Title: Pregnant women’s perception of midwifery-led continuity care model in Ethiopia: A
qualitative study
Version: 0 Date: 19 Dec 2022
Reviewer:  Lyn Ebert
Reviewer's report:
Thank You for the opportunity to read this wok. There are some amendments to make. However,
I enjoyed reading it and hope you progress with the work you are doing . The next step is to
look at how to implement the model. Well done. My comments are meant with kindness and
will help the readers to understand your work better.
Please find my comments below:
General Comments:
• Spelling of midwife in the plural is midwives, not midwifes.
• The tense was often incorrect.
• Renaming of themes:
o When you write – Theme 3: Improved satisfaction of pregnant women, it should be - Improved
satisfaction of care. That is because, the reader already knows it is the women’s perception. The
women’s perceptions are that their care is improved, and they are more satisfied with their care.
o When you write - Theme 1: Health Care Workers Related Characteristics, not right as the
subthemes talk of:
1.1 Unavailability of allocated midwives
1.3 Occurrences of disagreement between midwives and women
1.4. Difference in Level of health care workers knowledge
1.2. Absence of adequate Midwives
Therefore, the theme should be titled…
Theme 1: Health Care Workers Skills, Knowledge, and Availability
Or, better still,  make two themes…
Theme 1: Health Care Workers Skills and Attitudes
1.1 Occurrences of disagreement between midwives and women
Theme 2: Staff Skill mix and Health Service Staffing
2.1 Unavailability of allocated midwives
2.2 Difference in Level of health care workers knowledge
2.3 Absence of Adequate Midwives
This is because it is up to the health service (hospital) to ensure staffing and skills are adequate
for the models of care provided. It is not the characteristics of the midwives but the responsibility
of the hospital to employ and train staff.
Also, if you re-read ‘unavailability of allocated midwives’ AND ‘absence of adequate
midwives’, they are saying the same thing. They should be one subtheme.
Specific comments:
Line 39 and Line 75:
There is a difference between woman-centred care and women-centred care, see Leap, N. (2009).
Woman-centred or women-centred care: does it matter? British Journal of Midwifery 7:1, 12-16,
for difference in terminology .
Lines 87-89:
Did you mean Ethiopia shares the highest burden of maternal and neonatal mortality, with 412
maternal deaths per 10000 live births, and 30 neonatal deaths per 1000 live births.
Lines 33-39:
There is no information here regarding:
Were women informed they had a right to refuse to participate. Did the midwife recruiting know
if they agreed to participate or not. Were the women therefore concerned consent or declining
of participation might impact their care?
Lines 153-154:
What does the sentence….
Three authors (AM, YF, and AZ) facilitated the group discussions without any interference with
the idea of the participants… mean? This sentence is confusing, it needs rewriting as it sounds
like the facilitators didn’t let the participants direct the conversation.
Line 195:
You wrote….
showed that the majority (13 out of 31)
This is not true 13 is less than half and therefore NOT a majority. You need to reword this to
less than half of the participants achieved a secondary level education
Lines 196-197:
You wrote….
Regarding gravidity and parity, 25 and 27 out of 31 were multigravidas and multiparous
respectively…
This reads that 25 were multigravida and 27 were multiparous that adds up to more than 31.
You should write, how many were multigravida and how many were primiparous.
In table 1:
If four (4) women were primigravida (first pregnancy), how can six (6)  have been primiparous?
Not sure what you mean by ‘able to read and write’. Does this mean no formal education? As
currently it reads that only 4 women could read and write. I would remove the line…
Able to read and write  4 12.9
Or write:
No formal education  4 12.9
Table 2:
For subtheme, 1.2 Enhance rate of institutional delivery and postnatal care follow up
Do you mean enhance rate of institutional birth and….
Birth is a more woman friendly word that delivery.
Line 246- 247:
You wrote….
Therefore, enhancing the institutional birth rate is crucial to reducing home birth-associated
maternal and newborn mortality.
However, what is the maternal and neonatal mortality rate for hospital births compared to home
births in the same area? This is important information for the reader.
Lines 361-362:
Two new lines inserted…
The fourth theme identified in this study was related to barriers regarding the implementation
of midwifery-led continuity of care.
Lines 492-493:
You wrote:
In fact, the model allows a backup midwife who replaces those midwife who was not available
at work place due to different cases.
