Remarks

• This recommendation has been integrated from the 2016 WHO recommendations on antenatal care for a positive pregnancy experience (16), where it was considered a context-specific recommendation.
• The following remarks were made by the Guideline Development Group responsible for the original recommendation.
• MLCC models are models of care in which a known and trusted midwife (caseload midwifery), or small group of known midwives (team midwifery), supports a woman throughout the antenatal, intrapartum and postnatal periods, to facilitate a healthy pregnancy, childbirth and postnatal period and healthy self-care and parenting practices.
• MLCC models are complex interventions, and it is unclear whether the pathway of influence producing these positive effects is the continuity-of-care, the midwifery philosophy of care, or both. The midwifery philosophy inherent in MLCC models may or may not be enacted in standard midwifery practice in other models of care.
• Policy-makers in settings without well-functioning midwifery programmes should consider implementing this model only after successfully scaling up the number and quality of practising midwives. In addition, stakeholders may wish to consider ways of providing continuous care through other care providers, because women value continuity-of-care.
• The panel noted that, with this model of care, it is important to monitor resource use and health worker burnout and workload, to determine whether caseload or team care models are more sustainable in individual settings.
• MLCC requires that well-trained midwives are available in sufficient numbers for each woman to see only one or a small group of midwives throughout pregnancy and during childbirth. This model may therefore require a shift in resources to ensure that the health system has access to a sufficient number of midwives with reasonable caseloads.
• The introduction of MLCC may lead to a shift in the roles and responsibilities of midwives as well as other health workers who have previously been responsible for antenatal and postnatal care. Where this is the case, implementation is likely to be more effective if all relevant stakeholders are consulted and human resources departments are involved. In some settings, government-level consultation with professional organizations could also aid implementation processes.
• The need for additional one-off or continuing training and education should be assessed, and should be provided where necessary.