Caseload Care Research Articles

The sustainability of midwifery group practice: A cross-sectional study of midwives and managers

ProblemAlthough there is robust evidence for the benefits of midwifery group practice (MGP) caseload care, there are limited opportunities for women to access this model in Australia. There is also limited knowledge on how to sustain these services. BackgroundMGP can benefit childbearing women and babies and improve satisfaction for women and midwives. However, sustainability of the model is challenging. While MGPs are often supported and celebrated, in Australia some services have closed, while others struggle to adequately staff MGPs. AimTo investigate midwives and managers opinions on the management, culture, and sustainability of MGP. MethodsA national survey of MGP midwives and managers was distributed (2021 and 2022). Quantitative data were analysed using descriptive statistics, and qualitative data were analysed using content analysis. ResultsA total of 579 midwives and 90 managers completed the survey. The findings suggest that many MGPs do not support new graduates and students to work in MGP. Over half (59.8%) the participants (midwives and managers) reported that the women and families were the best aspect about working in MGP, while 44.3% said the effects on midwives’ lifestyle and families were the worst aspect. DiscussionThe relationship with women remains the major motivator for providing MGP care. However, work-life imbalance is a deterrent, exacerbated by staffing shortages. Staffing might be improved by adequate renumeration, strengthening orientation, and attracting new graduates and students through experience in MGP. ConclusionsThere is a need to attract midwives to MGP and improve work-life balance and sustainability.

Women\u2019s characteristics and care outcomes of caseload midwifery care in the Netherlands: a retrospective cohort study

BackgroundThe maternity care system in the Netherlands is well known for its support of community-based midwifery. However, regular midwifery practices typically do not offer caseload midwifery care – one-to-one continuity of care throughout pregnancy and birth. Because we know very little about the outcomes for women receiving caseload care in the Netherlands, we compared caseload care with regular midwife-led care, looking at maternal and perinatal outcomes, including antenatal and intrapartum referrals to secondary (i.e., obstetrician-led) care.MethodsWe selected 657 women in caseload care and 1954 matched controls (women in regular midwife-led care) from all women registered in the Dutch Perinatal Registry (Perined) who gave birth in 2015. To be eligible for selection the women had to be in midwife-led antenatal care beyond 28 gestational weeks. Each woman in caseload care was matched with three women in regular midwife-led care, using parity, maternal age, background (Dutch or non-Dutch) and region. These two cohorts were compared for referral rates, mode of birth, and other maternal and perinatal outcomes.ResultsIn caseload midwifery care, 46.9% of women were referred to obstetrician-led care (24.2% antenatally and 22.8% in the intrapartum period). In the matched cohort, 65.7% were referred (37.4% antenatally and 28.3% in the intrapartum period). In caseload care, 84.0% experienced a spontaneous vaginal birth versus 77.0% in regular midwife-led care. These patterns were observed for both nulliparous and multiparous women. Women in caseload care had fewer inductions of labour (13.2% vs 21.0%), more homebirths (39.4% vs 16.1%) and less perineal damage (intact perineum: 41.3% vs 28.2%). The incidence of perinatal mortality and a low Apgar score was low in both groups.ConclusionsWe found that when compared to regular midwife-led care, caseload midwifery care in the Netherlands is associated with a lower referral rate to obstetrician-led care – both antenatally and in the intrapartum period – and a higher spontaneous vaginal birth rate, with similar perinatal safety. The challenge is to include this model as part of the current effort to improve the quality of Dutch maternity care, making caseload care available and affordable for more women.

Women's unmet needs in early labour: Qualitative analysis of free-text survey responses in the M@NGO trial of caseload midwifery

