A scoping review to explore what is known about midwives working to support the delivery of high risk care (HRC)

Review Title: A scoping review to explore what is known about midwives working to support the delivery of high risk care (HRC). Contributors Abigail Marseilles, University of Plymouth Dr Christy Burden, University of Bristol Dr Heather Hopper, University of Plymouth Dr Susie Pearce, University of Plymouth Prof Jill Shawe, University of Plymouth Corresponding Author Abigail Marseilles, University of Plymouth, abigail.marseilles@postgrad.plymouth.ac.uk Acknowledgments The authors would like to thank University of Plymouth for assistance with database access / peer reviewers who provided feedback on the protocol draft Funding The authors gratefully acknowledge support from the Torbay Medical Research Fund, which provided fellowship funding for this project. Conflicts of Interest The authors declare no conflicts of interest Abstract Background Midwives are essential to global maternal health, providing woman-centred and culturally sensitive care. While their expertise in low-risk pregnancies is well documented, the increase in global pregnancy complexity has increased midwives’ working to support high-risk care delivery (HRC), often in obstetric-led models. In the UK, these shifts coincide with workforce strain and declining maternal outcomes. However, little is known internationally about how changes in midwifery may impact on how they experience their role. Methods This protocol outlines a scoping review conducted in accordance with JBI methodology and reported following the PRISMA-ScR checklist. Searches will be undertaken in PubMed, CINAHL, Web of Science, OVID, JSTOR, and ScienceDirect, supplemented with Google Scholar and grey literature sources. The search strategy draws on terms used by professional and regulatory bodies and includes conditions associated with high-risk pregnancy. Two reviewers will independently screen records in Rayyan, extract data using a standardised tool, and conduct inductive thematic analysis using NVivo. Expected Outcomes The review will map and synthesise international evidence on midwives’ experiences, attitudes, and perceptions of supporting the delivery of HRC. Findings will highlight common themes, context-specific insights, and gaps in knowledge, informing future research, education, and practice to strengthen midwifery contributions within obstetric-led care. Introduction Midwives are indispensable for achieving equitable, effective, and comprehensive sexual, reproductive, maternal, and adolescent health services globally. Their care not only improves maternal and infant health outcomes but also influences broader health and social determinants, a benefit linked to midwifery’s unique, woman-centred philosophy (Nove et al., 2021). While there is substantial evidence on midwives’ role in low-risk maternity care, less is known about their experiences when providing high-risk care (HRC). Internationally, the scope of midwifery practice varies widely. In many low- and middle-income countries, midwives take on broad responsibilities, adapting to community needs. This adaptability is critical as the complexity of pregnancies increases due to increasing numbers of preexisting conditions and other factors (Nove et al., 2021). Maternal morbidity and mortality remain largely preventable with skilled care yet continue to disproportionately affect women (Bar-Zeev et al., 2021; Nove et al., 2021). In high-income settings such as the UK, midwives’ scope may be more restricted in comparison to international colleagues. Tasks considered routine elsewhere are sometimes classified as advanced practice. Restrictive policies can limit midwives’ autonomy, affecting women’s experiences and outcomes. By contrast, when midwives are fully integrated into multidisciplinary teams and supported to practise to the full extent of their training, care is safer, higher-quality, and more respectful (Nove et al., 2021). Expanding midwife-led interventions could prevent maternal and newborn deaths globally (Lancet Midwifery Series Steering Group, 2014). Women are also presenting with increasingly complex pregnancies. In the UK, this shift has led to more obstetric-led models of care, where midwives follow doctor-directed care plans rather than working autonomously. These changes coincide with workforce attrition, rising maternal and perinatal deaths, and mounting pressure on maternity services, demonstrated by the proposed review of UK maternity services to be conducted by the UK Secretary for Health in 2025 (Royal College of Midwives, 2023). Models of Care Midwives are trained to provide autonomous care for women with uncomplicated pregnancies, supporting the natural processes of pregnancy, labour, and the postnatal period, often referred to as low-risk care (Pelak, Dahlen & Keedle, 2023). The International Confederation of Midwives defines midwifery as skilled, knowledgeable, and compassionate care