I do not understand this sentence, please explain it, or make it clearer.
Lines 522-523:
You wrote:
Recently, a Cochrane review conducted by Sandall J. et al recommends that a midwife-led
continuity care model should be provided for low-risk pregnant mothers
Normally, references are not included in the conclusion as it is your work now and your
recommendation therefore something along the lines of….
Evidence demonstrates that midwife-led models of maternity care reduce maternal morbidity
and mortality. Research also supports midwife-led continuity care models for low-risk pregnant
mothers.  While maternal mortality and morbidity rates are of concern in Ethiopia, there are
limited midwifery-led models of maternity care. Additionally, there is scarce understanding of
women’s perceptions of midwife-led care and or the barriers to implementing such a model.
Findings from the current study revealed that the majority of participating pregnant women are
willing to receive care from a known midwife or team of midwives. It is reasonable therefore, to
develop and implement midwifery-led practice for low-risk pregnant mothers in Ethiopia. The
barriers to implementation of such a model should be examined however, to facilitate a change
of practice in a safe and sustainable means,  and improve maternal health outcomes in Ethiopia.
I couldn't attach the manuscript,so have cut and pasted here, as I did some editing. Use as you
see fit:
Abstract
Background: Midwifery-led continuity care (MLCC) is the provision of care by a known
midwife (caseload model) or a team of midwives (team midwifery model) for women throughout
the antenatal, intrapartum, and postnatal period. Evidence shows that MLCC becomes the first
choice for all women and improves maternal and neonatal health outcomes. Despite this, little
is known about pregnant women’s perception of MLCC in Ethiopia. Therefore, the main aim of
this study was to understand pregnant women’s perception and experience of MLCC in Ethiopia.
Methods: A programmatic qualitative study was conducted in Guraghe zone public hospital,
Southwest Ethiopia, from May 1st to 15th, 2022. Three focus group discussions, and eight in-
depth interviews were conducted with pregnant women, who were selected using a purposive
sampling method. Data were first transcribed and then translated to English. Finally, the thematic
analysis technique using open code software was used for analysis.
Results: Thematic analysis shows that three themes emerged from pregnant women's perceptions
and experiences of midwife-led care. 1/ improved continuum of care, 2/ improved woman-
centred care, and 3/ improved satisfaction of care. The overarching theme was that most women
welcome midwife led continuity care, particularly as it can improve the continuum of care. Under
barriers to implementing midwife-led care, one theme emerged, healthcare workers' related
characteristics.
Conclusion: The finding of this study shows that pregnant women had positive experiences and
showed a willingness to receive midwife led continuity care. Woman-centred care, increased
satisfaction, and an improved continuum of care were identified as the main themes. Therefore,
it is reasonable to adopt and implement midwifery led care for low-risk pregnant mothers in
Ethiopia.
Key Words: Perception, Midwifery-led continuity care, Qualitative study, Ethiopia
Background
The World Health Organization (WHO) and International Confederation of Midwives (ICM)
recommend the midwifery-led continuity care (MLCC) model to scale up quality midwifery
care practice.1,2 A MLCC model is the provision of care by a known midwife (caseload model)
or a team of midwives (team midwifery model) for pregnant women throughout the antenatal,
intrapartum, and postnatal period.3
Midwife-led continuity care includes continuity of care throughout the childbearing cycle,
provision of woman-centred care, and reducing unnecessary medical interventions. The MLCC
model is based on the premise that pregnancy is a normal physiologic process. It is provided in a
multidisciplinary network of consultation such as  identifying and referring women who require
obstetric or other specialist attention.4,5
A recent Cochrane review by  Sandall J. et al. in 2016 showed that the MLCC model reduces
the rate of pre-term birth by 24%, foetal death/neonatal death by 19%, regional analgesia by
15%, instrumental birth by 10%; episiotomy by 16%, and increases the rate of spontaneous
vaginal birth by 5%. Furthermore, MLCC is cost-efficient, enhances the duration of exclusive
breastfeeding,  and women's satisfaction.6,7 Therefore, many women value a MLCC model and
it becomes their first choice.8 However, little is known about MLCC in low and middle income
countries including Ethiopia.3,9
Globally, 295 000 women died from preventable causes related to pregnancy and childbirth in
2017. Of this, 94% occurred in low and middle-income countries.10 Ethiopia shares the highest
burden of maternal and neonatal mortality, with 412 maternal deaths per 10000 live births
and 30 neonatal deaths per 1000 live births.11,12  A strategy to reduce this burden is largely
requested from developing countries.13 In Ethiopia, maternity care is affected by fragmentation
in the patient care process, creating a discontinuity of care and woman-carer relationships, and
unnecessary medical intervention. Thus, pregnant women have to interface with many health
care professionals, both during the pregnancy, childbirth, and the postpartum period.14
Evidence demonstrates that midwives have shown willingness to participate in the
implementation of MLCC model.14,15 However, evidence regarding pregnant women’s
perception and experience of midwife led care is not studied in Ethiopia. Therefore, the aim of
this study was to assess the perception and experience of pregnant women towards midwife led
care in Ethiopia. The finding of this study is vital for policymakers, hospitals, and stakeholders
to design further strategies for upgrading quality midwifery care.
