Saturday, October 11, 2008

Cochrane and midwifery-led care

The Cochrane Collaboration is widely considered to be one of the gold standard tools for evidence-based practice. It is a charity organization based in the UK that regularly carries out systematic reviews on health care practices and interventions. In other words, a panel of experts looks at all the research published (and sometimes unpublished) pertaining to a particular issue or treatment, evaluates all the results to come to a definitive decision about its effectiveness. Often that decision is that there is not enough research to be able to say one way or another. Other times, the way forward is clear.

Highly regarded

The idea is that the Cochrane is completely neutral and carries out unbiased reviews, which in turn can be used as evidence for health professionals and consumers when they are making decisions about health care. Now, I am not sure that there is a completely bias-free 'anything', but that's another conversation. Cochrane Reviews are highly regarded internationally, so they are one place to start when you are researching the effectiveness of particular treatments.

Free access
In New Zealand, free access is provided to the Cochrane Library via the Ministry of Health. I would highly recommend that you have a look at it. And for health consumers (and me), the reviews are summarized in 'plain language' so that we get past the difficult medical and statistical terms to reach the message of the review.

Midwifery-led care
For as long as I can remember there have been discussions, research studies and arguments about the effectiveness of midwifery-led care compared to doctor-led care. And as you can imagine, midwives say midwife-led care is safe, and doctors maintain that every pregnant woman should be overseen by a doctor. OK, that is a over-simplification, but it isn't too far from the truth.

What is midwife-led care?
By midwife-led care, I mean that the midwife is the primary care giver, as in the maternity system in New Zealand. In other words, when you or your partner get pregnant, you come to me as a midwife and I organize and provide your care from confirmation of pregnancy to discharge after the baby is born. If you are fit and healthy, and you have no complications during your pregnancy or when you have the baby, you may not get even a flying glimpse of another health professional. But if you have a medical condition, or if you or your baby develop complications then I would refer you to whatever health professional is appropriate.

At the center is the concept of midwife-led care is continuity of care and career. You have the same few people look after you throughout your birthing experience instead of a merry-go-round of health professionals who you do not know from one clinic visit to the next.

Midwife-led care is safe
So it is very heartening to see that the latest Cochrane Review which looks at midwife-led care concludes that it is safe and should be recommended for all women.

The main finding was that women are less likely to have a miscarriage before 24 weeks pregnancy, which I must admit I don't quite understand. The other findings are that women are more likely to have normal births and initiate breastfeeding when they have a midwife looking after them. And they are less likely to have regional anesthetics like epidural, instrumental deliveries ie forceps and ventouse, and less likely to have episiotomies.

Challenge for New Zealand midwives
This will be especially good news for women and midwives in Australia who working to implement more midwife-led schemes. As for us midwives in New Zealand, we need to keep looking at our practice and how we can work to lower intervention rates and an ever-increasing cesarean section rate.

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