across the reproductive continuum, with core characteristics including prevention and management of complications, timely referral, and partnership with women (International Confederation of Midwives, 2022). In most settings, women with low-risk pregnancies are cared for primarily by midwives throughout their childbearing journey (Toll et al., 2023). High-risk care refers to pregnancies where factors increase the likelihood of poor maternal or fetal outcomes. These may include complications of pregnancy (e.g., preeclampsia, haemorrhage), pre-existing conditions (e.g., diabetes, heart disease), or fetal anomalies (Isaacs & Andipatin, 2020). HRC is usually led by an obstetrician, with midwives providing ongoing support and clinical care within a multidisciplinary team. Worldwide declining maternal health (World Health Organisation, 2019) has increased demand for obstetric input, limiting opportunities for autonomous midwifery-led practice (International Confederation of Midwives, 2022). Maternity Services in the UK The UK has a long history of midwifery-led care. Women report valuing midwives’ support, particularly during high-risk pregnancies (Nursing and Midwifery Council, 2019; Pelak, Dahlen & Keedle, 2023). However, the profession faces rising attrition and service pressures. UK maternity care is now considered to be in crisis, with concerning upward trends in maternal and perinatal mortality (Royal College of Midwives, 2023). How these systemic shifts impact midwives’ experiences remains poorly understood. Framing the Issue Women with multiple adversities and co-morbidities are over represented in reports such as the UK maternal deaths reported by Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBBRACE) and (International Stillbirth Alliance Stillbirth Advocacy Working Group., 2023). Much research focuses on midwives delivering high quality care for women who require a routine pathway and normal birth. However, as women become more complex, midwives are increasingly involved in the delivery of HRC as part of wider teams providing complex medical and obstetric care. This review seeks to map what is currently known about midwives’ experiences in these contexts. Review Question What is known about the experience of Midwives supporting the delivery of high risk care (HRC)? Eligibility Criteria Participants This review will include studies focusing on midwives and midwifery professionals who have received formal education in maternity care that meets the standards recognised by the International Confederation of Midwives (ICM). This ensures comparability across health systems in more than 120 countries where ICM-recognised training is in place. To ensure inclusivity, search terms are aligned with the SRMNAH (Sexual, Reproductive, Maternal, Newborn, and Adolescent Health) workforce definitions (Nove et al., 2021) and will include: • Midwifery professionals • Nursing professionals with midwifery training • Midwifery associate professionals • Nursing associate professionals with midwifery training Studies where midwives are clearly identifiable as participants, either as autonomous practitioners or as part of multidisciplinary teams, will be considered eligible. Concept The review will consider studies that explore midwives’ experiences, perceptions, or attitudes when providing care for women identified as requiring high-risk maternity care (HRC). For the purposes of this review, HRC is defined as care provided outside the typical scope of low-risk, midwife-led practice, where obstetric input is required due to known or emergent complications. This includes contexts where midwives deliver care under obstetric-led decision-making or in partnership with obstetricians, rather than acting solely as autonomous providers. The review will exclude studies focused exclusively on low-risk models of care, or those where midwives have undertaken advanced practice training beyond standard midwifery education. Context This review will consider studies from any international setting where midwives contribute to the delivery of maternity care for women requiring obstetric-led input. To maintain comparability, studies must be situated within health systems that provide midwifery education recognised by the ICM. Studies published from 2014 onwards will be included. The date range was selected to align with two key milestones in global maternal health: the Lancet Midwifery Series (2014), which highlighted the potential of midwifery to transform outcomes, and the international adoption of the United Nations Sustainable Development Goals (2015), which prioritised maternal and newborn health worldwide. Restricting the timeframe ensures the review captures contemporary models of practice making findings more relevant to today’s workforce and policy environment. Only studies published in English will be included. The decision is consistent with scoping review methodology, which prioritises breadth of evidence mapping within feasible boundarie