Background
Pregnant women should have access to high-quality maternal health care, which is a fundamental human right [
1]. However, every day, nearly 830 women die worldwide from preventable causes related to pregnancy and childbirth. The majority of deaths occur in low- and middle-income countries, accountable for 95% of maternal deaths and 90% of all children’s deaths worldwide [
2,
3].
The expansion of basic and comprehensive emergency obstetric care centres and an increase in institutional births with skilled attendance are two significant strategies that low- and middle-income countries have used in recent years to overcome the adverse outcomes of maternal and new-born deaths [
4]. However, recent data demonstrate the persistent magnitude of the problem and emphasise the importance of developing additional solutions tailored to low- and middle-income countries [
5].
Midwifery-led care, an approach which is already widely practiced in developed nations [
6]; however, it is a relatively new approach in lower-income countries. In midwifery-led care, a midwife who is well known by their client, provides the care for a low-risk pregnant woman throughout antenatal care, delivery, and the postnatal period, instead of being cared for by various medical staff led by an obstetrician [
7]. The primary focus of midwifery-led care is on supporting a healthy physiological pregnancy and labour, and empowering women to give birth naturally with little to no regular intervention [
8].
Evidence regarding midwifery-led care links it to a number of advantages, including higher levels of maternal satisfaction and less needless uses of medical interventions [
9]. Various studies from high-income countries on the effect of midwifery-led care reported that midwifery-led care could avert about two-thirds of deaths among women and new-borns, reduce obstetric interventions by 13%, and decrease the number of severe adverse maternal outcomes and postpartum incidents [
6,
10]. A systematic Cochrane review (2016) of 15 trials involving a total of 17,674 women concluded that midwifery-led care models save infants’ lives, prevent preterm birth, reduce the need for interventions, and improve women’s experiences and clinical outcomes [
11]. Additionally, the follow-up Cochrane reviews from 2018 and 2020 also concluded that midwifery-led care prevents stillbirth and preterm birth [
12,
13]. Based on this finding, scaling up of midwifery-led care as a paradigm is being advocated by the WHO as well as global health specialists in many nations to enhance maternal and new-born outcomes, lower rates of unnecessary procedures, realise cost savings, and promote natural spontaneous vaginal birth [
14‐
16].
However, there is limited evidence available regarding low- and middle-income countries [
17,
18]. Most evidence is from high-income regions [
13,
19] and there are currently no pooled estimates on the effectiveness of midwifery-led care to improve maternal and neonatal outcomes in low- and middle-income countries. Pooled effects provide a more comprehensive understanding of the potential effectiveness of midwifery-led care and can inform policymakers and respective stakeholders on the potential implementation of strategies in regions with a high burden of maternal and neonatal deaths [
2,
3]. Therefore, this systematic literature review and meta-analysis aimed to assess the effectiveness of midwifery-led care on pregnancy outcomes in low- and middle-income countries.
Discussion
This systematic review and meta-analysis aimed to assess the effectiveness of midwifery-led care to improve maternal and neonatal outcomes in low- and middle-income countries. Over the past 20 years, reducing maternal mortality has been at the top of the global health agenda [
39]. It is well known that midwifery-led care can help to improve the quality of care, outcomes, and the efficient use of health care resources by lowering maternal and neonatal mortality and morbidity, lowering stillbirths and preterm births, lowering the number of unnecessary interventions, and raising psychosocial and public health outcomes [
40]. However, the current evidence mainly concerns high-income countries [
11,
19]. There is little evidence regarding low- and middle-income countries [
17,
18], with a lack of pooled estimates of the effectiveness of midwifery-led care on pregnancy outcomes in low- and middle-income countries.
A total of ten studies were eligible for inclusion in this review. According to the quality assessment, nine studies had high methodological quality and one studies had moderate methodological quality.
Findings from the systematic review indicated that midwifery-led care significantly lowered the rate of postpartum haemorrhage and reduced the rate of birth asphyxia. A reduced rate of emergency Caesarean section, increased odds of vaginal birth, a decreased rate of episiotomy and decreased average neonatal admission time in neonatal intensive care unit were significantly associated with midwifery-led care. However, the pooled odds ratio from the meta-analysis shows that early initiation of exclusive breastfeeding and rate of preterm births were not significantly associated with midwifery-led care.
