Effects of midwife-led maternity services on postpartum wellbeing and clinical outcomes in primiparous women under China’s one-child policy

There are many different models of maternity care available for looking after the health and wellbeing of pregnant women and newborns during pregnancy, labour and postpartum, each with their own distinct features based on local, cultural or social traditions and knowledge. Usually the obstetrician is the lead healthcare professional, but other times a midwife might be in charge. This responsibility can also be shared between obstetricians and midwives, while in other instances the midwife is only involved during labour (Midwife-led Care at Delivery, MCD). One of the recent models is called the Continuity of Midwife-led Care (CMC), where the midwife is responsible for the health care of pregnant women from the initial booking appointment, through labour and all the way to postpartum.

Research have indicated that midwife-led models of care are associated with improved benefits for mothers and newborns, including shorter labour, and decreased likelihood to require intrapartum analgesia or report dissatisfaction with their childbirth experiences [1‐3], which are typical indicators of optimal maternity care for low-risk childbearing women [4]. Midwife-led care facilitates birth, provides a better memory of the experience for the mothers, reduces or eliminates the need for medical intervention [5], decreases the number of maternal requested Caesarean Sections (CS) [6‐8] and helps pregnant women form a strong bond with their midwives. Midwife-led care may also lead to improved maternal psychosocial outcomes [9‐11], whereby pregnant women reported a stronger sense of emotional support, reassurance and were more in control during the midwives’ antenatal care [12]. Midwives who offer continuity of care can also provide better support, information and guidance for the feeding of newborns [3, 4, 13, 14].

China’s one-child family policy was introduced in 1979, restricting couples in urban areas to have only one child. Under the policy, most Chinese women are primiparous, and hence lack the experience of pregnancy and postpartum period. Moreover, the parents or parents-in-law of childbearing women are culturally expected to take the responsibility of caring for the new mothers and newborns from pregnancy to postpartum period. However, they may also lack the relevant experience because they have had only one child themselves under the population control policy and therefore may only be able to provide very limited assistance. Notably, due to the implementation of China’s one-child policy [15], there has been a dramatic increase in the overall rate of CS (54.90% throughout mainland China) over the past ten years [16, 17], and the most common reported indication for CS (28.43%) was maternal request for none-medical reasons [18]. Therefore, a midwife who can provide consultation, birth planning (encouraging low-risk pregnant women to choice vaginal birth if their health conditions are permissible), parent education and psychological support to inexperienced primiparous pregnant women from childbirth through to postpartum period, can play an important role for primiparous women under the one-child policy [19].

However, current maternity services in China are predominantly hospital-based, with the obstetrician as the lead professional in routine antenatal checkup [20]. Recently, some Chinese hospitals have started to introduce the midwife-led care model [21‐23], which generally provides one-to-one midwife-led care at delivery. A small proportion hospitals provides intentional continuity of midwife-led care from pregnancy to postpartum period [17, 24] Researchers have conducted pilot studies and reported that compared to the obstetrician-led antenatal care, midwife-led care is an effective way to reduce CS rate for childbearing women in mainland China [20]. Recently, an intervention study conducted in China showed that the midwife-led continuity care model decreased the CS rate and improved women’s general satisfaction [17] compared with obstetrician-led antenatal care. To our knowledge, few studies with clinical validation have reported on the effectiveness of Midwife-led Care at Delivery (MCD) and the Continuity of Midwife-led Care (CMC), which is needed in order to develop an optimal maternity service for childbearing women under China’s one-child policy. We therefore conducted a concurrent cohort study on maternal psychological outcomes in Shanghai, China. We hypothesized that midwife-led maternity care is an effective way to improving maternal satisfaction and wellbeing (i.e. general health, self-control, and vitality), reducing CS rates, and increasing the rate of breastfeeding. The continuity of midwife maternity care may be an optimal service for women due to their inexperience of maternity care under China’s one-child policy. The aim of this study was: (1) to explore the effects of MCD and CMC on the delivery mode and rate of breastfeeding within the first 24 h in primiparous women when compared with Obstetrician-led Maternity Care (OMC) under China’s one-child policy; (2) to compare the effectiveness of MCD and CMC with routine maternity care on postpartum satisfaction and wellbeing so as to provide the evidence for selecting an optimal maternity service in China.

The principles of the midwife-led service were to provide a home-like environment, minimize intervention, facilitate normal birth, improve women’s birth experiences and enhance the role of midwives. The present study provided supportive clinical evidence on the effectiveness of the midwife-led maternity services for inexperienced primiparous women under China’s one-child policy. Other than increased vaginal birth and breastfeeding rates, the continuity of midwife-led service has contributed to improving the maternal wellbeing and satisfaction in low-risk primiparous women with limited experience under China’s one-child policy.

