A comparison of midwife-led and obstetrician-led antenatal care for women with one previous Caesarean section

Abstract

This research compared midwife-led with obstetrician-led antenatal care for women who had previously given birth by Caesarean section (CS) and had no other risk factors. The primary outcomes under investigation were intended and actual mode of birth. Safety outcomes were also evaluated and compared.

Internationally, CS rates have risen dramatically over the last three decades. There is large variation between rates in different maternity units. Vaginal birth after Caesarean (VBAC) is considered a safe option for the majority of women who have a previous CS. Evidence suggests that factors in antenatal care can influence women’s mode of birth decision, most notably the interaction with health professionals. Midwife-led care is known to have benefits for ‘low-risk’ women; it is argued that these benefits can be extrapolated to women whose only risk factor is a prior CS.

This research was a retrospective, comparative cohort study. A quantitative methodology was applied to objectively compare intended and actual VBAC rates between women who received either midwife-led or obstetrician-led antenatal care. Women’s case-notes were reviewed and data collected (n=405). The sample size was calculated to test a non-inferiority hypothesis: that midwife-led antenatal care elicits a VBAC rate that is equal to or higher than obstetrician-led. Analysis indicates that receiving midwife-led antenatal care resulted in higher intended and actual VBAC rates compared with obstetrician-led antenatal care: 90% vs. 77%, OR 2.78 (95% confidence interval 1.57-4.92), p<0.001 and 61% vs. 47%, OR 1.79 (1.2-2.66), p=0.004, respectively. These findings remained significant after adjustment for clinically important confounding factors. Analysis also provides some evidence that midwife-led antenatal care is safe and results in fewer episodes of unscheduled antenatal care and antenatal inpatient admissions.

Significant improvements were demonstrated with midwife-led compared to obstetrician-led antenatal care with regard to continuity of carer, the environment of care and the time women had to make their mode of birth choice. It is theorised that these differences, the organisation’s support of the innovation and, perhaps most importantly, the midwifery expertise and focus on normal birth increased the VBAC rate by enhancing women’s confidence in their ability to birth naturally. This research has demonstrated an association between midwife-led antenatal care and increased VBAC rates and has provided some evidence that this type of care is safe.

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Identifiers

ORCID for Elizabeth Cluett: orcid.org/0000-0002-8707-5042

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