Method and Materials
Study Area and Period
This study was conducted in Guraghe Zone public hospital. Guraghe Zone is located in the
southern part of Ethiopia and is found 153 km southwest of Addis Ababa, the capital city of
Ethiopia. It has 15 districts and Wolkite town is the administrative centre of the Zone. According
to a report from the Central Statistical Agency of Ethiopia (CSA) in 2007, this Zone has a total
population of 1,279,646, of whom 622,078 are men and 657,568 women. Guraghe zone has a
total of 6 hospitals, 72 health centres, and 402 health posts. The study was conducted at Attat
hospital which is a service institution of the Catholic Church in Ethiopia. The antenatal care,
childbirth, and postnatal care service provision in Attat hospital is covered by midwives. It is
located about 175 kilometres southwest of the capital, Addis Ababa. The study was conducted
from May 1st to 15th, 2022.
Study Approach and Selection of Study Participants
A programmatic qualitative study approach was employed to explore the perception and
experience of pregnant women about midwifery-led continuity care. A convenience purposive
sampling method was used to recruit study participants. Eight pregnant women who were present
at the hospital during the data collection period participated in an in-depth interview. Twenty-
three pregnant women (7, 8, and 8 in each group) were included in a focus group discussion.
The point of idea saturation was the criteria for determining the sample size. A midwife who
works in the antenatal clinic provided information about the proposed and the study objective
to pregnant women. The midwife, then invited women to participate in this study.
Data Collection Procedure
The data were collected through face-to-face in-depth interviews and Focus Group Discussions
(FGDs) using a semi-structured guide. The in-depth interview was conducted in a place where
there was minimum sound disturbance and was convenient for the study participants. The
interview guide was prepared in English language and translated into Amharic (the local
language). Three authors (AM, YF, and AZ) conducted in-depth interviews. The data collectors
had experience in qualitative research data collection and analysis. The data were recorded using
a voice recorder and notes were taken by the investigators. The interviews took from a minimum
of 30 minutes to a maximum of 45 minutes.
Three FGDs with 7, 8, and 8 pregnant women were conducted to explore the group view as
well as their perception and experience of midwifery-led continuity care. The FGD was also
conducted in a calm room with minimum sound disturbance. The FGDs were between 50
minutes to one hour. Three authors (AM, YF, and AZ) facilitated the group discussions without
any interference with the idea of the participants. The FGDs were recorded with a voice recorder
and notes were taken by the facilitators.  To ensure the quality of the data, the guides were
reviewed by experts, and a pre-test was done to ensure the flow of the questions and cultural
sensitiveness. The investigators also used simple language and descriptions in conducting the
interview. Prolonged engagement and an audit trail were considered crucial techniques to ensure
the authenticity and credibility of the results.
Data Analysis
All audiotaped data from in-depth interviews, FGDs and field notes were independently
transcribed verbatim to Amharic (the local language) after repeatedly listening to the records and
then translated into the English language. The translated transcription documents were imported
into Open code version 4 3.1 software of qualitative data analysis for coding and analysis. After
repeatedly reading the transcribed document, the investigators coded and categorized the data
into themes and sub-themes. Central themes were constructed based on the natural meaning of
the categories. The investigators cross-checked the themes, that emerged after analysis, with
the respective quotes of the themes. The findings were reported by a detailed description and
interpretation of the meanings of the themes. Direct quotes from the participants were also
included in the write-up of the findings to provide clear images for readers. Braun and Clark’s
method of thematic analysis was used in the data analysis.16 The overall process of data analysis
used an inductive approach.
