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Literature review.

example of midwifery literature review

Impact of the midwife-led care model on mode of birth: a systematic review and meta-analysis

A systematic review is the best approach to determine the most effective intervention/treatment in clinical decision-making (Harvey and Land, 2017). This method follows explicit, rigorous and...

example of midwifery literature review

The role of egg consumption in the first 1001 days of life: a narrative review

For this narrative review, PubMed was searched to identify key articles published between 2019 and 2024 investigating egg consumption during pregnancy, breastfeeding and/or infancy. The following...

example of midwifery literature review

Autistic women's experiences of the antenatal, intrapartum and early postnatal periods

The PICO mnemonic (Stern et al, 2014) was used to identify key words and develop the research question: what can midwives in England learn from studies exploring the experiences of autistic women in...

example of midwifery literature review

Perinatal outcomes in persistent occiput posterior fetal position: a systematic review and meta-analysis

Meta-analysis is a quantitative, formal, epidemiological study design used to systematically assess the results of previous research to derive conclusions about that body of research (Haidich, 2010)....

example of midwifery literature review

Carbetocin vs oxytocin in third stage labour: a quantitative review of low- and middle-income countries

This review was carried out to determine if the use of carbetocin in low- and middle-income countries would reduce the risk of postpartum haemorrhage, and associated morbidity and mortality, in...

example of midwifery literature review

mHealth interventions to improve self efficacy and exclusive breastfeeding: a scoping review

The electronic search was carried out in September 2022, using the population/problem/patient, intervention, comparison, outcome and study design strategy. The primary source of literature was online...

 Routine examinations such as palpation can help to recognise adverse events

The use of gender-neutral language in maternity settings: a narrative literature review

A preliminary search of the Cochrane Library, CINAHL, and MEDLINE databases was undertaken to identify articles relating to the topic. Search terms or text words contained in titles, abstracts and...

example of midwifery literature review

Midwives’ practice of maternal positions throughout active second stage labour: an integrative review

An integrative review was considered suitable for this study, as this methodology allows inclusion of data from all types of literature to fully answer review questions (Whittemore and Knafl, 2005;...

example of midwifery literature review

Health-seeking behaviours of pregnant adolescents: a scoping review

This study was developed based on Arskey and O'Malley's (2005) scoping review methodology. According to this framework, there are six stages: (1) identifying the research question, (2) identifying...

example of midwifery literature review

Maternal intrapartum fluids and neonatal weight loss in the breastfed infant

Searches of key databases (CINAHL, MEDLINE, EMBASE, EMCARE) were conducted using a search strategy developed in collaboration with the local NHS library service (Table 1). Known researchers in this...

example of midwifery literature review

Midwives' and women's understanding of cytomegalovirus infection during pregnancy

The electronic databases CINAHL, Maternity and Infant Care, EMBASE and PubMed were systematically searched using key words and terms, which included: midwife, midwives, woman, women,...

Figure 8a. Roll over onto all fours position

Simulation and midwifery education 2011–2021: a systematic review

The focus of this review was the evaluation of articles describing the use of simulation in midwifery education. A search was carried out using the online database PUBMED for articles published...

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Nursing and Midwifery

  • Accessing NHS resources
  • Journals, Databases and Critical Thinking

What is a literature review?

Choosing a topic, developing your search strategy, carrying out your search, saving and documenting your search, formulating a research question, critical appraisal tools.

  • Go to LibrarySearch This link opens in a new window

So you have been asked to complete a literature review, but what is a literature review?

A literature review is a piece of research which aims to address a specific research question. It is a comprehensive summary and analysis of existing literature. The literature itself should be the main topic of discussion in your review. You want the results and themes to speak for themselves to avoid any bias.

The first step is to decide on a topic. Here are some elements to consider when deciding upon a topic:

  • Choose a topic which you are interested in, you will be looking at a lot of research surrounding that area so you want to ensure it is something that interests you. 
  • Draw on your own experiences, think about your placement or your workplace.
  • Think about why the topic is worth investigating.  

Once you have decided on a topic, it is a good practice to carry out an initial scoping search.

This requires you to do a quick search using  LibrarySearch  or  Google Scholar  to ensure that there is research on your topic. This is a preliminary step to your search to check what literature is available before deciding on your question. 

example of midwifery literature review

The research question framework elements can also be used as keywords.

Keywords - spellings, acronyms, abbreviations, synonyms, specialist language

  • Think about who the population/ sample group. Are you looking for a particular age group, ethnicity, cultural background, gender, health issue etc.
  • What is the intervention/issue you want to know more about? This could be a particular type of medication, education, therapeutic technique etc. 
  • Do you have a particular context in mind? This could relate to a community setting, hospital, ward etc. 

It is important to remember that databases will only ever search for the exact term you put in, so don't panic if you are not getting the results you hoped for. Think about alternative words that could be used for each keyword to build upon your search. 

Build your search by thinking about about synonyms, specialist language, spellings, acronyms, abbreviations for each keyword that you have.

Inclusion & Exclusion Criteria

Your inclusion and exclusion criteria is also an important step in the literature review process. It allows you to be transparent in how you have  ended up with your final articles. 

Your inclusion/exclusion criteria is completely dependent on your chosen topic. Use your inclusion and exclusion criteria to select your articles, it is important not to cherry pick but to have a reason as to why you have selected that particular article. 

example of midwifery literature review

  • Search Planning Template Use this template to plan your search strategy.

Once you have thought about your keywords and alternative keywords, it is time to think about how to combine them to form your search strategy. Boolean operators instruct the database how your terms should interact with one another. 

Boolean Operators

  • OR can be used to combine your keywords and alternative terms. For example "Social Media OR Twitter". When using OR we are informing the database to bring articles continuing either of those terms as they are both relevant so we don't mind which appears in our article. 
  • AND can be used to combine two or more concepts. For example "Social Media AND Anxiety". When using AND we are informing the database that we need both of the terms in our article in order for it to be relevant.
  • Truncation can be used when there are multiple possible word endings. For example Nurs* will find Nurse, Nurses and Nursing. 
  • Double quotation marks can be used to allow for phrase searching. This means that if you have two or more words that belong together as a phrase the database will search for that exact phrase rather than words separately.  For example "Social Media"

Don't forget the more ORs you use the broader your search becomes, the more ANDs you use the narrower your search becomes. 

One of the databases you will be using is EBSCOHost Research Databases. This is a platform which searches through multiple databases so allows for a comprehensive search. The short video below covers how to access and use EBSCO. 

A reference management software will save you a lot of time especially when you are looking at lots of different articles. 

We provide support for EndNote and Mendeley. The video below covers how to install and use Mendeley. 

Consider using a research question framework. A framework will ensure that your question is specific and answerable.

There are different frameworks available depending on what type of research you are interested in.

Population - Who is the question focussed on? This could relate to staff, patients, an age group, an ethnicity etc.

Intervention - What is the question focussed on? This could be a certain type of medication, therapeutic technique etc. 

Comparison/Context - This may be with our without the intervention or it may be concerned with the context for example where is the setting of your question? The hospital, ward, community etc?

Outcome - What do you hope to accomplish or improve etc.

Sample - as this is qualitative research sample is preferred over patient so that it is not generalised. 

Phenomenon of Interest - reasons for behaviour, attitudes, beliefs and decisions.

Design - the form of research used. 

Evaluation - the outcomes.

Research type -qualitative, quantitative or mixed methods.  

All frameworks help you to be specific, but don't worry if your question doesn't fit exactly into a framework. 

There are many critical appraisal tools or books you can use to assess the credibility of a research paper but these are a few we would recommend in the library. Your tutor may be able to advise you of others or some that are more suitable for your topic.

Critical Appraisal Skills Programme (CASP)

CASP is a well-known critical appraisal website that has checklists for a wide variety of study types. You will see it frequently used by practitioners.

Understanding Health Research

This is a brand-new, interactive resource that guides you through appraising a research paper, highlighting key areas you should consider when appraising evidence.

Greenhalgh, T. (2014) How to read a paper: The basics of evidence-based medicine . 5 th edn. Chichester: Wiley

Greenhalgh’s book is a classic in critical appraisal. Whilst you don’t need to read this book cover-to-cover, it can be useful to refer to its specific chapters on how to assess different types of research papers. We have copies available in the library!

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  • Research article
  • Open access
  • Published: 08 November 2012

Public health interventions in midwifery: a systematic review of systematic reviews

  • Jenny McNeill 1 ,
  • Fiona Lynn 1 &
  • Fiona Alderdice 1  

BMC Public Health volume  12 , Article number:  955 ( 2012 ) Cite this article

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Maternity care providers, particularly midwives, have a window of opportunity to influence pregnant women about positive health choices. This aim of this paper is to identify evidence of effective public health interventions from good quality systematic reviews that could be conducted by midwives.

Relevant databases including MEDLINE, Pubmed, EBSCO, CRD, MIDIRS, Web of Science, The Cochrane Library and Econlit were searched to identify systematic reviews in October 2010. Quality assessment of all reviews was conducted.

Thirty-six good quality systematic reviews were identified which reported on effective interventions. The reviews were conducted on a diverse range of interventions across the reproductive continuum and were categorised under: screening; supplementation; support; education; mental health; birthing environment; clinical care in labour and breast feeding. The scope and strength of the review findings are discussed in relation to current practice. A logic model was developed to provide an overarching framework of midwifery public health roles to inform research policy and practice.

Conclusions

This review provides a broad scope of high quality systematic review evidence and definitively highlights the challenge of knowledge transfer from research into practice. The review also identified gaps in knowledge around the impact of core midwifery practice on public health outcomes and the value of this contribution. This review provides evidence for researchers and funders as to the gaps in current knowledge and should be used to inform the strategic direction of the role of midwifery in public health in policy and practice.

Peer Review reports

The reproductive period offers maternity care providers the opportunity to maximise the health and well-being of women and their families potentially impacting on public health outcomes, both short and long term. Although all maternity care providers who engage with pregnant women are presented with such opportunities, it is the midwife that could have the most significant impact from regular contact and building of relationships through continuity of care. There are interventions that could be implemented by midwives, which potentially would have a public health impact but it is important such interventions are evidence based. Recognition of the importance of the relationship between public health and midwifery was highlighted when a general review of midwifery in the UK [ 1 ], named public health as one of five key areas of interest. While the review specifically focused on midwifery in the UK, the importance of preventative public health interventions during pregnancy and the postnatal period has been emphasized on a wider scale. Millennium Development Goal 5 focuses on improving maternal health specifying a secondary target aim to achieve universal access to reproductive health by 2015 [ 2 ]. Antenatal care and adolescent pregnancy are specifically mentioned as key to achieving this target, both of which are acknowledged widely, as areas of interest to public health [ 3 , 4 ]. Other areas of national and international interest, which impact on population health (both women and families), include rising caesarean section rates and other interventions during childbirth [ 5 – 7 ], the importance of positive parenting in the early postnatal period [ 8 ] and perinatal mental health [ 9 ]. Within these areas there is opportunity for evidence based public health interventions to be implemented with a view to potentially improving the long term health of women and families.

Aim of the review

This paper presents an update of a systematic review of systematic reviews conducted in 2009. The aim of the 2009 review was to evaluate the effectiveness of interventions relevant to the public health role of the midwife. The 2009 review was commissioned and conducted within the context of the Midwifery 2020 initiative. The final report of the Midwifery 2020 initiative (Delivering Expectations) and full report of the systematic review of reviews [ 10 ] are available freely online from: http://www.midwifery2020.org . A systematic review of systematic reviews was selected as the methodology, given the breadth of this topic area and the timescale of the project. This paper outlines the review methodology and builds on the original review findings by providing new and updated information about effective high quality public health interventions which could be implemented by midwives or other health care providers for women during pregnancy and the postnatal period who have a similar role, for example, public health nurses, obstetric nurses, labour and delivery nurses or health visitors.

The Preferred Reporting Items of Systematic reviews Meta-Analyses (PRISMA) guidelines was adhered to when conducting this review [ 11 ]. A systematic search strategy was formulated and definitive search terms used relative to key public health topics within midwifery following consultation with Expert Advisory Group members and Midwifery 2020 Public Health Work Stream members. Seven key areas were identified as relevant to the public health role of the midwife, which included: screening; vulnerable groups; breast feeding; mental health and wellbeing; education and support; childbirth and lifestyle factors. The complete list of search terms is available from McNeill et al. [ 10 ].

Search strategy

Databases searched included: MEDLINE, PubMed, EBSCO (CINAHL/British Nursing Index), MIDIRS Online Database, Web of Science, The Cochrane Library, CRD (NHS EED/DARE/HTA) and EconLit. Eligibility criterion included reviews published from 1999 onwards; English language publications and reviews originating from economically developed countries as indicated by membership of the Organisation for Economic Co-operation and Development (OECD). An additional search was conducted of the National Institute for Health and Clinical Excellence, UK (NICE) website to identify key publications or findings from systematic reviews within guidelines. Reference lists of identified reviews were manually searched for additional relevant reviews. The searches were initially conducted in November 2009 and updated in October 2010. The titles and abstracts were obtained and the decision process for eligibility was conducted by all members of the project team in collaboration (JM, FL & FA). Full text was obtained of all eligible reviews and those whose eligibility could not be discerned from reading the abstract. Eligible systematic reviews also had to publish a clearly identified search strategy or detail the reference databases used.

Data extraction

Data were extracted on: number of papers included in the review; methodological details; midwifery intervention; outcome measures and results. Data were systematically extracted using a data extraction form by individual project team members and verified by one other project team member. The project team subsequently met to discuss and achieve consensus regarding any contentious issues. A parallel process of developing a logic model to act as an overarching framework to inform forward planning was also conducted. Logic models are essentially a conceptual framework, which can be used for evidence‐based decision making and planning [ 12 ]. The model is composed of midwifery inputs and activities, producing a logical pathways to short, medium and long term public health outputs.

