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Introduction
Midwifery-led models of care have long been regarded as having better outcomes for women and babies at low-risk of complications (Sandall et al., 2016; Hatem et al., 2008). In these models, the midwife is the lead and primary caregiver with responsibility for the assessment of needs, care planning and delivery, as well as referral to other professionals should concerns arise (Sandall et al., 2016). Nove et al. (2021) recently estimated that a substantial increase in midwifery delivered care (in comparison to current provision) has the potential to prevent “41% of maternal deaths, 39% of neonatal deaths, and 26% of stillbirths, equating to 2.2 million deaths averted per year by 2035” (p.e24).
Midwifery-led models of care comprise ‘continuity of care’ where a common philosophy is shared amongst the midwifery professionals and can also involve ‘continuity of carer’ where the same midwife, or a small group, is responsible for the care throughout the maternity continuum or a specific period (Symon et al., 2016). The models can be employed in primary or secondary care services or in the full continuum.
The success mechanism of these models of care compared to medical-led models is yet to be fully understood (Symon et al., 2016) with questions of whether the effects are from the continuity of care, the philosophy of care or both (WHO, 2018). Yet many experts believe that the focus on the women and their babies' needs, in such a physiological event, rather than the identification and treatment of pathology, is the key (Renfrew et al., 2014; Davis-Floyd, 2001).
Much has been researched on the fields of midwifery-led care models including outcomes (Sandall et al., 2016) and cost comparisons (Attanasio et al., 2020; Kenny et al., 2015; Koto et al., 2019) with medical models of care, barriers and facilitators to the implementation of midwifery units into maternity services (Batinelli et al., 2022) or the experiences of midwives in their practice of a midwifery model of care in an integrated practice setting (e.g. obstetric units) (McFarland et al., 2020) but to the authors’ knowledge no other published review has focused on barriers and facilitators to the implementation of midwifery-led-care models in a health care system.
A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis was conducted and identified an in-progress mixed-methods systematic review and meta-synthesis on the barriers and facilitators to the implementation of midwife-led care for childbearing women in low and middle-income countries (Sangy et al., 2021). However, when the review protocol was consulted it was identified that the above-mentioned review is limited to low and middle-income countries and has a focus on midwifery-led care regardless of the current status quo, which makes it include studies aiming to study the shift from no care (or care from non-skilled birth attendants) to midwifery models of care. Our study investigates the shift from medical-led models of care onto midwifery-led models of care.
The proposed review is part of a wider research project that seeks to explore the viability to implement a midwifery-led care model to the antenatal care of women with uncomplicated pregnancies in the Portuguese national health service context. Portugal is a high-income country, with a universal healthcare system, where midwifery-led models of care have not yet been introduced despite establishment of legal regulation of autonomous practice, availability of trained midwives and women’s groups willingness to move towards these models, looking into reducing unnecessary interventions and seeking normalization of pregnancy and childbirth practices (Marcelino, 2016; (Observatório de Violência Obstétrica, 2022).
The evidence gathered will be used to inform a study that seeks to explore Portuguese stakeholders' ex-ante perceptions on the barriers and facilitators to the implementation of such a model in Portugal. But ultimately the outcomes of this review can be welcomed by anyone who is interested in implementation of midwifery-led care models in any healthcare system.
Review question
What are the barriers and facilitators perceived by stakeholders implementing a midwifery led care model in a health care system?
Inclusion criteria | Participants
This review will consider studies that report the views/perceptions of stakeholders involved in the implementation of a midwifery-led care model in a health care system: midwives, doctors, service users, maternity teams/health facilities managers and policy developers.
Phenomena of interest
This review will consider studies that explore the stakeholders’ perceptions about the implementation process of a midwifery-led care model in a health care system, institution, or team. The barriers can be described as factors that were perceived as an obstacle for the implementation of the new midwifery-led care model; the facilitators can be described as factors that were perceived as enablers to the implementation of the new model. Models of care not specific to midwifery and all other issues related to midwifery models of care that do not include implementation will be excluded from this qualitative review. Continuity midwifery led care models, from an already implemented midwifery model, will be excluded since the researchers are interested in understanding the factors affecting the transition from medical-led to midwifery-led care.
