Team Midwifery Care in a Tertiary Level Obstetric Service: A Randomized Controlled Trial

Background: In 1996 a new model of maternity care characterized by continuity of midwifery care from early pregnancy through to the postpartum period was implemented for women attending Monash Medical Centre, a tertiary level obstetric service, in Melbourne, Australia. The objective of this study was to compare the new model of care with standard maternity care. Methods: In a randomized controlled trial, 1000 women who booked at the antenatal clinic and met the eligibility criteria were randomly allocated to receive continuity of midwifery care (team care) from a group of seven midwives in collaboration with obstetric staff, or care from a variety of midwives and obstetric staff (standard care). The primary outcome measures were procedures in labor, maternal outcomes, neonatal outcomes, and length of hospital stay. Results: Women assigned to the team care group experienced less augmentation of labor, less electronic fetal monitoring, less use of narcotic and epidural analgesia, and fewer episiotomies but more unsutured tears. Team care women stayed in hospital 7 hours less than women in standard care. More babies of standard care mothers were admitted to the special care nurseries for more than 5 days because of preterm birth, and more babies of team care mothers were admitted to the nurseries for more than 5 days with intrauterine growth retardation. No differences occurred in perinatal mortality between the two groups. Conclusions: Continuity of midwifery care was associated with a reduction in medical procedures in labor and a shorter length of stay without compromising maternal and perinatal safety. Continuity of midwifery care is realistically achievable in a tertiary obstetric referral service.     

Temporal changes in key maternal and fetal factors affecting birth outcomes: A 32-year population-based study in an industrial city

Background

In Australia and internationally, there is concern about the growing proportion of women giving birth by caesarean section. There is evidence of increased risk of placenta accreta and percreta in subsequent pregnancies as well as decreased fertility; and significant resource implications. Randomised controlled trials (RCTs) of continuity of midwifery care have reported reduced caesareans and other interventions in labour, as well as increased maternal satisfaction, with no statistically significant differences in perinatal morbidity or mortality. RCTs conducted in the UK and in Australia have largely measured the effect of teams of care providers (commonly 6–12 midwives) with very few testing caseload (one-to-one) midwifery care. This study aims to determine whether caseload (one-to-one) midwifery care for women at low risk of medical complications decreases the proportion of women delivering by caesarean section compared with women receiving 'standard' care. This paper presents the trial protocol in detail.

Methods/design

A two-arm RCT design will be used. Women who are identified at low medical risk will be recruited from the antenatal booking clinics of a tertiary women's hospital in Melbourne, Australia. Baseline data will be collected, then women randomised to caseload midwifery or standard low risk care. Women allocated to the caseload intervention will receive antenatal, intrapartum and postpartum care from a designated primary midwife with one or two antenatal visits conducted by a 'back-up' midwife. The midwives will collaborate with obstetricians and other health professionals as necessary. If the woman has an extended labour, or if the primary midwife is unavailable, care will be provided by the back-up midwife. For women allocated to standard care, options include midwifery-led care with varying levels of continuity, junior obstetric care and community based general medical practitioner care. Data will be collected at recruitment (self administered survey) and at 2 and 6 months postpartum by postal survey. Medical/obstetric outcomes will be abstracted from the medical record. The sample size of 2008 was calculated to identify a decrease in caesarean birth from 19 to 14% and detect a range of other significant clinical differences. Comprehensive process and economic evaluations will be conducted.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN012607000073404.     

