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Midwife-led continuity of care increases women’s satisfaction with antenatal, intrapartum, and postpartum care: North Shoa, Amhara regional state, Ethiopia: A quasi-experimental study

  • Solomon Hailemeskel
    Correspondence
    Corresponding author at: Department of Midwifery, College of Health Science, Debre Berhan University, Postal address: 445, Debre Berhan, Ethiopia.
    Affiliations
    School of Midwifery, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia

    Department of Midwifery, College of Health Science, Debre Berhan University, Debre Berhan, Ethiopia
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  • Kassahun Alemu
    Affiliations
    Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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  • Kyllike Christensson
    Affiliations
    Department of Women’s and Children’s Health, Division of Reproductive Health, Karolinska Institute, Sweden
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  • Esubalew Tesfahun
    Affiliations
    Department of Public Health, College of Health Science, Debre Berhan University, Debre Berhan, Ethiopia
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  • Helena Lindgren
    Affiliations
    School of Midwifery, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia

    Department of Women’s and Children’s Health, Division of Reproductive Health, Karolinska Institute, Sweden
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Published:January 20, 2022DOI:https://doi.org/10.1016/j.wombi.2022.01.005

      Abstract

      Background

      The provision of midwife-led continuity of care (MLCC) is effective in high-resource settings in improving maternal satisfaction. This study aimed to evaluate the effect of MLCC on women’s satisfaction with care in a low-income/resource setting.

      Method

      A study with a quasi-experimental design was conducted from August 2019 to September 2020 in four primary hospitals in the north Shoa zone, Amhara regional state, Ethiopia. A total of 1178 low-risk women were allocated to one of two groups; the MLCC (intervention group) that received all antenatal, intrapartum, and immediate postnatal care from a primary midwife or backup midwife) (n = 589) and the shared model of care (SMC) group that received care following established practice in Ethiopia, care from different staff members at different times) (n = 589). Data for this paper were collected using face-to-face interviews at the women’s home at the end of the postpartum period. The study’s outcome was the mean sum-score of satisfaction with care through the antenatal, intrapartum, and postnatal period continuum, where mean sum-scores range from 1 (lowest) to 5 (highest).

      Findings

      Compared with SMC, MLCC was associated with statistically significantly higher satisfaction with all continuity of care (4.07 vs. 2.79 adjusted mean difference 1.27, 95% CI 1.18–1.35; p < 0.001), during antenatal care (4.14 vs. 2.81 adjusted mean difference 1.33 (95% CI 1.22–1.52), intrapartum care (3.83 vs. 2.71 adjusted mean difference 1.06 (95% CI 0.88–1.23) and postnatal care (5.46 vs. 3.71 adjusted mean difference 1.75 (95% CI 1.54–1.94)).

      Conclusion

      MLCC increased women's satisfaction with maternity care for women at low risk of medical complications. These findings confirm that the MLCC model will be applicable in the Ethiopian health care system with similar settings.

      Keywords

      Statement of significance
      Problem
      The effect of MLCC on maternal satisfaction during antenatal, intrapartum, and postnatal care in the lower- and middle-income country has not been well studied.
      What is already known?
      The provision of midwife-led continuity of care (MLCC), the model of care in which midwives are the lead professionals for women and newborn infants across the continuum in childbirth, is effective in high-resource settings in improving maternal satisfaction.
      What this paper adds
      MLCC increased women’s satisfaction with maternity care, and the finding confirms that previous evidence from high-income settings is also relevant in lower- and middle-income countries.

      1. Introduction

      The many different forms of maternal care practiced worldwide are reviewed in two reports that provide the background for our study. First, Miller et al. [
      • Miller S.
      • Abalos E.
      • Chamillard M.
      • Ciapponi A.
      • Colaci D.
      • Comande D.
      • Diaz V.
      • Geller S.
      • Hanson C.
      • Langer A.
      • et al.
      Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide.
      ] review the two main types of maternal care practiced worldwide in countries at all income levels. They give this review to guide low to middle-income countries, one of them Ethiopia, that want to improve maternal care. They do not recommend anyone’s approach. In the same year, the World Health Organization (WHO) provided a complete review of possible interventions that might be considered [
      • Miller S.
      • Abalos E.
      • Chamillard M.
      • Ciapponi A.
      • Colaci D.
      • Comande D.
      • Diaz V.
      • Geller S.
      • Hanson C.
      • Langer A.
      • et al.
      Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide.
      ,
      • World Health Organization
      WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience.
      ]. The WHO document is of particular interest here because it contains a section devoted to intervention that is the subject of this paper. The WHO refers to that intervention as Midwife-Led Continuity of Care (hereafter MLCC).
      MLCC describes a model where women are followed up through the continuum of pregnancy and contact a single midwife, the Primary midwife responsible for the entire process. This continued contact through the intrapartum and postnatal period facilitates the relationship between the women and known midwives [
      • World Health Organization
      WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience.
      ,
      • Homer C.
      • Brodie P.
      • Sandall J.
      • Leap N.
      Midwifery Continuity of Care: A Practical Guide.
      ]. The two primary forms of organization of MLCC are the caseload model and team midwifery model. In the caseload model, one midwife cares for up to 45 women and facilitates relational continuity. In contrast, in the team-midwifery model, a group of 4–6 midwives provides care for up to 360 women through pregnancy, birth, and the postnatal period. Ideally, in both models, women are cared for during antepartum, birth, and postpartum by a known midwife [
      • World Health Organization
      WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience.
      ,
      • Homer C.
      • Brodie P.
      • Sandall J.
      • Leap N.
      Midwifery Continuity of Care: A Practical Guide.
      ]. A Cochrane review measuring the effect of MLCC on maternal satisfaction compared with other models of care for childbearing women reported a higher level of satisfaction among women who had MLCC compared with those who did not [
      • Sandall J.
      • Soltani H.
      • Gates S.
      • Shennan A.
      • Devane D.
      Midwife-led continuity models versus other models of care for childbearing women.
      ]. Still, the limitations of these studies were that the reviewers could not identify which aspects of care increased women's satisfaction. In addition, the studies lacked consistency in how satisfaction with continuity of care was measured. Besides, all the studies included in this review were from high income countries and that less is known about the effectiveness of MLCC model in lower and middle income countries [
      • Sandall J.
      • Soltani H.
      • Gates S.
      • Shennan A.
      • Devane D.
      Midwife-led continuity models versus other models of care for childbearing women.
      ,
      • Smith V.
      Midwife-led continuity models versus other models of care for childbearing women.
      ].
      Ethiopia showed progressive improvement in reducing maternal mortality to 412 deaths per 100,000 live births in 2016 and neonatal mortality to 30 deaths per 1000 live births in 2019 [
      • ICF C
      Ethiopia Demographic and Health Survey Addis Ababa, Ethiopia, and Rockville, Maryland, USA. 2017.
      ,
      • Ethiopian Public Health Institute (EPHI), ICF
      Ethiopia Mini Demographic and Health Survey 2019: Key Indicators.
      ]. The key strategies to reduce maternal and neonatal mortality were increasing institutional service utilization (antenatal care, intrapartum care, and postnatal care) [
      • Tunçalp Ӧ.
      • Were W.M.
      • MacLennan C.
      • Oladapo O.T.
      • Gülmezoglu A.M.
      • Bahl R.
      • Daelmans B.
      • Mathai M.
      • Say L.
      • Kristensen F.
      • Temmerman M.
      Quality of care for pregnant women and newborns-the WHO vision.
      ]. For this reason, applying a women-centered model of maternal health care that improves continuity of care and maternal satisfaction is needed. Therefore, we in Ethiopia wanted to determine if it might be possible to employ a team-based midwifery model of MLCC in Ethiopia. In Ethiopia, the practice model is the shared model of care (SMC), often seen as fragmented with no continuity of care. In this model of care, care is shared among different health care providers (midwives, nurses, health officers, medical doctors, emergency surgical officers, and obstetricians) who are working in the maternity unit [
      • Sandall J.
      • Soltani H.
      • Gates S.
      • Shennan A.
      • Devane D.
      Midwife-led continuity models versus other models of care for childbearing women.
      ,
      • Sandall J.
      The Contribution of Continuity of Midwifery Care to High-Quality Maternity Care.
      ].
      We understood that the first step in doing this would be to set up a trial MLCC program and run a trial following a set of MLCC guidelines; we set up such a program and created a system for measuring Ethiopian women's satisfaction with this program. The MLCC program represents a significant departure from the Ethiopian Standard Care system (SMC) for maternal care, so it was essential to create a method for measuring maternal satisfaction in a control group.
      Measuring maternal satisfaction with care during childbirth is complex. Many studies have been published that examine the many different elements that must be studied to compare satisfaction for women entering two entirely different maternal care programs. Perriman and Davis identified four suitable instruments to measure satisfaction experienced by women passing through the continuum of pregnancy, birth, and the early postpartum period [
      • Perriman N.
      • Davis D.
      Measuring maternal satisfaction with maternity care: a systematic integrative review: what is the most appropriate, reliable, and valid tool that can be used to measure maternal satisfaction with continuity of maternity care?.
      ]. We chose a tool that we believed would help us measure the effect of MLCC women passing through the three episodes of maternal health care [
      • Waldenström U.
      • Brown S.
      • McLachlan H.
      • Forster D.
      • Brennecke S.
      Does team midwife care increase satisfaction with antenatal, intrapartum, and postpartum care? A randomized controlled trial.
      ].
      The primary aim of this study was on the effect of MLCC on women's assessment of their satisfaction with antenatal, intrapartum, and postpartum care. In addition, we investigated overall satisfaction with these episodes of care and specific aspects of care, such as perception of emotional support, information and decision making, and whether care was provided competently.

