29 August 2021
WHO recommendation on midwife-led continuity of care during pregnancy
Midwife-led continuity-of-care models, in which a known midwife or small group of known midwives supports a woman throughout the antenatal, intrapartum and postnatal continuum, are recommended for pregnant women in settings with well functioning midwifery programmes.
First published: November 2016
Updated: No update planned
Assessed as up-to-date: November 2016
Midwives are the primary providers of care in many ANC settings (1). In MLCC models, a known and trusted midwife (caseload midwifery), or small group of known midwives (team midwifery), supports a woman throughout the antenatal, intrapartum and postnatal period, to facilitate a healthy pregnancy and childbirth, and healthy parenting practices (2). The MLCC model includes: continuity of care; monitoring the physical, psychological, spiritual and social well-being of the woman and family throughout the childbearing cycle; providing the woman with individualized education, counselling and ANC; attendance during labour, birth and the immediate postpartum period by a known midwife; ongoing support during the postnatal period; minimizing unnecessary technological interventions; and identifying, referring and coordinating care for women who require obstetric or other specialist attention (3). Thus, the MLCC model exists within a multidisciplinary network in which consultation and referral to other care providers occurs when necessary. The MLCC model is usually aimed at providing care to healthy women with uncomplicated pregnancies.
The ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. These recommendations were developed in accordance with the methods described in the WHO handbook for guideline development (4). In summary, the process included: identification of priority questions and outcomes, retrieval of evidence, assessment and synthesis of the evidence, formulation of recommendations, and planning for the implementation, dissemination, impact evaluation and updating of the guideline.
The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (5) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) (6) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) (7) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at three Technical Consultations between October 2015 and March 2016.
To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.
In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.
Further information on procedures for developing this recommendation are available here.
For this recommendation, we aimed to answer the following question:
The evidence on the effects of MLCC models of care was derived from a Cochrane review that included 15 trials involving 17 674 women, in which pregnant women were randomized to receive ANC either by MLCC models or by other models of care (2). All the studies included were conducted in public health systems in HICs (Australia, Canada, Ireland and the United Kingdom) and 14 out of 15 contributed data. Eight trials compared an MLCC model with a shared care model, three trials compared MLCC with medical-led care, and three compared MLCC with “standard care” (mixed-care options, including midwife-led non-continuous care, medical-led, and shared care). Some MLCC models included routine visits to an obstetrician and/or family doctor. Eight trials included women with “low-risk” pregnancies only; six also included women with “high-risk” pregnancies. Four trials evaluated one-to-one (caseload) MLCC and 10 trials evaluated team MLCC. Caseload sizes for one-to-one models ranged from 32 to 45 pregnant women per midwife per year. Levels of continuity of care were measured (as the proportion of births attended to by a known carer), and were in the ranges of 63–98% for MLCC and 0–21% for other models. A random effects model was used in all meta-analyses.
Moderate-certainty evidence shows that MLCC compared with other models of care probably slightly increases the chance of a vaginal birth (12 trials, 16 687 participants; RR: 1.05, 95% CI: 1.03–1.07). MLCC may reduce caesarean sections (14 trials, 17 674 participants; RR: 0.92, 95% CI: 0.84–1.00), however, this evidence is of low certainty and includes the possibility of no effect. Low-certainty evidence suggests that MLCC models may be associated with lower rates of instrumental vaginal delivery than other models (13 trials, 17 501 participants; RR: 0.90, 95% CI: 0.83–0.97). Maternal satisfaction: The Cochrane review tabulated data on women’s satisfaction pertaining to various aspects of antenatal, intrapartum and postnatal care. A meta-analysis on satisfaction with ANC only was performed for the purposes of this guideline, the findings of which suggest that MLCC models may increase the proportion of women reporting high levels of satisfaction with the ANC compared with other models (4 trials, 5419 women; RR: 1.31, 95% CI: 1.11–1.54; low-certainty evidence).
Fetal and neonatal outcomes
Moderate-certainty evidence indicates that MLCC probably reduces the risk of preterm birth (8 trials, 13 338 participants; RR: 0.76, 95% CI: 0.64–0.91) and probably reduces perinatal mortality (defined in the review as fetal loss after 24 weeks of gestation and neonatal death) (13 trials, 17 561 women; RR: 0.84, 95% CI: 0.71–0.99). However, low-certainty evidence suggests that it may have little or no effect on low birth weight (7 trials, 11 458 women; RR: 0.96, 95% CI: 0.82–1.13). Evidence on other ANC guideline outcomes was not available in the review.
Although the mechanism for the probable reduction in preterm birth and perinatal death is unclear, the GDG considered the consistency of the results and the absence of harm to be important.
In settings with well-functioning midwife programmes, a shift in resources may be necessary to ensure that the health system has sufficient midwives with reasonable caseloads. There may also be training costs associated with changing to an MLCC model. However, one study in the Cochrane review found that ANC provider costs were 20–25% lower with the MLCC model than other midwife-led care due to differences in staff costs (8).
Equitable coverage and improvements in the quality of midwifery practice are major challenges in many LMICs (1). MLCC models in any setting have the potential to help to address health inequalities, for example, by providing a more supportive setting for disadvantaged women to disclose information that may facilitate the identification of risk factors for poor outcomes, such as intimate partner violence.
Qualitative evidence synthesized from a wide variety of settings and contexts indicates that women welcome the opportunity to build supportive, caring relationships with a midwife or a small number of midwives during the maternity phase (high confidence in the evidence) and appreciate a consistent, unhurried, woman-centred approach during ANC visits (high confidence in the evidence) (9). Evidence from providers, mainly in HICs, indicates that they view MLCC as a way of achieving the authentic, supportive relationships that women desire (moderate confidence in the evidence). There is very little evidence on MLCC models from LMICs. However, indirect evidence from providers in these locations suggests that they would welcome the opportunity to use an MLCC model but feel they do not have the resources to do so (low confidence in the evidence).
Qualitative evidence from high-, medium- and low-resource settings highlights concerns among providers about potential staffing issues, e.g. for the delivery of caseload or one-to-one approaches (high confidence in the evidence) (10).
Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:
The GDG identified these priority questions related to this recommendation
WHO recommendations on antenatal care for a positive pregnancy experience
Citation: WHO Reproductive Health Library. WHO recommendation on midwife-led continuity of care during pregnancy. (November 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.
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