Team midwifery: the views and job satisfaction of midwives

OBJECTIVE: As part of an evaluation of a team midwifery scheme we assessed the satisfaction of community and hospital midwives and their views about working practices and care provided. DESIGN: Survey of complete enumeration of community midwives (most working in teams) and hospital midwives providing antenatal, intrapartum and postnatal care to a population of women. SETTING: Community and district general hospital, in the UK. MEASUREMENTS: Socio-demographic data about midwives, ratings on Likert-type scales of job satisfaction, quality of care variables, relationships with other professionals and women; Glasgow Midwifery Process Questionnaire. FINDINGS: 80 out of 92 midwives (87%) responded. Community midwives were younger, more recently qualified, employed on lower grades, less likely to be married and have children than hospital midwives. The Glasgow Midwifery Process Questionnaire revealed that midwives, particularly hospital midwives, had low morale. Community midwives were more likely to report that their job was satisfying, offered a variety of work, enabled them to use skills and knowledge fully, and offered opportunities for professional development. Hospital midwives were more likely to report following strict guidelines. Community midwives, however, disliked the long on call and unsociable hours, and reported disruption to family/social life. Forty-one per cent of hospital midwives (12) and 28% of community midwives (14) reported regularly working beyond their shift. Whilst midwives thought that team midwifery was, in theory, a good idea, in practice it was not working well because of the size of teams and caseload. About half the community midwives felt that teams had detrimentally affected the quality and continuity of care. CONCLUSIONS: Whilst team midwifery aims to improve continuity of maternity care, in this instance, it does not appear to achieve this aim. Many midwives reported it had adversely affected care. Team midwifery is a source of disillusionment for midwives, since the continuity of carer ideal is unachievable in a system based on teams of seven or more. Attendance at the delivery may be a luxury provided at the expense of antenatal and postnatal continuity. IMPLICATIONS: Midwives recommended remedial measures: reducing team sizes, reducing caseloads, ensuring teams were fully staffed, reducing 'on call' and labour ward hours. It remains to be seen whether these will have the desired effects on continuity of care.     

Continuity of care in maternity services: women's views of one team midwifery scheme

OBJECTIVE: To describe the views of women using one team midwifery scheme and compare them with women using more traditional models of midwifery care. DESIGN: Postal and interview survey of 1482 consecutive women delivering over a six-month period. SETTING: Hospital and community in the South-East of England. SAMPLES: Three groups of women were surveyed: (1) the Study Group consisted of women who delivered either at Hospital A or at home, and who received their antenatal, intrapartum and postnatal care from one of seven midwifery teams; (2) Comparison Group A consisted of women who received their antenatal and postnatal care from traditionally organised community midwives who were delivered by hospital midwives at Hospital A; and (3) Comparison Group B consisted of women who received their antenatal and postnatal care from traditionally organised community midwives who were delivered by hospital midwives at Hospital B. METHODS: Postal questionnaires and interviews, and an audit of midwife contacts. MAIN OUTCOME MEASURES: Process of care and satisfaction with care. FINDINGS: 88% of women responded. Women cared for under the team scheme exhibited no overall advantages in terms of satisfaction with various aspects of their care. Women cared for under the traditional model of care were the most satisfied with antenatal care. They had reported the highest percentage of named midwives, the highest continuity of carer antenatally and were the most likely to say that they had formed a relationship with their midwives. The majority of women who had met their delivering midwives previously did report that it made them feel more at ease, however, the majority of those who had not met their delivering midwives previously reported that it did not affect them one way or the other. CONCLUSION: In the team scheme, attempts to increase continuity of carer throughout pregnancy, labour and the postnatal period appear to have occurred at the expense of continuity in the ante- and postnatal periods. From the women's perspective the findings of this study support the view that the smaller the size of midwifery teams the better. The current focus on continuity throughout pregnancy and childbirth and the postnatal period may be misguided, if it is provided at the expense of continuity of carer in pregnancy and the postnatal period.     

Does Team Midwife Care Increase Satisfaction with Antenatal,Intrapartum, and Postpartum Care? A Randomized Controlled Trial

Background: Although policymakers have suggested that improving continuity of midwifery can increase women's satisfaction with care in childbirth, evidence based on randomized controlled trials is lacking. New models of care, such as birth centers and team midwife care, try to increase the continuity of care and caregiver. The objective of this study was to evaluate the effect of a new team midwife care program in the standard clinic and hospital environment on satisfaction with antenatal, intrapartum, and postpartum care in low‐risk women in early pregnancy. Methods: Women at Royal Women's Hospital in Melbourne, Australia, were randomly allocated to team midwife care (n = 495) or standard care (n = 505) at booking in early pregnancy. Doctors attended most women in standard care, and continuity of the caregiver was lacking. Satisfaction was measured by means of a postal questionnaire 2 months after the birth. Results: Team midwife care was associated with increased satisfaction, and the differences between the groups were most noticeable for antenatal care, less noticeable for intrapartum care, and least noticeable for postpartum care. The study found no differences between team midwife care and standard care in medical interventions or in women's emotional well‐being 2 months after the birth. Conclusion: Conclusions about which components of team midwife care were most important to increased satisfaction with antenatal care were difficult to draw, but data suggest that satisfaction with intrapartum care was related to continuity of the caregiver.     

