A randomized, controlled trial of nurse-midwifery care. Team midwifery care in a tertiary level obstetric service: a randomized controlled trial. The 'Know Your Midwife' scheme--a randomised trial of continuity of care by a team of midwives. Does team midwife care increase satisfaction with antenatal, intrapartum, and postpartum care? A randomized controlled trial. Continuity of care by a midwife team versus routine care during pregnancy and birth: a randomised trial. Collaboration in maternity care: a randomised controlled trial comparing community-based continuity of care with standard hospital care. Changing Childbirth: a pilot project. Simulated home delivery in hospital: a randomised controlled trial. A randomised study of midwifery caseload care and traditional 'shared-care'.
In 1990 a pilot nurse-midwifery program was implemented in a tertiary care hospital in a major western Canadian city. a randomized, controlled trial was conducted to determine if, when maternal and newborn patient outcomes were compared, the midwifery program was as effective as traditional, low-risk health care available in the city.
                All low-risk women who requested and qualified for nurse-midwifery care were randomly assigned to an experimental or control group.
                One hundred one women received care from nurse-midwives and 93 received standard care from either an obstetrician or family physician. The rate of cesarean delivery in the nurse-midwife group was 4 percent compared with 15.1 percent in the physician group. The episiotomy rate, excluding cesarean deliveries, for the nurse-midwife group was 15.5 percent compared with 32.9 percent in the physician group. The rates of epidural anesthesia for pain relief in labor were 12.9 percent and 23.7 percent, respectively. Statistically significant differences were found ultrasound examinations, amniotomy, intravenous drug administration during labor, dietary supplements, length of hospital stay, and admission of infants to the neonatal intensive care unit.
                The results clearly support the effectiveness of the pilot nurse-midwifery program and suggest that more extensive participation of midwives in the Canadian health care system is an appropriate use of health care dollars. In 1996 a new model of maternity care characterized by continuity of midwifery care from early pregnancy through to the postpartum period was implemented for women attending Monash Medical Centre, a tertiary level obstetric service, in Melbourne, Australia. The objective of this study was to compare the new model of care with standard maternity care.
                In a randomized controlled trial, 1000 women who booked at the antenatal clinic and met the eligibility criteria were randomly allocated to receive continuity of midwifery care (team care) from a group of seven midwives in collaboration with obstetric staff, or care from a variety of midwives and obstetric staff (standard care). The primary outcome measures were procedures in labor, maternal outcomes, neonatal outcomes, and length of hospital stay.
                Women assigned to the team care group experienced less augmentation of labor, less electronic fetal monitoring, less use of narcotic and epidural analgesia, and fewer episiotomies but more unsutured tears. Team care women stayed in hospital 7 hours less than women in standard care. More babies of standard care mothers were admitted to the special care nurseries for more than 5 days because of preterm birth, and more babies of team care mothers were admitted to the nurseries for more than 5 days with intrauterine growth retardation. No differences occurred in perinatal mortality between the two groups.
                Continuity of midwifery care was associated with a reduction in medical procedures in labor and a shorter length of stay without compromising maternal and perinatal safety. Continuity of midwifery care is realistically achievable in a tertiary obstetric referral service. A team of four midwives provided the majority of care during pregnancy, labour and the puerperium to 503 women at low obstetric risk, over a 2-year period. Compared with standard hospital care randomly allocated to 498 women this 'Know Your Midwife' scheme was associated with greater continuity in all phases of maternity care. The scheme appeared very acceptable to women: they spent less time in the antenatal clinic, and overall, felt more satisfied, better prepared and better able to discuss problems. The scheme was characterised by less obstetric intervention particularly in respect of augmentation of labour and intrapartum analgesia; labours tended to be longer. Neonatal outcome was generally similar in the two groups but the size of the trial did not allow a precise assessment of differential effects in these terms. The 'Know Your Midwife' scheme is feasible. It should now be introduced more widely but in a way which allows continuing evaluation. Although policymakers have suggested that improving continuity of midwifery can increase women's satisfaction with care in childbirth, evidence based on randomized controlled trials is lacking. New models of care, such as birth centers and team midwife care, try to increase the continuity of care and caregiver. The objective of this study was to evaluate the effect of a new team midwife care program in the standard clinic and hospital environment on satisfaction with antenatal, intrapartum, and postpartum care in low-risk women in early pregnancy.
                Women at Royal Women's Hospital in Melbourne, Australia, were randomly allocated to team midwife care (n = 495) or standard care (n = 505) at booking in early pregnancy. Doctors attended most women in standard care, and continuity of the caregiver was lacking. Satisfaction was measured by means of a postal questionnaire 2 months after the birth.
                Team midwife care was associated with increased satisfaction, and the differences between the groups were most noticeable for antenatal care, less noticeable for intrapartum care, and least noticeable for postpartum care. The study found no differences between team midwife care and standard care in medical interventions or in women's emotional well-being 2 months after the birth.
                Conclusions about which components of team midwife care were most important to increased satisfaction with antenatal care were difficult to draw, but data suggest that satisfaction with intrapartum care was related to continuity of the caregiver. To compare continuity of care from a midwife team with routine care from a variety of doctors and midwives.
                A stratified, randomised controlled trial.
                814 women attending the antenatal clinic of a tertiary referral, university hospital.
                Women were randomly allocated to team care from a team of six midwives, or routine care from a variety of doctors and midwives.
                Antenatal, intrapartum and neonatal events; maternal satisfaction; and cost of treatment.