Quality assessment and effectiveness of reviews

It is important to consider both the type of evidence included in reviews i.e. was the review restricted to randomised trials only or were other types of studies included and also assess how well the review was conducted methodologically. As such, a two stage process was employed: initially the level of evidence was graded and secondly, the methodological quality was assessed. Recognised frameworks were used to support this process [ 13 , 14 ]. In the hierarchy of evidence, randomised controlled trials are perceived as the gold standard and as the aim of this paper is to present high quality evidence, an evidence grade was given to each review based on the Scottish Intercollegiate Guidelines Network [ 13 ] framework in order to distinguish between different levels of evidence. This framework grades the associated risk of bias based on the level of evidence in a hierarchal manner from a grade of 1++ (meta analysis and RCT evidence) through to 4 (expert opinion), as outlined in Table 1 . The SIGN framework was modified as this review was restricted to systematic reviews and therefore reviews could only be graded as 1++, 1+, 1- or 2++. This paper only presents evidence which was graded 1- or above; any review graded below 1- was not deemed eligible for inclusion. Following selection of the type of evidence, the second stage focused on the methodology of eligible reviews. Clarke [ 15 ] suggests the successful interpretation of results from systematic reviews should consider the methodological conduct of the review. The methodological quality of included reviews was assessed and rated as low, medium or high quality. Appraisal of methodological quality was based on Smith et al. [ 14 ], which contains similar elements to other tools used to assess review quality, for example, the AMSTAR tool [ 16 ]. Reviews were graded as high quality if they included evidence of a search strategy, selection and inclusion criterion, assessment of publication bias and assessment of heterogeneity. Reviews were rated as medium quality if no evidence of assessment of heterogeneity or publication bias was provided and low quality reviews were those which provided evidence of a search strategy only. Effectiveness of interventions was evaluated using a similar approach to van Sluijs et al. [ 17 ]. A differentiation was made between reviews which reported a statistically significant difference (P<0.05), therefore referred to as effective and those which reported no difference in effect between control and intervention group and are referred to as inconclusive or not effective (as appropriate). This paper focuses specifically on interventions which are evidenced by a statistically significant meta analysis or where the intervention is supported by a generally positive trend of results when a meta analysis was not possible. Reviews have been included where a small number of studies reported statistically significant positive effect of the intervention however the wider interpretation of these results is limited. As outlined previously, the aim of the original review was to identify any public health intervention relevant to midwifery. However for the purpose of this paper the focus was to report on public health interventions relating to midwifery that demonstrated a statistically significant effect in favour of the intervention (referred to subsequently as effective interventions for the sake of brevity). Reviews graded 1- or above and of high methodological quality which reported evidence of no effect, are not discussed in this paper. However, they have been summarised in Table 2 [ 18 – 23 ]. In the case of any disagreement regarding grading of evidence, quality appraisal of reviews or effectiveness of the intervention, consensus was reached by discussion between all three authors.

Data synthesis

A narrative review is provided for each of the systematic reviews and in table format the number and date range of papers included, intervention(s), primary outcome or other public health outcomes of interest, results (including key statistical findings e.g. p values or odds ratios) are described and whether the review included a meta analysis or not. It was not expected that a quantitative analyses would be conducted given the diversity of interventions across the broad subject of public health.

In total 214 systematic reviews were eligible of which 91 reported on effective interventions and 117 found no effect or were inconclusive. This paper only reports on high quality reviews with a level of evidence grading above 1-. Of the 91 systematic reviews which reported on effective interventions, 36 were identified which were graded as evidence level 1- or above and rated as high quality. The flow chart in Figure 1 presents the sequential process of identifying reviews eligible for inclusion in this paper. An overview of the key findings in relation to interventions demonstrating a statistically significant effect in favour of the intervention from good quality reviews will be presented in the following sections. A summary of included reviews is provided in Table 3 . The findings in this paper are presented chronologically through the reproductive period: preconceptual; antenatal; intranatal and postnatal. Within each section the reviews on similar broad topics have been further categorised: antenatal (screening; supplementation; support; education; mental health); intranatal (clinical care; environment); postnatal (breast feeding; mental health; education; support). The findings section also presents the logic model which was developed in parallel with the searching and analysis of reviews. Logic models enable the visualisation of how interventions or programmes work and the expected outcomes [ 24 ] and have been used to consider the strategic public health benefit of midwifery practice both in the short and long term [ 25 ].

figure 1

Identification of effective reviews of high quality *some reviews which were included at the request of funder have been excluded from this paper eg economic reviews (n=6) **non significant, non effective or inconclusive reviews, reviews graded 2++,2+ or 2- and medium or low quality reviews are not discussed in this paper.

Findings -effective interventions

Pre conceptual.

There were no high quality reviews that reported on effective interventions in the pre conceptual period.

The majority of reviews reporting effective interventions were relevant to the antenatal period (n=20). Included reviews have been grouped into screening, supplementation, support, education and mental health.

Reviews (n=4) related to screening reported on interventions relating to ultrasound [ 26 , 27 ], lower genital tract infection screening [ 28 ] and the use of decision making aids [ 29 ]. Bricker et al. [ 26 ] conducted a large Health Technology Assessment review on the clinical and cost effectiveness and women’s views of USS. The review comprised of three systematic reviews on routine ultrasound in early pregnancy, routine ultrasound in late pregnancy and routine Doppler ultrasound in pregnancy which were published in the Cochrane database around the time of Bricker et al. [ 26 ] however, all have since been updated or revised in the Cochrane database, one of which has been included in this paper. The final conclusions of Bricker et al. [ 26 ] indicated that a two stage regimen of USS in pregnancy, one in early pregnancy (booking USS) and a second anomaly USS around 20 weeks, was recommended. Whitworth et al. [ 27 ] reviewed the use of ultrasound for fetal assessment in early pregnancy and concluded that it reduces failure to detect multiple pregnancy (RR 0.07 95% CI 0.03-0.17) and accuracy of gestational dating may reduce the number of inductions of labour for post term gestation (RR 0.59; 95% CI 0.42-0.83). The authors also reported there was no reduction in adverse outcomes or health service use by mothers or infants and long term follow up did not indicate detrimental effect on children’s physical or mental development. The impact of antenatal screening for lower genital tract infection for preventing preterm delivery was reviewed by Sangkomkamhang et al . [ 28 ]. The review included one large RCT (n=4155), which indicated that preterm birth before 37 weeks was significantly lower in a group of women randomised to a screening programme before 20 weeks’ gestation (RR 0.55; 95% CI 0.41-0.75). The review provides evidence to suggest there may be some benefit to introducing a universal screening programme for lower genital tract infection; however the results are based on the findings of one study. O’Connor et al. [ 29 ] conducted a review on the use of decision aids for people facing screening decisions. The meta analysis indicated that the use of decision aids, such as leaflets or DVD’s are better than usual care and resulted in: greater knowledge (MD 15.2 out of 100; 95%CI 11.7 to 18.7), perception of risk (RR 0.6; 95% CI 0.5 to 0.8), lower decisional conflict related to feeling uninformed (MD −8.3 of 100; 95% CI −11.9 to −4.8), lower decisional conflict related to personal values (MD −6.4; 95% CI −10.0 to −2.7), reduced the proportion of people who were passive in decision making (RR 0.6; 95% CI 0.5-0.8) and reduced the proportion of people who remained undecided post intervention (RR 0.5; 95% CI 0.3-0.8). Although the results suggest decision aids are effective, the effect size was not consistent across studies and only three of the included studies related directly to antenatal screening.

Supplementation

Eight reviews [ 30 – 37 ] considered supplementation during pregnancy including iron, micronutrients, folic acid, calcium and Long Chain-Poly Unsaturated Fatty Acids (LC-PUFA’s). Two reviews [ 30 , 31 ] focused on folic acid supplementation, both of which concurred that the risk of neural tube defect was significantly reduced with supplementation: Blencowe et al., [ 30 ]; 70% reduction; 95% CI 35-86 and Lumley et al., [ 31 ]; RR 0.28; 95% CI 0.13-0.58. Iron supplementation during pregnancy was reviewed by Pena-Rosas and Viteri [ 32 ] who included 49 trials relating to the prevention of iron deficiency or anaemia at term. The authors concluded that daily iron supplementation was associated with increased haemoglobin before birth (MD 6.00; 95% CI 2.75-9.25) and reduced risk of anaemia at term (RR 0.46; 95% CI 0.29- 0.72) based on meta analyses of high quality trials only. Shah et al. [ 33 ] reviewed multi-micronutrient supplementation on pregnancy outcomes and reported there was a reduction in the risk of low birth weight amongst women given micronutrient supplementation (12 studies, RR 0.81; 95% CI 0.73-0.91) and iron-folic acid supplementation (RR 0.83; 95% CI 0.74-0.93) compared to placebo. The mean birth weight was higher (11 studies; WMD 54g; 95% CI 36-72g) in infants born to mothers who had micronutrient supplementation compared to iron-folic acid supplementation (no difference with placebo).

Calcium supplementation was the focus of three reviews [ 34 – 36 ]. Hofmeyr et al. [ 34 ] reported a reduction in pre-eclampsia (RR 0.68; 95% CI 0.57-0.81) and fewer babies born <2500g (RR 0.83; 95% CI 0.71-0.98). However the benefits seen were from small trials and not observed in the largest trial included. Hofmeyr et al. [ 35 ] reported that with supplementation a reduction in blood pressure (RR 0.7; 95% CI 0.57-0.86), pre-eclampsia (RR 0.48; 95% CI 0.33-0.69) and maternal death/morbidity (RR 0.80; 95% CI 0.65-0.97) was noted and advocated research to investigate calcium supplementation at community level. The most recent review [ 36 ] conducted by several of the same authors as Hofymeyr et al. [ 34 ] on calcium supplementation concluded that there was a reduced risk of increased blood pressure (RR 0.65; 95% CI 0.53-0.81) and preeclampsia (RR 0.45; 95% CI 0.31-0.65). The effect was greatest for high risk women (RR 0.22; 95% CI 0.12-0.42) and women with low baseline calcium (RR 0.36; 95% CI 0.20-0.65). Maternal death or serious morbidity was reduced (RR 0.80; 95% CI 0.65-0.97) although this was mostly in low risk women and women with low calcium and there was no effect on preterm births, stillbirth or death before discharge. Horvath et al. [ 37 ] reviewed the effect of advising high-risk pregnant women to take LC-PUFA supplementation on a number of pregnancy outcomes. The authors found a significantly lower rate of PTD <34 wks (RR 0.39; 95% CI 0.18-0.84) although this result was based on two trials (n=291). There was no effect on duration of pregnancy, PTD <37 wks, infant birth weight or the occurrence of IUGR. Although significant, the authors concluded that there was not enough evidence to recommend routine use of LC-PUFA supplements by high-risk women and that further research involving larger sample sizes was needed.

Three reviews [ 38 – 40 ] considered different types of supportive interventions for women during pregnancy. These ranged from using midwifery models of care to provision of emotional support to reduce the risk of preterm delivery or low birth weight infants. Hatem et al. [ 38 ] reviewed midwife led models of care versus other models of care and concluded that the majority of women should be offered midwifery led care. Women who had midwife led models of care were less likely to experience antenatal hospitalisation (RR 0.90; 95% CI 0.81-0.99), use of regional analgesia (RR 0.81; 95% CI 0.73-0.91), episiotomy (RR 0.82; 95% CI 0.77-0.88) and instrumental delivery (RR 0.86; 95% CI 0.78 to 0.96) and were more likely to experience no intrapartum analgesia/anaesthesia (RR 1.16; 95% CI 1.05-1.29), vaginal delivery (RR 1.04; 95% CI 1.02-1.06), to feel in control during childbirth (RR 1.74; 95% CI 1.32-2.30), attendance at birth by a known midwife (RR 7.84; 95% CI 4.15-14.81) and initiate breastfeeding (RR 1.35; 95% CI 1.03 to 1.76). In addition, women who were randomised to receive midwife-led care were less likely to experience fetal loss before 24 weeks’ gestation (RR 0.79; 95% CI 0.65-0.97). There was no difference between groups for birth by caesarean section (RR 0.96; 95% CI 0.87-1.06) and no statistically significant differences in fetal loss/neonatal death of at least 24 weeks (RR 1.01; 95% CI 0.67-1.53) or fetal/neonatal death overall (RR 0.83; 95% CI 0.70-1.00) and their babies were more likely to have a shorter length of hospital stay (mean difference in days: -2.00; 95% CI −2.15 to −1.85). Hodnett & Fredericks [ 39 ] assessed the value of emotional support to women who were judged, by a health professional, to be at increased risk of preterm delivery or having a low birth weight baby. No significant effect was detected for either outcome, however, women receiving support interventions were significantly less likely to undergo a caesarean section (RR 0.88; 95% CI 0.79-0.98) and were more likely to terminate their pregnancy (RR 2.96; 95% CI 1.42-6.17). There was also a trend towards improvement in maternal psychosocial outcomes although this was not significant. Denis & Kingston [ 40 ] reviewed the effect of telephone support during pregnancy and early postpartum period specifically on smoking, preterm birth, low birth weight, breast feeding and postpartum depression. The authors report a positive effect on breast feeding (3 trials; n=618; RR=1.18; 95% CI 1.05-1.33), low birth weight (3 trials; n=2,027; RR=0.78; 95% CI 0.63-0.97) and postpartum depression at 4 weeks (RR 0.24; 95% CI 0.06-1.00) and 8 weeks (RR 0.30; 95% CI 0.10-0.92), although all were from small numbers of trials and the finding on postpartum depression was from one pilot trial including 42 women.

Educational interventions in the antenatal period were the focus of four systematic reviews [ 41 – 44 ] that considered education about pelvic floor muscle training (PFMT) and promotion of smoking cessation in pregnancy Lumley et al. [ 41 ] reviewed the effect of interventions for promoting smoking cessation and included 72 studies of which 56 were RCT’s. Interventions to encourage cessation of smoking had a significant effect on the number of women smoking; 6 out of every 100 stopped, and a reduction in the number of cigarettes smoked by women was also evident. There was a significant reduction of smoking in late pregnancy (RR 0.94; 95% CI 0.93-0.96), reduction in LBW (RR 0.83; 95% CI 0.73 -0.95), preterm birth (RR 0.86; 95% CI 0.74-0.98) and an increase in mean birth weight (53.91g; 95% CI 10.44g - 95.38g). Naughton et al. , [ 42 ] reviewed the use of self help interventions for smoking and reported greater likelihood of quitting compared to usual care (13.2% v 4.9%; OR 1.83; 95% CI 1.23-2.73). The cost effectiveness of this method was also emphasised, however, further research is necessary to determine the intensity level of the intervention to maximise effectiveness. Hay-Smith et al. [ 43 ] and Lemos et al. [ 44 ] reviewed pelvic floor muscle training and concluded that for primigravida women PFMT was effective. Hay-Smith et al. [ 43 ] reported that women without prior incontinence were less likely to report incontinence in late pregnancy (RR 0.44; 95% CI 0.30-0.65) and up to 6 months postpartum (RR 0.71; 95% CI 0.52-0.97) similar to Lemos et al. [ 44 ] who reported significantly reduced development of urinary incontinence from 6 weeks to 3 months after delivery (OR 0.45; 95% CI 0.3-0.66; 4x RCT; n=675). Pregnant women with persistent incontinence 3 months after delivery and received PMFT were less likely to report urinary incontinence at 12 months post delivery (RR 0.79; 95% CI 0.70-0.90) and less likely to report faecal incontinence at 12 months (RR 0.52; 95%CI 0.31-0.87) [ 43 ].