Single Room Maternity Care and Client Satisfaction

Background: Single room maternity care is the provision of intrapartum and postpartum care in a single room. It promotes a philosophy of family centered care in which one nurse cares for the family consistently throughout the intrapartum and postpartum periods. At B.C. Women's Hospital, a tertiary level obstetric teaching hospital in Vancouver, British Columbia, a seven‐bed, single room maternity care unit was developed and opened as a demonstration project. As part of the evaluation of this unit, client satisfaction was compared between women enrolled in single room maternity care and those in a traditional setting. Method: The study group included 205 women who were admitted to the single room maternity care unit after meeting the low‐risk criteria. Their responses on a satisfaction survey were compared with those of a historical comparison group of 221 women meeting the same eligibility criteria who were identified through chart audits 3 months before the single room maternity care unit was opened. A second, concurrent comparison group comprised 104 women who also met eligibility criteria. Results: Study group women were more satisfied than comparison groups in all areas evaluated, including provision of information and support, physical environment, nursing care, patient education, assistance with infant feeding, respect for privacy, and preparation for discharge. Conclusions: Single room maternity care was associated with a significant improvement in client satisfaction because of many factors, including the physical setting itself, avoidance of transfers, and improved continuity of nursing care.     

Being safe practitioners and safe mothers: A critical ethnography of continuity of care midwifery in Australia

Objective

to examine how midwives and women within a continuity of care midwifery programme in Australia conceptualised childbirth risk and the influences of these conceptualisations on women's choices and midwives' practice.

Design and setting

a critical ethnography within a community-based continuity of midwifery care programme, including semi-structured interviews and the observation of sequential antenatal appointments.

Participants

eight midwives, an obstetrician and 17 women.

Findings

the midwives assumed a risk-negotiator role in order to mediate relationships between women and hospital-based maternity staff. The role of risk-negotiator relied profoundly on the trust engendered in their relationships with women. Trust within the mother–midwife relationship furthermore acted as a catalyst for complex processes of identity work which, in turn, allowed midwives to manipulate existing obstetric risk hierarchies and effectively re-order risk conceptualisations. In establishing and maintaining identities of ‘safe practitioner’ and ‘safe mother’, greater scope for the negotiation of normal within a context of obstetric risk was achieved.

Key conclusions and implications for practice

the effects of obstetric risk practices can be mitigated when trust within the mother–midwife relationship acts as a catalyst for identity work and supports the midwife's role as a risk-negotiator. The achievement of mutual identity-work through the midwives' role as risk-negotiator can contribute to improved outcomes for women receiving continuity of care. However, midwives needed to perform the role of risk-negotiator while simultaneously negotiating their professional credibility in a setting that construed their practice as risky.     

An exploration of midwives' views of the current system of maternity care in England

OBJECTIVE: to explore, in-depth, the views of midwives working in maternity services about birth setting, models of care and philosophy of care. DESIGN: an Appreciative Inquiry approach was adopted utilising focus group interviews as the method of data collection. SETTING: 15 focus group interviews were conducted at 14 sites in England. PARTICIPANTS: a purposive sample of 120 midwives and six student midwives who were serving women in different birth settings (home, free-standing maternity units, midwife-led units, and traditional obstetric units) participated, in 2001/2002. FINDINGS: the main themes generated by the midwives were: cultural changes; midwifery leadership; appropriate role models; training in normality; appropriate responsibility of care divisions; choice for women; equity of care provision between women considered to be at high or low risk; and staff morale. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: this study highlighted the consistency of views amongst midwives working in different settings. Midwives wanted support to practice autonomously in an environment that facilitated equity of care for women and job satisfaction for midwives. Suggestions were put forward by midwives on how to improve maternity services. A unified approach is required to develop these suggestions into strategies, that will remove the identified barriers and promote normality.     