      2. Methods

      2.1 Study design

      The present study is part of a prospective non-randomized (quasi-experimental study design) designed to evaluate the effect of MLCC intervention compared with the pre-existing SMC approach. The primary study aim was to measure the effect of MLCC on satisfaction with these elements: antenatal care, intrapartum care, and postnatal care [
      • Hailemeskel Solomon
      • Alemu Kassahun
      • Christensson Kyllike
      • Tesfahun Esubalew
      • Lindgren H.
      Midwife-led continuity of care improved maternal and neonatal health outcomes in north Shoa zone, Amhara regional state, Ethiopia: a quasi-experimental study.
      ].

      2.2 Setting

      The study area has nine primary hospitals. We conducted the study in these four randomly selected primary hospitals (Shewarobit, Ataye, Mehal Meda, and Alemketema Enat Hospitals) of the north Shoa zone Amhara Regional State, Ethiopia, from August 2019 to September 2020. North Shoa is one of the 13 zones of the Amhara National Regional State located in northern Ethiopia. Of the more than two million people (2,248,418) living in the zone, half are females (1,114,301) [
      • Federal Democratic Republic of Ethiopia Central Statistical Agency
      Population Projection of Ethiopia for All Regions at Wereda Level From 2014-2017.
      ]. The primary hospitals are located at the woreda level (the lowest administrative unit in Ethiopia) and are expected to serve 100,000 population. Approximately 10–15 midwives in each primary hospital work in the maternal and child health care units. All the primary hospitals have a similar governing structure and the type of service provided. All maternal health care service in Ethiopia is cost-free [

      North Shoa Zonal Heath Department Report: 2018.

      ].

      2.3 Eligibility criteria

      All pregnant women with a gestational age of less than 24 whole weeks at the first ANC booking, with a singleton pregnancy and low obstetric risk, were included in the study. Women who had already planned to have an elective cesarean section or were planning to book with another care provider (example, a general practitioner, other health care provider, or private obstetrician) were excluded. Besides, women with known medical and obstetric complications before the beginning of the study were also excluded. The obstetrics complications were: Birth weight of previous baby <2500 g, history of three or more consecutive spontaneous abortion, prior history of (multiple pregnancies, postpartum hemorrhage, pre-eclampsia, eclampsia, Puerperal psychosis, Rhesus iso-immunisation, stillbirth, cesarean section, and uterine myoma or malformation). The medical complication that had known hypertension, cardiac problem, diabetes mellitus, renal disease, respiratory disease, and thyroid disease were excluded during the baseline assessment.

      2.3.1 Intervention group

      One group of women, referred to as the Intervention group, consisted of women allocated to hospitals where they received their complete antenatal, intrapartum, and immediate postnatal care led by midwives trained to follow the MLCC model. The intervention group midwives were organized into a group of four, and they were responsible for providing continuity of care for each pregnant mother. The midwife who gives the first ANC would continue to provide the second, third and fourth ANC for each pregnant mother in which they initiated. In the absence of the first midwife, a backup midwife would give the ANC. If complications developed, the primary midwife collaborated with obstetricians and other health professionals to continue to provide MLCC. One midwife from each MLCC team was assigned to the labor ward to provide care during labor. Care during labor and birth was provided in the labor ward at the intervention hospitals by staff working 8-h shifts. If care took longer than 8 h, the midwife handed over responsibility to another midwife in the team. In addition, the midwife provided midwifery care in the operating theatre for women who underwent a cesarean section. If two women were in labor simultaneously, the midwife could call another midwife to assist, or the midwives in the labor ward could help the primary midwife. After birth, one of the midwives from each team was assigned to the postnatal ward each day to provide continuity of postnatal care for these new mothers. The midwife who delivered the ANC and the intrapartum care would give the PNC. In the absence of the first midwife who provides most of the ANC and intrapartum care, the other midwife in the team would provide the PNC.

      2.3.2 Control group

      Another group designated as the control group consisted of pregnant women who received all their antenatal, intrapartum, and postnatal care in hospitals where the SMC model was followed. Standard care was provided in the hospital-based antenatal clinic, the labor ward, and the postnatal ward. The result was that various midwives, nurses, health officers, and doctors provided the care. In this model, midwives and other health care providers worked conventional eight-hour shifts and handed over care to the next midwife or other health care provider coming on duty after the change. Midwives in the ward provided immediate postnatal care in the hospital. After the woman had been discharged from the hospital, a different group of midwives or nurses in the family planning and immunization room provided the late postnatal care.

      2.4 Outcome variables

      The outcome variable was the maternal level of satisfaction with antenatal care, intrapartum care, and postnatal care. Additionally, the sociodemographic characteristics and mothers’ past obstetric and gynecologic history were included as predictors for the outcome of interest. In addition, women were also asked about their preference and perception about MLCC and the presence of known care providers for labor, birth, postpartum hospital care, and domiciliary care.

