Pregnancy: Midwife vs Standard Maternity Care Study

Prof Sally K Tracy DMid Midwifery and Women's Health Research Unit University of Sydney, Royal Hospital for Women Randwick, NSW, Interview with:
Prof Sally K Tracy DMid
Midwifery and Women’s Health Research Unit
University of Sydney, Royal Hospital for Women
Randwick, NSW, Australia What are the main findings of the study?

Prof. Tracy: We recruited 1748 pregnant women, of all risk types, from two tertiary teaching hospitals in different states in Australia and allocated them to receive either caseload midwifery care (871) or standard maternity care (877).

The study found more women in caseload midwifery experienced an unassisted vaginal birth without pharmacological analgesia, and fewer women experienced an elective caesarean. While the trial findings did not show a statistically significant difference in the rate of caesarean sections between either group, the overall rate fell by more than 20 percent from pre-trial levels.

Newborn infants in both groups achieved similar physical assessment scores (Apgar scores). A slightly lower number of pre-term births and neonatal intensive care admissions among the midwifery caseload group was not statistically significant.

Important secondary findings of the study include:

  • 30 percent more spontaneous onset of labour
  • less induction of labour
  • less severe blood loss, and
  • stronger likelihood of breastfeeding at discharge from hospital.

These small differences accounted for an overall difference of AU$566.74 less with caseload midwifery than with standard care.

Caseload midwifery appeared to alter some of the pathways that recurrently contribute to increased obstetric intervention.  Having this level of continuity of care works on the assumption that women will labour more effectively, need to stay in hospital less time and feel a stronger sense of satisfaction and personal control if they have the opportunity to get to know their midwife at the beginning of pregnancy. Were any of the findings unexpected?

Prof. Tracy: This was the first randomised trial confirming that caseload midwifery care is feasible for women of all risk and cost effective at all levels of care.

Given the limited information available about the cost of maternity services in Australia, it’s significant to find that caseload midwifery produces a saving of $566.74 for each woman who gave birth in the public hospital. It refutes the common misconception that one-to-one caseload midwifery care was expensive. What should clinicians and patients take away from your report?

Prof. Tracy: The study found that continued care from a named midwife throughout pregnancy, birth, and after the baby is born (caseload midwifery) is just as safe as standard maternity care (shared between rostered midwives, and medical practitioners in discrete wards or clinics) for all women irrespective of risk, and is significantly cheaper. Caseload midwifery care has been largely overlooked because of the incorrect belief that the service will be too expensive and that the model is not safe for complex pregnancies. Our randomised trial showed that caseload care can achieve similar outcomes to standard care – and it costs the public purse significantly less. The perception that this is a ‘boutique’ service that will cost far too much is incorrect. The midwife is making much better use of her time in responding to the needs of each woman as she is needed – rather than clocking up her 40 hours rostered in a ward or clinic regardless of whether there are women coming though the system at that time. Baby’s have a habit of arriving unexpectedly  – and if a woman is booked with a caseload midwife in a small Midwifery group practice  – her midwife will be ready to be with her in labour whenever she begins the labour process.

In addition to this the study should dispel the confusion around the notion that having a caseload midwife means that women will not necessarily get to see a doctor if they need to. Having a caseload midwife means that a woman with a complex pregnancy not only has individualised midwifery care with a midwife whom she has grown to trust, but the collaboration between her midwife and an obstetrician who is also part of the team or formally connected as a consultant to the small group practice, means that the lines of communication between midwives and obstetricians have the potential to be further enhanced. What recommendations do you have for future research as a result of this study?

Prof. Tracy: Further study should examine the interface between the ‘core’ rostered midwives employed by the hospital and the caseload midwife coming in and out of the hospital and community to ascertain how to achieve optimum continuity? We should also look at what is the optimal time for going home and receiving postnatal care – how many visits – of for how many weeks after giving birth? And there could be further work in ascertaining what a sustainable caseload is – 35- 40 women per year?  Although we have survey data from 36 weeks during pregnancy and up to 6 months post birth recording the self assessed health status and the experience of the women, it would be very useful to have long term data on the infant and mother wellbeing. Also, given the success of the collaborative effort between obstetricians and midwives in this study it would be useful to research new ways of sharing education and training within this caseload model of care.


Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial
Prof Sally K Tracy DMid,Donna L Hartz PhD,Mark B Tracy FRACP,Jyai Allen BMid,Amanda Forti RM,Bev Hall MIPH,Jan White RM,Anne Lainchbury MMid,Helen Stapleton PhD,Michael Beckmann FRANZCOG,Andrew Bisits FRANZCOG,Prof Caroline Homer PhD,Prof Maralyn Foureur PhD,Alec Welsh FRANZCOG,Prof Sue Kildea PhD
The Lancet – 17 September 2013
DOI: 10.1016/S0140-6736(13)61406-3

Last Updated on September 20, 2013 by Marie Benz MD FAAD