing and Allied Health Literature
146
for normal pregnancies, CNMs have the opportunity to help (CINAHL) to identify publications that evaluated pregnant
147
women who are at low risk. In effect, matching a woman’s women who received midwifery-led care in intervention groups
148
needs with the level of provider will use the skill set of CNMs and non–midwifery-led care in control groups. Four people
149
to a greater extent and lead to increased provision of screened search results, and the full text of all publications
150
midwifery-led care. CNMs have a significant role in sup- were reviewed for inclusion as academic, peer-reviewed
151
porting the birthing process as a normal occurrence and are journals published in English between October 2011 and
152
thus well positioned to improve maternal health. We October 2017. Each was required to contain at least one of
153
reviewed the literature, with pregnant women as the popu- the four outcome interventions: cesarean births, instrumental
154
lation of focus. Intervention groups received predominantly vaginal births, oxytocin use, and regional analgesia use. There
155
midwifery-led care. To conduct this review of available and were 105 publications identified. Duplicate citations were
156
Photo ª buzzanimation / iStockphoto.com

recent literature, we examined labor and birth interventions eliminated, and then abstracts were reviewed for relevance
157
including primary outcomes of cesarean births, instrumental and strength of study design. Exclusion criteria included
158
vaginal births including use of forceps and vacuum, use of studies that were published before October 2011, research in
159 Q3 oxytocin (Pitocin; Pfizer, New York, NY), and use of regional which midwives were not the primary caregivers of
160
analgesia. The aim of this article is to answer the question intervention groups, studies in which researchers used control
161
Do midwifery-led care models for pregnant women have effi- groups that were not predominantly led by non-midwives, and
162
cacy related to their effect on reduction of labor and birth studies in which researchers did not measure at least one of
163
interventions? the four identified interventions. A total of 13 primary
164
165

- 2018 Nursing for Women’s Health 3

REV 5.5.0 DTD
NWH207_proof
4 September 2018
8:52 pm
ce
 Literature Review of Midwifery-Led Care

166 FIGURE 1 HENDERSON’S NEED THEORY FRAMEWORK

167
168
169
170
171 Pregnant
172 individual
173 with 14 basic
174 human needs
175
176
177
178
"Completeness"
179
180
achieved with
print & web 4C/FPO

181
182
birth of the
183
184
baby
185
186
187 Collaborative
188 care from
189 CNM and MD
190
191
192
193
194
195
196 publications were selected based on meeting the inclusion world, but the focus for this review was on who delivers care to
197 criteria. pregnant women. The following midwifery-led models of care
198 were identified: midwifery care in the antepartum setting,
199 Strength of Evidence caseload midwifery care, midwifery-led continuity models of
200 The 13 studies were reviewed and categorized according to care, CNM and midwife cohorts, CNM care in labor, midwife
201 the level of evidence and the quality of rating of scientific care delivered on midwifery units, and midwife-laborist
202 evidence, based on the Johns Hopkins Nursing Evidence- models. For purposes of this review, we refer to all as
203 Based Practice Model (Newhouse, Dearholt, Poe, Pugh, & midwifery-led care. Likewise, there were various physician-led
204 White, 2007). Four of the studies were randomized controlled models of care identified, which included general practi-
205 trials (RCTs), two were systematic reviews of randomized tri- tioners, obstetricians, and physicians: all are referred to
206 als, six were retrospective cohort studies, and one was a herein as physician-led care. All births took place in the hos-
207 systematic review of experimental and nonexperimental pital setting, whether attended by physicians or CNMs.
208 studies. On the basis of the strength of the evidence, six of
209 the studies were considered Level 1, and seven were Cesarean Births
210 considered Level 3. Eight of the studies were assessed as Authors of eight studies examined the effect of midwifery-led
211 Grade A (high quality), and five were assessed as Grade B care on cesarean births, for a total of 2,935,828 pregnant
212 (good quality; see Table 1). women of low-, moderate-, and high-risk category status.
213 There were three RCTs, one systematic review, three retro-
214 Review of Outcomes spective cohorts, and one retrospective observational study.
215 We evaluated four primary outcome interventions. The vast Begley et al. (2011) reported a decreased incidence of ce-
216 majority of literature strong enough for inclusion in the review sarean births in low-risk pregnant women from the Republic of
217 was of global origin, deriving from Ireland, Norway, China, Ireland randomized to midwifery-led care, although without
218 Australia, Canada, and the United Kingdom. Results for U.S. statistical significance. Gu, Wu, Ding, Zhu, and Zhang (2013)
219 studies were limited, with five such studies included. There reported that women randomized to midwifery-led antepartum
220 are clearly differences in health care systems across the care were less likely to have a cesarean birth. Likewise,

4 Volume - Issue - doi: 10.1016/j.nwh.2018.07.002

REV 5.5.0 DTD
NWH207_proof
4 September 2018
8:52 pm
ce

 275
274
273
272
271
270
269
268
267
266
265
264
263
262
261
260
259
258
257
256
255
254
253
252
251
250
249
248
247
246
245
244
243
242
241
240
239
238
237
236
235
234
233
232
231
230
229
228
227
226
225
224
223
222
221
-