Mental health

One review by Dennis & Creedy [ 45 ] considered interventions to prevent postnatal depression and all but one involved an intervention from a health professional. The authors reported that preliminary evidence suggests that intensive postnatal nursing home visits with at risk mothers assisted prevention of postpartum depression (RR 0.67; 95%CI 0.51-0.89).

Eligible systematic reviews relevant to the intranatal period yielded the smallest number in comparison to either the antenatal or postnatal periods. Five reviews [ 46 – 50 ] were included in this section and considered either clinical care during labour/delivery or the birthing environment.

Clinical care

Cluett & Burns [ 46 ] reviewed immersion in water for labour or birth (n=11) and reported from a meta analysis of 6 RCT’s. There was evidence to indicate that immersion in water for the first stage of labour significantly reduced the rate of epidural, spinal, paracervical analgesia and anaesthetic analgesia (478/1254 versus 529/1245; OR 0.82; 95% CI 0.70-0.98; p 0.025). However further research is required on other outcomes where there was no difference identified including assisted vaginal deliveries, C/S, perineal trauma, maternal infection, Apgar score < 7 at 5 mins, neonatal unit admissions or neonatal infection rates. Rabe et al. [ 47 ] reviewed delayed umbilical cord clamping and indicated from a meta analysis that there are benefits for both term and preterm infants. A delay of 30–120 seconds of cord clamping reduced the need for transfusions (RR 2.01; 95% CI 1.24-3.27, p=0.0049) and intraventricular haemorrhage (RR 1.74; 95% CI 1.08-2.81, p=0.022) in infants born <37 weeks [ 47 ]. Although the short term benefits are clear, further longitudinal work is needed to clarify the long term benefits.

Environment

The birth setting was the subject of four reviews although all were on different aspects. Hodnett et al. [ 48 ] reviewed the evidence regarding alternative versus conventional institutional settings for birth, which did not include any trials conducted in free standing birth centres. The review reported that for women allocated to the intervention (alternative setting) there was a significant increased likelihood of no analgesia/anaesthesia (RR 1.17; 95% CI 1.01-1.35), spontaneous vaginal delivery (RR 1.04; 95% CI 1.02-1.06), very positive views of care (RR 1.96; 95% CI 1.78-2.15), breastfeeding rates at 6–8 weeks (RR 1.04; 95% CI 1.02-1.06) and decreased episiotomy rate (RR 0.83; 95% CI 0.77-0.90). There was no effect on serious perinatal or maternal morbidity or mortality. Continuous support during childbirth was reviewed by Hodnett et al. [ 49 ]. The intervention involved one to one support during labour and found increased likelihood of shorter labour (WMD −0.43 hours; 95% CI −0.83 to −0.04), spontaneous vaginal delivery (RR 1.07; 95% CI 1.04 to 1.12) and were less likely to have intrapartum analgesia (RR 0.89; 95% CI 0.82- 0.96) or report dissatisfaction with childbirth experience (RR 0.73; 95% CI 0.65- 0.83). The authors only reported on outcomes where at least four trials were included in the meta analysis and highlighted that, generally, continuous intrapartum support was associated with greater benefits when it was not a member of hospital staff, when it began in early labour and in settings where epidural was not routinely available. Hodnett et al. [ 49 ] concluded that continuous support should be the norm rather than the exception for all women and further research is required as to the effectiveness of doula or lay support.

One review considered interventions aimed at reducing caesarean section rates [ 50 ]. Chaillet & Dumont [ 50 ] reported from a meta analysis that regular audit, detailed feedback regarding aspects of caesarean section performance (responsibility for decision making, rates, review of cases in clinical practice and multi faceted strategy approaches, such as development of guidelines, education of health professionals and women about vaginal birth after caesarean section (VBAC) were effective for reducing the caesarean section rate (RR 0.81; 95% CI 0.75-0.87). Details of relative risk for each type of strategy are included in Table 3 .

Eleven reviews [ 51 – 61 ] reporting on effective interventions related to the postnatal period. The reviews ranged across four areas: breast feeding; mental health; education and support.

Breast feeding

Reviews on this topic generally related to either support or promotion of breastfeeding. Britton et al. [ 51 ] reviewed the evidence in relation to support for breastfeeding mothers and key findings indicated that all forms of extra support for any breastfeeding (exclusive or partial) increased the duration of breastfeeding (RR 0.91; 95% CI 0.86-0.96) and the effect was greater for exclusive breastfeeding (RR 0.81; 95% CI 0.74-0.89). These findings were supported by Chung et al. [ 52 ] and Sikorski et al. [ 53 ]. Breastfeeding interventions included in both Britton et al. [ 51 ] and Chung et al. [ 52 ] involved formal or structured breastfeeding education, informal breastfeeding education or breastfeeding support either lay or professional. Chung et al. [ 52 ] from a meta analysis of 34 studies reported that breastfeeding interventions were effective in relation to increasing short term (1-3mths) and long-term (6-8mths) exclusive breastfeeding (RR 1.28; 95% CI 1.11-1.48 and RR 1.44; 95% CI 1.13-1.84) although statistically significant heterogeneity was noted for short term exclusive breast feeding (I 2 =55%; p= 0.006). The authors also highlighted an increased rate (22%) of any (RR 1.22; 95%CI 1.08-1.37) and exclusive (RR 1.65; 95%CI 1.03-2.63) short term breastfeeding with interventions that included a component of lay support. Sikorski et al. [ 53 ] reviewed additional support versus standard care and concluded that additional professional support was more beneficial than standard care for duration of any breastfeeding (RR 0.89, 95% CI 0.81-0.97; 10xRCT; n=19,696) and additional lay support was effective in reducing the cessation of exclusive breastfeeding (RR 0.66; 95% CI 0.49-0.89; 5xRCT; n=2530). Effect sizes for interventions with an antenatal education element (RR 0.85; 95% CI 0.70-1.04) were not statistically significant, while those with a postnatal element alone were (RR 0.80; 95% CI 0.80-0.96). Four trials using WHO/UNICEF training showed significant benefit in prolonging exclusive breastfeeding (RR 0.70; 95% CI 0.53-0.93), but were highly heterogeneous. The authors highlight the need to assess support in different settings especially with low rates, conduct economic analyses and use qualitative research to explore specific elements of support. Dyson et al. [ 54 ] focused on breastfeeding initiation rates and indicated from a meta analysis of five studies (n=582) that breastfeeding education had a significant effect on increasing initiation rates (RR 1.57, 95% CI 1.15-2.15, p=0.005) compared to standard care in low income groups although substantial statistical heterogeneity was noted (I 2 =53.4%). Early skin to skin contact was reviewed by Moore et al. [ 55 ] who reported statistically significant effects of early skin to skin on breastfeeding at one to four months post birth (OR 1.82, 95% CI 1.08-3.07) and breastfeeding duration (WMD 42.55, 95% CI −1.69 -86.79). In this review, data from more than two trials were only available for a small number of outcomes (8/64). Ahmed & Sands [ 56 ] reviewed breast feeding interventions. While the authors were unable to conduct a meta analysis they found from individual trials, statistically significant results relating to kangaroo care, peer counselling, in home breast milk measurement, and post discharge lactation support for improving breast feeding outcomes.

One review focused on improving maternal mental health and considered postnatal psychological and psychosocial interventions [ 57 ]. Dennis & Hodnett [ 57 ] reported that any psychosocial or psychological intervention compared to usual postpartum care was associated with a reduction in the likelihood of continued depression from their review of nine trials. Examples of psychosocial and psychological interventions reviewed included non-directive counselling, supportive interactions, delivered via telephone, home or clinic visits, or individual or group sessions in the postpartum period by a health professional or lay person, cognitive behavioural therapy and interpersonal psychotherapy.

Education and support

One review considered support for women in relation to weight reduction in the post partum period [ 58 ] focusing on the effect of diet or exercise or both for reducing weight after childbirth. They found that women who took part in a diet (1 trial; n=45; WMD −1.70 kg; 95% CI −2.08 to −1.32; z=8.73; p<0.00001), and women on a diet plus exercise programme (4 trials; n=169; WMD −2.89 kg; 95% CI −4.83 to −0.95; z=2.92; p<=0.00049), lost significantly more weight than women in the usual care. The authors also noted that there was no adverse effect on breastfeeding, although cautioned that further research is necessary to confirm this finding. Three reviews considered extra support for vulnerable groups of women in the form of home visiting or parenting interventions [ 59 – 61 ]. Corcoran & Pillai [ 59 ] reviewed rates in repeat pregnancy following the introduction of hospital-based programmes providing education and counselling to a sample of adolescent mothers. They found that although there was a 50% reduction in the odds of repeat pregnancy compared to comparison-control conditions at 19months (OR 0.474; 95% CI 0.322-0.695), the effect had dissipated by 31 months. All studies were US based and the majority conducted in low income groups (74%) and African Americans (60%). Two reviews focused on parenting interventions [ 60 , 61 ]. Pinquart and Teubert [ 60 ] reported small effects on parenting, parental stress, child abuse, health promoting behaviour, cognitive, social development, motor development, child mental health, parental mental health & couple adjustment from parenting education interventions. Vanderveen et al. [ 61 ] demonstrated an overall positive effect on neurodevelopment from early parental interventions (all involved teaching or enhancing parental skills) lasting up to 36 months. Meta analysis of twelve studies indicated higher cognitive scores at 12 months (WMD 5.57; 95% CI 2.29-8.86; p=0.0009), at 24 months (7 studies; WMD 7.59; 95% CI 5.01-14.31; p=0.0003) and at 36 months (2 studies; WMD 9.66; 95% CI 5.01-14.31; p=0.0001), but not at 5 yrs (3 studies p=0.24). The authors suggest further research is needed to clarify the most effective interventions and the long term effect.

Logic model

The parallel development of the logic model resulted in a summary model (Figure 2 ) provides a framework to visualise interventions across the perinatal period and the potential short, medium and long term impact on the health of women, their families and the community. Logic models display relationships between the core elements (context; inputs; outputs and outcomes) and the basic concept is to read from left to right, following a sequence of reasoning. An example of this is provision of education and information about screening in the antenatal period; an aspect of care where inequalities are known to occur [ 62 ]. The context in this example refers to the cultural, political, social circumstances in which the provision of screening is situated. Reading from left to right on the model indicates that the midwifery public health intervention is next so for example if a midwife provides information about antenatal screening for HIV (input), then uptake of screening may improve and at risk women will be identified earlier (outputs) and the effect will improve maternal and infant health during pregnancy. The medium and longer term outcomes are the resultant reduction in morbidity and or mortality in the local population.

figure 2

Summary Logic Model.

The focus of this paper is the development of the public health role of the midwife based on effective interventions and highlighting the short, medium and long term effects that these interventions could bring about. Any intervention must be considered within the context in which it is to be delivered as inequalities, resources, culture and vulnerable groups can influence the choice of intervention to best suit the population of women being served. The second column represents the inputs or activities; these are the interventions which are intended to bring about the change in outcomes. In relation to public health and midwifery these are interventions that may impact on public health primarily through education, screening and support. The outputs are the products or the targets of the service delivered and can been seen in the boxes entitled organisation of care under short and medium term outcomes. While the logic model provides a visual outline of midwifery public health roles, using this approach facilitates understanding of how public health programs can be planned and subsequently evaluated. Conducting the data synthesis in tandem with developing the logic model has also highlighted where the gaps in knowledge are and identified areas where midwives could potentially have a much greater role and subsequent impact on public health.

This paper sought to report on systematic reviews providing high quality evidence of effective interventions, in essence the ‘cream of the crop’. Reviews reporting on effective interventions were those which presented a statistically significant meta analysis or where the intervention was supported by a generally positive trend of results when a meta analysis was not possible to ensure the recommendations of the paper are based on strong evidence of good quality. There were a number of reviews included which presented statistically significant positive findings. However, in some cases these were limited by small numbers of participants or small numbers of trials included in the review. As a result of conducting the review and analyzing eligible systematic review evidence, three key areas for future consideration were identified including: recommendation and implementation of effective evidence; gaps in knowledge and developing the role of the midwife in public health which are discussed further in the following sections.

Recommendation and implementation of effective evidence

It is clear from this review of effective interventions, there are areas where evidence has been incorporated into guidelines and thus recommended for implementation into routine practice. However, it has also highlighted many areas where it has not. There has been extensive debate and commentary in the literature about knowledge transfer and translation of knowledge into practice, however, this paper confirms that despite the existence of good quality evidence, the gap remains. From this review, several effective interventions were identified, which are already recommended as routine practice, for example education about folic acid supplementation and pelvic floor muscle training to prevent or reduce the risk of urinary incontinence are advocated by current practice guidelines in the UK [ 63 ] and further afield [ 64 , 65 ]. However, to evaluate fully the extent to which guidelines have been applied it is essential to audit practice in order to provide evidence for knowledge transfer. To encourage implementation of NICE guidelines, audit support tools have been developed by NICE on antenatal care or diabetes in pregnancy for use at local level. Effective interventions were also identified which could easily be implemented by a midwife and could potentially impact on public health, such as education programs for parents of preterm infants and implementation of specific strategies to reduce caesarean section rates. Although there is recognition by health professionals these areas are important, this review provides definitive evidence and examples from systematic reviews, of interventions that are effective. Further consideration needs to be given to how to translate these effective interventions into practice using appropriate channels which are effective to facilitate knowledge transfer. These may include stronger collaborations between clinicians and academics and increasing the exposure students have to systematic reviews in education curricula at undergraduate level. Other effective interventions have been implemented on an ad hoc basis for example additional lay or professional support for breast feeding women and strategies to reduce caesarean section rates, which need to be included specifically in policy and strategy documents to ensure widespread implementation and thus contribute to an evidence based public health agenda to improve the health of women and families. Although this paper has focused on reporting effective interventions it is also important to take cognisance of those interventions that are not effective i.e. those which do not work and sometimes are deeply embedded into practice, for example, routine antenatal CTG for fetal assessment [ 20 ]. It was not possible to discuss reviews that demonstrated no effect within this current paper, however, Table 2 provides summary details of the areas where this was the case.