Results
Socio Demographic Characteristics
Overall, 33 pregnant women were invited to participate in this study. Of this, a total of 31
pregnant women (n=23 FGDs and n=8 in-depth interviews) were included with a response rate
of 94%. The mean age of study participants was 29.2 (±SD=4.2) years. The educational status
of the study participants showed that the majority (13 out of 31) had secondary education and
that half of them were government employees. Regarding gravidity and parity, 25 and 27 out of
31 were multigravidas and multiparous respectively (Table 1).
Table 1, socio demographic characteristics of study participants at attat hospital, Guraghe Zone,
southwest Ethiopia (n=31)
Variables  Categories  Frequency  Percentage (%)
Age 20-25 8 25.8
26-30 19 61.3
31-40 4 12.9
Gravidity  Primigravida  4 12.9
Multigravida  27 87.1
Parity  Primiparous 6 19.4
Multiparous  25 80.6
Educational level  Able to read and write  4 12.9
Primary 11 35.5
Secondary 13 41.9
College and above  3 9.7
Occupation  Housewife 5 16.2
Government employee 16 51.6
Daily labourer 10 32.2
The findings that emerged from the data analysis of the focus group discussions and in-depth
interviews resulted in four themes and ten subthemes (Table 2).
Table 2, Topics, theme, and subtheme identified in the data analysis.
Topic   Theme  Subtheme
Pregnant women experience and perception of midwifery led continuity care 1. Improved
Continuum of care 1.1. Improved antenatal care visit
1.2. Enhance rate of institutional delivery and postnatal care follow up
2. Improved women centred care 2.1. Improve women’s awareness about changes during
pregnancy
2.2. Improve maternal health care seeking behaviour
2.3 Build trustful woman–midwife relationships
3. Improved satisfaction of care
3.1. Satisfaction during pregnancy period
Barriers of implementing midwifery-led continuity care model 1. Health care workers related
characteristics  1.1. Unavailability of allocated midwives
1.3. Occurrences of disagreement between midwives and women
1.4. Difference in Level of health care workers knowledge 1.2. Absence of adequate Midwives
Pregnant Women Experience and Perception of MLCC
In this section, we discuss pregnant women’s perceptions and experiences of midwifery led care.
Three themes emerged. These are improved continuum of care, improved woman-centred care,
and improved satisfaction of care. We described each subtheme in detail.
Theme 1: Improved Continuum of Care
Subtheme 1.1: Improved Antenatal Care Visits
The midwifery led continuity of care is continuity across the whole continuum: antenatal,
intrapartum, and postnatal and in which women receive seamless care from a primary known
midwife or a team of midwives.17 In this study, the majority of pregnant women state that
receiving all antenatal care visits, labour and birth, and postnatal service from the same caregiver
(midwives) would ensure continuity of information and care.
‘‘Almighty GOD, I am reached now 9 months and 2 weeks. I have received my pregnancy
follow-up from the same midwives. She (the midwife) advised me to give birth in a hospital
and not to miss my appointment, and she thought me about the merits of giving birth at a health
facility and the demerits of giving birth at home. Additionally, she treats me with respect and
dignity. That’s why; I have never missed my follow-up. What you said the midwife-led unit
would be interesting, I wish I could get her in my childbirth period.’’ (Pregnant Women 1)
Another study participant stated that receiving care from many health care workers at one office
was stressful and uncomfortable.
‘‘...For instance, during my fourth antenatal care visit, there was more than six health care worker
at one office. Someone asked about my history, took my vital sign, other one did an abdominal
examination and requested lab investigations. And when I return back with laboratory results,
I found new health care workers, and again I reintroduce myself. In those movements, I felt
anxious, uncomfortable, and stressed.’’ (Pregnant women 5)
Subtheme 1.2. Enhance Rate of Institutional Birth and Postnatal Care Follow Up
According to the 2019 Ethiopian Mini Demographic Health Survey, the rate of institutional birth
was low (48%).12 Therefore, enhancing the institutional birth rate is crucial to reducing home
birth-associated maternal and newborn mortality. The finding of this study showed that midwife
led continuity care might enhance the rate of institutional birth and postnatal care follow-up.