      2.5 Sample size

      The sample size for this study was determined based on the study’s primary outcome, which was on the effect of MLCC on maternal and neonatal health outcomes [
      • Hailemeskel Solomon
      • Alemu Kassahun
      • Christensson Kyllike
      • Tesfahun Esubalew
      • Lindgren H.
      Midwife-led continuity of care improved maternal and neonatal health outcomes in north Shoa zone, Amhara regional state, Ethiopia: a quasi-experimental study.
      ]. And it was based on a previous study done in a women's Hospital at Leicester Royal Infirmary, Leicester, UK [
      • Benjamin Y.
      • Walsh D.
      • Taub N.
      A comparison of partnership caseload midwifery care with conventional team midwifery care: labour and birth outcomes.
      ]. In that study, 40% of the exposed women had the outcome Intact perineum, and 30% of unexposed with intact perineum, two-sided confidence level of 95% (CI) with the power of 80%, the ratio of mothers who received MLCC (intervention), and mothers who received care by other professionals (control) and the minimum detectable effect size of 10%, With an assumption of 10% withdrawals (lost to follow up), and considering the design effect of multistage sampling the final sample size was multiplied by 1.5 to become 1178 pregnant women; 589 in the SMC group and 589 in the MLCC group. We used STATA version 14 for analyzing the sample size.

      2.6 Procedure/study participant’s selection

      A two-stage stratified cluster sampling technique was used. In the first stage, four primary hospitals were randomly selected of the available nine primary hospitals in the study area. Pregnant women in two hospitals, the Shoa Robit and Ataye hospitals, were all in the MLCC group and considered intervention hospitals. The intervention hospitals were selected based on an adequate number of volunteer midwives to work with the MLCC model. Patients in the other two, the Mehal Meda and Alemketema Enat hospitals became the control hospital and considered SMC group. We used the number attending three months first Antenatal care to estimate the number of pregnant women who seek hospital care. First, we calculated the K value (the interval used to select the participants). Then a systematic random sampling technique with a K value (sampling interval) of 2 was used to determine the study participants. This means we will select every two pregnant mothers who came for the first ANC visit. Then to start the selection, we used the lottery method for the first study participants. Then after we got the first participant, we continued the selection of participants using the two intervals until we reached the required sample size in each hospital.
      The research team explained the purpose of the study, and the eligibility of the women was assessed. Then, women were recruited to study by research midwives when they attended their first visit at the antenatal clinic and were allocated to the intervention or control groups at the designated hospitals after written consent had been obtained and the background questionnaire dealing with demographic data was completed.

      2.7 Data collection

      The data collection tool for this study was adapted from the satisfaction with antenatal, intrapartum, and postpartum care tools [
      • Waldenström U.
      • Brown S.
      • McLachlan H.
      • Forster D.
      • Brennecke S.
      Does team midwife care increase satisfaction with antenatal, intrapartum, and postpartum care? A randomized controlled trial.
      ]. The tool was used to evaluate the three aspects of continuity of care – satisfaction with antenatal care, intrapartum care, and postnatal care). The tool consists of 33 Likert questions to evaluate the effects of employing MLCC on maternal satisfaction. Of the total, ten measured satisfaction with antenatal care, ten with intrapartum care, and 13 with postnatal care. Responses to 33 questions were registered on a five-point Likert scale, with five indicating strongly agree and one strongly disagree.
      During tool validation, the data collection instrument underwent forward and backward translation from English to Amharic and back to English to check for consistency. Six experts assessed the face and content validity of the data collection instrument, and the proposed changes from the expert panels were considered for refinement of the data collection instrument. Then, before actual data collection, a pilot study was done outside the study area in the Debre Berhan health center; the sample size was 329 postnatal mothers. The pilot study results were used to assess the data collection instrument’s validity, reliability, and exploratory factor analysis, and this analysis is reported in another paper [
      • Hailemeskel Solomon
      • Alemu Kassahun
      • Christensson Kyllike
      • Lindgren H.
      Evaluation of an Amharic-Language translation of continuity of care satisfaction tool among postnatal mothers in Ethiopia.
      ]. The internal consistency for each dimension of the data collection instrument was checked using Cronbach's alpha and scores on satisfaction with antenatal care (Cronbach alpha = 0.93), satisfaction with intrapartum (Cronbach alpha = 0.91), and satisfaction with postnatal care (Cronbach alpha = 0.90). An overall Cronbach's α value of 0.94 for all items was deemed acceptable.
      The baseline background characteristics of the study participants, such as sociodemographic, past obstetrics and gynecologic history, and medical and surgical information, were recorded routinely by midwives at each hospital by using the standard data collection tool prepared for this study. Eight female midwife data collectors and four supervisors with a Master’s degree in maternal and reproductive health were recruited. They were given three days of training in using the data collection instrument. The principal investigator provided the training, and the training content was the data collection tool, the objective of the study, and techniques used to conduct face-to-face interviews. The data collectors had no role in the clinical service given to the women. Finally, a face-to-face interview technique with the women was used to collect data at the end of the postnatal period (interviewer-administered questioner). Interviews were done at the study participants’ homes using the validated data collection instrument.

      2.8 Statistical analysis

      Data were entered using Epi Info version 7 and analyzed using Stata 14 software. Analyses were done by “intention to treat.” The study participants’ sociodemographic characteristics and birth outcomes were analyzed using the descriptive statistics mean, standard deviation, frequencies, and percentages. The difference in characteristics between the intervention and control groups were analyzed with two independent samples t-tests, Mann-Whitney U tests, X2, or Fisher’s exact tests, seen as appropriate. The Likert scale ordinal variables were highly skewed and first analyzed by conducting ordinal regression because this method had been used in previous studies using similar Likert scales. After fitting the ordinal regression, the proportional odds assumption was inspected by a Brant test, using the brant command in Stata/ SE, V.14. Results from the test showed that the proportional odds assumption was violated for several ordinal outcomes. Therefore, we summarized the answers, and the groups' mean sum-scores of satisfaction were compared by bootstrapping linear regression. The primary outcome, mean sum-score of satisfaction through the continuum of antenatal, intrapartum, and postnatal care, included results from the 33 different satisfaction questions. Negative questions were turned into positive questions so that satisfaction could be interpreted equally in all questions and the mean sum-scores thereby read as 1 (lowest) and 5 (highest). Factors that could influence the difference between groups were included for adjusting. Adjusted bias-corrected and accelerated bootstrap estimates with 95% CIs were given for non-normally distributed ordinal outcomes and based on 10,000 bootstraps. The significance level was set at 0.05. The analyses were performed with IBM SPSS 25

      2.9 Ethical approval

      Ethical approval was obtained from the Institutional Review Board of the University of Gondar. Permission letters were obtained from the regional health bureau, the zonal health department, and the hospital administration. An informed and signed consent was obtained from each participant. Participants were told that their participation in this study was voluntary, that the information they gave would remain confidential and would only be used for research purposes. They could also withdraw from participating in the study at any time. The participants were also informed that their participation in the study would not impact their current and future abilities to access the health facilities. Midwives and other healthcare providers working at the study hospitals were informed about the study. But, they were blinded for the outcome variables.

      3. Results

      Of the 1178 women recruited to the study, 589 were allocated to the MLCC and 589 to the SMC groups resulting in 582 and 584 eligible women in the intervention and control group after dropouts were considered (Fig. 1).
      Fig. 1
      Fig. 1Study participants’ selection process flow diagram, August 2019 to September 2020, north Shoa zone, Amhara regional sate.

