Collaboration in maternity care: a randomised controlled trial comparing community‐based continuity of care with standard hospital care

Abstract

Objective 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. Design Randomised controlled trial.Setting 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 ®rst antenatal booking visit at an Australian metropolitan public hospital.Main outcome measures Data were collected on onset and outcomes of labour, antenatal, intrapartum and postnatal complications, antenatal admissions to hospital and neonatal mortality and morbidity. Results There was a signi®cant 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 signi®cant 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 signi®cant (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.Conclusion Community-based continuity of maternity care provided by midwives and obstetricians resulted in a signi®cantly reduced caesarean section rate. There were no other differences in clinical outcomes.

Has the medicalisation of childbirth gone too far?

“…In a randomised controlled trial comparing community based care with standard hospital care a significant difference in caesarean section rates was found (13.3% v 17.8% respectively) 29. Planning a home birth30 or booking for care at a midwife led birth centre is also associated with lower operative delivery rates.…”

Does continuity of care impact decision making in the next birth after a caesarean section (VBAC)? a randomised controlled trial

“…Women who had midwife-led models of care were less likely to use regional analgesia (RR 0.81, 95% CI 0.73–0.91) or have an instrumental birth (RR 0.86, 95% CI 0.78–0.96), and were more likely not to use intrapartum analgesia/anaesthesia (RR 1.16, 95% CI 1.05–1.29), experience spontaneous vaginal birth (RR 1.04, 95% CI 1.02–1.06), feel in control during labour and childbirth (RR 1.74, 95% CI 1.32–2.30), and initiate breastfeeding (RR 1.35, 95% CI 1.03–1.76) [22]. Three trials have shown that midwifery continuity of care significantly reduced the CS rate: one small trial in Canada [28] and two in Australia, the most recent being published in 2012 [29,30]. …”

Public and private pregnancy care in Reggio Emilia Province: an observational study on appropriateness of care and delivery outcomes

“…Furthermore, they were less likely to experience foetal loss before 24 weeks’ gestation and their babies were more likely to have a shorter length of hospital stay. Even if there were no statistically significant differences in the overall estimates for caesarean births [10], two studies included in the Cochrane review, one conducted in Canada [28] and one in Australia [29], observed a lower CS rate for the midwife or midwife and obstetrician model of care compared to the standard physician-led model.…”