TABLE 1 SUMMARY OF STUDIES REVIEWED

2018

Study Intervention Type Intervention Outcome Country Sample Size Evidence Type Evidence
(N [ 5,388,057) Level
and Qualitya
Gu, Wu, Ding, Cesarean birth Women in the midwives’ antepartum clinic China 110 RCT Level 1
Zhu, & Zhang service group were less likely to have a Quality A
(2013) cesarean birth compared with women in
obstetrician-led care group: n ¼ 18
(33.96%) vs. 30 (56.60%), 95% CI for
REV 5.5.0 DTD
NWH207_proof
4 September 2018
8:52 pm
ce

difference ¼ [41.60, 3.69]. Q14

McLachlan et al. Cesarean birth Women allocated to caseload midwifery Australia 2,314 RCT Level 1
(2012). Regional analgesia care were less likely to have a cesarean Quality A
birth: 19.4% vs. 24.9% standard care,
RR ¼ 0.78, 95% CI [0.67, 0.91], p ¼ .001.
Women allocated to caseload midwifery
were less likely to have epidural analgesia:
30.5% vs. 34.6% standard care, RR ¼ 0.88,
95% CI [0.79, 0.996], p ¼ .04.
Sandall, Soltani, Regional analgesia Women randomized to midwifery-led Australia, Canada, 17,674 Systematic review Level 1
Gates, Instrumental vaginal continuity models of care were, on Ireland, United 15 randomized Quality A
Shennan, & birth average, less likely to experience Kingdom trials
Devane the following:
(2016)  Regional analgesia (epidural/spinal):
average RR ¼ 0.85, 95% CI [0.78,
0.92], participants ¼ 17,674,
studies ¼ 14, high quality.
Instrumental vaginal birth (forceps/
vacuum): average RR ¼ 0.90, 95%
CI [0.83, 0.97], participants ¼ 17,501,
studies ¼ 13, high quality.
They were more likely to experience no
intrapartum analgesia/anesthesia:
Nursing for Women’s Health

Raipuria, Lovett, Lucas & Hughes

average RR ¼ 1.21, 95% CI [1.06, 1.37],
participants ¼ 10,499, studies ¼ 7.
(continued)
5
 330
329
328
327
326
325
324
323
322
321
320
319
318
317
316
315
314
313
312
311
310
309
308
307
306
305
304
303
302
301
300
299
298
297
296
295
294
293
292
291
290
289
288
287
286
285
284
283
282
281
280
279
278
277
276
6

Literature Review of Midwifery-Led Care

TABLE 1 CONTINUED
Volume

Study Intervention Type Intervention Outcome Country Sample Size Evidence Type Evidence
(N [ 5,388,057) Level
-

and Qualitya
Issue

Sutcliffe et al. Instrumental vaginal Midwifery-led care reduced the need for a Canada, United 21,105 Systematic review Level 1
-

(2012) birth number of interventions with significance States, Australia, Review 1–13 Quality A Q15

Regional analgesia during labor and birth including avoiding United Kingdom controlled trials
vacuum extraction and/or forceps-assisted and 2 RCTs
birth (15 studies with n ¼ 12,497) and Review 2–11 RCTs
REV 5.5.0 DTD
NWH207_proof
4 September 2018
8:52 pm
ce

regional analgesia (11 studies with Review 3–3 RCTs

n ¼ 11,892).
Altman, Cesarean birth Women in CNM cohort during labor had United States 1,441 Retrospective Level III
Murphy, Instrumental vaginal significantly lower relative odds of the cohort study Quality A
Fitzgerald, birth following compared with women in the
Anderson, & Regional analgesia obstetrician/gynecologist cohort:
Daratha Oxytocin use  Cesarean birth: OR ¼ 0.29, 95%
(2017) CI [0.12, 0.69], p ¼ .005.
Vacuum-assisted birth: OR ¼ 0.30, 95%
CI [0.13, 0.70], p ¼ .006.
Epidural anesthesia: OR ¼ 0.24, 95%
CI [0.17, 0.45], p < .001.
Odds of using labor induction with oxytocin
were significantly lower with women in the
CNM cohort compared with women in the
obstetrician/gynecologist cohort:
OR ¼ 0.31, 95% CI [0.22, 0.45],
p < .001.
Carlson, Corwin, Instrumental vaginal Women who were obese and were cared United States 360 Retrospective Level III
& Lowe births for in labor by CNMs were 87.0% less cohort study Quality A
(2017) Regional analgesia likely to have an operative vaginal birth:
Oxytocin use aOR ¼ 0.15, 95% CI [0.06, 0.41].
Women who were obese and were cared
for by CNMs were significantly less likely
doi: 10.1016/j.nwh.2018.07.002

to use labor anesthesia or synthetic

oxytocin augmentation.
(continued)
 385
384
383
382
381
380
379
378
377
376
375
374
373
372
371
370
369
368
367
366
365
364
363
362
361
360
359
358
357
356
355
354
353
352
351
350
349
348
347
346
345
344
343
342
341
340
339
338
337
336
335
334
333
332
331
-

TABLE 1 CONTINUED
2018

Study Intervention Type Intervention Outcome Country Sample Size Evidence Type Evidence
(N [ 5,388,057) Level
and Qualitya
Thiessen et al. Regional analgesia The aOR [95% CI] for midwife vs. Canada 83,774 Retrospective Level III
(2016) Cesarean birth obstetrician/gynecologist cohorts showed cohort study Quality A
that women who had a midwife attend the
birth had reduced odds of having an
epidural (0.25 [0.23, 0.27]) and cesarean
REV 5.5.0 DTD
NWH207_proof
4 September 2018
8:52 pm
ce

birth (0.13 [0.10–0.16]).