Some of the study participants did not have a positive attitude towards health care workers,
particularly those who work in labour and birth service.
‘‘I have heard that sometimes the health care workers disrespect and abuse during childbirth.
And I believe that as long as I am healthy, why I come to the hospital. However, the health
extension workers advised me to start a follow-up. The care I received here is beyond my
expectation. They (midwives) received me warmly. She (midwife) provides health education
about preparation for my childbirth and the possible complications. I have decided to give my
birth and follow up here. Even I will inform for those women’s who had a negative attitude
towards midwives.’’ (Pregnant women 3)
Theme 2: Improved Woman Centred Care
Woman-centred care focuses on the woman’s unique needs, expectations, and aspirations;
recognizes her right to self-determination in terms of choice, control, and continuity of care;
and addresses her social, emotional, physical, psychological, spiritual, and cultural needs and
expectations.18 The midwife and woman relationship are central to the provision of woman-
centred care. The result of this study showed that the majority of women revealed that receiving
care from the same healthcare workers in antenatal care improved women’s awareness, and
healthcare-seeking behaviour, and build midwife and women relationships.
Sub theme 2.1. Enhance Women’s Awareness of Changes due to Pregnancy
The finding of this study revealed that receiving care from the same health care provider
encouraged women to ask questions and seek knowledge regarding any changes during
pregnancy and further helped them to have more awareness about changes that occurred due
to pregnancy.
‘‘The health care workers have sent me to the maternity waiting homes. I have spent more than
days here; however; there is no health care worker who explains the reason to stay here for such
a long time. I am depressed here. Even we don’t know who is responsible for us. What you said
receiving care by an individual midwife would be better because we will build a relationship
and have the confidence to ask for information about the reason why we stay here, the changes
during pregnancy, the health of my foetus, and the next care I received.’’ (Pregnant Women 12)
Subtheme 2.2. Improve Maternal Health Care Seeking Behaviour
Maternal and neonatal mortality is unacceptably high in Ethiopia. The three delays model
proposes that maternal mortality is associated with delays in deciding to seek care, reaching the
healthcare facility, and receiving care.19 The finding of this study revealed that receiving care
from known and trusted midwives would improve women’s healthcare-seeking behaviour and
at least reduce delays in deciding to seek care.
‘‘She (midwives) advised me to come to the hospital in the case of rupture of my amniotic
fluid, decreased foetal movement, headache, or any vaginal bleeding. I felt I had developed a
headache, and following her counsel I am here for chick up.’’ (Pregnant women 11)
Subtheme 2.3.  Build Trustful Woman–Midwife Relationships
It is crucial that the relationship between the midwife and the woman is essential for a positive
experience for a woman during the childbearing period. On the contrary, if the relationship
is worsened, women might experience bad obstetric outcomes. Therefore, study participants
revealed that midwifery led care could empower women to feel involved in decision-making
and to exercise choice.
‘‘Receiving care for the same caregiver is very joyful, and I will choose it. Because I am not
expected to tell all my information to every health care provider I meet in each office. The same
health care worker (midwife) can easily understand, and we will build trust and friendship. That
in turn, make us avoid the fear of asking for any information regarding my care and be fully
involved in the decision-making process.’’
(Pregnant women 19)
On the other hand, midwife led care builds trust between the midwife and pregnant women,
enhancing women’s confidence and reducing their fear. The experience of pregnancy, especially
in the early stages, differs for each woman. The stability of a woman’s relationships and social
environment influence her experience.
‘‘During my first and second antenatal care visits, I have been seen by the same midwives. Thus,
we became friendly, and I told them all of my histories. Later on, on my third visit, the midwives
who I know were not available and I felt disappointed. The continuity of information was broken
and I just began to tell again all my histories. I will be grateful if I received all my maternity
care from known and trusted midwives.’’(Pregnant women 17)
This finding demonstrates that receiving care from the same health care worker supports women
to make informed choices about their antenatal care and childbirth with a focus on enabling
them to labour and birth with minimal medical intervention. For instance, one study participant
states that she has a known doctor for her consecutive births and she feels empowered and has
a good relationship with her doctor.