      3.1 Sociodemographic characteristics of study participants

      There was no significant age difference between the members of the two groups. More than half of the participants in both groups were in the age range 20–29 years. More than one-fourth of the participants in both groups had no formal education. More than one-third of study participants in both groups had a low wealth index (Table 1).
      Table 1Sociodemographic characteristics of study participants among intervention and control groups, North Shoa Zone, Amhara Regional State, Ethiopia, 2020.
      VariableCategoryMidwife-led modelShared model of carep-Value
      n = 582n = 584
      n (%)n (%)
      Age (in years)<20100 (17.2)92 (15.8)0.132
      20–29394 (67.7)382 (65.4)0.112
      > = 3088 (15.1)110 (18.8)
      Mean (SD)25.10 (4.40)25.60 (4.89)0.071
      ResidenceUrban513 (88.3)423 (72.6)0.001
      Rural68 (11.7)160 (27.4)
      Educational status of the motherNo formal education185 (31.8)177 (30.3)0.001
      Primary education155 (26.6)103 (17.6)0.001
      Secondary education136 (23.4)133 (22.8)0.004
      More than secondary education106 (18.2)171 (29.3)
      Educational status of spousalNo formal education209 (36.3)159 (28.6)0.001
      Primary education123 (21.4)90 (16.2)0.001
      Secondary education115(20.0)107 (19.3)0.003
      More than secondary education128 (22.3)199 (35.9)
      Occupational status of the motherHousewife/farmer417 (71.6)316 (54.1)0.001
      Employed121 (20.8)171 (29.3)0.041
      Unemployed44 (7.6)97 (16.6)
      Occupational status of spouse (576/555)Farmer179 (31.1)171 (30.8)0.649
      Merchant90 (15.6)75 (13.5)0.944
      Employed267 (46.4)275 (49.5)0.440
      Unemployed40 (6.9)34 (6.1)
      Marital statusMarried576 (99.0)553 (94.7)0.001
      Unmarried6 (1.0)31 (5.3)
      ReligionOrthodox386 (66.3)573 (98.1)0.999
      Muslim and protestant196 (33.7)11 (1.9)
      EthnicityAmhara527 (90.5)562 (96.2)
      Tigrie8 (1.4)12 (2.1)
      Oromo47 (8.1)10 (1.7)
      Wealth indexLow219 (37.6)181 (31.0)0.149
      Middle171 (29.4)208 (35.6)0.213
      Highest192 (33.0)195 (33.4)

      3.2 Intervention exposure

      Women allocated to MLCC had a mean of 3.79 ± 0.65 pregnancy visits with their primary midwife, and 99.1% (577/582) of women allocated to MLCC took their antenatal care visit with the primary midwife. During labor, either the primary or the backup midwife provided intrapartum care for 96.6% (562/582) of the women in MLCC. During the postnatal period, the intervention group midwife who delivered the antenatal and intrapartum care provided the postnatal care for 88.8% (517/582) of postnatal mothers.

      3.3 Participant’s obstetrics and gynecologic characteristics

      Women allocated to MLCC had a mean age of 21.09 ± 3.35 at first pregnancy compared to 21.79 ± 3.51 for women in SMC. About 194 (33.3%) women in MLCC and 166 (28.4%) of women in SMC had their first pregnancy at the age of less than 20 years. More than half of women, 324 (55.7%) in MLCC and 299 (51.2%) in SMC, were multigravida. About 258 (44.3) of women in MLCC and 285 (48.8) in SMC were nullipara (Table 2).
      Table 2Participant’s obstetrics and gynecologic characteristics, North Shoa Zone, Amhara Regional State, Ethiopia, 2020.
      VariableCategoryMidwife-led modelShared model of carep-Value
      N = 582N = 584
      n (%)n (%)
      Age at first pregnancy<20 years194 (33.3)166 (28.4)
      > = 20 years388 (66.7)418 (71.6)0.070
      Mean (SD)21.09 (3.35)21.72 (3.51)0.002
      GravidityPrimi gravida258 (44.3)285 (48.8)0.126
      Multi gravida324 (55.7)299 (51.2)
      ParityNulli para258 (44.3)285 (48.8)0.042
      Primi para160 (27.5)164 (28.1)0.173
      Multi para164 (28.2)135 (23.1)
      Pregnancy wantedYes568 (97.6)568 (97.4)0.855
      Pregnancy plannedYes539 (92.6)565 (96.7)0.002

      3.4 Women’s preference for continuity of care

      In total, 528 (90.7%) and 388 (66.4%) of women allocated to MLCC and SMC respectively had preferred to see the same midwife at each pregnancy check-up. The vast majority of study participants (93.6% vs. 79.4%) reported that they wanted to be looked after during birth by the midwife they had met in their first antenatal care visit. A majority of 563 (96.7%) in MLCC had said that they wanted to be looked after during postnatal care by the midwife they had met in their first antenatal care visit. In contrast, a majority, 409 (70.0%) of women allocated to SMC, said that they did not want to have their postnatal care to be given by the midwife they had met in their first antenatal care visit (Table 3).
      Table 3Participant’s preference on continuity of care among intervention and control groups, North Shoa Zone, Amhara Regional State, Ethiopia, 2020.
      VariableCategoryMidwife-led modelShared model of careTest statistics (Chi2, p-value)
      N = 582N = 584
      n (%)n (%)
      Prefer to see the same midwife at each check-upYes528 (90.7)388 (66.4)<0.001
      Want to be looked after during birth by a midwife that you met in your ANC visitYes, I want this very much545 (93.6)464 (79.4)<0.001
      No, I would prefer not to have this37 (6.4)120 (20.6)
      Want to be looked after during postnatal by a midwife that you have already met in your ANC visitYes563 (96.7)175 (30.0)<0.001
      Important of having same midwife during ANC, intrapartum and postnatal periodImportant565 (97.1)458 (78.4)<0.001
      Not important at all17 (2.9)126 (21.6)
      Seeing the same midwife at each antenatal checkImportant568 (97.6)508 (87.0)<0.001
      Not important at all14 (2.4)76 (13.0)
      Knowing the midwife who looks after you in labour/birthImportant567 (97.4)504 (86.3)<0.001
      Not important at all15 (2.6)80 (13.7)
      Seeing the intrapartum midwife at postnatal visitImportant569 (97.8)439 (75.2)<0.001
      Not important at all13 (2.2)145 (24.8)

      3.5 Women’s perception about continuity of care

      A majority of the women allocated to MLCC 565 (97.1%) reported that it was very important to have the same midwife during the ANC, labor, and postnatal periods whereas the percentage of women allocated to SMC reporting this view was smaller 458 (78.4%) (p = 0.001). In addition, the women were asked about their perception of the continuity of care provider. Seeing the same midwife at each antenatal check was considered very important by MLCC 568 (97.6%) and SMC 508 (87.0%), respectively. Women’s views about continuity in relation to labor showed that most women in MLCC 567 (97.4%) and 504 (86.3%) (p = 0.001) in SMC wanted to know their intrapartum midwife, and they rated this as very important. Regarding continuity of care provider at the postnatal visit, seeing the intrapartum midwife at the postnatal visit was also reported as very important by 569 (97.8%) MLCC and 439 (75.2%) SMC, respectively (p = 0.001) (Table 3).