Thornton Oxytocin use Labor induction is less likely with a United States 2,411,980 Retrospective Level III
(2017) Regional analgesia midwife (CM/CNM) attended birth: cohort study Quality A
OR ¼ 0.76, 95% CI [0.76, 0.77].
Epidural analgesia use is less likely with
a midwife (CM/CNM)-attended birth:
OR ¼ 0.54, 95% CI [0.53, 0.54].
Begley et al. Oxytocin use Women having midwifery-led care were Republic of 1,653 RCT Level I
(2011) Cesarean births significantly less likely to have Ireland Quality B
Instrumental vaginal augmentation of labor by oxytocin or
births amniotomy: 39.6% MLU vs. 56.9% CLU,
Regional analgesia RR ¼ 0.50, 95% CI [0.40, 0.61].
Incidence of cesarean births was lower
with MLU care (14.8%) vs. CLU care
(15.2%); likewise, incidence of instrumental
vaginal births was lower with MLU care
(12.6%) vs. CLU care (14.3%). However,
both findings were not statistically
significant.
There were significantly fewer women
under midwifery-led care choosing to have
epidural analgesia: 18.3% MLU vs.
24.3% CLU, RR ¼ 0.76, 95% CI [0.62,
Nursing for Women’s Health

Raipuria, Lovett, Lucas & Hughes

0.92].
Bernitz, Aas, & Regional analgesia Women allocated to the MU were Norway 1,110 RCT Level I
Oian (2012) Oxytocin use significantly less likely to use the following: Quality B
 Epidural analgesia: MU, 15.6%; SCU,
23.9%; (p ¼ .001).
Augmentation with oxytocin: MU, 26.3%;
SCU, 37.2%; p < .001.

(continued)
7
 440
439
438
437
436
435
434
433
432
431
430
429
428
427
426
425
424
423
422
421
420
419
418
417
416
415
414
413
412
411
410
409
408
407
406
405
404
403
402
401
400
399
398
397
396
395
394
393
392
391
390
389
388
387
386
8

Literature Review of Midwifery-Led Care

TABLE 1 CONTINUED
Volume

Study Intervention Type Intervention Outcome Country Sample Size Evidence Type Evidence
(N [ 5,388,057) Level
-

and Qualitya
Issue

Johantgen et al. Regional analgesia 10 studies of overall moderate evidence United States 2,836,961 Systematic review Level III
-

(2012) Cesarean births grade support the idea that care from 2 RCTs, 19 Quality B
Instrumental vaginal CNMs leads to lower use of epidural observational
births analgesia. studies
15 studies of overall high evidence grade (retrospective
REV 5.5.0 DTD
NWH207_proof
4 September 2018
8:52 pm
ce

support the idea that care from CNMs cohort and

leads to fewer cesarean births. prospective cohort)
8 studies of overall high evidence grade
support the idea that care from CNMs
leads to fewer instrumental vaginal births
using forceps or vacuums.
Nijagal, Cesarean birth Women under the private obstetrician-led United States 9,381 RCT Level III
Kupperman, Regional analgesia model of care were more likely to use an Quality B
Nakagawa, & epidural in the intrapartum phase
Cheng (2015) (p <.001).
Cesarean birth occurrence rates ¼ 31.6%
of women under private obstetrician-led
model and 17.3% of women under the
midwife-laborist (midwifery-led) model
(p < .001).
Adjusted odds of a cesarean birth for
women in the private obstetrician-led
group was twice that of women in the
midwife-laborist group (aOR ¼ 2.11, 95%
CI [1.73, 2.58]; therefore, it was more
likely to occur for women in the private
model cohort.
NTSV women under the private
obstetrician-led model (29.8%) were
doi: 10.1016/j.nwh.2018.07.002

almost twice as likely as those under the

midwife-laborist model (15.9%) to have a
cesarean birth: p < .001, aOR ¼ 1.86,
95% CI [1.33, 2.58].
(continued)
 Raipuria, Lovett, Lucas & Hughes

Q17

Q16
441 McLachlan et al. (2012) reported that low-risk pregnant

and Qualitya
442
Evidence
women randomized to primary caseload midwifery-led care in

Note. aOR ¼ adjusted odds ratio; CI ¼ confidence interval; CLU ¼ consultant-led unit; CM ¼ certified midwife; CNM ¼ certified nurse-midwife; MLU ¼ midwifery-led unit; MU ¼ midwifery unit; NTSV ¼ nulliparous term
Quality B
Level III
Level
443 an Australian RCT were less likely to have a cesarean birth. A
444 retrospective cohort study of low-risk pregnant women in the
445 United States supported that women assigned to the CNM
446 cohort during labor had significantly lower relative odds of
observational study

447
Evidence Type

having a cesarean birth (Altman et al., 2017). Thiessen et al.

Retrospective

448 (2016) reported reduced odds of having a cesarean birth for a

449 Canadian study of low-risk pregnant women who had midwife-
450 attended births.
451 Rayment-Jones, Murrells, and Sandall (2015) reported
452 reduced occurrences of cesarean births with the provision of
453 midwifery-led care in a study from the United Kingdom. There
(N [ 5,388,057)

454 was also less likelihood of having a cesarean birth when

Sample Size

455 antepartum, intrapartum, and postpartum care from midwives

194

456 was offered to women with complex social factors (Rayment-

457 Jones et al., 2015). Findings from a California-based retro-
458 spective cohort study similarly supported that cesarean birth
459 rates were reduced for women under a midwifery-led model of
Articles were appraised using the Johns Hopkins Nursing Evidence-Based Practice Model (Newhouse, Dearholt, Poe, Pugh, & White, 2007).

460 care (Nijagal, Kupperman, Nakagawa, & Cheng, 2015).