Context
This review will consider studies that describe perceptions of the stakeholders to the implementation of a midwifery-led care model in a health care system. The health care system can be of public or private nature; can include rural or urban areas and no geographical limitations will be applied. Healthcare system is defined as an organization, institution or other resource that intends to improve the health of a specific population by delivering health services that meet their needs (White, 2015).
Types of studies
This review will consider all study designs that include qualitative data collection and analysis that draw on the barriers and facilitators focusing on the perceptions of the stakeholders when implementing a midwifery-led care model. The review will therefore consider designs such as phenomenology, grounded theory, ethnography, action research, qualitative description, and feminist research. Mix-methods studies will also be accepted; however, only the qualitative nature of data will be extracted.
Studies and abstracts published in English, Portuguese and Spanish will be considered. There are no geographical or date limits to this review.
1. Methods
The proposed systematic review will be conducted in accordance with the JBI methodology for systematic reviews of qualitative evidence. This study received ethical approval by ICBAS, School of Medicine and Biomedical Sciences Ethical Committee (reference 2022/CE/P02/(P380/CETI/ICBAS), and the review is registered and publicly available in PROSPERO (CRD42022355495).
Search strategy
The search strategy will aim to locate both published and unpublished studies. An initial limited search of MEDLINE (PubMed) and CINAHL (EBSCO) was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for MEDLINE (PubMed) (see table 1). The search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference list of all studies selected for critical appraisal will be screened for additional studies.
The databases to be searched include MEDLINE (Pubmed), CINAHL (EBSCO), PsyInfo (EBSCO) and Web of Science (EBSCO). A grey literature search strategy was developed incorporating grey literature databases such as ProQuest Dissertations and Theses, and relevant organizational websites. We will also search Google and Google Scholar using keywords based on those found in our preliminary database searches. These searches will be iterative, as it is typical for grey literature searches.
Table 1 Medline via Pubmed - Search conducted on the 30thof May 2022
| Search | Query | Results |
|---|---|---|
| #1 | "Nurse"[Title/Abstract] OR "Midwife"[Title/Abstract] OR "Obstetrician"[Title/Abstract] OR "Women"[Title/Abstract] OR "Family doctor"[Title/Abstract] OR "General practitioner"[Title/Abstract] OR "Manager"[Title/Abstract] | 1281464 |
| #2 | "Experience"[Title/Abstract] OR "facilitator"[Title/Abstract] OR "barrier"[Title/Abstract] | 973345 |
| #3 | "Midwifery"[MeSH Terms] | 20537 |
| #4 | "Physician Assistants"[MeSH Terms:noexp] OR "Nurses"[MeSH Terms] OR "Obstetrics"[MeSH Terms] OR "Women"[MeSH Terms] | 163903 |
| #5 | #1 OR #4 | 1377642 |
| #6 | #2 AND #3 AND #5 | 1486 |
Study selection
Articles and documents identified in the search will be collated and uploaded into Mendeley and duplicates removed. The refined results will then be uploaded into Rayyan where, following a pilot test, two independent reviewers will screen titles and abstracts against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and uploaded into Rayyan. The full text of selected citations will be assessed in detail against the inclusion criteria by the two independent reviewers. In the case of any disagreement between the two reviewers, a third reviewer will arbitrate. Reasons to further exclude full-text documents will be recorded, described, and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram (Page et al., 2021) in the review report.
Assessment of methodological quality
Eligible studies will be critically appraised by two independent reviewers for methodological quality using the standard JBI critical appraisal checklist for qualitative research (The Joanna Briggs Institute, 2017). If missing data or additional clarification required, authors of the papers will be contacted. Once again, any disagreements that arise between the reviewers will be resolved through discussion or a third reviewer. The results of critical appraisal will be reported in narrative form or in a table.
Regardless of methodological quality, all the studies will be included in this review since the authors aim to identify all barriers and facilitators identified and perceived by stakeholders to the implementation of a midwife-led care model.