Evaluation of satisfaction with midwifery care

OBJECTIVE: to determine if there were differences in women's satisfaction with maternity care given by doctors and midwives. In addition a simple, six-question, satisfaction questionnaire was to be tested. DESIGN: a randomised controlled trial comparing two models of maternity care. SETTING: a tertiary referral centre in Alberta, Canada. PARTICIPANTS: one hundred and ninety four women with a low-risk pregnancy were randomly assigned to either the midwife care, experimental group (n = 101), or the doctor care, control group (n = 93). INTERVENTIONS: a pilot midwifery programme was introduced into a maternity services delivery system that did not have established midwifery. MEASUREMENTS: women's satisfaction was measured, at two weeks postpartum, with the Labour and Delivery Satisfaction Index (LADSI), general attitudes toward the birth experience, also at two weeks postpartum; with the Attitudes about Labour and Delivery Experience (ADLE) questionnaire. Fluctuations in satisfaction were measured with a Six Simple Questions (SSQ) questionnaire at 36 weeks gestation and 48 hours, two and six weeks postpartum. FINDINGS: women in the midwife group reported significantly greater satisfaction and a more positive attitude toward their childbirth experience than women in the doctor group (p < 0.001). The SSQ demonstrated scores similar to the LADSI. Satisfaction in both groups was lowest at 36 weeks gestation and highest immediately postpartum. KEY CONCLUSIONS: women experiencing low-risk pregnancies were more satisfied with care by midwives than with care provided by doctors. Satisfaction scores were high for both groups and may have been lower for women in the doctor group as a result of disappointment with caregiver assignment as all women had sought midwifery care. The SSQ measures similar dimensions to the LADSI but the agreement is not strong enough to recommend its use as a substitute at this time. IMPLICATIONS FOR PRACTICE: the significantly higher satisfaction of the women with the care provided by the midwives together with better clinical outcomes reported elsewhere suggest that the option of midwifery care should be accessible as an option for all women in Canada. Further research is suggested to determine the usefulness of the SSQ.     

Midwifery in the Industrialized World

Because of the successful attempt at the beginning of this century to dismantle midwifery in Canada and the United States, there is much ignorance and misunderstanding among the public and health professionals about the essential role of midwives in modern maternity services. With the renaissance of midwifery in North America, health administrators, health providers and the public need information about modern midwifery.Midwifery is primary health care for women with a focus on reproductive health. Key elements of the midwifery model of care are normality, facilitation of natural processes with the minimal amount of evidenced-based intervention, and die empowerment of the woman and the family.Scientific evidence proves that: midwives are as safe or safer than doctors for primary maternity care; using midwives greatly reduces the rates of unnecessary obstetrical interventions; midwifery services lead to considerable cost savings; midwives have more success in reaching socially disadvantaged groups; women have more satisfaction with midwife-managed care.In nearly every industrialized country outside North America, midwives provide primary maternity care, and obstetricians, generally, are hospital-based specialists providing tertiary maternity care. In Scandinavia, the Netherlands, New Zealand and other countries, all prenatal, intrapartum and post-partum care for at least 70 percent of women is provided solely by midwives. These countries have much lower obstetrical intervention rates than Canada, and have maternal and perinatal mortality rates equal to and, in some cases, better than Canada.An autonomous midwifery profession in equal standing with the medical profession is a key component of an optimal modern maternity care system.     

Women's Satisfaction with Birth Center Care: A Randomized,Controlled Study

This randomized, controlled trial compared women's satisfaction with care at an in-hospital birth center with standard obstetric care in Stockholm. Subjects were 1230 women with an expected date of birth between October 1989 and February 1992, who expressed interest in birth center care, and who were medically low risk. The intervention was the random allocation of maternity care at the birth center or standard obstetric care. Birth center women expressed greater satisfaction with antenatal, intrapartum, and postpartum care, especially psychological aspects of care. Of these women, 63 percent thought that the antenatal care had raised their self-esteem, versus 18 percent of the control group. Eighty-nine percent of the experimental group would prefer birth center care for any future birth, and 46 percent of the control group would prefer standard care. Birth center care successfully meets the needs of women who are interested in natural childbirth and active involvement in their own care, and are concerned about the psychological aspects of birth.     