United Kingdom

461 Nijagal et al. (2015) reported that the adjusted odds of having
Country

462 a cesarean birth for women in a physician-led model were

463 twice that of women in the midwifery-led model. One final
464 result reported by Nijagal et al. found that women who pre-
465 sented as nulliparous term singleton vertex were almost twice
singleton vertex; OR ¼ odds ratio; RCT ¼ randomized controlled trial; RR ¼ risk ratio; SCU ¼ standard of care unit.

466 as likely to have cesarean births if in a physician-led model of

(antepartum, intrapartum, and postpartum

467 care compared with those in a midwifery-led model of care.

care from a known midwife) had reduced

 Cesarean birth: 11% caseload vs. 33%

intrapartum pain relief: 35% caseload

468 In a systematic review of 21 articles with 2,836,961 low-,

occurrences of and were less likely to

vs. 56% standard care, RR ¼ 0.64,

in standard care, RR ¼ 0.26, 95%

469 moderate-, and high-risk pregnant women, findings from 15

Women who received caseload care

95% CI [0.46, 0.86], p ¼ .004.

470 studies of high evidence grade indicated that care from CNMs
 Epidural/spinal anesthesia for
Intervention Outcome

471 led to fewer cesarean births (Johantgen et al., 2012). Overall

CI [0.12, 0.55], p < .001.

472 research supports that midwifery-led care results in less

473 likelihood, lower odds, and reduced occurrences of cesarean
474 births (Altman et al., 2017; Begley et al., 2011; Gu et al.,
have the following:

475 2013; Johantgen et al., 2012; McLachlan et al., 2012;

476 Nijagal et al., 2015; Rayment-Jones et al., 2015; Thiessen
477 et al., 2016).
478
479 Instrumental Vaginal Births
480 In six articles, researchers examined the effect of midwifery-
481 led care on instrumental vaginal births, including forceps and
482 vacuum use, with 2,879,194 pregnant women of all risk
Intervention Type

Regional analgesia

483 categories. This included one RCT, two retrospective cohort

Cesarean birth

484 studies, and three systematic reviews. Begley et al. (2011)

485 identified that the incidence of instrumental vaginal births was
TABLE 1 CONTINUED

486 lower for low-risk women randomized to a midwifery-led care

487 unit in Ireland. In 13 high-quality studies from a recent sys-
488 tematic review, researchers showed that women randomized
489 to midwifery-led care were less likely to experience instru-
Rayment-Jones,

490 mental vaginal births with forceps or vacuum (Sandall,

Murrells, &

491 Soltani, Gates, Shennan, & Devane, 2016). Carlson, Corwin,

Sandall

492
(2015)

and Lowe (2017) reported that nulliparous women with

493 obesity from a retrospective cohort study based in Colorado
Study

494 were found to be less likely to have an operative vaginal birth

495 when cared for by CNMs while in labor. Likewise, findings from
a

- 2018 Nursing for Women’s Health 9

REV 5.5.0 DTD
NWH207_proof
4 September 2018
8:52 pm
ce
 Literature Review of Midwifery-Led Care

