Caseload midwifery compared to standard or private obstetric care for first time mothers in a public teaching hospital in Australia: a cross sectional study of cost and birth outcomes

Abstract

BackgroundIn many countries midwives act as the main providers of care for women throughout pregnancy, labour and birth. In our large public teaching hospital in Australia we restructured the way midwifery care is offered and introduced caseload midwifery for one third of women booked at the hospital. We then compared the costs and birth outcomes associated with caseload midwifery compared to the two existing models of care, standard hospital care and private obstetric care.MethodsWe undertook a cross sectional study examining the risk profile, birth outcomes and cost of care for women booked into one of the three available models of care in a tertiary teaching hospital in Australia between July 1st 2009 December 31st 2010. To control for differences in population or case mix we described the outcomes for a cohort of low risk first time mothers known as the 'standard primipara'.ResultsAmongst the 1,379 women defined as 'standard primipara' there were significant differences in birth outcome. These first time ‘low risk’ mothers who received caseload care were more likely to have a spontaneous onset of labour and an unassisted vaginal birth 58.5% in MGP compared to 48.2% for Standard hospital care and 30.8% with Private obstetric care (p < 0.001). They were also significantly less likely to have an elective caesarean section 1.6% with MGP versus 5.3% with Standard care and 17.2% with private obstetric care (p < 0.001). From the public hospital perspective, over one financial year the average cost of care for the standard primipara in MGP was $3903.78 per woman. This was $1375.45 less per woman than those receiving Private obstetric care and $1590.91 less than Standard hospital care per woman (p < 0.001). Similar differences in cost were found in favour of MGP for all women in the study who received caseload care.ConclusionsCost reduction appears to be achieved through reorganising the way care is delivered in the public hospital system with the introduction of Midwifery Group Practice or caseload care. The study also highlights the unexplained clinical variation that exists between the three models of care in Australia.

Models of maternity care: evidence for midwifery continuity of care

“…In this study, a “standard primipara”, defined as a first time, “low‐risk” mother, was used as the unit of comparison, to reduce differences between the caseload care, standard hospital care and private obstetric care groups. Women who received caseload care were more likely to have a spontaneous onset of labour and an unassisted vaginal birth and less likely to have an elective caesarean delivery than those in the other two groups, with lower average costs of care 24 …”

“…Midwifery continuity of carer has also been examined in non‐randomised studies, although these carry an inherently increased risk of bias. These include a study in a large referral centre in Sydney, where a third of pregnant women received care through a midwifery continuity of care (caseload care) model 24 . Midwives were organised in groups of four and were responsible for the care of a specified caseload of women throughout pregnancy, birth and the post partum period 25 .…”

Primiparous women's preferences for care during a prolonged latent phase of labour

“…Our results indicate that perhaps more small midwife-led units would allow for low-risk women to receive better care, especially during early labour. Two large studies from Australia have shown that case-load midwifery, that is, having a known midwife during antenatal, intrapartum and postpartum care, increased the likelihood of later admission in a later stage of labour [43] and for primiparas an increased proportion of spontaneous onset of labour, reduction in caesarean sections and lower costs [44].…”

Updates from the Literature, November/December 2018

“…Case‐load midwifery describes a continuity of care model in which women see one midwife or a partner midwife for antepartum, intrapartum, and postpartum care. This model of care is also associated with higher rates of spontaneous labor, lower elective cesarean birth rates, and higher levels of maternal satisfaction with the birth experience . It would be interesting to consider research about how midwifery education can include or does include the concept of being “with woman” and the impact of this competency training on practice after education and population‐wide childbirth outcomes.…”