Gaps in knowledge

The review identified many gaps in systematic review literature relating to core midwifery practice, which potentially could impact on public health population goals. The UK Department of Health, Public Health Strategy [ 66 ] emphasizes the importance of improving maternal health and the subsequent impact on reducing infant mortality and premature births and yet this review identified limited systematic review evidence to support the implementation of midwifery interventions that could impact on perinatal morbidity and mortality. The review also highlighted it was difficult to accurately assess the potential public health impact in terms of effectiveness as some interventions were not well evaluated, evidenced by the large number of inconclusive reviews and reviews demonstrating no effect. The review of reviews identified some interventions that were effective but were limited in terms of methodological quality of included studies, for example, small numbers and design flaws, thus demonstrating the need for robust research and evaluation. One example of this is systematic review evidence in relation to weight management or obesity; a topic of growing concern to maternity care providers and yet the evidence from systematic reviews is limited in terms of quality. The systematic reviews included in the original review generally indicated that additional support related to diet or exercise for women in the postnatal period was effective, however, only one review was of a high quality. Another example of this is the evidence around home visiting for vulnerable groups of women in the postnatal period. While a significant body of research, including longitudinal studies has been published on parenting interventions indicating generally positive effects [ 67 , 68 ] the evidence from this current systematic review of reviews is mixed. Current early years governmental policy in the UK focuses on giving children the best start in life and various interventions have been, or are currently being rolled out, for example, SureStart and the Family Nurse Partnership, however the longer term impact on women and families remains to be seen. Logic models highlight the causal linkage between inputs, outputs and outcomes (24). This is illustrated very clearly in relation to support for parents in the form of parenting interventions (input) which can result in the short term outcome of increasing support for women to improve health and lifestyle; optimize lifestyle and child development beyond the immediate perinatal period (medium term) and in the long term improve family health and wellbeing for this generation and those to come.

Developing the role of the midwife in public health

In order for midwives to utilise their potential in relation to public health it is important not only to consider the interventions that could be implemented but also take cognisance of wider strategies and policy relating to public health. The logic model (Figure 2 ), which was developed as a parallel process to the review, provides an overarching framework that should be used by midwives to visualise their contribution to public health. The model illustrates possible future roles but also facilitates recognition of the current contribution of midwives to improving the health of women and their families as part of their core role. An example of this is how vulnerable women (either social or medical) could be identified in the antenatal period by midwives and a supportive or educational intervention implemented which would result in improved outcomes in the short term i.e. reduced pre term birth or improved birth weight. A medium term outcome of this intervention would focus on optimising lifestyle beyond the perinatal period for example collaborating with health visiting services to provide education and support that would potentially have a longer term outcome of improved family health and well being. The review did not identify any systematic reviews which specifically focused on interventions relating to midwifery public health roles, highlighting a gap in review evidence. Biro [ 69 ] suggests it may be challenging for midwives to think beyond individual women but ultimately necessary in order to meet the challenge of public health to improve population health. Reframing routine midwifery activities in a public health context, identifying midwives as public practitioners and building on existing activities, such as collaboration, organisation of care and interagency working are essential to clearly define the relationship between midwifery and public health. An earlier, wider review on health-led parenting interventions in pregnancy and the first three years of life [ 8 ] suggested that many interventions, particularly in relation to supporting parenting, could be provided as part of routine care and that although the optimal time to start programmes was not clear, there was some consensus that those initiated in the antenatal period were more effective. Development of the public health role of the midwife will also require strategic thinking and support from planners and commissioners of maternity services to ensure that midwives can influence policy and effectively implement public health strategies. This will involve dedicating time and resources to develop local policies, providing training for midwives and building good relationships with other healthcare disciplines to work together.

Limitations

There are a number of methodological challenges in using systematic review evidence which must be taken into account. It is difficult to summarise the evidence from systematic reviews as often there is significant diversity between interventions included in individual reviews or outcome measures used. In addition the results presented may be inconsistent between reviews or inconclusive, however, Smith et al. [ 14 ] suggest the strength of systematic reviews of reviews is that the best quality reviews can be highlighted in a single document. Systematic reviews are generally limited to published work and thus may be subject to publication bias. In addition, more recent, potentially conflicting, research may be available since the review was published or there may be effective interventions that have not been evaluated in a systematic review. A recent Cochrane overview of systematic reviews [ 70 ] highlighted that such reviews provide an accessible summary on the totality of the evidence in the area and minimised the need for referral to individual reviews, however suggested that readers may wish to do so for specific details. This review was similar in that it covered a broad scope of the evidence in relation to public health, providing a strategic overview while also providing a valuable resource for those who wish to consult individual reviews for additional specific details. In this paper, only high quality reviews (based on level of included evidence and methodology of review) reporting on effective interventions were included. While this provides reassurance regarding review findings, in that the conclusions are based on top level evidence, some interventions demonstrating effect may have been excluded because the review itself did not meet either the quality or level of evidence criteria for inclusion. In most cases this relates to areas worthy of future investigation, which need more robust evaluations. The search strategy utilised in the review was specifically focused on the public health role of the midwife and therefore incorporated key terms relative to key areas. However in doing so, some postnatal interventions, which extend beyond the role of the midwife, for example, parenting interventions that continue into early childhood may not have been included. In addition, due to the inclusion and exclusion criteria applied, it is possible that extensive broad reviews on particular topics have been excluded from this review due to the nature of evidence included within them, for example, the NICE Guideline on Antenatal and Postnatal Mental Health [ 9 ]. However, it is recognised these are valuable resources and contribute to wider understanding on specific subjects.

This paper has reported on high quality effective interventions identified from a larger systematic review on public health interventions that could be delivered primarily by midwives or maternity care providers. From the effective interventions identified it is clear that while some have been recommended for implementation into routine practice, others have not. This highlights the continuing gap between evidence and practice and the need for professionals and researchers to work better together to ensure specific interventions that are effective, are translated into practice and subsequently audited to provide evidence of knowledge translation. The public health role of the midwives has not been well researched or reviewed and the impact of everyday midwifery practice on longer term, holistic maternal and family well-being outcomes is poorly articulated in review literature. A shift in research, policy and practice is needed to fully articulate the public health role of the midwife. This systematic review of systematic reviews identifies a number of effective interventions that provide a useful starting point on which to build future practice. The logic model demonstrates the need to fill in major gaps in our knowledge on effective interventions to achieve both short and long term public health benefits for women and their families. Such benefits will remain elusive without investment in a collaborative, strategic approach to the role of public health in midwifery.

Advisory group members

Ms Liz Bannon , Senior Midwife, & Co Director of Maternity Services, Social Services, Family & Child Care Belfast Health and Social Care Trust, Belfast, Northern Ireland; Professor Debra Bick , Professor of Evidence Based Midwifery Practice, Kings College London, England; Dr Helen Cheyne , Nursing, Midwifery & Allied Professions Research Unit, University of Stirling, Scotland; Professor Mike Clarke , then Professor of Clinical Epidemiology & Director of UK Cochrane Centre, now Professor/Director of MRC Methodology Hub, Queen’s University Belfast; Ms Joanne Gluck , Consumer Representative; Professor Billie Hunter , Professor of Midwifery, Swansea University, Wales; Dr Dermot O’Riley , Centre of Excellence for Public Health Northern Ireland, Queen’s University Belfast, Northern Ireland.

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We would like to thank all members of the Advisory Group for their contribution and guidance throughout the project. In addition, we would like to thank Midwifery 2020 for funding the original review and in particular, The Public Health Workstream Group who commissioned the original review.

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The original review was funded by NHS Education for Scotland, Midwifery 2020, UK.

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JM extracted and interpreted data and wrote the first draft of the manuscript. FL conducted the searches of the literature, extracted and interpreted data and assisted with the manuscript. FA extracted and interpreted data and assisted with the manuscript. All authors read and approved the final manuscript.

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McNeill, J., Lynn, F. & Alderdice, F. Public health interventions in midwifery: a systematic review of systematic reviews. BMC Public Health 12 , 955 (2012). https://doi.org/10.1186/1471-2458-12-955

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Midwifery continuity of care: A scoping review of where, how, by whom and for whom?

Roles Data curation, Formal analysis, Methodology, Project administration, Validation, Writing – original draft, Writing – review & editing

Affiliations Maternal, Child, and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia, Mater Research, University of Queensland, Brisbane, Queensland, Australia

Roles Data curation, Formal analysis, Validation, Writing – review & editing

Affiliations Maternal, Child, and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia

Roles Conceptualization, Funding acquisition, Methodology, Supervision, Validation, Writing – review & editing

Affiliation Department of Maternal, Newborn, Child, and Adolescent Health, World Health Organisation, Geneva, Switzerland

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Roles Conceptualization, Funding acquisition, Methodology, Writing – review & editing

Roles Formal analysis, Methodology, Validation, Writing – review & editing

Affiliation Department of Women and Children’s Health, Kings College London, London, United Kingdom

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Validation, Writing – review & editing

* E-mail: [email protected]

Affiliation Maternal, Child, and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia

  • Billie F. Bradford, 
  • Alyce N. Wilson, 
  • Anayda Portela, 
  • Fran McConville, 
  • Cristina Fernandez Turienzo, 
  • Caroline S. E. Homer

PLOS

  • Published: October 5, 2022
  • https://doi.org/10.1371/journal.pgph.0000935
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Fig 1

Systems of care that provide midwifery care and services through a continuity of care model have positive health outcomes for women and newborns. We conducted a scoping review to understand the global implementation of these models, asking the questions: where, how, by whom and for whom are midwifery continuity of care models implemented? Using a scoping review framework, we searched electronic and grey literature databases for reports in any language between January 2012 and January 2022, which described current and recent trials, implementation or scaling-up of midwifery continuity of care studies or initiatives in high-, middle- and low-income countries. After screening, 175 reports were included, the majority (157, 90%) from high-income countries (HICs) and fewer (18, 10%) from low- to middle-income countries (LMICs). There were 163 unique studies including eight (4.9%) randomised or quasi-randomised trials, 58 (38.5%) qualitative, 53 (32.7%) quantitative (cohort, cross sectional, descriptive, observational), 31 (19.0%) survey studies, and three (1.9%) health economics analyses. There were 10 practice-based accounts that did not include research. Midwives led almost all continuity of care models. In HICs, the most dominant model was where small groups of midwives provided care for designated women, across the antenatal, childbirth and postnatal care continuum. This was mostly known as caseload midwifery or midwifery group practice. There was more diversity of models in low- to middle-income countries. Of the 175 initiatives described, 31 (18%) were implemented for women, newborns and families from priority or vulnerable communities. With the exception of New Zealand, no countries have managed to scale-up continuity of midwifery care at a national level. Further implementation studies are needed to support countries planning to transition to midwifery continuity of care models in all countries to determine optimal model types and strategies to achieve sustainable scale-up at a national level.

Citation: Bradford BF, Wilson AN, Portela A, McConville F, Fernandez Turienzo C, Homer CSE (2022) Midwifery continuity of care: A scoping review of where, how, by whom and for whom? PLOS Glob Public Health 2(10): e0000935. https://doi.org/10.1371/journal.pgph.0000935

Editor: Ahmed Waqas, University of Liverpool, UNITED KINGDOM

Received: June 3, 2022; Accepted: September 5, 2022; Published: October 5, 2022

Copyright: © 2022 Bradford et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All data are in the Supporting information files.

Funding: This review was commissioned by the World Health Organization Department of Maternal, Newborn, Child and Adolescent Health and Ageing and funded through a grant received from Merck Sharp and Dohme Corp (MSD). CFT is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South London, a NIHR Global Health Research Group (NIHR133232) and a NIHR Development and Skills Award (NIHR301603). CSEH is supported by an Australian National Health and Medical Research Council Fellowship (APP1137745). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Continuity of care is a concept rooted in primary care involving the care of individuals (rather than populations) over time by the same care provider. It encompasses relational continuity, informational continuity and management continuity [ 1 ]. In the primary care setting, continuity of care has been shown to reduce mortality and hospitalisations, and increase patient satisfaction [ 2 ]. Continuity of care also has an important place in chronic care settings, such as palliative care [ 3 ].

In the maternal and newborn care setting, midwife-led continuity of care refers to a model whereby care is provided by the same midwife, or small team of midwives, during pregnancy, labour and birth, and the postnatal periods with referral to specialist care as needed [ 4 ]. Midwife-led also refers to a model of care which is provided there is a distinct occupational group of midwives [ 5 ] and the person is fully qualified, regulated and deployed only as a midwife. This contrasts to systems in many countries (most countries in Africa for and South East Asia for example) where nurse-midwives are rotated to either nursing or midwifery duties. Midwife-led continuity models in a small number of HICs have been associated with lower rates of preterm birth (24% reduction), and lower fetal loss before and after 24 weeks and neonatal deaths (16%) less likely to lose their babies overall (combined reduction in fetal loss and neonatal death) for women at low and mixed risk of complications compared to other models of care. In addition, women are less likely to experience interventions and more likely to report positive experiences of care [ 4 ]. A Cochrane review of reviews of interventions during pregnancy to prevent preterm birth also found that these models had clear benefit in reducing preterm birth and perinatal death [ 6 ]. Women prefer the personalised experience provided by such models, leading to trust between midwife and woman and empowerment of both women and midwives [ 7 ].