496 15 studies from a systematic review drawn from Canada, the pregnant women of all risk categories. This included three
497 United States, Australia, and the United Kingdom supported RCTs, two systematic reviews of 44 RCTs, five retrospective Q6
498 an association between midwifery-led care and a reduced cohort studies, one retrospective observational study, and
499 need for interventions during labor and birth, including avoid- one systematic review of two RCTs; there were 19 observa-
500 ance of vacuum extraction and forceps use (Sutcliffe et al., tional studies of retrospective cohort and prospective cohort
501 2012). In a retrospective cohort study for low-risk pregnant designs. McLachlan et al. (2012), Begley et al. (2011), and
502 women in the United States, Altman et al. (2017) found that Bernitz et al. (2012) found that women birthing in the
503 those assigned to the CNM cohort during labor had signifi- midwifery-led care model were less likely to experience
504 cantly lower relative odds of a vacuum-assisted birth. epidural analgesia. In the two systematic reviews of RCTs,
505 In a systematic review of 21 articles incorporating researchers reported that women randomized to a midwifery-
506 2,836,961 pregnant women in the United States of all risk led model of care were less likely to experience regional
507 categories, researchers found eight studies of high evidence analgesia (Sandall et al., 2016; Sutcliffe et al., 2012). In a
508 grade to support the idea that care from CNMs led to fewer systematic review of 10 observational studies, Johantgen
509 instrumental vaginal births using forceps or vacuum et al. (2012) reported that use of the midwifery-led care model
510 (Johantgen et al., 2012). Overall research supported the led to lower use of epidural analgesia. Five retrospective
511 notion that midwifery-led care results in less likelihood and cohort studies found that women in midwifery-led models of
512 reduced occurrences of instrumental vaginal births with for- care were significantly less likely to use epidural analgesia
513 ceps or vacuum, as well as lower odds of a vacuum vaginal (Altman et al., 2017; Carlson et al., 2017; Nijagal et al.,
514 birth (Altman et al., 2017; Begley et al., 2011; Carlson et al., 2015; Thiessen et al., 2016; Thornton, 2017). Additionally,
515 2017; Johantgen et al., 2012; Sandall et al., 2016; Sutcliffe the retrospective observational study indicated that women in
516 et al., 2012). midwifery-led care were less likely to have an epidural or
517 spinal anesthesia (Rayment-Jones et al., 2015). Overall, in
518 Oxytocin Use nearly all of the publications that were reviewed, authors re-
519 Authors of five articles examined the effects of midwifery-led ported that midwifery-led care models led to significantly lower
520 care on oxytocin use for induction and augmentation of labor, odds of regional analgesia use.
521 with 2,500,318 pregnant women of all risk categories. This
522 included two RCTs and three retrospective cohort studies. The Discussion Q7
523 American College of Obstetricians and Gynecologists indi-
524 cated that labor induction can be performed by using a Limitations
525 number of interventions, including cervical ripening via pros- The literature reviewed was predominantly of global origin,
526 taglandins or Foley bulb devices, membrane stripping, with only 5 of 13 studies based solely in the United States.
527 amniotomy, or oxytocin use (American College of This has implications for generalizability, because many find-
528 Obstetricians and Gynecologists, 2017). Begley et al. (2011) ings reported were from studies conducted in Ireland, Norway,
529 reported that women who had midwifery-led care were signif- China, Australia, Canada, and the United Kingdom. Although
530 icantly less likely to experience augmentation of labor with the focus of this review was on who delivers care to pregnant
531 oxytocin or amniotomy. In an RCT conducted in Norway, women, there are significant differences in health care sys-
532 Bernitz, Aas, and Oian (2012) found that women who were tems and use of practitioners across the world. There were
533 cared for by midwives were significantly less likely to experi- differences in types of midwifery-led models of care, which
534 ence labor augmentation with oxytocin. In three retrospective may have implications for reported findings, although mid-
535 cohort studies conducted in the United States in 2017, re- wives were primary caregivers of each intervention group. All
536 searchers found reduced odds of oxytocin use in midwifery-led reported births took place in hospital settings; therefore,
537 care when compared with other care models (Altman et al., births in birthing centers and home births attended by mid-
538 2017; Carlson et al., 2017; Thornton, 2017). Altman et al. wives were not accounted for. Seven studies were isolated to
539 (2017) reported that the odds of labor induction with oxytocin one hospital setting only, which has further implications for
540 were significantly lower with midwifery-led care compared with generalizability. Six studies focused only on low-risk pregnant
541 the obstetrician/gynecologist model. Carlson et al. (2017) women, with the remainder examining women of mixed-risk
542 found that women who used midwifery-led care were also status.
543 significantly less likely to use synthetic oxytocin augmentation
544 Q5 during labor. Furthermore, Thornton (2017) reported that all Implications for Clinical Practice
545 types of labor induction were less likely with a midwifery-led Substantial evidence of high to good quality is presented to
546 birth. support the efficacy of midwifery-led care. The evidence shows
547 that use of midwives results in more positive health outcomes
548 Regional Analgesia for women; a reduced incidence of cesarean births and
549 Authors of 12 articles examined the effects of midwifery-led instrumental vaginal births; lower odds and less likelihood of
550 care on regional analgesia use during labor, with 5,387,947 oxytocin use; and less incidence, likelihood, and odds of

10 Volume - Issue - doi: 10.1016/j.nwh.2018.07.002

REV 5.5.0 DTD
NWH207_proof
4 September 2018
8:52 pm
ce

 Raipuria, Lovett, Lucas & Hughes

551 Midwifery-led care is

552 strongly associated with
553 fewer labor and birth in-
554 terventions, with no evi-
555 dence of any greater risk
556 for low-risk pregnant
557 women (Sutcliffe et al.,
558 2012). Vedam et al.
559 (2018) suggested that ob-
560 stetric interventions were
561 more judiciously imple-
562 mented when associated
563 with midwifery-led care.
564 With a growing emphasis
565 on woman-centered care
566 and empowering women to
567 make informed health care
568 choices, it is commonplace
569 to find women desiring
570 more control of their preg-
571 nancy and birth experi-
572 ences. Nurses have a
573 unique role to play by of-
574 fering education to women
575 in primary care and hospi-
576 tal settings about the ben-
577 efits of using midwives.
578 To address the need for
579 regional analgesia use (Altman et al., 2017; Begley et al., improving maternal and neonatal outcomes, there is a requi-
580 2011; Bernitz et al., 2012; Carlson et al., 2017; Johangten site for CNMs and physicians to collaborate. Although a strong
581 et al., 2012; McLachlan et al., 2012; Nijagal et al., 2015; culture of physician-led care for women of all risk categories
582 Rayment-Jones et al., 2015; Sandall et al., 2016; Sutcliffe exists in the United States, there are many instances in which
583 et al., 2012; Thiessen et al., 2016; Thornton, 2017). There is interprofessional collaboration would be effective for pregnant
584 a need to address the provision of care by type of provider and women. Collaborative clinical practice supports the Institute
585 number of subsequent labor and birth interventions. The high of Medicine in its goals to increase interprofessional relations
586 Q8 pregnancy-related maternal mortality ratio of 17.3 deaths per and teamwork, which is critical in the provision of safe, high-
587 100,000 live births in the United States is indicative of the quality care (Johnson, 2013). This collaboration can improve
588 need for change (Centers for Disease Control and Prevention, maternal and neonatal outcomes and increase maternal
589 2017). An analysis of maternal health policy indicated that satisfaction.
590 countries with sustained reductions in maternal mortality The current birthing care model in the United States favors
591 rates had increased access to health care and focused in- physician-led care. This model reflects the importance of
592 vestments in midwifery-led care (Van Lerberghe et al., 2014). matching women’s health care needs with the appropriate level
593 From the evidence that has been presented, there are several of care, as midwives are underused. Midwifery-led care models
594 implications for clinicians. serve the needs of women with low-risk pregnancies; physician-
595 led care models are more appropriate for high-risk pregnancies
596 and surgical births. Thus, care provided by CNMs for women at Q9
597 Greater use of midwifery-led care in
Photo ª FatCamera / iStockphoto.com

low-risk and collaboration with physicians for women at high-risk

598 the United States could result in offers an alternative option. Furthermore, using physician-led
599 care primarily for high-risk pregnancies and surgical births may
600
fiscal savings, alleviation of pressure serve to reduce mortality rates by ensuring that physicians are
601 on physicians, and fewer medical available for such cases and are not overwhelmed with deliv-
602 ering care in more prevalent low-risk pregnancies.
interventions for women during the
603 The midwifery-led model of care is focused on childbirth as
604 birthing process a natural process of the female body and allows for the time
605