‘‘I have given birth 3 times at attat hospital. I am pregnant now four times. In all my previous
obstetric history I have received from the same health care workers (doctor). She (the doctor)
knows everything about my health. Having known health care worker is fantastic in all aspects
of pregnancy care.’’  (Pregnant women 29)
Theme 3: Improved satisfaction of Care
Subtheme 3.1. Improved satisfaction of care
In this subtheme, the study participants highlight the midwife counselling regarding daily intake
of iron and folic acid supplementation, avoidance of unsubscribed drugs intake during the early
phase of pregnancy, and unnecessary medical interventions such as caesarean section delivery.
‘‘The health education I have received in antenatal care class empowered me to make decisions
during the entire period of my pregnancy. A midwife informs me to avoid unnecessary intakes
of drugs, to take iron and folic acid supplementation, including immunization intake, and to
avoid unnecessary caesarean section delivery. She (midwives) also told me all danger signals
occurred during pregnancy and to prepare myself financially, and to decide where to give birth.
I am satisfied with all the care I have received in the health care workers.’’ (Pregnant women 20)
Other study participants stated that health care workers' counselling helped them to alleviate
some minor disorders during their pregnancy.
‘‘I have experienced nausea and vomiting around 7 to 8 months of my pregnancy. She (the
midwives) advised me to take hard foods frequently and to use large pillows during the night
time. That helps me a lot.’’ (Pregnant women 11)
Barriers of Implementing Midwifery-Led Continuity Care
The fourth theme identified in this study was related to barriers regarding the implementation
of midwifery-led continuity of care.
Theme 1: Health Care Workers Skills, Knowledge and Availability
Subtheme 1.1.  Unavailability of Allocated Midwives
Study participants mentioned that there are four major barriers to adopting, developing, and
implementing midwifery-led continuity care. The first might be unavailability of allocated
midwives due to different reasons such as holidays, transfers to other institutions, and accidents.
‘‘Currently, I am near to give birth. For my future pregnancy, I will choose a known midwife.
However, a midwife who is responsible to provide the entire care for me might be absent from
the hospital due to different unforeseen reasons. In that case, I might face challenges’’. (Pregnant
women 6)
‘‘My labour might start day or night. For example, if my labour starts at night time, my
individual midwife might not be available at all times. On that occasion we encountered
difficulties.’’(Pregnant women 15)
Subtheme 1.2. Disagreement between Midwives and Pregnant Women
Some of the study participants mentioned that there are different behaviours and personalities
of health care workers. We might encounter difficulties when disagreement around care options
occur, or not having a good relationship between the midwife and woman.
‘‘…For instance, previously, I have followed my pregnancy in a private clinic. There, I smiled,
unfortunately. However, the doctor threw his pen and mistreated me. Immediately, I decided to
change my follow-up clinic and come to this hospital. A midwife is welcoming and friendly.
She (midwife) is a good listener; I have told all my histories, and she appoints me for the next
visit. Sometimes, it might be difficult to continue the entire journey of pregnancy with the same
midwife in the case of disagreement like I encountered with the one who works in a private
clinic.’’ (Pregnant women 23)
Subtheme 1.3. Difference in Level of Health Care Worker’s Knowledge
A handful of study participants state that they prefer to receive care from different healthcare
providers as there are variations in the level of knowledge and skill between healthcare providers.
‘‘I personally prefer to receive care from different health care providers (midwife and doctors).
Because every health care provider has a different level of knowledge, skill, character, and
empathy. For example, some health care workers have good knowledge while others might have
poor knowledge and attitude. That might affect me from receiving adequate and quality care
service.’’ (Pregnant women 10)
Subtheme 1.4. Absence of Adequate Midwives
Study participants raised their concerns about the availability of adequate midwives to adopt
and implement a midwife-led continuum of care.
‘‘I accept to receive care from the same midwife. However, the number of pregnant mothers
and midwives is not proportional. Sometime during our pregnancy follow-up, we waited a
long period of time. There are a large number of pregnant mothers in this hospital. If we need
individual midwives, we might not get enough midwives for each of us.’’  (Pregnant women 27)
Discussion
The current qualitative study aimed to explore pregnant women’s perceptions and experiences
of midwifery-led continuity care in Ethiopia. Three themes emerged (i.e. improved continuum
of care, improved woman-centred care, and improved satisfaction of care). On the other hand,
under the barrier of implementing midwifery-led continuity care, one theme emerged (i.e. health
care workers related characteristics).