      3.6 Satisfaction with all continuum of care

      Compared with women in SMC, women in the MLCC were more likely to be satisfied with all continuum of care with a mean sum-score of 4.07 vs. 2.79 (adjusted mean difference 1.27, 95% CI 1.18–1.35; p < 0.001). Fig. 2 shows the dichotomized sum of the questions to measure satisfaction with the continuity of care model. In these analyses, the percentage refers to comparing women scoring ‘1’ to ‘3’ as dissatisfied with care vs. ‘4’ to ‘5’ as satisfied with care on the scale for overall satisfaction with the continuity of care. The majority of women allocated to MLCC 513 (88.1%) were satisfied with their antenatal care compared to 305 (52.2%) women in SMC. Similarly, 486 (83.5%) and 511 (88.4%) of mothers allocated to MLCC were satisfied with their intrapartum and postnatal care as compared to 288 (49.3%) and 294 (51.8%) in SMC, respectively.
      Fig. 2
      Fig. 2Comparison of maternal satisfaction and dissatisfaction with antenatal, intrapartum and postnatal care among intervention and control groups, North Shoa zone, Amhara regional state, 2020.
      The intervention and control groups were looked at separately to look further at any association between being in MLCC and the effect on satisfaction with antenatal, intrapartum, and postnatal care. This analysis analyzed the mean sum score of each care component.

      3.7 Care during pregnancy

      Statistically, significantly higher satisfaction with care was observed for the group receiving MLCC during antenatal care, with a crude mean sum-score of 4.14 (0.89) vs. 2.81 (0.93) in SMC care. The adjusted mean difference between the groups was 1.33 (95% CI 1.22–1.52), p < 0.0001). Compared with women in SMC, women in the MLCC were more likely to report that midwives kept them informed about what was happening in their pregnancy (adjusted mean difference 1.26, 95% CI 1.06–1.47; p < 0.001); that they were given an active say on decisions about their care in pregnancy (adjusted mean difference 1.39, 95% CI 1.17–1.60; p < 0.001); and that care during pregnancy was provided safely and competently (adjusted mean difference 1.77, 95% CI 1.57–1.98; p < 0.001) (Table 4).
      Table 4Participant’s satisfaction with Antenatal care among intervention and control groups, North Shoa Zone, Amhara Regional State, Ethiopia, 2020.
      Statement assessedMean sum score
      Mean (SD) sum-score is calculated from the 1–5 Likert scale where 1 means very low satisfaction and 5 means very high.
      Crude mean differenceAdjusted mean difference
      Bias-corrected and accelerated estimates with 95% CIs, analyzed by bootstrapping linear regression, adjusted for mothers’ age, parity, gravida, age at first pregnancy, birth interval, pregnancy planned, pregnancy wanted, residence, mothers occupation, mothers education, and marital status.
      p Value
      Midwife-led continuity of careShared model of care95% CI95% CI
      At my check-ups I was always asked whether I had any questions4.01 (1.40)3.05 (1.33)0.95 (0.79–1.11)0.93 (0.70–1.17)<0.0001
      The midwife/doctor always kept me informed about what was happening4.07 (1.20)2.87 (1.38)1.20 (1.05–1.35)1.26 (1.06–1.47)<0.001
      I was always given an active say in decisions about my care in pregnancy3.96 (1.34)2.66 (1.32)1.30 (1.14–1.45)1.39 (1.17–1.60)<0.001
      I always felt my worries, anxieties or concerns about the pregnancy and the baby were taken seriously4.28 (1.08)3.00 (1.41)1.27 (1.13–1.42)1.26 (1.06–1.46)<0.001
      The midwives/doctor provided reassurance when I needed it4.26 (1.11)2.94 (1.55)1.31 (1.16–1.47)1.26 (1.05–1.48)<0.001
      At my check-ups the midwives/doctor often seemed rushed3.96 (1.07)2.63 (1.35)1.33 (1.19–1.47)1.40 (1.20–1.60)<0.001
      Care in pregnancy was provided in a safe and competent way4.36 (1.11)2.63 (1.41)1.73 (1.58–1.87)1.77 (1.57–1.98)<0.001
      Happy with the emotional support I received in pregnancy from midwives/doctors4.02 (1.29)2.58 (1.55)1.43 (1.27–1.59)1.47 (1.22–1.71)<0.001
      I was happy with the physical aspects of care I received in pregnancy from midwives/doctors4.20 (1.18)2.73 (1.44)1.46 (1.31–1.6)1.60 (1.38–1.82)<0.001
      Overall care during pregnancy was very good (1 = very poor; 5 = very good)4.28 (1.18)2.98 (1.52)1.30 (1.15–1.46)1.44 (1.23–1.67)<0.001
      Satisfaction with all care during pregnancy4.14 (0.89)2.81 (0.93)1.33 (1.23–1.44)1.33 (1.22–1.52)<0.0001
      a Mean (SD) sum-score is calculated from the 1–5 Likert scale where 1 means very low satisfaction and 5 means very high.
      b Bias-corrected and accelerated estimates with 95% CIs, analyzed by bootstrapping linear regression, adjusted for mothers’ age, parity, gravida, age at first pregnancy, birth interval, pregnancy planned, pregnancy wanted, residence, mothers occupation, mothers education, and marital status.

      3.8 Intrapartum care

      Statistically, significantly higher satisfaction with care was observed in favor of the group receiving the MLCC, during intrapartum care, with a crude mean sum-score of 3.83 (1.13) vs. 2.71 (1.02) in the group receiving regular care. The adjusted mean difference between the groups was 1.06 (95% CI 0.88–1.23), p < 0.0001). Compared with women in SMC, women in the MLCC were more likely to be informed about what was happening in labor and birth (adjusted mean difference 1.17, 95% CI 0.94–1.41; p < 0.001); that care was provided safely (adjusted mean difference 1.02, 95% CI 0.85–1.19; p < 0.001); and that they were happier with the emotional support provided by midwives (adjusted mean difference 1.32, 95% CI 1.15–1.48; p < 0.001) (Table 5).
      Table 5Participant’s satisfaction with intrapartum care among intervention and control groups, North Shoa Zone, Amhara Regional State, Ethiopia, 2020.
      Statement assessedMean sum score
      Mean (SD) sum-score is calculated from the 1–5 Likert scale where 1 means very low satisfaction and 5 means very high.
      Crude mean differenceAdjusted mean difference
      Bias-corrected and accelerated estimates with 95% CIs, analyzed by bootstrapping linear regression, adjusted for mothers’ age, parity, gravida, age at first pregnancy, birth interval, pregnancy planned, pregnancy wanted, residence, mothers occupation, mothers education, and marital status.
      p Value
      Midwife-led continuity of careShared model of care95% CI95% CI
      The midwives/doctors always kept me informed about what was happening during labour and birth3.74 (1.42)2.57 (1.389)1.16 (1.01–1.33)1.17 (0.94–1.41)< 0.0001
      I was always given an active say in decisions about my care during labour and birth3.54 (1.49)2.39 (1.29)1.15 (0.99–1.31)1.19 (0.94–1.42)< 0.001
      The midwives/doctors/were encouraging3.84 (1.35)2.84 (1.45)0.99 (0.83–1.15)0.77 (0.54–0.99)<0.001
      The midwives provided reassurance if I needed it3.93 (1.36)2.78 (1.52)1.15 (0.98–1.31)1.14 (0.96–1.31)<0.001
      I often felt the midwives/doctors were very rushed4.05 (1.29)3.29 (1.59)0.76 (0.59–0.93)0.77 (0.59–0.95)<0.001
      Care during labour and birth was provided in a safe way3.85 (1.398)2.81 (1.32)1.03 (0.88–1.19)1.02 (0.85–1.19)<0.001
      Care during labour and birth was provided in a competent way3.82 (1.42)2.69 (1.44)1.13 (0.96–1.29)1.12 (0.94–1.29)<0.001
      I was happy with the emotional support I received from midwives/doctors3.73 (1.40)2.40 (1.34)1.32 (1.17–1.48)1.32 (1.15–1.48)<0.001
      My privacy needs were well respected during labour and birth3.89 (1.36)2.78 (1.45)1.11 (0.94–1.27)1.08 (0.91–1.25)<0.001
      Overall how would you describe your care in labour and birth (1 = very poor; 5 = very good)3.94 (1.43)2.54 (1.36)1.40 (1.24–1.56)1.41 (1.24–1.58)<0.001
      Satisfaction with all care during intrapartum3.83 (1.13)2.71 (1.02)1.12 (0.99–1.24)1.06 (0.88–1.23)<0.0001
      a Mean (SD) sum-score is calculated from the 1–5 Likert scale where 1 means very low satisfaction and 5 means very high.
      b Bias-corrected and accelerated estimates with 95% CIs, analyzed by bootstrapping linear regression, adjusted for mothers’ age, parity, gravida, age at first pregnancy, birth interval, pregnancy planned, pregnancy wanted, residence, mothers occupation, mothers education, and marital status.