- 2018 Nursing for Women’s Health 11

REV 5.5.0 DTD
NWH207_proof
4 September 2018
8:52 pm
ce
 Literature Review of Midwifery-Led Care

606 and freedom to use countless comfort measures for a Recommendations

607 laboring woman without confining her to a hospital bed. This From the abundant literature supporting the benefits of
608Q10 experience is more often appropriate for low-risk pregnancies midwifery-led care, recommendations are integral to promote
609 that require less monitoring and restriction during labor and the effective collaborative practice provided by CNMs. These
610 birth. This can be supported with midwifery-led units for low- recommendations are applicable to all APRNs to enhance and
611 risk women to allow for more frequent vaginal births and advocate for advanced practice in areas such as clinical
612Q11 decreased use of invasive interventions. Vedam et al. (2018) practice, education, research, administration, and consulta-
613 indicated that U.S. states with care models supporting the tion. Additionally, recommendations for changes in health
614 regulatory environment for midwifery services experience policy must be considered.
615 increased numbers of midwife-attended births. Consequently, APRNs can further enhance the scope of practice by
616 a significantly greater rate of spontaneous vaginal birth oc- advocating for the level of care that can be delivered by mid-
617 curs, thus reducing the cesarean birth rate (Vedam et al., wives and associated positive health outcomes. When a
618 2018). Using this model of care promotes the natural birthing woman is cared for by a midwife, nurses and APRNs are well
619 process to incorporate the most natural experience for preg- placed to ensure lower odds of cesarean birth, instrumental
620 nant women. If a pregnancy becomes high risk, collaboration vaginal birth, use of epidural analgesia, and use of oxytocin
621 with physicians supports delivery of the most fitting and for labor augmentation. All APRNs should be aware of the
622 appropriate care while supporting interprofessional relations. most recent literature to educate childbearing women and
623 With a decrease in the use of labor and birth interventions, recommend that care should begin with midwives, with
624 there is a strong possibility that there will be reductions in transfer to a physician-led unit if a change in health and risk
625 costs to the health care industry. Salary rates differ with the status occurs.
626 level of provider; CNMs earn a median rate of $48.36 per Nursing research is needed to support midwifery-led care.
627 hour, whereas physicians earn a median rate of $100 per Recommendations include the need for more U.S.-based
628 hour (Bureau of Labor Statistics, n.d.-a, n.d.-b). The lower cost randomized studies focused on low-risk populations. Pilot
629 of midwifery-led care will certainly affect costs if the services studies in various clinical antepartum, intrapartum, and
630 of midwives are more greatly used, with women transferring to postpartum settings can further the investigation into the use
631 costlier physician-led care only when risk status requires it. of midwives for low-risk women and the ways in which
632 This offers financial feasibility for the U.S. health care system collaboration can occur for high-risk women. Conducting
633 if monetary savings can be made and further supports this studies to validate the efficacy of midwifery-led units in side-
634 model of care. by-side hospital settings is one way to promote the collabo-
635 In addition to salary variations between midwives and rative delivery of care. In addition, research to examine
636 physicians, there are also implications for other financial various models of midwifery-led care is encouraged and
637 benefits regarding the use of midwifery-led care. Labor in- needed. Cases beyond the scope of practice for a CNM, such
638 terventions are costly, and midwives use fewer interventions as those that are high-risk or require surgery, would be
639 during labor and birth (Vedam et al., 2018). A significant in- excluded.
640 crease in cost is associated with health systems that have A final recommendation is for APRNs to advocate for policy
641 greater cesarean birth rates (Vedam et al., 2018). Further- changes to enhance partnership and collaboration with phy-
642 more, Vedam et al. (2018) identified improved vaginal birth sicians. As an option for women who are low-risk, care that
643 rates and reduced rates of preterm births, which also have a begins with midwives has multiple benefits. The level of care
644 dramatic effect on financial implications for consumers and provided by CNMs is evidence based and will have financial
645 the health care system. Alleviating serious potential maternal implications to decrease malpractice costs and control costs
646 and neonatal health deficits related to operative births and for the individual and the health care system (Sandall et al.,
647 preterm births will have a remarkable financial effect (Vedam 2016). Advocating for interprofessional collaboration among
648 et al., 2018). physicians and CNMs will have a positive influence on
649 Clinicians need to consider alternative modalities of care maternal and neonatal clinical outcomes.
650 for pregnant women beyond physician-led care and include
651 midwifery-led care that has global support in clinical practice
652 (Begley et al., 2011; Bernitz et al., 2012; Gu et al., 2013; Conclusion
653 McLachlan et al., 2012; Rayment-Jones et al., 2015; Sandall A considerable number of women experience pregnancy and
654 et al., 2016; Sutcliffe et al., 2012; Thiessen et al., 2016). As childbirth each year. Throughout the process, they will require
655 advocates, nurses can help women make informed health antepartum, intrapartum, and postpartum care predominantly
656 care choices by highlighting the availability of different models offered by physicians. Global research indicates reduced Q12

