Quality & Safety

Quality & Safety

I. Cochrane Systematic Review: Midwife-led versus other models of care for childbearing women (Hatem et al., 2009)

The objective of this Systematic Review was to compare midwife-led models of care with other models of care for childbearing women and their infants. The review 11 trails (12,276 women) in which pregnant women were randomly allocated to midwife-led or other models of care during pregnancy, and where care is provided during the ante and intrapartum period in the midwife-led model. The review conducted that women who had midwife-led models of care were less likely to experience antenatal hospitalisation, regional analgesia, episiotomy and instrumental delivery. Further, women more likely to experience no intrapartum analgesia/anaesthesia, spontaneous vaginal birth, feel in control during childbirth, being attended at birth by a known midwife and initiate breastfeeding. There were no statistically significant differences between groups for caesarean births. Women who were randomised to receive midwife-led care were less likely to experience fetal loss before 24 weeks’ gestation, although there were no statistically significant differences in fetal loss/neonatal death of at least 24 weeks or in fetal/neonatal death overall.

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II. A systematic review comparing continuity of midwifery care with standard maternity services (Waldenstrom and Turnbull, 1998)

The objective of the systematic review was to assess randomised controlled trials of alternative maternity services characterised by continuity of midwifery care. Seven trials identified included 9148 women. The review found that alternative models with continuity of midwifery care were associated with less use of obstetric interventions during labour (eg, induction, augmentation of labour, electronic fetal monitoring, obstetric analgesia, instrumental vaginal delivery and episiotomy). However, the caesarean section rate did not differ statistically between the trial groups. There was no maternal death, and rates of maternal complications based on unpooled estimates did not show any statistically significant differences. The proportion of babies with an Apgar score < 7 at five minutes after the birth was approximately the same in the pooled alternative groups as in the control groups. Admission to intensive care or special care baby unit was similar (OR 0.86; 95% CI 0.71 to 1.04). The difference in perinatal deaths was bordering on statistical significance.

Waldenstrom, U., & Turnbull, D. (1998). A systematic review comparing continuity of midwifery care with standard maternity services. British Journal of Obstetrics and Gynaecology, 105, 1160-1161 1170.

III. Cochrane Systematic Review: Alternative versus conventional institutional settings for birth (Hodnett, Downe and Walsh, 2012)

The objective of the review was to assess all randomized or quasi-randomized controlled trials which compared the outcomes of alternative institutional birth environments compared to care in a conventional institutional setting and to determine if the effects of birth settings are influenced by staffing, architectural features, organizational models or geographical location. Nine trials involving 10684 women met the inclusion criteria. Allocation to an alternative setting increased the likelihood of: no intrapartum analgesia/anaesthesia; spontaneous vaginal birth; breastfeeding at six to eight weeks; and very positive views of care. Allocation to an alternative setting decreased the likelihood of epidural analgesia; oxytocin augmentation of labour; and episiotomy. There was no apparent effect on serious perinatal or maternal morbidity/mortality, other adverse neonatal outcomes, or postpartum hemorrhage. No firm conclusions could be drawn regarding the effects of variations in staffing, organizational models, or architectural characteristics of the alternative settings.

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IV. Women’s experiences of continuity of midwifery care in a randomised controlled trial in Australia (Homer et al., 2002)

Objective: to compare the experiences of women who received a new model of continuity of midwifery care at the St George Outreach Maternity Project (STOMP) with those who received standard hospital care during pregnancy, labour, birth and the postnatal period. Questionnaires were returned from 69% of consenting women. STOMP women were significantly more likely to have talked with their midwives and doctors about their personal preferences for childbirth and more likely to report that they knew enough about aspects of labour and birth, particularly induction of labour, pain relief and caesarean section. STOMP women reported a significantly higher ‘sense of control during labour and birth’. In a secondary analysis, women who had a midwife during labour who they felt that they knew, had a more positive birth experience compared with women who reported an unknown midwife.

Homer, C., Davis, G., Cooke, M., & Barclay, L. (2002). Women’s experiences of continuity of midwifery care in a randomised controlled trial in Australia. Midwifery, 18, 102-112.

V. Collaboration in maternity care: a randomised controlled trial comparing community-based continuity of care with standard hospital care (Homer et al., 2001)

The objective of this study was 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. There was a signifcant difference in the caesarean section rate between the community-based group and the control group.

Homer, C., Davis, G., Brodie, P., Sheehan, A., Barclay, L., Wills, J., et al. (2001). Collaboration in maternity care: a randomised controlled trial comparing community-based continuity of care with standard hospital care. British Journal of Obstetrics and Gynaecology, 108, 16-22.

