Midwifery models of care in practice : a national survey of midwives' knowledge and practice patterns

Abstract

Purpose: The World Health Organization (2024) identifies that midwifery-led care as an effective strategy for reducing maternal and neonatal morbidity and mortality. In Malta, however, the maternity system remains predominantly obstetric-led, limiting midwives’ autonomy and constraining the implementation of midwifery-led models. This study explored Maltese midwives’ perceptions, knowledge, and practices of midwifery models of care, and examined opportunities for reform towards more womancentred, continuity-based care. Methods: A descriptive, cross-sectional quantitative survey was conducted among practising midwives working across public and private sectors in Malta, including Gozo. The research instrument was developed following an in-depth literature review to ensure comprehensive coverage of relevant domains, and it was validated for content validity, demonstrating good internal consistency and reliability. In Malta, approximately 260 midwives are actively employed in clinical practice (estimated from recent national reports; EMA Malta, 2025). All practising midwives were invited to participate, and 174 (n=67%) completed questionnaires were returned. This represents a high response rate among the active midwifery workforce, providing robust national coverage and exceeding the requirement for a 95% confidence level with a 5% margin of error. The survey explored midwives’ knowledge, practice patterns, autonomy, professional satisfaction, and perceived barriers to midwifery-led care. Quantitative data were analysed using descriptive and inferential statistics, while optional open-text comments were analysed using a simple inductive qualitative content analysis approach (Elo & Kyngäs, 2008) to contextualise quantitative findings Results: Midwives reported greatest familiarity with team-based hospital models, while continuity of care and community-based approaches were cited less frequently. Midwifery-led care were typically limited to low-risk women. One-to-one care was mostly achievable during labour, particularly in smaller units such as Gozo. Participants valued holistic, woman-centred care and continuity, however, they reported barriers including medical dominance, staff shortages, time constraints, and limited autonomy. Leadership from midwifery managers and the Ministry of Health was viewed as essential for system-level reform, although midwives acknowledged their own role in advocating for change. Conclusion: This study provides locally grounded quantitative evidence supporting the expansion of midwifery-led care in Malta. Strengthening midwifery education, autonomy, and policy support for continuity-of-care models has the potential to enhance maternal and neonatal outcomes and to further empower the midwifery profession. Recommendations for practice, education, policy, and research are proposed.