                405 women were randomly allocated to team care and 409 to routine care; they delivered 385 and 386 babies, respectively. Team care women were more likely to attend antenatal classes (OR, 1.73; 95% CI, 1.23-2.42); less likely to use pethidine during labour (OR, 0.32; 95% CI, 0.22-0.46); and more likely to labour and deliver without intervention (OR, 1.73; 95% CI, 1.28-2.34). Babies of team care mothers received less neonatal resuscitation (OR, 0.59; 95% CI, 0.41-0.86), although there was no difference in Apgar scores at five minutes (OR, 0.86; 95% CI, 0.29-2.57). The stillbirth and neonatal death rate was the same for both groups of mothers with a singleton pregnancy (three deaths), but there were three deaths (birthweights of 600 g, 660 g, 1340 g) in twin pregnancies in the group receiving team care. Team care was rated better than routine care for all measures of maternal satisfaction. Team care meant a cost reduction of 4.5%.
                Continuity of care provided by a small team of midwives resulted in a more satisfying birth experience at less cost than routine care and fewer adverse maternal and neonatal outcomes. Although a much larger study would be required to provide adequate power to detect rare outcomes, our study found that continuity of care by a midwife team was as safe as routine care. To test whether a new community-based model of continuity of care provided by midwives and obstetricians improved maternal clinical outcomes, in particular a reduced caesarean section rate.
                Randomised controlled trial.
                A public teaching hospital in metropolitan Sydney, Australia. Sample 1089 women randomised to either the community-based model (n = 550) or standard hospital-based care (n = 539) prior to their first antenatal booking visit at an Australian metropolitan public hospital.
                Data were collected on onset and outcomes of labour, antenatal, intrapartum and postnatal complications, antenatal admissions to hospital and neonatal mortality and morbidity.
                There was a significant difference in the caesarean section rate between the groups, 13.3% (73/550) in the community-based group and 17.8% in the control group (96/539). This difference was maintained after controlling for known contributing factors to caesarean section (OR = 0.6, 95% CI 0.4-0.9, P = 0.02). There were no other significant differences in the events during labour and birth. Eighty babies (14.5%) from the community-based group and 102 (18.9%) from the control group were admitted to the special care nursery, but this difference was not significant (OR 0.75, 95% CI 0.5-1.1, P = 0.12). Eight infants died during the perinatal period (four from each group), for an overall perinatal mortality rate of 7.3 per 1000 births.
                Community-based continuity of maternity care provided by midwives and obstetricians resulted in a significantly reduced caesarean section rate. There were no other differences in clinical outcomes. To compare the outcomes of an adapted pilot Changing Childbirth initiative providing continuity of care by a group of known midwives with traditional maternity care.
                Between-groups trial to compare levels of satisfaction and clinical outcomes for two groups of women, cared for either under this Changing Childbirth scheme or the traditional model of care.
                Of the 200 women who agreed to participate in the project, 100 were randomly allocated to the pilot scheme and 100 to the traditional care package. During the postpartum period, information was collected via a questionnaire about participants' levels of satisfaction with a variety of aspects of care provided during the antenatal, delivery and postpartum periods. Data about clinical outcomes for the two groups were also obtained.
                Women in the pilot group had significantly more continuity of care throughout each of the three periods, were generally more satisfied with their care, felt that they had more choice over a variety of aspects of care and experienced no compromise in clinical outcomes (P = 0.05 or less in each case).
                Many previous attempts to introduce the Changing Childbirth initiative have revealed significant problems, particularly with regard to the continuity of carer requirement. Taking account of local health care needs and existing provision, the present study adapted this concept to continuity of care. This did not apparently affect any of the guiding principles contained in the original document, and yet enhanced satisfaction. It would appear that the Changing Childbirth agenda can be adapted and integrated with local health care situations without sacrificing any of the overarching principles. To compare the outcome of two methods of maternity care during the antenatal period and at delivery. One was to be midwife-led for both antenatal care and delivery, the latter taking place in rooms similar to those in one's own home to simulate home confinement. The other would be consultant-led with the mothers labouring in the delivery suite rooms with resuscitation equipment for both mother and baby in evidence, monitors present and a delivery bed on which both anaesthetic and obstetric procedures could be easily and safely carried out.
                Randomised controlled trial.
                Leicester Royal Infirmary Maternity Hospital.
                Of 3510 women who were randomised, 2304 were assigned to the midwife-led scheme and 1206 were assigned to the consultant-led scheme.
                Complications in the antenatal, intrapartum and postpartum periods were compared as was maternal morbidity and fetal mortality and morbidity. Satisfaction of the women with care over different periods of the pregnancy and birth were assessed.
                There were few significant differences in antepartum, intrapartum and postpartum events between the two groups. There was no difference in the percentage of mothers and babies discharged home alive and well. Generally higher levels of satisfaction with care antenatally and during labour and delivery were shown in those women allocated to midwife care. To evaluate caseload midwifery care in comparison to traditional 'shared care'.
                Comparative study with area randomisation.
                District general hospital in England.
                'Known carer at delivery,' 'normal vaginal delivery' and 'obstetric intervention'.
                All pregnant women delivering in the six areas chosen for the study.
                A highly significant difference was found between caseload and traditional care groups in terms of level of 'known carer at delivery' (696/770 94.7%; cf. 52/735 (6.7%), p < 0.001). However, no differences in 'normal vaginal delivery' rates were found (542/770 (70%) cf. 509/735 (69%). There were fewer 'obstetric interventions' in the caseload group, particularly epidural analgesia (80/770 (10%) cf. 110/735 (15%) p = 0.01) and oxytocin augmentation (351/77 (46%) cf. 387/735 (53%), p = 0.01). There were no significant differences found in terms of neonatal outcome.
                Caseload midwifery results in high levels of 'known carer at delivery' which appears to be associated with a reduction in augmentation and epidural rates but which were not associated with an increase in normal vaginal delivery rate.
Most women should be offered midwife-led models of care and women should be encouraged to ask for this option although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.