Models of care that provide continuity across the childbearing continuum are complex interventions, and the pathway of influence that produces these positive outcomes is unclear. A number of plausible hypotheses require further investigation. For example, it could be that midwives provide a mechanism that enables effective and equitable care to be provided by better coordination, navigation and referral; and/or that relational continuity and advocacy engenders trust and confidence between women and midwives, resulting in women feeling safer, less stressed and more respected [ 4 ]. Access to organisational infrastructure, innovative partnerships, and robust community networks has been found crucial to overcome barriers, address women’s, newborns’ and parents’ needs and ensure quality of care [ 8 ].

Inequity is a key driver of adverse perinatal outcome, both between and within countries. Some observational studies of midwife-led continuity of care models in socially and economically disadvantaged populations in high-income countries (HIC) have reported significant reductions in pre-term birth and caesarean sections in diverse cohorts of women in the United Kingdom [ 9 – 12 ]. In Australia, a study of maternity care during significant floods in Queensland showed that midwife-led continuity of care mitigated the social and emotional impacts of the floods [ 13 ]. Another Australian study showed reduced preterm births amongst Australian Aboriginal and Torres Strait Islander women who received midwife-led continuity of care [ 14 ]. These studies suggest that women who typically experience a greater burden of adverse perinatal outcome, may derive greater benefit from continuity of care. However, understanding how continuity per se may mitigate inequities in maternal and newborn health remains a research priority.

Despite evidence supporting midwife-led continuity of care and guidelines from the World Health Organization which recommend midwife-led continuity-of-care models for pregnant women in settings with well-functioning midwifery programmes [ 15 – 17 ] only a small proportion of women internationally have access to such care. The current evidence suggests that access to midwife-led continuity of care models is largely confined to a small number of HICs notably Australia, Canada, New Zealand and the United Kingdom [ 17 ] where a distinct occupational group of midwives has been a central part of the health systems for decades. Barriers to implementation of midwifery-led continuity of care exist across all country income levels and include a lack of local health system financing, shortage of personnel including administrative and other support staff [ 4 ]. It is not clear to what extent midwife-led continuity of care has been implemented in low- to middle-income countries (LMIC). Many LMICs have a model of predominantly nurse-midwives who are deployed to both nursing and midwifery duties, often preventing midwife-led continuity of care models. Advancing understanding around which countries have implemented continuity of care models for maternal and newborn health, how, for whom, and in what context, is crucial for successful implementation, scale-up and sustainability.

The overall aim of this review was to understand the global implementation of midwifery continuity of care, asking the questions: Where, how, by whom and for whom are midwifery continuity of care initiatives implemented?

Materials and methods

A scoping review was undertaken guided by the approach described by Arksey and O’Malley [ 18 ] and further defined by Levac and colleagues [ 19 ]. The following five steps were followed: i) identifying the research question; ii) identifying the relevant literature; iii) study selection, iv) charting the data; and v) collating, summarising and reporting the results.

We used the broad definition of midwifery from The Lancet Series on Midwifery as our starting point, that is, “skilled, knowledgeable, and compassionate care for childbearing women, newborn infants and families across the continuum from pre-pregnancy, pregnancy, birth, postpartum and the early weeks of life [ 20 ]. Midwifery continuity of care was defined as care delivered by the same known care provider or care provider team across two or more parts in the care continuum–antenatal, intrapartum, postnatal and neonatal periods. In some settings, continuity of care may be provided by cadre other than midwives, for example, nurses or physicians. Thus, eligible papers could include care providers that were midwives and non-midwives, such as, nurses, community health workers and physicians. We excluded reports on care primarily by traditional birth attendants (TBA).

Identifying the relevant literature—Search strategy and selection criteria

In order to develop the search strategy, a preliminary search of PubMed and Google scholar using the terms ‘midwifery or midwife-led continuity of care’ were used to locate key systematic and scoping reviews on the topic and identify relevant search terms for the systematic search strategy (see S1 Text for the search strategy). We then searched the following electronic databases: MEDLINE, CENTRAL, CINAHL, PsychINFO and Web of Science. A subject librarian reviewed search terms, keywords and strategies. In addition, we searched PubMed, Google Scholar, PROSPERO, Scopus and Dimensions and the WHO International Clinical Trials Registry platform. We conducted the search on the 20 February 2022 and included publications (peer reviewed studies and reports) in the past 10 years.

A key area of interest was implementation of continuity of midwifery care in LMICs but we recognised that reports of implementation may be published in formats other than peer reviewed publications. Eligible papers therefore included implementation studies or reports of implementation of midwifery continuity of care in the grey literature. We sourced grey literature through online searches on the websites of relevant professional groups, United Nations agencies and non-government organisations (NGO). We circulated a call for relevant materials through online list servs (email groups) and through midwifery contacts. The International Confederation of Midwives assisted by emailing all member associations asking for any relevant reports.

Eligible reports could report on midwifery continuity of care efforts in HICs and LMICs. Reports from implementation efforts by government programmes, private providers, professional organisations, NGOs and universities and research studies of any design were eligible for inclusion. Protocols that reported studies that were underway, but not concluded, were also eligible. Opinion pieces, editorials and other materials, which included details of midwifery continuity of care initiatives, were also eligible. Publications in any language were eligible. The search was limited to reports published in the last ten years (January 2012 to January 2022) to ensure the information was contemporary and therefore of greatest relevance to policy makers.

Reports identified through both peer-reviewed and grey literature databases were hand-searched for other potentially relevant studies. These included reference lists of relevant systematic reviews, and published conference abstracts, as well as any reports forwarded to authors in response to a call for notification of new or ongoing initiatives from key global stakeholder organisations, such as the International Confederation of Midwives.

Reports were excluded they if reported on midwifery continuity of care in general but did not report on a continuity of care practice initiative. We excluded systematic and literature reviews although their reference lists were searched for relevant primary studies.

Study selection

All reports identified through database searching were imported into Endnote referencing programme (Endnote 20, Clarivate Analytics, Philadelphia), and duplicates removed. Remaining citations (n = 5789) were uploaded into systematic review software Covidence (Covidence 2022, Veritas Health Innovations, Melbourne). Two authors independently conducted initial title and abstract screening and undertook full-text review. A third author screened a random selection of 10% of studies and discrepancies were discussed and resolved.

Charting the data

The following information was extracted for all included reports: country, income-level (as defined by the World Bank [ 21 ], study design (if applicable), setting (urban/rural and community-based or facility-based), novel or scaled-up initiative, model of care, level of continuity (antenatal and intrapartum, antenatal and postnatal, intrapartum and postnatal) and cadre of care providers, (e.g. mix of providers involved). We also collected information on the inclusion of priority population groups–these are groups of people who are persistently disadvantaged by existing systems of power with demographic features known to be associated with adverse perinatal outcomes, such as ethnic minorities, urban and remote women, socially disadvantaged, and Indigenous women. We have described these specific groups as priority rather than vulnerable populations [ 22 ]. Reporting of the scoping review findings follows the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) format (see S1 Checklist ) and reference ( Fig 1 ) [ 23 ]. Appraisal of study quality or meta-analysis was not undertaken.

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In total, 6595 references were identified from electronic peer-reviewed databases, 821 duplicate records were removed prior to uploading to Covidence, a further 634 duplicates were removed by automation. Of the 5136 remaining references, 4728 did not meet the inclusion criteria. A further 256 references were excluded at the full-text stage as either: they did not describe continuity of care according to our pre-determined criteria (167); did not include primary source data (42); were duplicates (41); or did not have insufficient detail regarding the model of care (6). One hundred and fifty-two (152) peer-reviewed publications were eligible based on inclusion and exclusion criteria. A further 23 reports were identified following the grey literature search, bringing the total to 175 ( Fig 1 ). Details are listed in S1 Table .

Of the 175 individual reports, 152 (86.8%) were peer reviewed publications, 18 (10.3%) were conference abstracts, and the remaining five (3%) were published or unpublished reports. Reports primarily reported on birth outcomes (n = 54, 31%), women’s (including some partners’) views and experiences (n = 47, 27%) and midwives (including doctors) views and experiences (n = 33, 19%). There were 18 reporting on the model of care more broadly, including implementation challenges (n = 18, 10%), and 14 (7%) that were focussed on the experience of midwifery students providing continuity of care as part of their education. The majority of these student-focused reports were from Australia. Fewer reports focussed on the experience of midwifery managers (n = 3, 2%), while four were cost analyses (2%).

There were 163 unique studies including eight (4.9%) randomised or quasi randomised trials, 58 (38.5%) qualitative, 53 (32.7%) quantitative (cohort, cross sectional, descriptive, observational), 31 (19.0%) survey studies, and three (1.9%) health economics analyses. There were 10 practice-based accounts that did not include research.

‘The where’: Country and setting

Of the 175 included reports, the majority (n = 157, 90%) were from HICs and 18 (10%) from LMICs ( Table 1 ). Most were from Australia, (n = 71, 41%), followed by the United Kingdom (England, Scotland, Wales) (24, 14%), Sweden (13, 8%), Canada (8, 5%), Denmark (6, 4%), New Zealand (7, 4%), Japan (5, 3%), with less than five reports described initiatives conducted in Belgium, Finland, Germany, Greece, Ireland, Netherlands, Norway, Singapore, Switzerland and the United States of America (USA). In the LMICs, three from Palestine, three from China, two each from Bangladesh and Indonesia, and one from each of the remaining countries.

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https://doi.org/10.1371/journal.pgph.0000935.t001

Overall, most midwifery continuity of care models were based in urban areas (n = 126, 72%). In HIC, three-quarters of services (n = 118, 75%) were urban-based, whereas in LMICs just under half (n = 8, 44%) were urban-based. Hospital or facility-based services were most common across all income levels (n = 124, 72% overall).

‘The how’: Describing the way continuity of care is provided

There were a number of different terms used to define the model of care, and the level of continuity provided across the continuum of care varied with no single term used. Overall, the most common terms were caseload midwifery (n = 63, 36%), midwifery-led continuity (n = 60, 34%), or team/midwifery group practice (n = 40, 23%). Most described services designed so that the same providers provided care across the continuum–antenatal, intrapartum and postnatal (n = 159, 91%). There were eight which described continuity only across the antenatal and postpartum periods [ 24 – 31 ] (excluding labour and birth), and five reported [ 32 – 36 ] (including 3 unique examples) where the continuity was provided only across antenatal and intrapartum periods without postpartum care.

In HICs, the most dominant approach is where small groups of midwives provide care for designated women, known as caseload midwifery or midwifery group practice in countries like Australia [ 37 ], the United Kingdom [ 9 ], Denmark [ 38 ], Sweden [ 39 ], and Singapore [ 40 ] where the number of midwives is usually two to four. In other countries, for example, Japan [ 41 ] and Switzerland [ 42 ], the approach is also called team midwifery and the number of midwives is five or more.

The continuity of care services were located as part of the usual hospital [ 37 , 43 ], in an alongside birth centre [ 44 – 46 ] or in a free-standing birth centre [ 47 ]. Some midwife-led continuity of care services were offered through homebirth practices, either as part of the hospital system [ 48 , 49 ] or as a private service [ 50 ]. Most services were based in urban areas but there were some examples from rural areas in Australia [ 51 – 53 ], Sweden [ 54 – 56 ] and Scotland [ 57 ] ( Table 2 ).

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https://doi.org/10.1371/journal.pgph.0000935.t002

Although midwife-led continuity of care was available in a number of countries, mostly high-income with a cadre of midwives, in select facilities and locations, it was generally not scaled-up nationally. The exception being New Zealand, where the Lead Maternity Carer model is national allowing to midwives provide continuity of care to all women regardless of risk, in either caseloading or small community-based group practices, under a national funding arrangement and with medical or other collaboration when required [ 58 ].

In LMICs there was greater diversity in structure of arrangements for provision of midwifery continuity of care models. Models of care included a lead midwife delivering care across the continuum [ 59 , 60 ], midwives on-call for women during labour who they had previously seen for antenatal care [ 61 ], and a midwifery continuity of care team that ran in parallel with an obstetric team [ 62 ]. An initiative in Ethiopia involved the same midwife providing antenatal, intrapartum and postnatal care to the same women [ 63 , 64 ]. An initiative in Kenya involved midwifery care across the childbearing continuum, embedded within a family planning and HIV care service [ 65 ]. One initiative in China [ 66 ] facilitated continuity of care for women wishing to have a vaginal birth, where efforts were made for women to see the same midwife for intrapartum and postnatal care. In the Palestinian initiative [ 67 – 69 ], midwives were allocated geographical areas to provide antenatal and postnatal care for between 50–100 women. One initiative in Bangladesh [ 70 ] and another in Iran [ 71 ] involved teams of midwives providing care in a private midwifery clinic associated with two local hospitals.

Similar to HICs, continuity of care services were located as part of the usual hospital services (eg in Pakistan [ 59 , 72 ], China [ 61 ], Ethiopia [ 63 , 64 ], Palestine [ 67 – 69 ] or in community health centres or maternity clinics, for example in Bangladesh [ 60 , 70 ], Kenya [ 65 ] and Afghanistan [ 73 ]. Most services were based in urban or semi-urban areas but there were some examples from rural areas, for example, Palestine [ 67 – 69 ], Bangladesh [ 70 ], Afghanistan [ 73 ] and Indonesia [ 74 ].

Reports from China [ 62 ], Ethiopia [ 63 ], Iran [ 71 ], Kenya [ 65 ] and Pakistan [ 59 ] provided some degree of continuity of care across all antenatal, intrapartum and postnatal periods. Two reports, one from China [ 61 ] and the one from Kenya [ 65 ] provided care across antenatal and intrapartum. A study in China [ 66 ] involved the provision of midwife-led care at antenatal, intrapartum and postnatal time points, but continuity of care with the same/a known provider was only guaranteed at intrapartum and postnatal time points. S1 Table provides more details on each of the initiatives and S2 Table gives additional detail on models of care from LMICs.

The ‘by whom’: Providers of midwifery continuity of care

Midwives were the dominant provider of continuity of care across all settings. Services were mostly midwife-led with some reports including other cadre as well. Integration with existing services including systems for referral to obstetric services when needed was usual.

In HIC, almost all models of continuity of midwifery care involved care provided by midwives and/or midwifery students. A small number included midwives and other cadre. For example, programs with midwives and Aboriginal Health Workers (Indigenous health providers) [ 14 , 75 – 78 ]; collaborations with general practitioners, obstetricians or a social worker [ 44 , 79 – 81 ]. Just two examples did not include midwives; a model in Finland where continuity of care is provided by a nurse who takes care of the family from the pregnancy until the child reaches school age [ 26 , 82 ], and an example in Ireland [ 83 ], where continuity of care was provided by a privately practising obstetrician.