Objectiveto analyse women's experiences of early labour care in caseload midwifery in Australia. Designthis study sits within a multi-site randomised controlled trial of caseload midwifery versus standard care. Participant surveys were conducted at 6-weeks and 6-months after birth. Free-text responses about experiences of care were subject to critical thematic analysis in NVivo 11 software. Settingtwo urban Australian hospitals in different states. Participantswomen 18 years and over, with a singleton pregnancy, less than 24 weeks’ pregnant, not planning a caesarean section or already booked with a care provider; were eligible to participate in the trial. Interventionsparticipants were randomised to caseload midwifery or standard care for antenatal, labour and birth and postpartum care. Measurements and findingsThe 6-week survey response rate was 58% (n = 1,019). The survey included five open questions about women's experiences of pregnancy, labour and birth, and postnatal care. Nine-hundred and one respondents (88%) provided free text comments which were coded to generate 10 categories. The category of early labour contained data from 84 individual participants (caseload care n = 44; standard care n = 40). Descriptive themes were: (1) needing permission; (2) doing the ‘wrong’ thing; and (3) being dismissed. Analytic themes were: (1) Seeking: women wanting to be “close to those who know what's going on”; and (2) Shielding: midwives defending resources and normal birth. Key conclusionsRegardless of model of care, early labour care was primarily described in negative terms. This could be attributed to reporting bias, because women who were neutral about early labour care may not comment. Nevertheless, the findings demonstrate a gap in knowledge about early labour care in caseload midwifery models. Implications for practiceMaternity services that offer caseload midwifery are ideally placed to evaluate how early labour home visiting impacts women's experiences of early labour.

Implementation and upscaling of midwifery continuity of care: The experience of midwives and obstetricians

ProblemDespite high quality evidence supporting midwifery continuity of care, access to this model is limited in many parts of Australia and internationally. BackgroundThe models of care provided to women have a strong influence on their perinatal experience and clinical outcomes. Midwifery Continuity of Care (CoC) is arguably the most significant factor in enhancing women’s clinical outcomes during child-bearing and facilitating a positive childbirth experience. Health system change is required, yet little literature has detailed the actualisation of this in the context of upscaling midwifery CoC. Research question/aimThis study aimed to explore the perceptions and experiences of midwifery and obstetric staff during the implementation and upscaling of midwifery CoC within a regional hospital and health service in coastal Queensland, Australia. MethodsA single-site, qualitative enquiry. Obstetricians and midwives participated in semi-structured interviews or focus groups at two-time points: within 2 months of introduction of the CoC service (obstetricians n=6; midwives n=15); and 2-years after implementation (obstetricians n=5; midwives n=17). Data were analysed thematically. FindingsFour key themes and several categories were generated from the data: hopes and expectations; clinical and practice changes; organisational and structural change; and, future directions. DiscussionOrganisational culture, structural change, communication processes and collaborative relationships can be used to inform future scale-up and sustain midwifery caseload care. Specifically, communication, inter-disciplinary collegial relationships, and managerial support are crucial to the sustainability and ultimate upscaling of caseload midwifery care. ConclusionSystem change is challenging, but in order to improve access to midwifery CoC is necessary.

Can continuity bring birth back to women and normality back to midwives?

Continuity of midwifery care, and caseload care in particular, is associated with a vast and varied array of improved outcomes for mothers and their families, including reduced intervention, reduced need for analgesia in labour, reduced preterm birth, and improved satisfaction with the birth experience. Caseload models of care may also increase midwives' satisfaction with their role and, contrary to what is often thought, may result in an improved work-life balance, and reduced burnout when compared to models of standard care. This article discusses how caseload midwifery might result in both women and midwives becoming more empowered and autonomous, and may facilitate a redirection of midwifery philosophy back to promoting and protecting normal birth.

Socioeconomic differences in access to care in Australia for women fearful of birth

Objective Fear of childbirth is known to increase a woman's likelihood of having a Caesarean section. Continuity of midwifery care is known to reduce this risk, but less than 8% of women have access to this relationship-based, primary care model. The aims of this study were to determine whether healthcare use and access to continuity models are equal across different indicators of socioeconomic status for women who are fearful of birth. Methods A secondary analysis was conducted of data obtained during a randomised controlled trial of a psychoeducation intervention by trained midwives to minimise childbirth fear (the Birth Emotions and Looking to Improve Expectant Fear (BELIEF) study). In all, 1410 women were screened, with 339 women reporting high levels of fear (Wijma-Delivery Expectancy/Experience Questionnaire ≥66). Demographic, obstetric information, birth preference and psychosocial measures were collected at recruitment and at 36 weeks gestation for the 339 fearful women, with the birth method and health service use returned by 183 women at 6 weeks after the birth. Results Univariate analysis revealed no significant difference in the number of general practitioner and midwife visits between women of high and low income and high and low education. However, women with higher levels of education had 2.51-fold greater odds of seeing the same midwife throughout their pregnancy than women with lower education (95% confidence interval 1.25-5.04), after adjusting for age, parity and hospital site. Conclusions Given the known positive outcomes of continuity of midwifery care for women fearful of birth, health policy makers need to provide equity in access to evidence-based models of midwifery care. What is known about this topic? Caseload midwifery care is considered the gold standard care due to the known positive outcomes it has for the mother and baby during the perinatal period. Pregnant women who receive caseload midwifery care are more likely to experience a normal vaginal birth. What does this paper add? There is unequal access to midwifery caseload care for women fearful of birth across socioeconomic boundaries. Midwifery caseload care is not used for all fearful mothers during the perinatal period. What are the implications for practitioners? Health policy makers seeking to provide equity in access to maternity care should be aware of these inequalities in use to target delivery of care at this specific cohort of mothers.

