Caseload midwifery care versus standard maternity care for women of any risk: MANGO, a randomised controlled trial

Midwifery and Women's Health Research Unit, University of Sydney, Royal Hospital for Women, Randwick, NSW, Australia. Electronic address: .
The Lancet (Impact Factor: 45.22). 09/2013; 382(9906). DOI: 10.1016/S0140-6736(13)61406-3
Source: PubMed


Women at low risk of pregnancy complications benefit from continuity of midwifery care, but no trial evidence exists for women with identified risk factors. We aimed to assess the clinical and cost outcomes of caseload midwifery care for women irrespective of risk factors.
In this unblinded, randomised, controlled, parallel-group trial, pregnant women at two metropolitan teaching hospitals in Australia were randomly assigned to either caseload midwifery care or standard maternity care by a telephone-based computer randomisation service. Women aged 18 years and older were eligible if they were less than 24 weeks pregnant at the first booking visit. Those who booked with another care provider, had a multiple pregnancy, or planned to have an elective caesarean section were excluded. Women allocated to caseload care received antenatal, intrapartum, and postnatal care from a named caseload midwife (or back-up caseload midwife). Controls received standard care with rostered midwives in discrete wards or clinics. The participant and the clinician were not masked to assignment. The main primary outcome was the proportion of women who had a caesarean section. The other primary maternal outcomes were the proportions who had an instrumental or unassisted vaginal birth, and the proportion who had epidural analgesia during labour. Primary neonatal outcomes were Apgar scores, preterm birth, and admission to neonatal intensive care. We analysed all outcomes by intention to treat. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12609000349246.
Publicly insured women were screened at the participating hospitals between Dec 8, 2008, and May 31, 2011. 1748 pregnant women were randomly assigned, 871 to caseload and 877 to standard care. The proportion of caesarean sections did not differ between the groups (183 [21%] in the caseload group vs 204 [23%] in the standard care group; odds ratio [OR] 0·88, 95% CI 0·70-1·10; p=0·26). The proportion of women who had elective caesarean sections (before onset of labour) differed significantly between caseload and standard care (69 [8%] vs 94 [11%]; OR 0·72, 95% CI 0·52-0·99; p=0·05). Proportions of instrumental birth were similar (172 [20%] vs 171 [19%]; p=0·90), as were the proportions of unassisted vaginal births (487 [56%] vs 454 [52%]; p=0·08) and epidural use (314 [36%] vs 304 [35%]; p=0·54). Neonatal outcomes did not differ between the groups. Total cost of care per woman was AUS$566·74 (95% 106·17-1027·30; p=0·02) less for caseload midwifery than for standard maternity care.
Our results show that for women of any risk, caseload midwifery is safe and cost effective.
National Health and Medical Research Council (Australia).