VI. Australian caseload midwifery: The exception or the rule (Hartz, Tracy and Foureur, 2010)

The aim of this paper was to review the clinical outcomes of descriptive and comparative cohort studies of the Australian caseload midwifery models of care that emerged during the late 1990s and early 2000s. The Australian studies show that caseload midwifery is a model of care that is associated with lowered rates of caesarean section operations, and other obstetric intervention rates. The paper calls for further randomised controlled trials of caseload midwifery in order to provide definitive answers relating to the effect of the caseload midwifery model of care for women of all risk in the Australian context.

Hartz, D. L., Tracy, S. K., & Foureur, M. (2010). Australian caseload midwifery: the exception or the rule.. Women and Birth, 25, 39-46.

VII. Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial (McLachlan et al., 2012)

The objective of this RCT was to determine whether primary midwife care (caseload midwifery) decreases the caesarean section rate compared with standard maternity care. The study was conducted in a tertiary-care women’s hospital in Melbourne, Australia with a total of 2314 low-risk pregnant women who were randomised to either caseload care from a primary midwife or to standard care with either midwifery or obstetric-trainee care. Women allocated to caseload were less likely to have a caesarean section, more likely to have a spontaneous vaginal birth, less likely to have epidural analgesia and less likely to have an episiotomy. Infants of women allocated to caseload were less likely to be admitted to special or neonatal intensive care. No infant outcomes favoured standard care.

McLachlan, H. L., Forster, D. A., Davey, M. A., Farrell, T., Gold, L., Biro, M. A., et al. (2012). Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial. BJOG, 119, 1483-1492.

VIII. Continuity of care by a midwife team versus routine care during pregnancy and birth: a randomised trial (Rowley et al, 1995)

To compare continuity of care from a midwife team with routine care from a variety of doctors and midwives with a stratified, randomised controlled trial of 814 women attending the antenatal clinic of a tertiary referral, university hospital. The study found that 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.

Rowley, M. J., Hensley, M. J., Brinsmead, M. W., & Wlodarczyk, J. H. (1995). Continuity of care by a midwife team versus routine care during pregnancy and birth: a randomised trial. The Medical Journal of Australia, 163(6), 289-293.

IX. A randomised controlled trial of caseload midwifery care: M@NGO (Midwives @ New Group practice Options) (Tracy et al., 2011)

This RCT proposes to compare the outcomes and costs of caseload midwifery care compared to standard or routine hospital care through a two-arm randomised controlled Trial. Women will be recruited from tertiary women’s hospitals in Sydney and Brisbane, Australia. Women allocated to the caseload intervention will receive care from a named caseload midwife within a Midwifery Group Practice. Control women will be allocated to standard or routine hospital care. Data will be collected at recruitment, 36 weeks antenatally, six weeks and six months postpartum by web based or postal survey. Mesaured outcomes will include caesarean section rates; instrumental birth rates; rates of admission to neonatal intensive care. Other significant findings will be reported, including a comprehensive process and economic evaluation.

Tracy, S. K., Hartz, D., Hall, B., Allen, J., Forti, A., Lainchbury, A., et al. (2011). A randomised controlled trial of caseload midwifery care: M@NGO (Midwives @ New Group Practice Options). BMC Pregnancy and Childbirth, 11.

X. The first year of a midwifery-led model of care in Far North Queensland (Scherman, Smith and Davidson, 2008)

The objective of this paper was to describe a midwifery-led model of care in Far North Queensland and the outcomes obtained in its first year of operation. Prospective analysis of data was conducted for all 203 women who were booked for antenatal care with the midwifery-led unit at Mareeba District Hospital (MDH) and who gave birth during its first year of operation. The paper presents the outcomes from the first year of operation of the midwifery-led model of care, showing that they are consistent with a viable maternity unit, with delivery outcomes and transfer rates that compare favourably with other similar units in Australia.

Scherman, S., Smith, J., & Davidson, M. (2008). The first year of a midwifery-led model of care in Far North Queensland. Medical Journal of Australia, 2, 85-88.

XI. Mothers’ views of caseload midwifery and the value of continuity of care at an Australian regional hospital (Williams et al., 2010)

The objective of this paper was to evaluate mothers’ satisfaction with a caseload-midwifery scheme (MGP) established at Wollongong Hospital as well as clinical data outcomes. 174 women gave birth during the evaluation period. The study found the MGP achieved high levels of continuity of care, mothers’ evaluations of their care were very positive.

Williams, K., Lago, L., Lainchbury, A., & Eagar, K. (2010). Mothers’ views of caseload midwifery and the value of continuity of care at an Australian regional hospital. Midwifery, 26, 615-621.

XII. General obstetrics: Does size matter? A population-based study of birth in lower volume maternity hospitals for low risk women (Tracy, 2005).