The findings regarding the increased odds of vaginal births with midwifery-led care, [
11,
41‐
43] and the reduced rate of emergency Caesarean sections [
11,
41‐
45] are in line with previous research conducted in high-income countries [
41,
42].
A possible explanation for the effectiveness of midwifery-led care in improving maternal and neonatal outcomes could be related to the fact that midwifery-led care focuses on the maintenance of well-being of the women and the promotion of normality by enhancing the physiological capacity of women to give birth with a minimum of – or even no – interventions [
46]. The level of knowledge, education, trust, and empowerment of midwives toward midwifery-led care may be connected to the possible impact of the midwives' work during the pregnancy [
47]. Women's confidence and comfort during labour, along with the support of the familiar midwife they already know, may have had an impact on the frequency of medical interventions like emergency Caesarean sections [
48].
In line with this, the study revealed that midwifery-led care was associated with a reduced rate of episiotomies. Similar findings were reported among women in midwifery-led care among women with a singleton pregnancy, showing that the rate of episiotomy was significantly reduced compared to the rate in women given standard care [
11,
41,
43,
46].
Two systematic reviews conducted in high-income countries reported the same conclusion: women who received midwifery-led care were less likely to undergo an episiotomy [
11,
49]. Episiotomies are controversial in the majority of developing nations, since they are frequently and sometimes routinely performed, even when not medically indicated [
50]. Due to this, many women have considerable health challenges as a result of an episiotomy, often with little to no benefit [
51]. When women receive midwifery-led care, midwives are more familiar with their patients, so that information about a delivery plan and the possible interventions are discussed, and closer attention is paid to a woman's individual needs [
52].
In this review and meta-analysis, neonatal admission time of neonates in a neonatal intensive care unit was significantly reduced by midwifery-led care, in line with studies from high-income countries [
41,
42]. This suggests that midwifery-led care leads to shorter hospital stays, and fewer tests and interventions and the development of a trusting relationship between midwives and expectant mothers may have lowered labour-related stress, which may have in turn decreased the reasons for neonatal admission [
38,
52].
The present study concluded that early initiation of exclusive breastfeeding was borderline significant. The possible reason might be that the difference in quality of the included studies affect the pooled effect. Preterm birth was not significantly associated with midwifery-led care. A possible reason might be due to the limited number of studies included in the case of preterm births in the current review. By contrast, studies conducted in high-income countries revealed that midwifery-led care improves the outcomes [
11,
53,
54].
Strengths and limitations
The current study has several strengths. To our knowledge, this study is the first systematic review and meta-analysis evaluating the effectiveness of midwifery-led care to improve pregnancy outcomes in low- and middle-income countries. The meta-analysis provided additional strong evidence to the systematic review. The researchers used extensive and comprehensive search strategies based on a pre-specified protocol. The literature search was systematic and assessed by two independent reviewers within the desired scope. We also adhered to PRISMA guidelines and conducted the quality assessment of the included studies. However, only studies in the English language were included, which could have led to missed research written in local languages. The number of included studies was limited, reflecting the lack of research in this area. As a result, the findings might not be representative of the entire region, meaning that low-income countries, especially eastern Africa, lack adequate studies.
In addition, we were not able to show combined pooled estimates for all outcome variables associated with midwifery-led care because the included studies classified the variables in different ways.
Implications for practice and research
The implementation of midwife-led care should be taken into consideration as a choice in maternal health care in low- and middle-income countries. We should scale up such interventions as they are critical for providing quality of care during the antenatal, delivery, and postpartum periods. A comprehensive approach should be implemented to prevent adverse pregnancy outcomes including facility-based midwifery-led care. This requires that all responsible bodies, including ministries of health, the respective regional health bureaus, and other stakeholders should work together to reduce maternal and neonatal mortality. Furthermore, additional research is needed on the effects of midwifery-led care on a broader range of outcomes, including longer term follow-up of infants’ development.
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