657 of care. Part of the responsibility is on nurses and APRNs to incidence, odds, and likelihood of cesarean births, instru-
658 be aware of the most recent literature and research findings mental vaginal births, oxytocin use, and use of regional
659 available so that they can relay this information to child- analgesia for intervention groups that received predominantly
660 bearing women. midwifery-led care. Retrospective cohort studies provided

12 Volume - Issue - doi: 10.1016/j.nwh.2018.07.002

REV 5.5.0 DTD
NWH207_proof
4 September 2018
8:52 pm
ce

 Raipuria, Lovett, Lucas & Hughes

661 large amounts of population-based data supported by findings Retrieved from http://www.midwife.org/ACNM/files/ACNMLibrary
662 from 50 RCTs. With a total of 5,388,057 pregnant women as Data/UPLOADFILENAME/000000000266/Definition%20of%
20Midwifery%20and%20Scope%20of%20Practice%20of%20CNMs%
663 participants and of all risk categories in this literature review, 20and%20CMs%20Feb%202012.pdf
664 there is strong evidence for the efficacy of midwifery-led care. American College of Nurse-Midwives. (2012b). Midwifery: Evidence-based
665Q13 The ACNM reported that care by CNMs is less likely to practice. A summary of research on midwifery practice in the United
666 result in the use of labor and birth interventions, including States. Retrieved from http://www.midwife.org/acnm/files/
667 cesareans, resulting in less invasive and costly practices ccLibraryFiles/Filename/000000004184/Midwifery-Evidence-Based-
Practice-March-2013.pdf
668 (ACNM, 2012b). Midwifery-led care is safe and effective for
American College of Nurse-Midwives. (2016). CNM/CM-attended birth
669 low-risk pregnant women (Altman et al., 2017; Begley et al., statistics in the United States. Retrieved from http://www.midwife.org/
670 2011), and in fact, health benefits can occur for low-risk acnm/files/ccLibraryFiles/Filename/000000005950/CNM-CM-
671 populations (Sutcliffe et al., 2012). Midwifery-led models of AttendedBirths-2014-031416FINAL.pdf
672 care have been found to be effective in reducing cesarean American College of Obstetricians and Gynecologists. (2017). Labor
673 birth rates in the United States (Nijagal et al., 2015; Thiessen induction. Retrieved from https://www.acog.org/Patients/FAQs/
Labor-Induction
674 et al., 2016). Midwives offer continuity of care, which plays a
Begley, C., Devane, D., Clarke, M., McCann, C., Hughes, P., Reilly, M., …
675 significant role in caseload care, particularly for women with Doyle, M. (2011). Comparison of midwife-led and consultant-led care of
676 complex social situations. Midwifery-led care offers greater healthy women at low risk of childbirth complications in the Republic of
677 health benefits and reduced harmful outcomes for vulnerable Ireland: A randomised trial. BioMed Central Pregnancy and Childbirth,
678 women (Rayment-Jones et al., 2015). 11(85), 1–10. https://doi.org/10.1186/1471-2393-11-85
679 For higher-risk pregnancies, there is evidence to support Bernitz, S., Aas, E., & Oian, P. (2012). Economic evaluation of birth care
in low-risk women. A comparison between a midwife-led birth unit and
680 the notion that similar outcomes exist for collaboration be- a standard obstetric unit within the same hospital in Norway. A
681 tween midwives and physicians with respect to spontaneous randomised controlled trial. Midwifery, 28(5), 591–599. https://
682 vaginal births (Thornton, 2017). Population-based evidence doi.org/10.1016/j.midw.2012.06.001
683 from the United States indicates that delivery of midwifery-led Bureau of Labor Statistics. (n.d.-a). Occupational employment and wages,
684 care for higher-risk pregnancies is safely taking place for May 2017: 29-1161 Nurse Midwives. Retrieved from https://www.bls.
gov/oes/current/oes291161.htm
685 spontaneous births (Thornton, 2017). One suggestion is to
Bureau of Labor Statistics. (n.d.-b). Occupational outlook handbook:
686 continue to review data from low-risk populations before
Physicians and surgeons. Retrieved from https://www.bls.gov/ooh/
687 investigating middle- and higher-risk pregnancies. healthcare/physicians-and-surgeons.htm
688 Further research into the efficacy of midwifery-led care in Carlson, N. S., Corwin, E. J., & Lowe, N. K. (2017). Labor intervention and
689 U.S. health systems, including its effect on labor and birth outcomes in women who are nulliparous and obese: Comparison of
690 interventions and other maternal and neonatal outcomes, is nurse-midwife to obstetrician intrapartum care. Journal of Midwifery
and Women’s Health, 62(1), 29–39. https://doi.org/10.1111/
691 imperative for the delivery of safe, effective, and low-
jmwh.12579
692 intervention women’s health care. The extant data and find-
Centers for Disease Control and Prevention. (2017). Pregnancy mortality
693 ings show vast support for the use of midwifery-led care. The surveillance system. Retrieved from https://www.cdc.gov/
694 challenge lies in educating women and health care providers reproductivehealth/maternalinfanthealth/pmss.html
695 regarding its numerous benefits. Although physician-led care Gu, C., Wu, X., Ding, Y., Zhu, X., & Zheng, Z. (2013). The effectiveness of
696 has been dominant, there are notable benefits to collabora- a Chinese midwives’ antenatal clinic service on childbirth outcomes
for primipare: A randomised controlled trial. International Journal of
697 tion between physicians and midwives. With further random-
Nursing Studies, 50(12), 1689–1697. https://doi.org/10.1016/
698 ized U.S.-based studies to underscore the findings of this j.ijnurstu.2013.05.001
699 literature review, the midwifery-led model of care has strong Johantgen, M., Fountain, L., Zangaro, G., Newhouse, R., Stanik-Hutt, J., &
700 potential to become the mainstream modality of care for low- White, K. (2012). Comparison of labor and delivery care provided by
701 risk pregnant women. NWH certified nurse-midwives and physicians: A systematic review, 1990 to
702 2008. Women’s Health Issues, 22(1), e73–e81. https://doi.org/
10.1016/j.whi.2011.06.005
703
704 References Johnson, J. E. (2013). Working together in the best interest of patients.
The Journal of the American Board of Family Medicine, 26(3), 241–
705 Ahtisham, Y., & Jacoline, S. (2015). Integrating nursing theory and 243. https://doi.org/10.3122/jabfm.2013.03.130075
706 process into practice; Virginia Henderson’s Need Theory. International
McLachlan, H. L., Forster, D. A., Davey, M. A., Farrell, T., Gold, L.,
Journal of Caring Sciences, 8, 443–450.
707 Biro, M. A., … Waldenstrom, U. (2012). Effects of continuity of
Alligood, M. R. (2014). Nursing theorists and their work (8th ed.). St.
708 Louis, MO: Elsevier Mosby.
care by a primary midwife (caseload midwifery) on cesarean
section rates in women of low obstetric risk: The COSMOS
709 Altman, M. R., Murphy, S. M., Fitzgerald, C. E., Anderson, F., & Daratha, randomised controlled trial. British Journal of Obstetrics and
710 K. B. (2017). The cost of nurse-midwifery care: Use of interventions, Gynaecology, 119(12), 1483–1492. https://doi.org/10.1111/
711 resources and associated costs in the hospital setting. Women’s j.1471-0528.2012.03446.x
712 Health Issues, 27, 434–440. https://doi.org/10.1016/j.whi.2017 Newhouse, R. P., Dearholt, S. L., Poe, S. S., Pugh, L. C., & White, K. M.
.01.002
713 (2007). Johns Hopkins nursing evidence-based practice model and
American College of Nurse-Midwives. (2012a). Definition of midwifery and guidelines. Indianapolis, IN: Sigma Theta Tau International Honor
714 scope of practice of certified nurse midwives and certified midwives. Society of Nursing.
715