      3.9 Postnatal care

      Statistically, significantly higher satisfaction with care was observed in favor of the group receiving MLCC, during postnatal care, with a crude mean sum-score of 5.46 (1.06) vs. 3.71 (1.27) in the group receiving SMC. The adjusted mean difference between the groups was 1.75 (95% CI (1.54–1.94), p < 0.0001). Compared with women in SMC, women in the MLCC were more likely to report that midwives kept them informed about what was happening in the postnatal ward (adjusted mean difference 1.46, 95% CI 1.31–1.60; p < 0.001); that they were given an active say on decisions about the care of themselves and their baby (adjusted mean difference 1.56, 95% CI 1.40–1.71; p < 0.001); that care in hospital after the birth was provided safely and competently (adjusted mean difference 1.45, 95% CI 1.25–1.66; p < 0.001) and that they were happier with the emotional and physical aspects of care (adjusted mean difference 1.53, 95% CI 1.32–1.75; p < 0.001) (Table 6).
      Table 6Participant’s satisfaction with postnatal care among intervention and control groups, North Shoa Zone, Amhara Regional State, Ethiopia, 2020.
      Statement assessedMean sum score
      Mean (SD) sum-score is calculated from the 1–5 Likert scale where 1 means very low satisfaction and 5 means very high.
      Crude mean differenceAdjusted mean difference
      Bias-corrected and accelerated estimates with 95% CIs, analyzed by bootstrapping linear regression, adjusted for mothers’ age, parity, gravida, age at first pregnancy, birth interval, pregnancy planned, pregnancy wanted, residence, mothers occupation, mothers education, and marital status.
      p Value
      Midwife-led continuity of careShared model of care95% CI95% CI
      The midwives/doctors always kept me informed about what was happening in the postnatal ward4.30 (1.09)2.87 (1.39)1.43 (1.28–1.57)1.46 (1.31–1.60)< 0.0001
      I was always given an active say in decisions about care of my baby and myself4.05 (1.23)2.51 (1.32)1.53 (1.39–1.68)1.56 (1.40–1.71)< 0.001
      I was given the advice and support I needed with breast feeding4.08 (1.10)2.71 (1.44)1.38 (1.23–1.52)1.38 (1.23–1.53)<0.001
      I was given the advice and support I needed4.05 (1.15)2.88 (1.36)1.17 (1.02–1.31)1.15 (1.00–1.30)<0.001
      I was given the advice and support I needed about any problems with the baby4.05 (1.19)2.94 (1.37)1.11 (0.96–1.26)1.10 (0.95–1.25)<0.001
      I was given the advice and support I needed about my own health and recovery4.13 (1.14)3.01 (1.51)1.12 (0.97–1.28)1.11 (0.89–1.33)<0.001
      The midwives/doctors were sensitive and understanding4.22 (1.13)2.96 (1.39)1.26 (1.12–1.41)1.16 (0.95–1.37)<0.001
      The midwives/doctors were encouraging and reassuring4.10 (1.27)2.87 (1.52)1.23 (1.07–1.39)1.17 (0.93–1.40)<0.001
      I often felt the midwives/doctors were very rushed4.40 (1.06)3.20 (1.63)1.20 (1.04–1.36)1.24 (1.01–1.47)<0.001
      Care in hospital after the birth was provided in a safe and competent way4.38 (1.04)2.86 (1.37)1.52 (1.38–1.66)1.45 (1.25–1.66)<0.001
      I was happy with the emotional and physical aspects of care4.35 (1.08)2.83 (1.41)1.53 (1.38–1.67)1.53 (1.32–1.75)<0.001
      Overall the care you received in hospital after the birth was very good (1 = very poor; 5 = very good)4.24 (1.140)2.77 (1.358)1.48 (1.33–1.62)1.46 (1.25–1.68)<0.001
      Overall the care your baby received in hospital after the birth was very good? (1 = very poor; 5 = very good)4.28 (1.191)2.76 (1.402)1.53 (1.38–1.68)1.52 (1.28–1.75)<0.001
      Satisfaction with all care during postnatal care5.46 (1.06)3.71 (1.27)1.75 (1.16–1.88)1.75 (1.54–1.94)<0.001
      a Mean (SD) sum-score is calculated from the 1–5 Likert scale where 1 means very low satisfaction and 5 means very high.
      b Bias-corrected and accelerated estimates with 95% CIs, analyzed by bootstrapping linear regression, adjusted for mothers’ age, parity, gravida, age at first pregnancy, birth interval, pregnancy planned, pregnancy wanted, residence, mothers occupation, mothers education, and marital status.

      3.10 Further exploration of the findings

      Fig. 3 provides a visual presentation of the adjusted mean difference for the composite variables of satisfaction where the items illustrate different aspects of care. Based on the exploratory factor analysis, the items were grouped into the following aspects of care: information provision and relationship with midwives, womens’ assessment of the quality of care, and have included the overall satisfaction for each component of care. The figure shows that the difference between the women’s assessments in the MLCC and SMC groups was most pronounced regarding the provision of information and the relationship with midwives, and this was most obvious in the assessment of postnatal care (Adjusted Mean difference 0.91; 95% CI 0.80–1.0). In addition, the adjusted mean difference of the midwives providing care in a competent and quality manner during each of the separate episodes of care was also more significant for women with the MLCC, again, most during postnatal care (Adjusted Mean difference 0.84; 95% CI 0.73–0.93). Similarly, women in MLCC were more likely to rate their overall satisfaction higher for postnatal care (Adjusted Mean difference 1.75; 95% CI 1.54–1.94).
      Fig. 3
      Fig. 3Comparison of women’s assessment of different aspects of antenatal, intrapartum, and postpartum care, an overall assessment of these episodes of care. Adjusted mean difference based on comparisons of the score on 5-point scales ranging from ‘1’ (Disagree strongly) to ‘5’ (Agree strongly). All p values for mean difference shown are p < 0.001.