All except two of the continuity of care initiatives in LMICs were midwife-led. The initiative from Ghana [ 84 ] was provided by midwives, nurses and doctors while the one in Kenya [ 65 ] was provided by community based midwives who may have nursing or midwifery qualifications and other health professional with obstetric skills who reside in the community.

There were 16 reports which described midwifery students providing continuity of care, most of these were from Australia, Norway and Indonesia [ 74 , 85 – 101 ]. Midwifery students were placed with women, providing continuity of care to a defined number of women over their education program, as a way to engage them in this model of care [ 91 , 94 ].

The ‘for whom’: Priority groups for continuity of care initiatives

Of the 175 initiatives, 44 (25.5%) of these were implemented for women and newborns with risk of adverse outcomes ( Table 3 ). These included women from Indigenous communities, refugee and migrant populations, young mothers, women living in rural and remote areas, women who experience socioeconomic disadvantage, women with a history of substance abuse, chronic illness, and ethnic minority groups. The majority were from Australia [ 23 ], United Kingdom [ 9 ] and Canada [ 3 ]. There were four examples from LMICs, these were designed primarily for rural and remote communities in Palestine [ 67 – 69 ], Bangladesh [ 70 ], Afghanistan [ 73 ] and Kenya [ 84 ].

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https://doi.org/10.1371/journal.pgph.0000935.t003

This scoping reviewed aimed to map where, how, by whom, and for whom are midwifery continuity of care models are being implemented globally. The majority of models identified were in HICs, largely in Australia and the United Kingdom. Notably, all countries where five or more continuity of midwifery care initiatives were identified in the last 10 years are high-income and provide free public healthcare to their citizens and have a distinct cadre of midwives which makes this possible (Australia, Canada, Denmark, Japan, New Zealand, Sweden, and United Kingdom). Only 18 initiatives were identified in LMICs.

There is a growing body of literature demonstrating beneficial effects of midwifery continuity of care [ 4 , 8 ]. Midwifery continuity of care is a complex, multi-faceted intervention and teasing out which elements impart benefit to recipients of care is difficult. We found that almost all papers included in this review, involved continuity of care initiatives led by midwives or midwifery students (with midwife supervision). This was despite casting the net wide to identify continuity of care initiatives provided by any health provider across two or parts of the maternal and newborn care continuum.

Reviews of continuity of care in maternal and newborn care have focused on midwife-led continuity of care compared with other models of care such as doctor-led and shared care models [ 4 , 102 ]. However, a previous integrative review of midwife-led care in LMICs, found that just over half of studies included in the review included only midwives, with other cadres of health professionals including nurses, nurse-midwives, doctors, traditional birth attendants and family planning workers [ 103 ]. Whilst there is scope for other non-midwife health providers to provide continuity of care, such as family physicians [ 104 ]and community health workers [ 105 ], which may particularly be of value in LMICs countries where there is a shortage of midwives [ 106 ], there are few studies or reports available about these continuity of care models and their benefits. Although other cadre are not precluded from providing continuity of care, this review has shown that in the global literature, continuity of care across the maternal and newborn continuum is reported to be almost exclusively provided by midwives and is a significant area of quality improvement and research interest for midwives.

An encouraging finding from this review was the significant proportion of initiatives in HICs which focussed on women and newborns with vulnerabilities related to social and economic determinants of health (23.2%). The evidence that such initiatives are feasible for a diverse range of priority groups across many countries could demonstrate recognition of the benefits of continuity of care in improving outcomes for those with greater social and economic barriers to good health outcomes. This has implications for future research in that previous studies exploring childbirth outcomes from midwifery continuity of care frequently involve low-risk women [ 4 ], or women who had self-selected to be part of a midwife-led care project and thus are more likely to experience a positive outcome. This review has revealed that initiatives in a range of settings involve groups acknowledged to be at increased risk of adverse outcome. Larger scale and robust studies of midwifery continuity of care initiatives involving populations who experience social and economic disadvantage, and/or are at increased obstetric risk are both feasible and desirable.

Implications for policy, practice, research

This review has revealed that most studies, or reports, on midwifery continuity of care describe models led by midwives within HICs. Despite the benefits of midwife-led continuity of care, none of these countries has managed to scale-up this approach to being the standard of care at a national level, other than New Zealand. This highlights the organisational challenges of widespread implementation and the importance of system-level reform to enable countries to transition to this model of care and to scale-up. This reform means having adequate funding, support to enable midwives to be educated, and regulated, to work to their full scope of practice including flexibility and autonomy, self-managed time, team space, telephone access, and being able to work safely in the community and having access to transport and referral services [ 8 , 107 ].

Fewer than 10% of initiatives included in this review were from LMICs and only one was a clinical trial. The greatest burden of maternal and newborn deaths and stillbirths exists in LMICs. In HICs, midwife-led continuity of care has potential to reduce preventable maternal and newborn mortality and morbidity and stillbirths, however system-level reform and ensuring an enabling environment is still key [ 44 ]. The lack of midwifery continuity of care initiatives in LMICs, highlights the need for greater investment to ensure well-functioning midwifery systems can be developed with monitoring, evaluation and research to understand the effect of different models and associated benefits and/or challenges in different contexts. Operational research that identifies the barriers, facilitators and blockages to implementing models of midwifery continuity of care is needed, including in settings where there are shortages of midwives. In order to facilitate transition to, and scale-up of, midwifery continuity of care in LMICs, key considerations include strengthening midwifery education and regulation and ensuring the presence of an enabling environment [ 66 , 73 ].

Future systematic and scoping review studies would be enhanced by clear reporting of midwifery continuity model type, implementation details (including on midwife competence, scope of practice, deployment) and degree of continuity achieved within published studies and reports. Establishment of a classification system for this purpose would also enhance implementation efforts. One example of a classification system in a country which has an identifiable cadre of midwives is the Maternity Care Classification System (MaCCS) which was developed to classify, record and report data about maternity models of care in Australia [ 108 , 109 ]. The MaCCS includes a series attributes including the target groups, profession of provider, the caseload size, the extent of planned continuity of care and the location of care to come up with 11 major model categories (see S3 Table for details) [ 110 ]. This classification system is now being included in all routine data systems in Australia so that, in the future, outcomes by model of care will be reported. While this is developed for one high-income country, an adaptation for global utility could be useful.

Measuring the extent to which continuity of care is achieved is the second key area. The health insurance industry in the USA has developed measures to assess patterns of visits to providers and therefore, the level of continuity of care [ 111 ]. The measures include the Bice-Boxerman Continuity of Care Index (measures the degree of coordination required between different providers during an episode), the Herfindahl Index (the degree of coordination required between different providers during an episode), the Usual Provider of Care (the concentration of care with a primary provider) and Sequential Continuity of Care Index (the number of handoffs of information required between providers). The Usual Provider of Care index has also been used to assess continuity of care in general practice in the UK, that is, to assess the proportion of a patient’s contacts that was with their most regularly seen doctor [ 112 ]. For example, if a patient had 10 general practitioner contacts, including six with the same doctor, then their usual provider of care index score would be 0.6. With the exception of one study, none of the papers in this review had applied such indexes. This is an important consideration for the future.

Strengths and limitations

This review provides a summary of midwifery continuity of care efforts globally. As countries look to strengthen midwifery and quality of care for women and newborns during pregnancy, childbirth and postnatal periods, understanding implementation in all resource settings is important. In this review the broad criteria for inclusion allowed for identifying the maximum number of implementation efforts in LMICs to be identified. Despite the efforts to reach out, and although no language filters were applied, search terms were in English thus we may have missed some ongoing efforts. We also did not measure, or account for, the skills and competencies in the different cadres providing care, or if they are always deployed as midwives or provide details about the profile/qualifications of the healthcare providers, the way the midwifery system function, if any affiliation to healthcare centres, support systems, health costs and coverage or safety outcome indicators as these were reported differently or not at all across the papers. Finally, in this review we were not able to reliably determine the extent to which women receiving care were able to see the same individual care provider. Relational continuity is a key element of continuity of care, and possible mechanism for beneficial effects, which requires repeat contact over time between individual care providers and recipients of care.

Conclusions

This review mapped midwifery continuity of care initiatives globally. The majority of initiatives identified were in HICs, with fewer identified in LMICs. Almost all initiatives identified in LMICs were led by midwives (some of whom worked in a model in which they were also deployed as nurses), despite our efforts to identify models led by other skilled health professionals. Almost no countries have managed to scale-up midwifery continuity of care to being the standard of care at a national level. This highlights the organisational challenges of widespread implementation and the importance of system-level reform to enable these models of care to scale-up. Nevertheless, examples of successful implementation of midwifery continuity of care in low-resource settings reported show that advances in this area are possible.

A number of initiatives identified in HICs focused on women and newborns at risk of adverse outcomes, demonstrating the value of midwifery continuity of care in populations who experience social and economic disadvantage and vulnerabilities. There is a need for further research on midwifery continuity of care models in LMICs, and strategies to facilitate transition to, and scale-up of, midwifery continuity of care initiatives globally.

Supporting information

S1 text. search strategy..

https://doi.org/10.1371/journal.pgph.0000935.s001

S1 Table. All included items.

https://doi.org/10.1371/journal.pgph.0000935.s002

S2 Table. Additional details from low- and middle-income countries.

https://doi.org/10.1371/journal.pgph.0000935.s003

S3 Table. Major model categories in MaCCS.

https://doi.org/10.1371/journal.pgph.0000935.s004

S1 Checklist. Preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews.

https://doi.org/10.1371/journal.pgph.0000935.s005

Acknowledgments

Thank you to Rana Islamiah Zahroh, PhD student and researcher at the University of Melbourne in Australia for assistance mapping the data. Thanks also to Rosemary Rowe, Subject Librarian at Faculty of Health, Victoria University of Wellington in New Zealand and to Allisyn Moran and Joao Paolo Souza (WHO) for useful feedback and advice.

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A review of the literature: Midwifery decision-making and birth

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Midwifery Dissertation Topics

Published by Owen Ingram at January 3rd, 2023 , Revised On August 16, 2023

There have been midwives around for decades now. The role of midwives has not changed much with the advent of modern medicine, but their core function remains the same – to provide care and comfort to pregnant women during childbirth.

It is possible to be a midwife in the healthcare industry, but it is not always a rewarding or challenging career. Here are five things you didn’t know about midwifery nursing to help you decide if it could be the right career choice for you.

The profession of midwifery involves caring for women and newborns during pregnancy, childbirth, and the first few days following birth. Registered nurses are trained with four additional years of education along with major research on methods involve in midwifery and writing on midwifery dissertation topics, while midwives provide natural health care for mothers and children.

As a midwife, your role is to promote healthy pregnancies and births while respecting women’s rights and dignity. Midwives provide care to patients at every stage of life, from preconception to postpartum, family planning to home delivery to breastfeeding support.

Important Links: Child Health Nursing Dissertation Topics , Adult Nursing Topics , Critical Care Nursing Dissertation Topics . These links will help you to get a broad experience or knowledge about the latest trends and practices in academics.

Midwifery Is A Good Fit for the Following:

● Those who want to work with women, especially those at risk of giving birth in a                    hospital setting. ● Those who enjoy helping people and solving problems. ● Those who like to be creative and solve complex problems. ● Those who want to help others and make a difference in their lives.

Midwifery is a career with many benefits for both the midwife and the baby. They are well-trained and experienced in caring for pregnant women and newborns and often have access to the exceptional care that other nurses may not have.

Related Links:

  • Evidence-based Practice Nursing Dissertation Topics
  • Child Health Nursing Dissertation Topics
  • Adult Nursing Dissertation Topics
  • Critical Care Nursing Dissertation Topics
  • Dementia Nursing Dissertation Topics
  • Palliative Care Nursing Dissertation Topics
  • Mental Health Nursing Dissertation Topics
  • Nursing Dissertation Topics
  • Coronavirus (COVID-19) Nursing Dissertation Topics

Midwifery Dissertation Topics With Research Aim

Topic:1 adolescence care.

Research Aim: Focus on comprehensive medical, psychological, physical, and mental health assessments to provide a better quality of care to patients.

Topic:2 Alcohol Abuse

Reseasrch Aim: Closely studying different addictions and their treatments to break the habit of drug consumption among individuals.

Topic:3 Birth Planning

Research Aim: Comprehensive birth planning between parents discussing the possible consequences of before, between, and after labour.

Topic:4 Community midwifery

Research Aim: Studying different characters in community midwifery and the midwife’s role in providing care for the infant during the early days of the child’s birth.

Topic:5 Contraception

Research Aim: Understand the simplicity of contraception to prevent pregnancy by stopping egg production that results in the fertilization of egg and sperm in the later stages.

Topic:6 Electronic fetal monitoring

Research Aim: In-depth study of electronic fetal monitoring to track the health of your baby during the womb, record construction per minute, and make a count of your baby’s heart rate.

Topic:7 Family planning

Research Aim: Importance to follow the basic rhythm methods for the couple to prevent pregnancy and use protection during the vaginal sex to plan a family without fertility treatments.

Topic:8 Foetal and newborn care

Research Aim: Expansion of the maternal-fetal and newborn care services to improve the nutritional quality of infants after delivery during their postnatal care time.

Topic:9 Foetal well being

Carefully tracking indications for the rise in heart rate of the fetal by weekly checkups to assess the overall well-being of the fetal.

Topic:10 Gender-based violence

Research Aim: Studying the consequences of male desire for a child that results in gender-based violence, harming the child’s physical and mental health.

Topic:11 Health promotion

Research Aim: Working on practices that help in controlling the amount of pollution of people, taking care of their overall health, and improving quality of life through adapting best health practices.

Topic:12 High-risk pregnancy

Research Aim: Calculating the ordinary risks of a high-risk pregnancy and how it affects a pregnant body resulting in a baby with poor health or any by-birth diseases, increasing the chance for complications.

Topic:13 HIV infection

Research Aim: Common causes of HIV infection and their long-term consequences on the body’s immune system. An in-depth study into the acquired immunodeficiency and the results leading to this.

Topic:14 Human Rights

Creating reports on human rights and their link with the freedom of thought, conscience, religion, belief, and other factors.