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Available from: Sally K Tracy, Nov 05, 2014
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    • "Research has established the benefits of a continuity model of care for women with improved birthing outcomes and increased satisfaction of care (Browne and Taylor, 2014; Fereday et al., 2009; Mclachlan et al., 2013; Sandall et al., 2013). Continuity of carer also results in better birthing outcomes for the newborn (Sandall et al., 2013; Turnbull et al., 2009) and financial benefits for the health service (Homer et al., 2001; Tracy et al., 2013). The student Continuity of Care Experiences can reduce the pressure for clinical practicum hours in maternity units as students are allocated women with whom they form relationships and accumulate their clinical hours 'with woman' rather than 'with institution'. "
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    ABSTRACT: Discussions continue within the midwifery profession around the number of and type of clinical experiences required to ensure competent midwifery graduates. Introduction of the three year Bachelor of Midwifery in Australia, almost two decades ago, was intended to reduce the pressure students were under to complete their academic requirements whilst ensuring students developed midwifery practice that encapsulates the philosophical values of midwifery. Currently, midwifery students are mandated to achieve a minimum number of clinical skills and Continuity of Care Experience (CCE) relationships in order to register upon completion of their degree. To achieve these experiences, universities require students to complete a number of clinical practicum hours. Furthermore students are required to demonstrate competent clinical performance of a number of clinical skills. However, there is no evidence to date that a set number of experiences or hours ensures professional competence in the clinical environment. The aim of this paper is to promote discussion regarding the mandated requirements for allocated clinical practicum hours, specified numbers of clinical-based skills and CCE relationships in the context of learning to be a midwife in Australia.
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    • "Continuity of care during pregnancy has also been identified as a major factor contributing to the welfare of pregnant women (Crafter et al., 1997), which can lead to improved health outcomes for both mother and child (Sandall et al., 2013). However, as with formal health literacy screening, continuity of midwifery care is often difficult to provide within established working practices and available resources (Tracy et al., 2013). Therefore, the use of media and communication technologies to provide information about pregnancy potentially forms a vital link between patients and health care providers (Raine et al., 2010). "
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    ABSTRACT: Objective To examine the informal approaches taken by midwives and other antenatal staff to adapt health communication to the needs of their patients, as well as their perception of the barriers faced when trying to provide tailored health promotion. Design Qualitative research methods (participant observation, individual and group interviews) were utilised to gain an understanding of how media and communication resources were used in practice within the study hospital. Setting A major metropolitan teaching hospital located in the Northern suburbs of Adelaide, South Australia. Participants Individual semi-structured interviews with antenatal staff (n=8) were combined with group interviews (n=2; total number of staff=13), and observational research. Findings Midwives and other antenatal staff use a range of strategies to meet the perceived health literacy level of their patients. However, their attempts to tailor health information to individual needs are frequently based on incomplete information about patients' health literacy, may be inconsistent in delivery and contentand are seldom assessed to determine whether communication has been understood or led to patient behaviour change. Key conclusions Midwives fully recognise the need to adapt standard printed materials to meet the diverse health literacy needs of patients but lack the resources required to evaluate whether these adaptations have positive effect. Implications for practice Midwives' commitment to improving health communication provides a latent resource that institutions can build on to improve health outcomes for patients with low health literacy. This requires improvements in health communication training, willingness to use a range of validated instruments for measuring health literacy, and commitment to use of innovative approaches to health promotion where these have been shown to have a positive impact on health behaviours.
    Full-text · Article · Dec 2014 · Midwifery
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    • "In some Australian regions continuity of care from a known midwife is being successfully implemented for Aboriginal women living in remote areas [33,45,62] as well urban areas [34,63]. Recent Australian evidence suggests that midwifery-led continuity of care models are safe, cost effective [64] and are highly desired by women [33,65-67]. The opportunity for continuity of care is promoted as a national maternity reform objective as is providing choices of care to women in a range of settings, including rural settings where a disproportionately high number of Indigenous women are located [20]. "
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    ABSTRACT: Background: To describe the maternity care experiences of Aboriginal and/or Torres Strait Islander women in Queensland, Australia and to identify areas for policy and practice improvements. Methods: A culturally-tailored survey requesting both quantitative and qualitative information was completed by respondents either independently (online or in hard copy) or with the assistance of a trained peer-interviewer. Data were analysed using descriptive statistics and thematic analysis.Eligible women were over 16 years of age, identified as Aboriginal and/or Torres Strait Islander, resided in Queensland, and had a live, singleton birth between the first of July 2011 and the first of July 2012. Results: 187 women of 207 respondents were included in analyses. Women reported high rates of stressful life events in pregnancy, low levels of choice in place of birth and model of care and limited options to carry out cultural practices. High levels of confidence in parenting were also reported. Women were less likely to report being treated with kindness, understanding and respect by maternity care staff than women answering a similar mainstream survey. Conclusions: Aboriginal and Torres Strait Islander women have additional needs to mainstream Australian women. This study identified a number of recommendations to improve services including the need to enhance the cultural competence of maternity services; increase access to continuity of midwifery care models, facilitate more choices in care, work with the strengths of Aboriginal and Torres Strait Islander women, families and communities, and engage women in the design and delivery of care.
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