      4. Discussion

      We found the MLCC model was associated with a higher sum-score of satisfaction with care than the SMC throughout the three periods, antenatal, intrapartum, and postpartum. The difference was most prominent in antenatal and postpartum care. The women receiving MLCC were explicitly satisfied with the care provided safely and competently, their decision-making involvement, and the emotional support received from the midwives. The results from this study show that the majority of women in MLCC preferred having the same midwife during all three periods and saw this as very important.
      We observed that MLCC was associated with increased women’s satisfaction with antenatal care. Women’s satisfaction with antenatal care was more pronounced as concerning emotional support, information and decision making, and whether care was provided safely and competently or not. Like other studies on the continuity of midwifery care, women were more likely to feel satisfied with midwives regarding information transfer, explanation of procedures, feeling in control over what is being done to themselves, choices, and decisions [
      • Shields N.
      • Turnbull D.
      • Reid M.
      • Holmes A.
      • McGinley M.
      • Smith L.N.J.M.
      Satisfaction with midwife-managed care in different time periods: a randomised controlled trial of 1299 women.
      ]. The results of the current study were also consistent with those from the previous report that showed continuity of care by a primary midwife (caseload midwifery) on maternal satisfaction reported that compared with women in standard care, women in the caseload group were more likely to report that they were asked if they had any questions; that midwives kept them informed; that they were given an active say about decisions, and that care was provided safely and competently [
      • McLachlan H.L.
      • Forster D.A.
      • Davey M.A.
      • Farrell T.
      • Gold L.
      • Biro M.A.
      • Albers L.
      • Flood M.
      • Oats J.
      • Waldenstrom U.
      Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial.
      ,
      • Waldenström U.
      • Brown S.
      • McLachlan H.
      • Forster D.
      • Brennecke S.J.B.
      Does team midwife care increase satisfaction with antenatal, intrapartum, and postpartum care? A randomized controlled trial.
      ]. As previous studies have pointed out [
      • Hildingsson I.
      • Rådestad I.
      Swedish women’s satisfaction with medical and emotional aspects of antenatal care.
      ], the psychosocial aspects of birth care and information and caregiver support are the most critical factors associated with antenatal satisfaction. In contrast, the lack of support from midwives or other inappropriate antenatal services is often linked to dissatisfaction. The generally high satisfaction with pregnancy care could be explained by noting that this period is less demanding and stressful than intrapartum period for most women and recall bias might have influenced the women ability to report [
      • Mortensen B.
      • Diep L.M.
      • Lukasse M.
      • Lieng M.
      • Dwekat I.
      • Elias D.
      • Fosse E.
      Women’s satisfaction with midwife-led continuity of care: an observational study in Palestine.
      ].
      The current study showed that as compared to SMC, women who received MLCC were more satisfied with all aspects of intrapartum care. In our study, consistent with the previous studies [
      • Sandall J.
      • Soltani H.
      • Gates S.
      • Shennan A.
      • Devane D.
      Midwife-led continuity models versus other models of care for childbearing women.
      ,
      • Waldenström U.
      • Brown S.
      • McLachlan H.
      • Forster D.
      • Brennecke S.J.B.
      Does team midwife care increase satisfaction with antenatal, intrapartum, and postpartum care? A randomized controlled trial.
      ,
      • Forster D.A.
      • McLachlan H.L.
      • Davey M.A.
      • Biro M.A.
      • Farrell T.
      • Gold L.
      • Flood M.
      • Shafiei T.
      • Waldenstrom U.
      Continuity of care by a primary midwife (caseload midwifery) increases women’s satisfaction with antenatal, intrapartum and postpartum care: results from the COSMOS randomised controlled trial.
      ], women in the MLCC were more likely to be informed about what was happening in labor and birth; that they were given an active say on decisions about their care during labour and birth; that the midwives were encouraging; that the midwife was reassuring and emotionally supportive; that care was provided safely and competently; that they were happier with the emotional support provided by midwives and that their privacy needs were met during labor and birth. In addition, consistent findings were reported by Hodnett et al., indicating that women who are continuously supported during labor are less likely to report dissatisfaction [
      • Hodnett E.D.
      • Gates S.
      • Hofmeyr G.J.
      • Sakala C.
      Continuous support for women during childbirth.
      ]. Similar to the current study, many studies have shown that women in labor are more appreciative of reliable midwifery practice [
      • Parratt J.A.
      • Fahy K.M.J.W.
      Including the nonrational is sensible midwifery.
      ], especially health professionals who are open to listening, being honest, and can provide both physical and emotional support; in other words, the professionals who showed the ability to care for the women's needs during labor were reported as factors affecting women's satisfaction with intrapartum care [
      • Homer C.S.
      • Passant L.
      • Kildea S.
      • Pincombe J.
      • Thorogood C.
      • Leap N.
      • Brodie P.M.J.M.
      The development of national competency standards for the midwife in Australia.
      ,
      • Homer C.S.
      • Passant L.
      • Brodie P.M.
      • Kildea S.
      • Leap N.
      • Pincombe J.
      • Thorogood C.J.M.
      The role of the midwife in Australia: views of women and midwives.
      ,
      • Hunter B.
      • Berg M.
      • Lundgren I.
      • Ólafsdóttir Ó.Á.
      • Kirkham M.J.M.
      Relationships: the hidden threads in the tapestry of maternity care.
      ].
      We observed that MLCC was associated with increased satisfaction also with postpartum care. In common with results from the current study, previous studies had reported a positive contribution of MLCC on postnatal maternal satisfaction. Consistent with our study, women in the caseload group in these published studies reported higher satisfaction with postnatal care overall and were more likely to report feeling informed by midwives; having had an active say in decisions about the care of themselves and their baby; that midwives were sensitive, encouraging and emotionally supportive; that midwives were not rushed; and that care was provided safely and competently. They were also more likely to report that they were given the advice they needed with breastfeeding, handling, settling, and caring for the baby and about their health and recovery after the birth [
      • Waldenström U.
      • Brown S.
      • McLachlan H.
      • Forster D.
      • Brennecke S.J.B.
      Does team midwife care increase satisfaction with antenatal, intrapartum, and postpartum care? A randomized controlled trial.
      ,
      • Forster D.A.
      • McLachlan H.L.
      • Davey M.A.
      • Biro M.A.
      • Farrell T.
      • Gold L.
      • Flood M.
      • Shafiei T.
      • Waldenstrom U.
      Continuity of care by a primary midwife (caseload midwifery) increases women’s satisfaction with antenatal, intrapartum and postpartum care: results from the COSMOS randomised controlled trial.
      ]. Based on the research findings and philosophy of midwife-led care, developing relational continuity with the women is an essential tool to enhance communication and thus improves maternal satisfaction with care [
      • Homer C.S.J.W.
      Challenging midwifery care, challenging midwives and challenging the system.
      ]. Besides, a pregnant woman would feel safe knowing that the midwife following her throughout pregnancy also worked at the intrapartum care where she would give birth and that her midwife would provide her postnatal care [
      • Sandall J.
      • Soltani H.
      • Gates S.
      • Shennan A.
      • Devane D.
      Midwife-led continuity models versus other models of care for childbearing women.
      ].
      In this study, regardless of group allocation, almost all women had preferred to see the same midwife at each pregnancy check-up and wanted to be looked after during the intrapartum and postnatal period by the midwife they met in their antenatal care visit. The positive result for these aspects of care are in line with the study reported on the importance of continuity of care in the form of having the same midwife through the antenatal period, labor, and postnatally as the most critical aspects of care wanted by mothers [
      • Fereday J.
      • Collins C.
      • Turnbull D.
      • Pincombe J.
      • Oster C.J.W.
      An evaluation of midwifery group practice: part II: women’s satisfaction.
      ]. McCourt et al., too, found women who participated in the continuity of care models often had ‘raised expectations’ regarding continuity of career [
      • McCourt C.
      • Page L.
      • Hewison J.
      • Vail A.J.B.
      Evaluation of one‐to‐one midwifery: women’s responses to care.
      ]. The importance attributed to this aspect of continuity of care is supported by the findings of two Australian studies of women’s satisfaction with team midwifery care [
      • Waldenström U.
      • Brown S.
      • McLachlan H.
      • Forster D.
      • Brennecke S.
      Does team midwife care increase satisfaction with antenatal, intrapartum, and postpartum care? A randomized controlled trial.
      ,
      • Biró M.A.
      • Waldenström U.
      • Brown S.
      • Pannifex J.H.J.B.
      Satisfaction with team midwifery care for low‐ and high‐risk women: a randomized controlled trial.
      ]. By contrast, a review of the literature conducted by Green et al. did not find increased satisfaction for women who knew their midwife in labor compared to those who did not [
      • Green J.M.
      • Renfrew M.J.
      • Curtis P.A.J.M.
      Continuity of carer: what matters to women? A review of the evidence.
      ]. On the other hand, it is understandable that women sometimes feel disappointed if the lead midwife, the person with whom they have built a close rapport, is not available. This highlights the importance of establishing realistic expectations with women enrolled in the continuity of midwifery care [
      • Fereday J.
      • Collins C.
      • Turnbull D.
      • Pincombe J.
      • Oster C.J.W.
      An evaluation of midwifery group practice: part II: women’s satisfaction.
      ].
      On the other hand, 70% of the women in the control group did not consider continuity of care to be good to be cared for by the ANC midwife during the postpartum period. The possible explanation would be that women in the SMC (control group) had limited access to continuity of care provided by midwives. In Ethiopia, most women have not previously had an opportunity to receive continuity of midwifery care in antenatal, labor, and postnatal care. If models of care providing continuity of care in labor become more common, expecting a known midwife may become more customary. In line with this, reports indicate that women who have not been exposed to the particulars of continuity of care models can have difficulty understanding the value of such models [
      • Dawson K.
      • McLachlan H.
      • Newton M.
      • Forster D.
      Implementing caseload midwifery: exploring the views of maternity managers in Australia – a national cross-sectional survey.
      ,
      • Haines H.M.
      • Baker J.
      • Marshall D.
      Continuity of midwifery care for rural women through caseload group practice: delivering for almost 20 years.
      ].
      One of the indicators of quality of maternal health care is women's satisfaction with health care delivery [
      • Edlund M.J.
      • Young A.S.
      • Kung F.Y.
      • Sherbourne C.D.
      • Wells K.B.
      Does satisfaction reflect the technical quality of mental health care?.
      ]. Evidence showed that satisfaction affects maternal health care service utilization [
      • Goodman P.
      • Mackey M.C.
      • Tavakoli A.S.
      Factors related to childbirth satisfaction.
      ]. In low and middle-income countries, less than 50% of the mothers are satisfied with the childbirth services [
      • Srivastava A.
      • Avan B.I.
      • Rajbangshi P.
      • Bhattacharyya S.
      Determinants of women’s satisfaction with maternal health care: a review of literature from developing countries.
      ]. According to the Ethiopian Ministry of Health sector transformation plan, maternal and newborn health is prioritized. Respect for patients' autonomy, dignity, feelings, and preferences is mandatory. To increase antenatal care, intrapartum care and postnatal care utilization, the care should focus on maintaining client satisfaction [
      • CSA, International I
      Ethiopian Demographic and Health Survey 2016: Key Indicators Report.
      ]. For this reason, a model of care that would increase maternal satisfaction along the continuum of care would have a positive contribution to the improvement of maternal health care service utilization.