This study demonstrated that low-risk primiparous women who received the CMC or MCD services were less likely to undergo caesarean section than those who received the standard obstetrician-led birth care. These results supported previous studies that showed continuity of midwife-led care with a focus on normal birth in a friendly supportive birth environment makes a significant difference on the mode of delivery [4, 10, 19, 23] For low-risk pregnant women, collaboration and support other than standard obstetric management allowed a greater number of spontaneous vaginal deliveries [28]. It has been reported that midwives could provide plenty of information regarding childbirth to childbearing women. Increased self-confidence brought about by the presence of midwives made childbearing women more confident in facing labour [29]. However, in most areas in China, obstetrician-led birth care remains the most common form of pregnancy healthcare management. This physician-based obstetric care model is more likely to turn birth from natural process to a contrived medical process. A pregnant woman is often considered as a patient, and is therefore more likely to receive frequent obstetric intervention [30]. Under these circumstances, normal child birth usually ends up as caesarean delivery.

Breastfeeding education from midwives also plays an important role in protecting and supporting breastfeeding women [31, 32]. In our study, the continuity of midwife-led maternity service has been found to be linked to an increased rate of breastfeeding for inexperienced primiparous woman. However, the MCD service did not improve the breastfeeding rate. Breastfeeding knowledge from health professionals involves providing supportive attitudes and behaviors, but this knowledge must be accurate and thorough to effectively promote breastfeeding [33]. Multiple studies have shown that inconsistent and conflicting advices are detrimental to breastfeeding outcomes [34‐36]. In the MCD model, the childbearing women may receive inconsistent information about breastfeeding during pregnancy because it is likely that they would have met a different obstetrician on each visit to the antenatal clinic at the out-patient department. Furthermore, they may also receive limited information regarding breastfeeding because the midwives in MCD care condition only provide services from labour to 2 h postpartum.

We observed that the continuity of midwife-led service was associated with increased women’s satisfaction. Similar to other studies on the continuity of midwifery care [37], women were more likely to feel satisfied with midwives in terms of information transfer, choices and decisions, and were more pleased with the antenatal and intra-partum care provided by the midwives compared to other models [38]. A recent review reported that women who received midwife-led continuity models of care were less likely to experience intervention and more likely to be satisfied with their maternity care compared to women who received other models of care [26]. The results of the current study were also consistent with a previous report that showed low-risk pregnant women in China were more likely to be satisfied with the care and support of midwives [39]. Many studies have showed that women in labour are more appreciative of reliable midwifery practice [40], especially health professionals who are open to listening, being honest, and can provide both physical and emotional support; in other words, the professionals who showed ability to care for the women’s needs during labour [41‐44]. As previous studies have pointed out [45], the psychosocial aspects of birth care, as well as information and caregiver support are the most important factors associated with antenatal satisfaction; whereas the lack of support from midwives or other inappropriate antenatal services are often linked to dissatisfaction. However, our study did not observe any association between MCD and women’s satisfaction due to the limited service provided by the midwife from labour to 2 h postpartum.

In this study, we found that compared to the routine obstetrician-led birth care, the CMC service resulted in improved postpartum wellbeing, increased self-control and lower anxiety. However, MCD only had a positive influence on overall wellbeing. These results were similar to previous studies that showed midwife-led care could improve the maternal psychological status. Receiving support from midwives was one of the most effective methods to reduce the level of maternal anxiety [46]. Homer et al. also reported that women who had a familiar midwife during labour had a significantly higher sense of ‘control’ and a more positive childbirth experience compared to women with an unfamiliar midwife [10]. Cheung et al. [29] pointed out that there was a significant negative association between maternal anxiety and feelings of control during labour. Researchers [47] also reported that maternal feelings of control during labour might help in decreasing the level of anxiety during pregnancy.

Using a concurrent cohort study design, we found that the introduction of CMC significantly improved vaginal birth rate, breastfeeding rate, maternal satisfaction and overall wellbeing in pregnant women. However, MCD was only associated with vaginal mode of delivery and overall wellbeing. This study provides supportive evidence that CMC is the optimal healthcare service for the management of low-risk primiparous women under China’s one-child policy. Therefore a general implementation of CMC in Shanghai and across China should be encouraged. In our study, the majority of women (71.1%) still received the routine obstetrician-led birth care. Further efforts should be made to inform the public on the advantages of CMC in low-risk pregnant women.