Continuity of Care
Care from a known midwife is often referred to as midwifery continuity of care, midwifery group practice or caseload midwifery. Women who have the same midwife caring for them throughout pregnancy, labour, birth and post birth have the opportunity to build a trusting relationship which increases their confidence.
What are the benefits?
Benefits for Women
A woman who receives care from a known midwife is more likely to:
- have a normal birth
- have a more positive experience of labour and birth
- be satisfied with her maternity care
- successfully breastfeed her baby
- cost the health system less
Benefits for Babies
A baby whose mother received care from a known midwife is more likely to:
- be born at term
- be born healthy
ACM envisages a future where all childbearing women have the option of being supported by a known midwife.
A summary of the evidence
Care from a known midwife, or a small group of midwives, enables women to develop a relationship with their care providers. Women who have the same midwife caring for them during pregnancy, labour, birth and post birth have the opportunity to build a trusting relationship which increases their confidence (1, 2).
Midwifery continuity of care has been widely studied. A review of midwifery continuity of care models in the Cochrane Library included 13 trials involving over 16,000 women from around the world including trials from Australia. Women who had continuity of midwifery care were less likely to need epidurals or to use other drugs for pain relief in labour or have an instrumental birth. Women in the midwifery care groups were also more likely to have a normal birth, more likely to feel in control during labour and birth, and commenced breastfeeding earlier than women who had other models of care (3).
Four trials have shown that midwifery continuity of care significantly reduces the need for women to have a caesarean section: one small trial in Canada (4) and three large trials in Australia (5, 6, 9). A recent trial undertaken in Melbourne (6), which included healthy, low risk women in both groups , found that the caesarean section rate in the known midwife group was 19% compared with 25% in the usual care group, where women did not have a known midwife through pregnancy, labour and birth.
The Melbourne trial included more than 2000 women (6). Those who received care from a known midwife were more likely to have a normal birth, less likely to have a caesarean and less likely to need pain relief in labour compared with the women having the usual care. Women in the known midwife group also reported that they coped better physically and emotionally and had more positive experiences of labour and birth (7). The babies were also less likely to need to be admitted to a special or neonatal intensive care unit. There were a small number of babies who were stillborn or died in the early days after birth and this was not different between the groups.
Having a known midwife saves the health system money (8, 9). A trial undertaken in Sydney showed that there were cost savings to the health system with midwifery continuity of care (8). That study was with a small team of midwives.
More recently, a trial of caseload midwifery for women regardless of risk factors in Sydney and Brisbane has also shown that there are significant cost savings when women have a known midwife (9). This two centre trial (1700 women) did not show any negative outcomes for women or babies associated with having continuous care from a known midwife, even for women with risk factors. Though the trial findings do not show a reduction in caesarean sections in either cohort, the overall rate fell by more than 20% from pre-trial levels. More women in the continuity of midwifery care group experienced an unassisted vaginal delivery and labour without pharmacological analgesia, while less women had an elective caesarean. Newborn infants had similar Apgar scores in the two groups, though the midwifery group experienced less preterm births and admissions to neonatal units. Important secondary findings of this study included 30% more spontaneous onset of labour, less induction of labour, less severe blood loss and more likelihood of breastfeeding after 6 weeks and 6 months. The overall median cost of birth per woman was AU$566.74 less with continuity of midwifery care than with standard care. In this study, continuity of midwifery care appeared to alter some of the pathways that recurrently contribute to increased obstetric intervention (9).
Other Australian studies have shown benefits for women who have a known midwife. For example, an evaluation of a midwifery group practice in Adelaide included women who were high, medium and low risk and compared the outcomes for women who received continuity of midwifery care with those who did not. Women who received continuity of midwifery care had fewer assisted births, fewer labour inductions, less epidural analgesia, no significant differences in post-partum haemorrhage rates, being admitted to hospital in pregnancy or the baby being admitted to Special or Intensive Care Nurseries(10). Women who received care from a known midwife valued the continuity of care, accessibility, the personal and professional attributes of the midwife and were highly satisfied with the care they received (11).
Continuity of care with a known midwife is good for women, their babies, families and even the taxpayer.
1. Leap N, Sandall J, Buckland S, Huber U. Journey to confidence: Women's experiences of pain in labour and relational continuity. Journal of Midwifery & Women's Health. 2010; 55(3): 234-42.
2. Homer C, Brodie P, Leap N. Midwifery Continuity of Care: A Practical Guide. Elsevier, 2008.
3. Sandall J, Soltani H,Gates S, Shennan A,Devane D.Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub3
4. Harvey S, Jarrell J, Brant R, Stainton C, Rach D. A randomised, controlled trial of nurse-midwifery care. Birth: Issues in Perinatal Care and Education. 1996; 23(3): 128-35.
5. Homer C, Davis G, Brodie P, et al. Collaboration in maternity care: a randomised controlled trial comparing community-based continuity of care with standard hospital care. British Journal of Obstetrics and Gynaecology. 2001; 108: 16-22.
6. McLachlan H, Forster D, Davey M, Farrell T, Gold L, Biro M, et al. Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: The COSMOS randomised controlled trial. BJOG. 2012: DOI: 10.1111/j.471-0528.2012.03446.x.
7. McLachlan H, Forster D, Davey M, Farrell T, Gold L, Biro M, et al. The effect of caseload midwifery on women’s experience of labour and birth: results from the COSMOS randomised controlled trial. In: Australian College of Midwives 18th Biennial Conference. Australian College of Midwives, 2013.
8. Homer CSE, Matha D, Jordan LG, Wills J, Davis GK. Community-based continuity of midwifery care versus standard hospital care: a cost analysis. Australian Health Review. 2001; 24(1): 85-93.
9. Sally K Tracy, Donna L Hartz, Mark B Tracy, Jyai Allen, Amanda Forti, Bev Hall, Jan White, Anne Lainchbury, Helen Stapleton, Michael Beckmann, Andrew Bisits, Caroline Homer, Maralyn Foureur, Alec Welsh, Sue Kildea Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial. The Lancet 2013 doi:10.1016/S0140-6736(13)61406-3.
10. Turnbull D, Baghurst P, Collins C, Cornwell C, Nixon A, Donnelan-Fernandez R, et al. An evaluation of Midwifery Group Practice. Part I: clinical effectiveness. Women & Birth: Journal of the Australian College of Midwives. 2009; 22(1): 3-9.
11. Fereday J, Collins C, Turnbull D, Pincombe J, Oster C. An evaluation of Midwifery Group Practice. Part II: women's satisfaction. Women & Birth: Journal of the Australian College of Midwives. 2009; 22(1): 11-6.