The findings of this study revealed that most women have positive views toward receiving
care from the same health care workers. For instance, they expressed receiving adequate
health counselling and promotion during their antenatal visits which enhanced their awareness
regarding changes during pregnancy and reduced their fear of childbirth. This finding is in line
with a study conducted by Shahinfar S. et al., which reported that midwife-led care in antenatal
clinics improved women’s self-efficacy, the ability of decision-making processes, and  coping
ability during pregnancy.20 Similar studies showed that midwife led care reduces women’s
fear of birth and postpartum depression, and it also promotes exclusive breastfeeding.21,22 The
possible explanation might be that receiving continuous care from known midwives enhances
women’s confidence and trust in midwives.23 Based on the findings from this study, we
can conclude that women are positive about developing, introducing, and implementing a
midwifery-led continuum of care in our setting.
Our study shows that women who had the experience of receiving care from a known midwife
had reduced fear of asking questions and more importantly reduced worries and stress. This
finding is in line with two studies conducted in Sweden indicating that a known midwife can
make a difference in women's positive childbirth experience.24,25
The finding of this study also showed that receiving care from known health care workers
facilitates woman centred care and the building of  a trusting woman midwife relationship.
Similar findings were reported in Ireland and Scotland, with midwife-led care seen as an
important strategy for enhancing women’s choice, decision-making, and sense of involvement
in the care process.26,27 The possible justification might be that known midwives easily
recognized each woman’s social, emotional, physical, spiritual, and cultural needs. Therefore,
midwife-led care can improve woman-centred care including the needs of the baby, the woman’s
family, and the community.
In this study, according to the women’s experience, midwife-led health service provision in an
antenatal class increased their satisfaction. This finding is supported by a study conducted by
Forster, DA et al. and  McLachlan, H. et al., who  showed that women who had received midwife-
led care had a higher rate of satisfaction and a more positive experience with their antenatal care
follow-up, intrapartum care, and postpartum care.28,29 Similarly, studies conducted in Pakistan
and China showed that women were satisfied with midwife-led care.30,31 The findings might
be due to receiving care from  known midwives reducing waiting time in the clinic; enhancing
emotional support of women, which might led them to have more satisfaction. In addition,
midwife-led care addresses the individual woman's needs like allowing a championship, giving
sufficient time for questions, perinatal counselling on a wide range of issues including labour
pain, help with breastfeeding, and post-labour recovery.
This study also identified the possible barriers to adopting and implementing midwifery-led
continuity care in our setting might be the absence of appropriately skilled midwives during
childbirth. The finding is in line with another study conducted in a different setting.32 The
possible explanation might be that pregnant women can develop fear, stress, and anxiety during
the absences of their known midwives. In fact, the model allows a backup midwife who replaces
those midwife who was not available at work place due to different cases.4
Moreover, the occurrence of disagreements between the allocated midwife and woman, and
the absence of adequate health care workers (midwives) for each pregnant woman are also
mentioned as barriers to implementing midwife-led maternity service. The finding is in
agreement with a study conducted in a Swiss university hospital.33 The possible justification
might be due to the shortage of midwives in Ethiopia which might pose a serious obstacle to
implementing this midwife-led continuity care.
Strength and Limitation of the Study
To our knowledge, this is the first qualitative study conducted in the Ethiopian context
to understand women’s perceptions and experience towards midwifery-led continuity care
throughout antenatal, childbirth, and postpartum period.  We identified the positive view of
women to the midwife-led unit and the possible barriers to adopting and implementing midwife
led care in the maternity health care service of Ethiopia. However, this study has a limitation. It
was conducted in one hospital. Therefore, the finding is not generalizable for all study settings.
Thus, we recommend a larger, multi-site study in the future to identify the barriers and facilitators
of implementing midwife-led maternity services in the Ethiopian context.
Conclusion and Recommendation
Recently, a Cochrane review conducted by Sandall J. et al recommends that a midwife-led
continuity care model should be provided for low-risk pregnant mothers.17 In line with this, our
findings revealed that the majority of pregnant mothers have shown a willingness to receive care
from a known midwife or team of midwives. Therefore, it is reasonable to adopt and implement
midwifery-led practice for low-risk pregnant mothers in Ethiopia.