Data extraction
Data will be extracted from papers included in the qualitative review using a data extraction form developed by the reviewers (see Table 2) based on JBI QARI data extraction tool for qualitative research version 2014 (Aromataris & Munn, 2020). The form will include additional space to allow the emergence of new key themes once the authors are more familiar with the information retrieved. The data extracted will include specific details about the population, phenomena of interest, context, geographical location, study methods, and key findings relevant to the review objectives. The data extraction tool will be modified and revised as necessary during the extraction data process. Modifications will be detailed in the full qualitative review report. Authors of papers will be contacted to request missing or additional data, where required.
Table 2 Data extraction instrument (modified from JBI QARI data extraction tool for qualitative research 2014)
| Reviewer: | Date: | |
| Qualitative Systematic Review Title: | ||
| Review Question: | ||
| Details and characteristics of the analysed study/document | ||
| Title: | ||
| Authors: | ||
| Year: | ||
| Study Aim: | ||
| Study Design and Methods used: | ||
| Participants: | ||
| Phenomena of Interest: | ||
| Context: | ||
| Setting: | ||
| Data analysis: | ||
| Findings: | ||
| BARRIERS to the implementation of a midwifery-led-care model | ||
| FACILITATORS to the implementation of a midwifery-led-care model | ||
| Quality of the study: | ||
| Authors conclusions: | ||
| Gaps identified in the documents: | ||
| Other key findings that relate to the systematic review question/s: | ||
| Comments: | ||
Data synthesis
Qualitative research findings will, where possible, be pooled using thematic analysis. Thematic analysis, first described by Thomas and Harden (Thomas & Harden, 2008) is considered an appropriate method of analysis when seeking to understand experiences, thoughts, or behaviours across a data set (Kiger & Varpio, 2020). The method generally involves a six-step process: familiarizing with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report. As part of the thematic analysis, a theoretical framework will be identified to guide the synthesis process.
Assessing confidence in the findings
The final synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings (Aromataris & Munn, 2020). The summary of findings will include the major elements of the review and details how the ConQual score is developed. Included in the summary of findings will be the title, population, phenomena of interest and context for the specific review. Each synthesized finding from the review will then be presented along with the type of research informing it, score for dependability and credibility, and the overall ConQual score.
2. Results and discussion
The authors expect to find articles that describe the experiences of stakeholders in the implementation of a midwife-led care model. As in many countries, such as the United Kingdom, the shift from medical-led care to midwifery-led care happened some time ago the researchers expect to have results that can be over 20 years old.
We anticipate that our systematic review will provide guidance for the implementation of midwifery-led care models in any healthcare setting.
Conclusion
As previously stated, the proposed review is part of a wider research project that seeks to explore the viability to implement a midwifery-led care model to the antenatal care of women with uncomplicated pregnancies in the Portuguese national health service context. The researchers plan to identify the barriers and facilitators to the implementation of the midwife-led care model for the Portuguese context through a review of the theme followed by interviews to stakeholders. This review is important to reveal the experiences other countries faced when implementing a midwife-led care model and will enable an understanding of the possible obstacles Portugal would face. It will also inform the development of an interview guide for the planned study.
Finally, this protocol sets out the planning and documents the methodology the researchers will employ in this systematic review. This is both to ensure transparency and reproducibility but also to ethically avoid work duplication.
Author contributions
Conceptualization, A.S.G. and M.P.S.; data curation, A.S.G. and M.P.S.; formal analysis, A.S.G. and M.P.S; funding acquision, A.S.G.; investigation, A.S.G., M.P.S, C.M. and A.P.P.; methodology, A.S.G., M.P.S, C.M. and A.P.P.; project administration, A.S.G.; supervision, C.M. and A.P.P.; validation, A.S.G., M.P.S, C.M. and A.P.P.; visualization A.S.G., M.P.S, C.M. and A.P.P.; writing-original draft, A.S.G. and M.P.S.; writing-review and editing, C.M. and A.P.P.
