Midwifery one-to-one support in labour (Hunter 2007; Cheung 2011, 2010; Fox et al. 2013) or referred to as continuous attendance (Sandall et al. 2013) during labour, birth and the immediate postpartum period is considered an attribute of midwife-led care. Midwife-led care is woman-centred and based on the premise that pregnancy and birth are normal life events (Rooks 1999; Blaaka and
Schauer Eri 2008; Sandall et al. 2013; Wiysonge 2009). Women are low-risk and receive autonomous care from a midwife (Devane et al. 2010). Women are regarded as an ‘active partner’ in their care (Rooks 1999:371). Midwife-led care includes monitoring the psychological social and spiritual wellbeing of women as well as the physical (Rooks 1999; Sandall et al. 2013). Midwives are able to choose to be present with women (Devane et al. 2010). The presence is ‘time- intensive and relationship-intensive’ (Rooks, 1999: 107) with flexible time frames rather than rigid (Davis 2010; Devane et al. 2010).
63 Midwife-led care supports normality, thus midwives try to avoid interfering with the normal processes of labour therefore unnecessary interventions are avoided (Rooks1999; Sandall et al. 2013). Understanding what constitutes normality is therefore crucial for midwives as it has been noted that midwives failure to define normality has contributed to increasing technicalisation and medicalisation of labour and birth (Gould 2000). Such midwifery knowledge comes from extensive experience and is enhanced when midwives are able to tolerate wide variations of normality in labour and birth (Davis 2010) and recognise when complications develop so that a referral is made to the appropriate specialist, usually an obstetrician (Devane et al. 2010).
No research was found in relation to midwife-led care that has directly measured midwifery one-to-one support in labour as an outcome. Systematic reviews comparing midwife-led care with ‘other models of care’ (medical model of care provided by an obstetrician or a family doctor or both collaborating with nurses and midwives in variable environments) have consistently shown that women who had midwife-led care were less likely to experience regional analgesia (epidural/spinal), episiotomy, and instrumental delivery. They were more likely to experience spontaneous vaginal birth, no intrapartum analgesia/anaesthesia and to have a longer length of labour and feel in control during labour and childbirth. Interestingly there was no difference in the caesarean section rate (Hatem et al. 2009; Devane et al. 2010; Sandall et al. 2013). Although continuous attendance during labour was described as one of the attributes of midwife-led care, it was not amongst the outcomes measured (Hatem et al. 2009; Devane et al. 2010; Sandall et al. 2013). These reviews included the United Kingdom (UK) and other high income countries (Australia, Canada, Ireland and New Zealand).
Improved birth outcomes were also found in cohort studies who introduced midwifery one-to-one support as part of a midwife-led care model at a midwife- led normal birth unit (MNBU) in China (Cheung et al. 2010; 2011) and a National University Hospital in Singapore (Fox et al. 2013). Both cohort studies compared the midwife-led care model with usual care. The latter included midwives
supporting more than one woman per shift and birthing partners were not permitted. As part of the midwife–led care model, partners were permitted and the concept was named ‘two-to-one’ at one study site as one midwife and birthing partner accompanied one labouring woman (Cheung et al. 2010, 2011).
64 The findings of the two cohort studies showed that women were more likely to have a spontaneous vaginal birth (Cheung et al. 2011; Fox et al. 2013), be satisfied with care (Cheung et al. 2010, 2011), less likely to have a caesarean section (Cheung et al. 2011; Fox et al. 2013), an epidural (Fox et al. 2013) and interventions (Cheung et al. 2011). Both cohort studies concluded that midwifery one-to-one/two-to-one support in labour played a major factor in relation to promoting higher spontaneous vaginal births (Cheung et al. 2011; Fox et al. 2013). It was not explicithow the researchers came to this conclusion however as the level of midwifery presence had not been indicated and there were other influencing factors mentioned in the descriptions of the midwife-led care model including the care being woman centred, continuity of carer and increased motivation not intervening with the physiological processes of labour (Cheung et al. 2011; Fox et al. 2013).
An Ethnographic study by Hunter (2007; 2010, Hunter and Segrott 2010) highlighted the challenges faced when introducing a clinical pathway (which included midwifery one-to-one support in labour) to guide midwives working with a midwife-led care model for low-risk women within hospital organisations in Wales. The clinical pathway was part of a national policy initiative titled the ‘All Wales Clinical Pathway for Normal Labour’ (All Wales Clinical Pathway for Normal Labour 2004) aimed to decrease the caesarean section rate and increase the number of normal births. Over a two year period however caesarean sections did not reduce and spontaneous births did not increase. More recent statistics show that this trend continues (Welsh Government 2014). Contributing factors for the results included the lack of early collaboration from all parties (including obstetricians), small numbers of women entering the pathway, disagreement with regards to the inclusion and exclusion criteria for the pathway, and no clinical experts in normality as staff rotated.
Although midwifery one-to-one support in labour was part of the clinical pathway, no data was collected to measure the outcomes and a lack of data collection from the hospital overall in relation to outcomes was identified by the researchers (Hunter and Segrott 2010). A case study (Bick et al. 2009) conducted an adapted version of the All Wales Clinical Pathway in an AMU in England. The outcomes featured all challenges previously described (Hunter 2007; Hunter and Segrott 2010). Unfortunately again no data was collected to assess midwifery one-to-one support in labour. There are questionsoutstanding relating to why the midwife-
65 led care clinical pathway did not impact more positively (Hunter 2007; Bick et al. 2009). It is unclear if the issues are associated with the clinical pathway, the method that it was introduced or the transition of using new ideologies that are woman centered.