Topic:15 Infection prevention and control

Research Aim: Practices for infection prevention and control using efficient approaches for patients and health workers to avoid harmful substances in the environment.

Topic:16 Infertility and pregnancy

Research Aim: Evaluating the percentage of infertility and pregnancy, especially those facing no prior births, and who have high chances of infertility and pregnancy complications.

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Midwives are nurses who provide continuous support to the mother before, during, and after labour. Midwives also help with newborn care and educate parents on how to care for their children.

How Much Do Midwives Make?

The salary of a midwife varies depending on the type of work, location, and experience of the midwife. Midwives generally earn $132,950 per year. The average annual salary for entry-level midwives is $102,390.

The minimum requirement for becoming a midwifery nurse is a bachelor’s degree in nursing, with the option of pursuing a master’s degree.

An accredited educational exam can also lead to certification as a nurse-midwife (CNM). The American College of Nurse-Midwives (ACNM) enables you to practice independently as a midwife.

There are many pros and cons to working as a midwife. As a midwife, you have the following pros and cons:

  • Midwives have the opportunity to help women during one of the most memorable moments in their lives.
  • Midwives can positively impact the health of mothers and their children.
  • Midwives can work in many hospitals, clinics, and homes.
  • In midwifery, there are many opportunities for continuing education and professional development.
  • You will often have to work nights and weekends, which can be mentally draining.
  • You will have to travel a lot since most births occur in hospitals or centres in different areas.
  • You will have to deal with stressors such as complex patients and uncooperative families.
  • You will be dealing with a lot of pain, so you need to be able to handle it without medication or other treatment methods.

A career in midwifery is a great fit for those with a passion for health and wellness, an interest in helping people, and a desire to work in a supportive environment.

It is important to become involved in your local midwifery community if you are contemplating a career in midwifery – the best source of learning is your major research work, along with writing a lengthy thesis document on midwifery dissertation topics that will submit to your university to progress your midwifery career.

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To find midwifery dissertation topics:

  • Explore childbirth challenges or trends.
  • Investigate maternal and infant health.
  • Consider cultural or ethical aspects.
  • Review recent research in midwifery.
  • Focus on gaps in knowledge.
  • Choose a topic that resonates with your passion and career goals.

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How to Write A Literature Review - Steps with Examples

This is something, as a student, I remember very well: writing literature reviews. They were always assigned, yet few of us knew how to write anything really impactful. For me, a good literature review is not the mere act of summarizing; rather, it is analysis, synthesis, and illumination all about discovered knowledge gaps. So let us break it down step-by-step and notice exactly how WPS Office can be used as your secret weapon in getting this one right.

What is a Literature Review & What are the Parts of it? 

It's not a book report for adults—a literature review is a critical examination of research that is already published, which plumbs deep into the scholarly conversation around your topic. Think of it this way: you are giving a guided tour through the general intellectual landscape, and you're not only pointing at landmarks but also explaining their importance, their relations to one another, and where the unknown areas can be.

The Blueprint: Introduction, Body, and Conclusion

Any well-constructed literature review will be built around the clear structure of an introduction, body, and conclusion.

Introduction: This is your opening act. Here you introduce your topic and lay out the central question or thesis your review will address. You might also give a sneak peek at the key themes or sources you'll be exploring, should you do a stand-alone review. This will also be a good place to explain how you picked and analyzed sources.

Body: This is the meat of your review. This is where you are going to put together the information from your sources in such a way that it makes sense. Again, do not just summarize, but also include your own ideas pointing out strengths as well as weaknesses of each document and relating the different studies. You will need to write clear paragraphs with effective transitions so that your reader can easily follow through the material.

Conclusion: Time to wind up: According to your literature review, there is a need to summarize the major findings and explain how they relate to your question. What are the big takeaways? What remains unanswered? Your conclusion should leave the reader with a great sense of evaluation about the present state of knowledge on a subject area and indication of where future research in this area might lead.

This framework will help you to structure a good literature review. Once more, this is only a rough expectation—remember, it is not etched in the stone. While the basic structure will usefully be applied as it is for most of the assignments or projects, sometimes maybe you will need to slightly adjust it according to the concrete needs of the assignment or project. The key is the following: Your review needs to be reader-friendly and organized, and it needs to communicate clearly the research findings.

How to organize the literature review [4 approaches]

Now that you have collected your sources and extracted their key insights, you are well on your way to developing a well-structured story. In many ways, this is akin to choosing the appropriate lens for a camera—the literature review snaps into focus. There are four common ways to approach literature review organization:

1. Chronological: This approach is almost like a timeline of ideas. You will trace the development of a topic in chronological order, so you will center on central milestones, swings in ideas, and influential debates.

2. Thematic: View this as thematically organizing your research. This will allow exploration of the subject under study in a more systematic way.

3. By Method: If you are dealing with research that utilizes a variety of methods, then this can be a revealing approach. You will draw out comparisons and contrasts between studies based on their methodology, where appropriate, pointing out the strengths and weaknesses of each approach.

4. Theoretical: This is commonly used within the humanities and social sciences, where theories are key. You will look at some of the several theoretical frameworks scholars have reached for to grasp your topic at hand, debating their strengths, limitations, and how they relate to each other.

The best approach for you will depend on what kind of research question you're asking and the body of literature involved. Don't be afraid to experiment and find the structure that works the best. You could also use a combination in your approach—like a primarily thematic approach with chronological elements there to help provide additional context for each theme.

How to Write a Literature Review Faster in 3 Steps

This type of strategic planning and effecting proper organization distinguishes an efficient literature review. The process of streamlining it is as follows:

Step 1: Gathering and Evaluating Relevant Sources

Research credible sources on academic databases like Google Scholar. Use specific keywords in order to find recent and influential publications that contribute to the topic at hand. Appraise every source according to your criteria of relevance and credibility.

Step 2: Identification of Themes and Literature Analysis

Skim through your selected sources in the search for emerging themes, debates, or gaps in the literature. Secondly, summarize key findings and methodologies for each source. Find the patterns or recurrent discussion which will help you categorize your review well and organize it.

Step 3: Outline and Structure Your Literature Review

Devise a clear structure for your literature review: introduce the topic and the thesis in the introduction, develop sources cohesively in the body, and summarize key findings in the conclusion. You could make use of organizational strategies such as chronological, thematic, methodological, or theoretical in representing your topic.

Use tools like WPS Office to plan your literature review and keep all of your sources well-organized. This will save you much time and guarantee that your literature review stays organized while you remain focused on your research objectives.

Remember: Do not simply list and summarize, but analyze and synthesize. Your literature review is not just a compilation of sources but one that critically relates the strengths and weaknesses of each piece of research, identifies the important debates in the area under consideration, and makes links between diverse pieces of research. WPS AI can help you to do this, through its identification of key terms, concepts, and relationships within the literature.

Bonus Tips: How to Perfect your Literature Review with WPS AI

Want WPS AI to be that magic weapon to help you make an extraordinary literature review? Here is how this intelligent assistant will supercharge your effort.

Annotation and Highlighting: WPS AI  permits direct annotation and highlighting of parts of interest within its software. This is quite useful to facilitate the marking of key findings, interesting quotes, or even areas in which authors have differed. By annotating through WPS AI, all critical points will be easy to refer to while you compose your review.

This WPS AI summarization tool will give you a condensed version of the long article or paper. It saves time by putting together exactly what the point or argument is from each source. On this, you will have a digest of several studies at your fingertips. This helps you easily compare and synthesize in your literature review.

Writing Assistance: Use WPS AI's writing tools to build your literature review section. These allow you to check the grammar, refine the sentence structure, work on the text length, and basically improve clarity. With these, you then ensure that it is well-written and easy for the readers to understand.

Build in these WPS AI features into your process of writing a literature review for refining workflow and bringing about a polished and insightful review that answers to academic standards.

FAQs about writing a literature review

Q1. what is the step before writing a literature review.

You must choose a topic, research existing literature, gather sources, determine themes, and make a defined scope of review before you begin writing your literature review.

Q2. Where should the literature review be placed within a dissertation?

Place the literature review after the introduction and before the methodology section of your dissertation.

Q3. Why do we need to write literature reviews?

Literature reviews would hence be a summary of earlier research on a topic, identification of gaps, building a context for fresh research, and devising credibility in an academic writing.

A literature review is one of the most critical steps of any research project. This aids in the placement of knowledge, pointing out the gaps, and placing one's research in a certain field. With accurate tools and strategies,or msg like WPS Office and WPS AI, the process can be streamlined in the production of quality literature reviews.

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Peer review in nursing and midwifery: a literature review

Affiliation.

  • 1 School of Nursing and Midwifery, Keele University, Clinical Education Centre, University Hospital of North Staffordshire, Stoke-on-Trent, UK. [email protected]
  • PMID: 17419775
  • DOI: 10.1111/j.1365-2702.2007.01934.x

Aims and objectives: The Clinical Education Project investigated clinical education in nursing and midwifery settings. The aim of this phase was to investigate and evaluate the processes and outcomes of clinical assessment of preregistration nurses and midwives, focusing on the assessment interview, and to evaluate the feasibility of introducing peer review of the clinical assessment interview in acute clinical settings.

Background: Peer review is common in many professional areas. The literature describes various applications of peer review and makes recommendations for its use. However, there is a shortage of studies investigating the use of peer review in nursing and midwifery education and practice.

Design: The project involved a systematic literature review and a qualitative exploratory study. This article describes the first part of the study: a systematic literature review of peer review. The second part of the study is reported elsewhere.

Methods: The systematic literature review investigated international articles written since 1994 that contained information on peer review in pre/post registration nursing and midwifery within higher education or practice.

Results: From the available literature, 52 specific initiatives were analysed. The majority of articles originated in America and involved nursing staff working in secondary care settings. Fifty-one articles had missing information varying from not stating the sample size to not including information about evaluations.

Conclusions: The literature review found that whilst peer review is commonplace in nursing and midwifery practice, there is a lack of robust literature about its use. Relevance to clinical practice. Peer review in clinical settings such as nursing and midwifery can facilitate the sharing of good practice and personal and professional growth. It allows participants to learn from each other and gain insight into their development.

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The quantification of midwifery research: Limiting midwifery knowledge

Elizabeth newnham.

1 Griffith University, Brisbane Queensland, Australia

2 University of Newcastle, New South Wales New South Wales, Australia

Barbara Katz Rothman

3 The City University of New York, New York New York, USA

Associated Data

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

As two academics researching in the area of maternal health, we are increasingly concerned with what we see as a positivist turn in midwifery research. In this paper, we examine this idea of the quantification of midwifery research, using as an example the current esteem given to the systematic literature review, and its creep into other methodologies. We argue that the current favor toward quantitative research and expertise in midwifery academia risks the future of midwifery research by the lack of equal development of qualitative experts, diluting qualitative research rigor within the profession, and limiting the kinds of questions asked. We identify the similarity between the current prominence of quantitative research and medical dominance in midwifery and maintain that it is of vital importance to the profession (research and practice) that the proper attention, contemplation, and merit are given to qualitative research methods.

As academics whose work is in the area of maternal health, we have grown increasingly concerned with the positivist turn in midwifery research. We can only offer observational evidence of this, for example, examining qualitative theses with (poorly conducted and ill‐fitting) “systematic‐styled” literature reviews, comments from colleagues about what kinds of research projects are publishable or fundable, criteria for systematic styling of literature reviews in master's degree marking guides, reviewing incoherent qualitative manuscripts, by which we mean nonreflexive use of inappropriate language style (such as use of third person), or attempting to apply quantitative measures of rigor (eg, lack of bias, sample size, and generalizability). Our concern stems from the following premises—that the quantification of midwifery research:

  • Limits knowledge, including research direction, design, funding, and the form research projects then take; and
  • Risks reproducing patriarchal, colonizing and medically dominant systems of thought and knowledge creation, despite midwifery having human rights–based foundational principles that promote women's autonomy and claiming to value other forms of knowledge. 1 , 2

Medicine entered the university early—before anything we would call “scientific method,” well before asepsis, back when physicians were focused on translating historical medical knowledge into Latin. 3 Medicine was in the university long before what Foucault called “the birth of the clinic” in the early 1800s, the beginning of what we now think of as a “teaching hospital,” offering clinically based education. 4

Midwifery as a university‐based field of study and research, on the contrary, is in its infancy, although with different histories and trajectories of training and education worldwide, and with much of early midwifery education subsumed first into medicine, then nursing. We also need to recognize and value much more the knowledge of traditional, Indigenous, and lay midwives. However, when we look at university‐based midwifery research, many of the first professors of the modern discipline of midwifery are still living and working among us. Over the last few decades there has been an extraordinary amount of research by midwifery scholars that asks different questions, from the perspective of women and other birthing people, and of midwives. However, it seems to us that there is now a greater significance and authority placed on quantitative research. This can partly be explained by needing to produce research that is taken seriously by medicine and is certainly the route to attaining funding from medically‐oriented research bodies. It is also a symptom of the more widespread problems within academia including increasing pressure to publish, which has trickled down to postgraduate research students, and can lead to a favoring of research with clear lines and discrete projects, rather than traditional exploratory theses, which may not be dissectable into publication‐sized chunks. It is wrong, however, that there is not an equivalent growth, significance, and authority given within the profession to qualitative methodologies and paradigms, particularly given the claimed feminist nature of midwifery, and the importance of childbirth in the human experience. Although many midwives do conduct qualitative research projects, particularly in postgraduate research programs, there is less enthusiasm for, and status given to, continuing on with and building expertise in qualitative research. In addition, although midwives often identify as feminists because of the nature of their work with women's bodies, upholding autonomy and holding space for birth, 5 it has been argued that the profession of midwifery does not engage fully enough with feminism. 6 , 7 This is something we think can be, in part, remedied by this call to reprioritize the role of qualitative research in midwifery academia.

The importance of quantifiable research in maternity care is not under question. Quantifiable evidence by midwifery researchers has made groundbreaking advancements in knowledge, for example, demonstrating the importance of midwifery models of care 8 , 9 and place of birth 10 , 11 on improving outcomes for women and babies. The issue we are raising is the apparent incline toward quantifiable research within academia, to the exclusion of other forms of knowledge production, and the effect this has on robust qualitative research production.