Obstetric Team Care by a Private Midwife and Obstetrician—A Pilot Trial

Autonomous obstetric care by either midwife or doctor excludes the complementary expertise of each other. However, in the present Australian hospital system midwives are usually unable to provide continuity of antepartum, intrapartum and postpartum care to the individual patient and thus are less able to accept ongoing clinical responsibilities or provide satisfactory psychological support to the patient. A pilot trial was instituted to assess the practicality of team care by an obstetrician and a midwife where the midwife, having joined with the obstetrician in the care of the patient at all antenatal visits, attended the patient on her admission to the labour ward until 1 hour after her delivery. This personalized midwifery service did not, in this trial, involve the midwife in duties or responsibilities greater than those of the normal labour ward staff but provided the patient with continuity of care and support by a midwife known to the patient throughout her labour and delivery. The midwife visited the patient twice postnatally. Sixty private patients entered the trial and 56 were attended by the midwife in labour. The mean length of attendance of the midwife in the labour ward was 6.6 hours (range 2-14 hours). The mean length of labour in the hospital was 5.2 hours. There was an apparent reduction in analgesic requirements in the trial patients compared to the concurrent rates in the hospital. All patients in the trial were very enthusiastic about the service, the words 'confidence' and 'security' recurring in their later comments. The service was well accepted by the rostered labour suite staff after an initial orientation programme.(ABSTRACT TRUNCATED AT 250 WORDS)     

Care providers’ views and experiences of postnatal care in private hospitals in Victoria,Australia

Objectivein Australia, as in other developed countries, women have consistently reported lower levels of satisfaction with postnatal care compared with antenatal and intrapartum care. However, in Victoria Australia, women who receive private hospital postnatal care have rated their care more favourably than women who received public hospital care. This study aimed to gain a further understanding of this by exploring care providers’ views and experiences of postnatal care in private hospitals.Designqualitative design using semi-structured interviews and thematic analysis.Settingprivate maternity hospitals in Victoria, Australia.Participantseleven health-care providers from three metropolitan and one regional private hospital including eight midwives (two maternity unit managers and six clinical midwives) and three obstetricians.Findingstwo global themes were identified: ‘Constrained Care’ and ‘Consumer Care’. ‘Constrained care’ demonstrates the complexity of the provision of postnatal care and encompasses midwives’ feelings of frustration with the provision of postnatal care in a busy environment complicated by staffing difficulties, a lack of continuity and the impact of key players in postnatal care (including visitors, management and obstetricians). ‘Consumer care’ describes care providers’ views that women often approach private postnatal care as a consumer, which can impact on their expectations and satisfaction with postnatal care. Despite these challenges, care providers, particularly midwives, highly valued (and generally enjoyed working in) postnatal care.Key conclusionsthis study, along with other Australian and international studies, has identified that hospital postnatal care is complex and characterised by multiple barriers which impact on the provision of quality postnatal care. Further research is needed to evaluate routine postnatal practices and continuity of care within the postnatal period. In-depth qualitative studies investigating women's expectations and experiences of postnatal care in both the public and private sector are also needed.     

A Survey of Midwives in Quebec: What are Their Similarities and Differences?