The study looked at the association between volume of hospital births per annum and birth outcome for low risk women in Australia. The participants were 331,147 (47.14%) medically ‘low risk’ women who gave birth during 1999-2001. The main outcome measures were rates of intervention at birth and neonatal mortality for low risk women in relation to hospitals with <100, 100-500, 501-1000, 1001-2000 and >2001 births per annum. The study found that, in Australia, lower hospital volume is not associated with adverse outcomes for low risk women.

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XIII. Outcomes in rural obstetrics, Atherton Hospital 1981-1990 (Cameron, 2008).

Analysis of annual obstetric audit data collected over the decade 1981-1990 from the Atherton Hospital in far north Queensland provides evidence of safe obstetric practice provided by a group of non-specialist doctors in a rural community. During that period, there were 2883 deliveries with an overall perinatal mortality of 5.2/1000. There were 1974 public confinements (perinatal mortality 5.1/1000) and 909 private confinements (perinatal mortality 5.5/1000). By including those perinatal deaths that occurred in public patients who were transferred because of intrapartum complications, such as premature labour or neonatal problems, the corrected perinatal mortality rate for the public patients was 9.6/1000, which compares favourably with rates for Queensland and the Far North Statistical Division in 1987 of 13.5/1000 and 16.9/1000, respectively. This was achieved with low intervention, as indicated by an overall Caesarean section rate of 13.0% (public 10.6%, private 18.3%) and an antenatal referral rate of less than 2% of patients from the hospital public clinic for delivery under specialist care.

Cameron, B. (1998) Outcomes in rural obstetrics, Atherton Hospital 1981-1990. Australian Journal of Rural Health, 6(1), 46-51.

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XIV. Do All Hospitals Need Cesarean Delivery Capability? (Leeman and Leeman, 2002)

The study analysed perinatal outcomes at a rural hospital without cesarean delivery capability. The study population included all pregnant women at 20 weeks or greater of gestational age (n = 1132) over a 5-year period in a predominantly Native American region of northwestern New Mexico. The study found that the presence of a rural maternity care unit without surgical facilities can safely allow a high proportion of women to give birth closer to their communities. This study demonstrated a low level of perinatal risk. Most transfers were made for induction or augmentation of labor. Rural hospitals that do not have cesarean delivery capability but are part of an integrated perinatal system can safely offer obstetric services by using appropriate antepartum and intrapartum screening criteria for obstetric risk.

Leeman, L., & Leeman, R. (2002). Do all hospitals need cesarean delivery capability? An outcomes study of maternity care in a rural hospital without on-site cesarean capability. Journal of Family Practice, 52(2), 129-134.

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XV. Does having cesarean section capability make a difference to a small rural maternity service? (Lynch et al., 2005)

The study objective was to determine whether having cesarean section capability in an isolated rural community makes a difference in adverse maternal or perinatal outcomes using a retrospective study comparing population-based obstetric outcomes of two rural remote hospitals in northwestern British Columbia. One hospital had cesarean section capability; one did not. The participants were women who carried pregnancies beyond 20 weeks’ gestation and who gave birth between January 1, 1986, and December 31, 2000. The rate of preterm deliveries in the hospital without c-section capablity was higher. Otherwise, there were no differences in adverse maternal or perinatal outcomes in the two populations. The hospital with c-section capability, 69.8% of women delivered locally compared with 50.2% of women in the hospital without c-section capability. Having local cesarean section capability is associated with a greater proportion of local deliveries and a lower rate of preterm deliveries.

Lynch et al. (2005). Does having cesarean section capability make a difference to a small rural maternity service? Canadian Family Physician, 51 (9), 1238-1239.

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XVI. Rural Maternity Care Joint Position Paper (Society of Obstetricians and Gynaechologists of Canada, 2012)

Objective: To provide an overview of current information on issues in maternity care relevant to rural populations.

Evidence: Medline was searched for articles published in English from 1995 to 2012 about rural maternity care. Relevant publications and position papers from appropriate organizations were also reviewed.

Outcomes: This information will help obstetrical care providers in rural areas to continue providing quality are for women in their communities.

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XVII. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study (Birthplace in England Collaborative Group, 2011)

To compare perinatal outcomes, maternal outcomes, and interventions in labour by planned place of birth at the start of care in labour for women with low risk pregnancies using a prospective cohort design in England. 64 538 eligible women with a singleton, term (≥37 weeks gestation), and “booked” pregnancy who gave birth between April 2008 and April 2010. Planned caesarean sections and caesarean sections before the onset of labour and unplanned home births were excluded. The results support a policy of offering healthy women with low risk pregnancies a choice of birth setting. Women planning birth in a midwifery unit and multiparous women planning birth at home experience fewer interventions than those planning birth in an obstetric unit with no impact on perinatal outcomes. For nulliparous women, planned home births also have fewer interventions but have poorer perinatal outcomes.

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