Table 1.

Models of midwife-led delivery care with rapid access to advanced care

Location	Programme description	Results	Study notes
Onsite midwife-led birth unit (OMBU)—low-risk birthing unit on the same premises as, but separated from, an obstetric unit with capacity to provide care for severe peripartum complications
South Africa19	OMBU is in the same facility as obstetrics (OB) unit. Clinical interventions are kept to a minimum, but midwives can provide opioid injections, artificial rupture of membranes, electronic fetal monitoring. Care is provided based on the prevailing primary care guidelines and is administered and funded by the primary care service, rather than the hospital.	Facility deliveries increased from 6352 to 7375 per year and Caesarean section (CS) rates were reduced from 38% to 35%.	Routinely collected data from 12 months before and after implementation of OMBU (2011–2013).
China83	Midwife-led unit for low-risk clients. Located in a hospital and close to the standard OB unit. Provides home-like environment for childbirth, where women can move about freely, birth companionship is encouraged, and interventions are kept to a minimum. Complications are referred to the standard OB unit.	CS rate was 8.4% in the OMBU vs 38.5% in the standard care unit, with lower rates of oxytocic augmentation 15.5% in OMBU (15.5% vs 39.8%). Most (94%) of OMBU clients reported being happy with their birth experience in the OMBU.	Retrospective study of the first 6 months of the implementation of the OMBU, involving 452 women (2008).
Hong Kong84	OMBU is in the same unit as OB and uses the same protocols. Midwives manage all aspects of care and decide if and when to consult OB.	Lower obstetric intervention rates but no difference in 5 min APGAR scores less than seven and no difference in transfers on account of fetal distress.	Randomised controlled trial with 1050 low-risk women (1994–1995).
Norway85	OMBU is on the same floor as OB unit and provides a home-like environment that minimises interventions. No inductions or augmentation of labour in OMBU. Midwives manage all aspects of intrapartum and postpartum care and consult OB if complications arise.	No difference in low 5 min APGAR scores, transfers to neonatal intensive care unit or CS rates.	Prospective cohort study of 453 primiparous low-risk clients conducted (2001–2002).
Japan86	OMBU is on the same premises as the OB unit and provides a home-like environment in traditional Japanese rooms. Midwives refer any complications to OB and interventions are limited.	No difference in obstetric complications (postpartum haemorrhage or 3rd/4th degree perineal tears) or CS rates. No difference in neonatal outcomes (5 min APGAR score less than 7 or umbilical artery pH).	Retrospective study of 1031 low-risk women (2008–2010).
Near-site midwife-led birth unit (NMBU)—low-risk birthing unit located outside of, but close to (and contractually linked) to an obstetric unit with capacity to provide care for severe peripartum complications
USA87	NMBU across the street from a rural referral hospital with which it partners. NMBU was set-up by the referral hospital to provide care for indigent rural population. Midwives manage all low-risk antenatal care and deliveries at the NMBU; family physicians manage high-risk clients, medical problems, complicated deliveries and provide paediatric care; and OBs consult on particularly high-risk clients and perform CS. Outreach visits are made to counties where there is no health centre.	Facility deliveries increased by 30% over 5 years with the introduction of the maternity clinic with lower costs in the NMBU than in the obstetrician-led practice. There was no significant change in newborns requiring specialist care.	Before and after review (1984–1989).
Nepal88	NMBU is attached to a hospital with OB services. Labour management guided by clearly defined labour ward protocols. Discharge from unit occurs within 1 day, with appropriate counselling.	NMBU clients had lower rates of interventions, including CS. For normal births, delivery at the NMBU cost $11 vs $27 for standard care.	Cohort study of 988 low-risk women (1997–1998).