Background: Until recently, Canada was the only industrialized country that had not legalized midwifery. In the province of Quebec the government adopted a law to evaluate midwifery in eight pilot projects before generalizing the practice. This study examined the similarities and differences among midwives in Quebec. Methods: Using data from a 1991 mail survey, we compared 31 nurse-midwives, 12 professional midwives, and 27 lay midwives to assess professional background and opinions about selected maternity care issues and aspects of future midwifery practice, such as midwife training options, responsibilities, setting for midwifery care, relationship to other maternity caregivers, autonomy, and control over their profession. Results: Midwives largely shared the same philosophy of care but had different viewpoints on two main professional aspects: compared with professional midwives and nurse-midwives, lay midwives preferred to deliver antepartum, intrapartum, and postpartum care at a client's home or an independent birthing center; like professional midwives, they rejected nursing as a prerequisite to midwifery training. Other interrelated personal, social, political, and legal factors were also associated with different beliefs. Conclusions: Despite the differences among the three groups, the process under way in Canada is to recognize a single profession of midwife. Creating a unified profession is a challenge that Canadian midwives with different backgrounds face in the 1990s.     

A Retrospective Evaluation of a Model of Midwifery Care

We conducted a retrospective evaluation of intrapartum outcomes of 452 women who had no medical or obstetric complications. Seventy-nine women were cared for in a midwifery service and the remainder were under a physician's care. Most women were white, married, and middle-class. All deliveries occurred in a tertiary referral center in Ontario, Canada. The midwifery group had statistically significant reductions in the frequency of amniotomy, epidural block, and episiotomy, and significant increases in the use of transcutaneous nerve stimulation and the occurrence of lacerations. The observed differences in intrapartum outcomes are of interest because of the unique circumstances of this service in a country where midwifery is an unfamiliar and unregulated profession.     

A Randomized Controlled Study of Birth Center Care versus Standard Maternity Care: Effects on Women's Health

ABSTRACT: Background : The safety of birth center care for low-risk women is an important issue, but it has not yet been studied in randomized controlled trials. Our purpose was to evaluate the effect of birth center care on women's health during pregnancy, birth, and 2 months postpartum by comparing the outcomes with those of women experiencing standard maternity care in the greater Stockholm area. Methods : Of 1860 women, 928 were randomly allocated to birth center care and 932 to standard antenatal, intrapartum, and postpartum care. Information about medical procedures and health outcomes was collected from clinical records, and a questionnaire was mailed to women 2 months after the birth. Analysis was by “intention to treat;” that is, all antenatal, intrapartum, and postpartum transfers were included in the birth center group. Results : During pregnancy, birth center women made fewer visits to midwives and doctors, experienced fewer tests, and reported fewer health problems. No statistical difference occurred in hospital admissions (4.8%) compared with the control group (4.7%). During labor, birth center women used more alternative birth positions, had longer labors, and did not differ inperineal lacerations. In both groups 1.7 percent of women developed complications, requiring more than 7 days of hospital care after the birth. During the first 2 postpartum months, about 20 percent of women in both groups saw a doctor for similar types of health problems, and no statistical difference occurred in hospital readmissions, 1.4 and 0.8 percent in the birth center and control groups, respectively, Conclusion : The results suggest that birth center care is effective in identifying signijicant maternal complications and as safe for women as standard maternity care.     

To see or not to see? Midwives'' perceptions of reduced antenatal attendances for ‘low-risk’ women

Objective: to explore the views of midwives towards traditional and flexible schedules of antenatal attendance for women at low risk.Design: a qualitative approach using focus groups.Setting: three NHS Trusts providing maternity care in and around Bristol.Sample: 14 midwives who had provided antenatal care to women participating in the Bristol Antenatal Care Study.Findings: midwives generally expressed support for a move away from the traditional schedule of antenatal attendances, suggesting that this represented a move towards the acceptance of pregnancy as a normal life event. They recognised that some women would prefer flexible care and the possibility of a reduction in the number of antenatal attendances. However, they suggested that some women would require additional information in order to feel confident in these circumstances. The midwives also recognised that both they and pregnant women have reservations about reducing contact during the antenatal period. Central to these reservations is a concern that women's psychosocial as well as physical needs may go unmet if antenatal contact is reduced.Implications for practice: although in principle supporting a move away from the traditional schedule of antenatal attendances, the reservations felt by midwives towards a reduction in antenatal attendances are reflected in their practice. These concerns currently impede any radical move away from the traditional schedule of antenatal check-ups and will need to be addressed by midwifery managers prior to the implementation of a more flexible schedule of antenatal attendances, if any such change is to be sustainable.