Effects of Continuity of Care by a Primary Midwife (Caseload Midwifery) on Cesarean Section Rates in Women of Low Obstetric Risk

Various studies and reviews have assessed the cesarean delivery (CD) rate as it relates to obstetric care provided by midwives, either in midwife teams or as a single midwife provider for a given patient. Caseload midwifery is a model of care delivery in which women are cared for by a primary midwife along with one or 2 backup midwives throughout pregnancy, birth, and the early postnatal period. This 2-arm, randomized controlled study was undertaken to determine whether caseload midwifery care for women at low risk of obstetric complications decreases the proportion of women giving birth by CD compared with women receiving standard care. Women allocated to the caseload arm received antenatal, intrapartum, and postpartum care from a primary midwife, with backup midwives used when needed. If complications occurred, the primary midwife collaborated with obstetricians and other professionals but continued to provide patient care. For women in the standard care arm, delivery care options included midwifery-led care but without the degree of continuity available in the caseload arm. Women who received obstetric trainee care and community-based care that was provided primarily by a general medical practitioner (GP) were also included in this group. With these care options, women were cared for by whichever midwife or doctor was on duty when the patient came to the hospital for labor, birth, and postnatal care. Care to both groups was provided according to the same hospital guidelines and protocols, and all patients saw an obstetrician at the first prenatal visit and at 36 weeks’ gestation. The primary outcome was cesarean delivery. Secondary outcomes were instrumental vaginal births, analgesia, perineal trauma, induction of labor, infant admission to NICU, gestational age, Apgar scores, and birth weight. Of 2314 women who were recruited into the study, the final groups included 1146 women in the caseload arm and 1151 in the standard care arm. Of women in the standard care group, 78% had antenatal care with midwives, 2% had obstetric trainee care, 15% had GP shared care, and 5% transferred their care to other institutions or alternative models. The caseload and standard groups were similar in background characteristics, with no difference in gestational age at booking. Of women in the caseload group, 98.7% saw their primary midwife at least once. During labor either the primary or backup midwife provided intrapartum care for 895 of the women in the caseload arm of the study. CD rates were 19.4% for the caseload group and 24.9% for the standard care group (relative risk, 0.78; P=0.001). Women in the caseload arm were more likely to have a spontaneous vaginal birth, a difference that was most apparent in primiparous women (51.8% vs. 41.5%). Rates for instrumental vaginal births were 17.7% and 19.4% for the caseload and standard care groups, respectively. Episiotomies were less common in the caseload group; rates of third-degree and fourth-degree tears did not differ. Rates for analgesia during labor were 30.5% for the caseload women versus 34.6% for the standard care group. The groups did not differ in rates for labor induction, mean gestational age at birth, percentage of women who gave birth at <37 weeks gestation, estimated blood loss, or postpartum hemorrhage. Mean lengths of postpartum stay were 55.4 and 60.5 hours in the caseload and standard care groups, respectively. Infants of women in the caseload arm were less likely to be admitted to the special care nursery or NICU (4.0% vs. 6.4%) although when admissions only to the NICU were analyzed there was no difference between groups (1.3% vs. 1.9%). No infant outcomes favored standard care. In this study the caseload midwifery model of care for women at low obstetric risk reduced the CD rate compared with standard maternity care, with the greatest difference being a reduction in unplanned CDs. In settings with a high baseline CD rate, caseload midwifery might be an appropriate approach to reduce the rate of CDs.