- 2018 Nursing for Women’s Health 13

REV 5.5.0 DTD
NWH207_proof
4 September 2018
8:52 pm
ce
 Literature Review of Midwifery-Led Care

716 Nijagal, M. A., Kupperman, M., Nakagawa, S., & Cheng, Y. (2015). Two Thiessen, K., Nickel, N., Prior, H. J., Banerjee, A., Morris, M., & Robinson,
717 practice models in one labor and delivery unit: Association with cesarean K. (2016). Maternity outcomes in Manitoba women: A comparison
delivery rates. American Journal of Obstetrics and Gynecology, 212(4), between midwifery-led care and physician-led care at birth. Birth,
718
491.e1–491.e8. https://doi.org/10.1016/j.ajog.2014.11.014 43(2), 108–115. https://doi.org/10.1111/birt.12225
719
Rayment-Jones, H., Murrells, T., & Sandall, J. (2015). An investigation of Thornton, P. (2017). Characteristics of spontaneous births attended by
720 the relationship between the caseload model of midwifery for socially midwives and physicians in US hospitals in 2014. Journal of Midwifery
721 disadvantaged women and childbirth outcomes using routine data—A and Women’s Health, 62(5), 531–537. https://doi.org/10.1111/
722 retrospective, observational study. Midwifery, 31(4), 409–417. jmwh.12638
https://doi.org/10.1016/j.midw.2015.01.003
723 Van Lerberghe, W., Matthews, Z., Achadi, E., Ancona, C.,
Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Campbell, J., Channon, A., … Turkani, S. (2014). Country
724
Midwife-led continuity models versus other models of care for experience with strengthening of health systems and deployment
725 childbearing women. Cochrane Database of Systematic Reviews, of midwives in countries with high maternal mortality. The
726 2016(4), CD004667. https://doi.org/10.1002/14651858 Lancet, 384(9949), 1215–1225. https://doi.org/10.1016/
727 .CD004667.pub5 S0140-6736(14)60919-3
728 Sutcliffe, K., Caird, J., Kavanagh, J., Rees, R., Oliver, K., Dickson, K., … Vedam, S., Stoll, K., MacDorman, M., Declercq, E., Cramer, R., Cheyney,
Thomas, J. (2012). Comparing midwife-led and doctor-led maternity M., … Powell Kennedy, P. (2018). Mapping integration of midwives
729
care: A systematic review of reviews. Journal of Advanced Nursing, across the United States: Impact on access, equity, and outcomes.
730 68(11), 2376–2386. https://doi.org/10.1111/j.1365-2648.2012 PLOS ONE, 13(2), 1–20. https://doi.org/10.1371/journal.pone.
731 .05998.x 0192523
732
733
734
735
736
737
738
739
740
741
742
743
744
745
746
747
748
749
750
751
752
753
754
755
756
757
758
759
760
761
762
763
764
765
766
767
768
769
770

14 Volume - Issue - doi: 10.1016/j.nwh.2018.07.002

REV 5.5.0 DTD
NWH207_proof
4 September 2018
8:52 pm
ce