      5. Strengths and limitations

      The pragmatic and novel approach, adapting the model to the Ethiopian context and implementing it within the public health system, provided a unique experience of MLCC working in a low-income setting. A strength of the study is it tries to assess the effect of MLCC on maternal satisfaction with the three aspects of continuity of care. Another strength is using a validated and piloted comprehensive questionnaire with a Likert scale used in previous studies that measured satisfaction with MLCC models, using the recommended focus on women’s satisfaction with the process of care and interpersonal behavior throughout the continuum of care [
      • Perriman N.
      • Davis D.
      Measuring maternal satisfaction with maternity care: a systematic integrative review: what is the most appropriate, reliable, and valid tool that can be used to measure maternal satisfaction with continuity of maternity care?.
      ,
      • Forster D.A.
      • McLachlan H.L.
      • Davey M.A.
      • Biro M.A.
      • Farrell T.
      • Gold L.
      • Flood M.
      • Shafiei T.
      • Waldenstrom U.
      Continuity of care by a primary midwife (caseload midwifery) increases women’s satisfaction with antenatal, intrapartum and postpartum care: results from the COSMOS randomised controlled trial.
      ]. Since there is no previously established MLCC in Ethiopia, we used a quasi-experimental study design that lacks randomization. Using an interviewer-administered questioner would also be another limitation of the study. The study finding should be interpreted in the context that it uses low-risk pregnancy during antenatal care visits.

      6. Conclusions

      This study has investigated the use of an MLCC model adapted to the Ethiopian setting. MLCC increases women's satisfaction with antenatal, intrapartum, and postpartum care for women at low risk of medical complications. Therefore, implementing an MLCC model in the Ethiopian health care system should be encouraged. Furthermore, further efforts should be made to inform the public of the advantages of MLCC in low-risk pregnant women. A randomized intervention study and feasibility and cost-effectiveness analysis of the model may be necessary for the near future involving high-risk pregnant mothers.

      7. Implication to practice

      Quality of maternal health care and service utilization is associated with maternal satisfaction. Therefore, this study has practical implications for maternal health care leaders. Given the high number of women who had improved satisfaction with the MLCC model, considering the MLCC model as one alternative model is promising to strengthen women-centered care in Ethiopia.

      Author contributions

      SHB conducted the study. KAG, KC, ETA, and HL guided the design and conduct of the study. All the authors were involved in data analysis and manuscript write-up. All authors read and approved the final manuscript to be published.

      Conflicts of interest

      None declared.

      Funding

      This work was supported by the Laerdal foundation with grant number 40521 . The foundation has no role in the design, data collection, analysis and interpretation of the study findings.

      Ethics approval

      The study obtained ethical approval from the University of Gondar Institutional Ethical Review Board (ref no: O/V/P/RCS/05/1050/2019).

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