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The midwife’s public health role

Midwifery is a public health strategy

Public health is “the art and science of preventing disease, prolonging life and promoting health” (WHO, 1988). The Quality Maternal and Newborn Care Framework highlights the preventative and supportive care midwives provide – tailored to individual needs and focussed on strengthening capabilities (QMNC, 2021).  Midwives use strategies that prevent or minimise complications during pregnancy, birth, or early parenting – and promote health and well-being (QNMC, 2021). For example, brief-interventions about smoking, screening and support for perinatal mental health, and promotion of normal birth and breastfeeding. The World Health Organization (2020) underscores the importance of working to strengthen families to provide a nurturing environment for children to thrive.

Midwifery continuity provides ideal context for change

Midwives in continuity of carer models are best placed to form genuine caring relationships with women (Jepsen et al., 2016). The midwife-woman relationship provides the context for women to buy-in to maternity care. Women buy-in when they feel safe enough to disclose risks and concerns, and trust and accept the midwife’s recommendations for making positive health changes (Allen et al., 2016).  There is high level evidence for midwifery continuity of care in terms of clinical outcomes (Sandall et al., 2016) and cost-efficiency (Callander et al., 2021). However, the evidence of effective midwifery public health interventions is still growing.

Evidence on midwifery public health interventions

Definitive evidence of effective midwifery public health interventions comes from a systematic review of systematic reviews (McNeill et al., 2012). This study considered the level of evidence included in reviews, and assessed how well each review was conducted. McNeill et al. (2012) identified 36 good quality systematic reviews which reported on effective interventions during the antenatal period (20 reviews), labour and birth (5 reviews) and postpartum (11 reviews). The review included 8 interventions categorised as:

  1. screening
  2. supplementation
  3. support
  4. education
  5. mental health
  6. birthing environment
  7. clinical care in labour
  8. breast feeding

Effective antenatal public health interventions included screening for lower genital tract infection, use of decision-aids, and specific nutrient supplementation – i.e., iron and folic acid (McNeill et al., 2012). However, the review noted a need for further research on calcium supplementation to reduce risk of pre-eclampsia (McNeill et al., 2012). Interventions designed to help women stop smoking during pregnancy were particularly effective (McNeill et al., 2012). While emotional support interventions, including telephone support, showed a trend towards positive psycho-social outcomes – further research is needed (McNeill et al., 2012).

Effective intrapartum public health interventions included having a known midwife, which reduced the risk of intrapartum analgesia and caesarean section, and increased the chance of spontaneous vaginal birth and breastfeeding (McNeill et al., 2012). Other effective interventions included access to birth centres, continuous emotional support in labour, warm water immersion, and delayed cord clamping (McNeill et al., 2012).

Effective postpartum public health interventions, included intensive midwifery home visiting which reduced the incidence of postnatal depression by 33% (Dennis & Creedy, 2004). Indeed, any intervention design to provide psycho-social support (e.g., non-directive counselling, group support) reduced postnatal depression when compared to standard care (McNeill et al., 2012). Interestingly, all types of interventions tested to increase breastfeeding had a positive impact. Antenatal education increased breastfeeding initiation for low-income women, whereas only postnatal interventions had an impact on duration and exclusivity (McNeill et al., 2012). Teaching and enhancing parenting skills improved children’s neurodevelopment up to 3 years of age compared to standard care (McNeill et al., 2012).

COVID-19 and the public health role of midwives

The COVID-19 pandemic has shown the importance of investing in public health care to meet population health needs (Szabo et al., 2021). Dr Zoe Bradfield, Transforming Maternity Care Collaborative’s Health Promotion Program Co-Director, led a survey of midwives about providing maternity care during the pandemic (Bradfield et al., 2021). The results showed that having a known midwife was important particularly when woman had limited face-to-face midwifery contact during pregnancy and postpartum, and restrictions around social support in labour (Bradfield et al., 2021). Women’s experience of becoming mothers during the pandemic created additional needs for psycho-social support to manage isolation, anxiety, and stress; advocacy and access to reliable information; and reassurance (Sweet et al., 2021). Midwives are ideally placed to meet these needs through advocacy, education and support.

Midwifery investment improves public health

There is a lack of understanding about the impact and value of midwifery practice on public health outcomes. The 2021 State of the World’s Midwifery Report calls for significant investment in the education of midwives and expansion of midwifery-led models of care, to promote the health and well-being of mothers and babies (UNPF, WHO & ICM, 2021).  Midwives are essential providers of public health care contributing to improved outcomes, especially for women who may not experience equitable access to maternity care.

Highlighted research

McNeill J, Lynn F. & Alderdice F. (2012) Public health interventions in midwifery: A systematic review of systematic reviews. BMC Public Health, 12, 955. Retrieved from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-12-955

References

Allen, J., Kildea, S., & Stapleton, H. (2016). How optimal caseload midwifery can modify predictors for preterm birth in young women: integrated findings from a mixed methods study. Midwifery. https://doi.org/10.1016/j.midw.2016.07.012

Bradfield, Z., Hauck, Y., Kuliukas, L., Sweet, L., Homer, C. Wilson, A., Vasilevski, V., Wynter, K. & Szabo, R.(2021). Midwifery care during the CoVID-19 pandemic in Australia: A cross-sectional study. Women and Birth (In Press). https://doi.org/10.1016/j.wombi.2021.02.007

Callander, E. J., Slavin, V., Gamble, J., Creedy, D. K., & Brittain, H. (2021). Cost-effectiveness of public caseload midwifery compared to standard care in an Australian setting: a pragmatic analysis to inform service delivery. International Journal for Quality in Health Care, 33(2). https://doi.org/10.1093/intqhc/mzab084

Jepsen, I., Mark, E., Nohr, E. A., Foureur, M., & Sorensen, E. E. (2016). A qualitative study of how caseload midwifery is constituted and experienced by Danish midwives. Midwifery, 36, 61-69. https://doi.org/10.1016/j.midw.2016.03.002

Quality Maternal and Newborn Care. (2021). Framework for Quality Maternal and Newborn Care. Retrieved from: https://www.qmnc.org/qmnc-research-alliance/framework-for-quality-maternal-and-newborn-care/

Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, 4, Cd004667. https://doi.org/10.1002/14651858.CD004667.pub5

Sweet, L., Bradfield, Z., Vasilevski, V. Wynter, K.  Hauck, Y., Kuliukas, L., Homer, C., Szabo, R. & Wilson, A. (2021). Becoming a mother in the ‘new’ social world in Australia during the first wave of the COVID-19 pandemic. Midwifery. (In Press)https://doi.org/10.1016/j.midw.2021.102996

Szabo, R. Sweet, L., Homer, C., Wilson, A., Kuliukas, L., Hauck, Y., Vasilevski, V., Wynter, K. & Bradfield, Z. (2021). COVID-19 changes to maternity care: Experiences of Australian doctors. ANZJOGhttp://dx.doi.org/10.1111/ajo.13307

United Nations Population Fund (UNPF), World Health Organization (WHO), & International Confederation of Midwives (ICM).(2021). State of the world’s midwifery: delivering health, saving lives. United Nations Population Fund.

World Health Organization. (2020). Improving Early Childhood Development: WHO Guideline. WHO.

World Health Organization. (1988). Public Health Services. Retrieved from: https://www.euro.who.int/en/health-topics/Health-systems/public-health-services/public-health-services