Midwives were engaged in “research” long before it was understood as such. Techniques and substances were tried, evaluated, adjusted as more subtle variables became clear, and moved into practice or abandoned. 12 , 13 There is a long‐standing tendency within the culture at large and within contemporary midwifery in particular to dismiss this as research, and instead attribute this hard‐won, thoughtfully gained knowledge to “intuition.” When a neurosurgeon with many years of practice sees three patients with very similar charted attributes and says two should be okay but is concerned about the third, we recognize experience‐based wisdom and knowledge. When a midwife does the same with three laboring women, the language of “intuition” gets evoked. It would be wiser and truer to call this “tacit knowledge”: when we know things but cannot always articulate precisely how we know. 14 Research on that tacit knowledge, how one knows, is what is truly needed.

One of us (BKR) is a sociologist, coming from the perspective of symbolic interactionism, the sociology of knowledge, and grounded theory. One could discuss these perspectives in great detail but suffice it to say that how people know things, and how knowledge is developed, constructed, and shared, is itself worthy of study, and has extraordinary power in our world. Rather than coming up with a hypothesis in a causal relationship and testing it, the researcher might do better to take an educated, thoughtful, analytic mind into the field and listen. Early sociological work in this vein brought us the concept of a “midwifery model” in contradistinction to a “medical model” of what birth itself is. 15 Listening to the midwives who had been trained in one system and worked in another, the idea of fundamental differences in the model of birth became clear. This kind of qualitative work, deep listening, and open‐minded and open‐ended research is precisely what is being undervalued.

For the other of us (EN), a midwifery academic, this is most clearly illustrated in the “systematization” of literature reviews. There is an apparent push, in midwifery academia, toward systematic‐styled literature reviews, even for those reviews foregrounding a qualitative research project. Commonly now, midwifery postgraduate students and researchers are persuaded that a “systematic‐styled review” is the only (authoritative) kind of literature review that can be accomplished (or published). Coming to midwifery research with a social/political science background, which has different academic practices, EN has watched this emphasis grown over the last decade with increasing dismay.

Systematic reviews are a form of primary quantitative research, where meta‐analysis of randomized controlled trials aims to give a more robust account of the intervention in question because it can draw on a greater sample size. Systematic reviews have been incredibly useful to maternity care research, particularly in the early days of the Cochrane database, 16 in identifying practices that were harmful to birthing women and eschewing practices based on clinician preference. The methodology of meta‐synthesis (or meta‐ethnography) attempts a similar aim: to provide a systematic qualitative “synthesis” of data about human experience, and so these also make use of a predetermined protocol and search strategy.

Preordained protocols and search strategies are fundamental to the systematic review and meta‐analysis/meta‐synthesis as a primary research methodology so that they can be replicated and/or verified by others. However, it is important to remember that replicability is a quantitative measure of rigor; invariably, primary qualitative research cannot be replicated in the same way. In qualitative research, it is important to show the “workings out” in terms of raw data, analytic transparency, reflexivity, and so on. But there is no expectation that, for example, one ethnographic study can be replicated by another ethnographer in the way that a laboratory experiment must be replicable. To some extent, this is because the researcher is an instrument of the research. 17 Thus, the more experienced the researcher, the keener their critical thinking skills and breadth of knowledge, the better the quality of the research.

Yet, it is increasingly common to see systematic‐styled literature reviews with quasisystematic aspects, foregrounding what would otherwise be a (qualitative) narrative literature review. Not only is a structured and predetermined search strategy unnecessary for these kinds of reviews, but it is also completely incongruous with qualitative research rigor and methodology. Literature reviews for qualitative research projects may include historical, theoretical, or anthropological–sociological literature, which is chosen, read, and deliberated on by the student or researcher, using critical thinking, depth, and breadth of reading in their field, deep reflection, and attention to theoretical arguments. The criticality needed to produce high‐quality qualitative research is not fostered by a quasisystematic literature review based on quantitative methodological principles.

Attempts to conduct qualitative research in a quantitatively rigorous way not only defies all logic but also significantly reduces the rigor of that research. It is important to note that the rigor of most qualitative research methods and findings is reliant on their relationship to the underpinning social theory and the ability to construct a critical argument. Here is yet another basis to our concerns about the quantitative turn in midwifery research, as the requisite knowledge and expertise of the social theories that accompany qualitative research are at risk of not being understood or developed. Embedding beginning social theory courses into midwifery undergraduate programs (and certainly in postgraduate programs) may help to alleviate this.

We are not at all diminishing the importance, rigor, or use of quantitative and systematic methods, particularly when reviewing clinical or experimental research. However, for reasons inexplicable to us, the idea of the systematic‐styled review as the only robust measure of reviewing literature has crept into midwifery academia. The extent of the creep now leaves little room for other ways of reviewing literature that might be more exploratory, or critical, or discursive, or transdisciplinary. The uncritical acceptance of the quantification of the literature review discounts the need for also having narrative, inquiring, critical, purposive, theoretical literature reviews, which have a different intent and a different process.

What is lost by conforming only to stepped, recipe‐like, preordained literature review approaches, with their “robust and nonbiased” knowledge claims (the same claims of science over the centuries, while simultaneously asking research questions from a point of view of gendered, cultural, and economic dominance), is critical, theoretical, and intellectual rigor, in both research direction and execution. There is a danger therefore of reproducing the reductionism and dominance of medical and scientific discourse, which feminist theorists and midwifery scholars alike have painstakingly identified, dissected, and resisted. Crucially, midwifery needs good qualitative research. It needs skilled researchers who are willing to take chances, and dissertation supervisors who are competent to supervise students in rigorous qualitative study. Midwifery needs journal editors who are able to see past the “systematic‐styled review” blindness, and professors who are experts in qualitative research and its accompanying social theory.

The risk of not valuing qualitative expertise, or of perceiving qualitative research as easy, or an adjunct to the more important quantitative data (especially now that policymakers and research bodies are interested in participant experience), is poorly conducted qualitative research design and analysis (see, eg, Coates & Catling's 18 discussion on this issue in the use of ethnography in maternity research). It is as risky to midwifery—to research, practice, and praxis—as understanding childbirth only in terms of measurable “outputs.”

The quantification of life has some use but can also approach absurdity, and it is toward the absurd that an uncritical acceptance of “quantification as rigorous” is leading us. What is surprising is that there appears to be little backlash to this turn from within the midwifery research community, and, perhaps more astounding, even less insight into how this stance is reminiscent of (or reproduces) medical and scientific dominance. 19 Audre Lorde wrote: “For the master's tools will never dismantle the master's house. They may allow us temporarily to beat him at his own game, but they will never enable us to bring about genuine change.” 20

In order to continue to bring about genuine change in maternal health and maternity care, as well as continuing attempts to systematically measure outcomes, we must recognize the patriarchal and colonial roots of knowledge production and dissemination, and critically engage with theories of antioppression, antiracism, and feminism that address decolonization, intersectionality, and reproductive justice, 21 , 22 which remain absent from much midwifery research design. We call for midwifery and maternity care researchers to hold space for qualitative expertise; for deep, slow, reflective, theoretical thinking; for exploring tacit and experiential knowledge; for tangential asides; for creativity; for meandering down various paths; for seeing what is possible; and for discussion of why these are important to midwifery research, just as we discuss how such things are important to midwifery practice.

ACKNOWLEDGMENTS

Open access publishing facilitated by Griffith University, as part of the Wiley ‐ Griffith University agreement via the Council of Australian University Librarians.

Newnham E, Rothman BK. The quantification of midwifery research: Limiting midwifery knowledge . Birth . 2022; 49 :175–178. doi: 10.1111/birt.12615 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

DATA AVAILABILITY STATEMENT

Proceedings of the 2nd Lawang Sewu International Symposium on Health Sciences: Midwifery (LSISHS-M 2023)

Literature Review: Legal Protection for Midwifery Students in Midwifery Clinical Practice in Hospital

In the clinical practice learning process, midwifery students cannot be separated from legal consequences because during clinical practice there is interaction between students and patients so that it does not rule out the possibility of midwifery risks occurring which could be detrimental to the patient. This research aims to determine the limits of authority and legal protection given to midwifery clinical practice students when there is a risk of midwifery procedures being carried out in the hospital. This research method uses a literature review method, starting with determining the topic and then the keywords to search for. Searching using the Google School database, the keywords used are Legal Protection, Midwifery, and Clinical Practice. The research results show that no law protects students in carrying out clinical practice. Students have the authority to carry out all basic health care actions under normal conditions but remain under the supervision of the clinical supervising midwife. Midwifery clinical practice students have legal protection if they carry out basic health care actions by their authority, by Standard Operating Procedures (SOP), and by theories that have been accepted at the institution of midwifery education. However, if students carry out social and religious affairs actions outside their authority, not by the SOP and accepted theories, then the students are to blame.

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    Review Literature as Topic*. This paper highlights the key steps to follow when conducting a systematic review (see Box 2). Healthcare practitioners may be limited by time and resources when conducting literature reviews, however, a systematic and transparent approach should be adopted wherever possible. Further detailed guidan ….

  13. Midwifery continuity of care: A scoping review of where, how, by whom

    Using a scoping review framework, we searched electronic and grey literature databases for reports in any language between January 2012 and January 2022, which described current and recent trials, implementation or scaling-up of midwifery continuity of care studies or initiatives in high-, middle- and low-income countries.

  14. The Role of Midwives in US Perinatal Palliative Care: A Scoping Review

    This scoping review of the literature investigated what is known about the role of midwives in PPC in the United States. ... Midwifery students who receive PPC education develop knowledge and skills necessary to provide holistic midwifery care to those with a fetus with a LLFC in antepartum, intrapartum, and postpartum periods and clinical care ...

  15. A literature review to determine midwifery students' perceived

    Background: Midwifery students' experiences with preceptors in the clinical environment plays an integral role in developing the confidence and competence of students. As up to 50% of the midwifery program is taught in the clinical environment, an analysis of the preceptorship role in the context of midwifery student confidence and competence may be important to inform future practice and policy.

  16. A review of the literature: Midwifery decision-making and birth

    The major findings. synthesised from this review, are that; 1) midwifery decision-making in during birth is. socially negotiated involving hierarchies of sur veillance and control; 2) the role of ...

  17. Midwife experiences of providing continuity of carer: A qualitative

    Sample extracted data ... Prevalence of and factors associated with burnout in midwifery: a scoping review. Eur. J. Midwifery, 4 (2020) Google Scholar [31] ... Continuity of carer and partnership A review of the literature. Women Birth, 19 (2) (2006), pp. 39-44. View PDF View article View in Scopus Google Scholar [61]

  18. Midwifery Dissertation Topics , Ideas & Examples

    To find midwifery dissertation topics: Explore childbirth challenges or trends. Investigate maternal and infant health. Consider cultural or ethical aspects. Review recent research in midwifery. Focus on gaps in knowledge. Choose a topic that resonates with your passion and career goals.

  19. Fathers' involvement in pregnancy and childbirth in Africa: an

    A systematic integrative literature review guided the process. The review comprised problem identification, literature search, data evaluation, data analysis and presentation of results. ... For example, studies from Kenya ... a scoping review. Midwifery. 2021 Dec;103:103089. doi: 10.1016/j.midw.2021.103089

  20. How to Write A Literature Review

    This is something, as a student, I remember very well: writing literature reviews. They were always assigned, yet few of us knew how to write anything really impactful. For me, a good literature review is not the mere act of summarizing; rather, it is analysis, synthesis, and illumination all about discovered knowledge gaps. So let us break it down step-by-step and notice exactly how WPS ...

  21. Midwives' use of best available evidence in practice: An integrative review

    Data abstraction from the literature included in this review was guided by the approach described by Munn et al. ... The sample included nursing and midwifery diplomats and graduates (n = 172) from a single university in the UK and was conducted between June-December 2013. The web-based software Qualitrix™ was used to develop the survey ...

  22. Peer review in nursing and midwifery: a literature review

    The literature describes various applications of peer review and makes recommendations for its use. However, there is a shortage of studies investigating the use of peer review in nursing and midwifery education and practice. Design: The project involved a systematic literature review and a qualitative exploratory study. This article describes ...

  23. Informing the development midwifery standards for practice: A

    The literature review results are presented firstly with: the definition of a midwife; regulation of midwifery with a focus on the midwifery standards in Australia and internationally; midwifery roles and scope of practice; and policy perspectives on culturally sensitive care. ... The following are examples of the scope of practice categories ...

  24. The quantification of midwifery research: Limiting midwifery knowledge

    In this paper, we examine this idea of the quantification of midwifery research, using as an example the current esteem given to the systematic literature review, and its creep into other methodologies. We argue that the current favor toward quantitative research and expertise in midwifery academia risks the future of midwifery research by the ...

  25. Literature Review: Legal Protection for Midwifery Students in Midwifery

    This research method uses a literature review method, starting with determining the topic and then the keywords to search for. ... CONF AU - Fitriani Nur Damayanti AU - Puji Nor Fatimah PY - 2024 DA - 2024/07/16 TI - Literature Review: Legal Protection for Midwifery Students in Midwifery Clinical Practice in Hospital BT - Proceedings of the 2nd ...

  26. Trauma-informed approaches in the context of cancer care in Canada and

    A trauma-informed approach to care (TIC) has potential to enhance care and outcomes; however, literature regarding cancer-related TIC is limited. Accordingly, the objective of this scoping review was to identify what is known from existing literature about trauma-informed approaches to cancer care in Canada and the United States.

  27. A global overview of midwives' working conditions: A rapid review of

    Midwifery leaders displayed different leadership styles. For example, for Julie, a midwife manager, a good manager should be "[m]idwifing the midwife in the best possible way, so as we midwives are with the woman" [60;p172]. On the other hand, in Nagle et al. [62], another midwife manager refers to telling their staff,

  28. What multimodal components, tools, dataset and focus of emotion are

    For example, research by Davies et al. (Citation 2019), Chou and Budenz ... Based on the literature review, by taking into account the general components of emotional multimodal research, this study suggests that the researchers examine emotions using more modes. The more modes are used, the more comprehensive and higher quality the results ...

  29. A literature review to determine midwifery students' perceived

    A literature review to determine midwifery students' perceived essential qualities of preceptors to increase confidence and competence in the clinical environment. ... optimised the learning experience of midwifery students, and served as an example of a hospital taking responsibility for the midwives in their employment [21].