Comparing caseload and non-caseload midwives’ burnout levels and professional attitudes: A national, cross-sectional survey of Australian midwives working in the public maternity system

BackgroundCaseload midwifery has many benefits for women and their babies, however only around 8% of women receive caseload care in the public maternity system in Australia. Midwives working within caseload models are required to provide activity-based care (working on-call, responsively to the needs of their caseload of women) rather than undertaking shift work. There has been debate regarding the impact of caseload work on midwives, but recently caseload work has been associated with higher professional satisfaction and lower burnout when compared to midwives working in traditional models. However, there continues to be debate about the impact of caseload on midwives, so further investigation is needed. Design and settingA national cross-sectional survey of midwives working in Australian public hospitals that have birthing services was undertaken. We explored burnout and midwives’ attitudes to their professional role using the Copenhagen Burnout Inventory and the Midwifery Process Questionnaire, respectively. Comparisons were made across three groups of midwives: those who worked in the caseload model, midwives who did not work in this model but worked in a hospital with a caseload model, and midwives who worked in a hospital without a caseload model. Participants and findingsWe received 542 responses from midwives from 111 hospitals from all Australian states and one of the territories. Of respondents, 107 midwives worked in a caseload model, 212 worked in a hospital with a caseload model but did not work in caseload, and 220 midwives worked in a hospital without a caseload model. Midwives working in caseload had significantly lower burnout scores in the personal and work-related burnout subscales, and a trend toward lower scores in the client-related burnout subscale. They also had higher scores across all four subscales of the midwifery process questionnaire, demonstrating more positive attitudes to their professional role. Key conclusionsAlthough concerns have been raised regarding the impact of caseload midwifery on midwives, this national study found that midwives working within caseload had a more positive attitude to their work and lower burnout scores than those not working in the model, compared with both midwives working in a hospital with a caseload model and midwives working in a hospital without caseload. This large national study does not support earlier suggestions that caseload midwifery causes increased burnout. Implications for practiceGiven the benefits of caseload for women and their infants, and the benefits for midwives found in this study, policy-makers and health care providers should focus on how the caseload model can be expanded to provide increased access for both women and midwives.

Operationalising caseload midwifery in the Australian public maternity system: Findings from a national cross-sectional survey of maternity managers.

Despite high-level evidence of the benefits of caseload midwifery for women and babies, little is known about specific practice arrangements, organisational barriers and facilitators, nor about workforce requirements of caseload. This paper explores how caseload models across Australia operate. A national cross-sectional, online survey of maternity managers in public maternity hospitals with birthing services was undertaken. Only services with a caseload model are included in the analysis. Of 253 eligible hospitals, 149 (63%) responded, of whom 44 (31%) had a caseload model. Operationalisation of caseload varied across the country. Most commonly, caseload midwives were required to work more than 0.5 EFT, have more than one year of experience and have the skills across the whole scope of practice. On average, midwives took a caseload of 35-40 women when full time, with reduced caseloads if caring for women at higher risk. Leave coverage was complex and often ad-hoc. Duration of home-based postnatal care varied and most commonly provided to six weeks. Women's access to caseload care was impacted by many factors with geographical location and obstetric risk being most common. Introducing, managing and operationalising caseload midwifery care is complex. Factors which may affect the expansion and availability of the model are multi-faceted and include staffing and model inclusion guidelines. Coverage of leave is a factor which appears particularly challenging and needs more focus.

Culturally capable and culturally safe: Caseload care for Indigenous women by Indigenous midwifery students.

Evidence is emerging of the benefits to students of providing continuity of midwifery care as a learning strategy in midwifery education, however little is known about the value of this strategy for midwifery students. To explore Indigenous students' perceptions of providing continuity of midwifery care to Indigenous women whilst undertaking a Bachelor of Midwifery. Indigenous Bachelor of Midwifery students' experiences of providing continuity of midwifery care to Indigenous childbearing women were explored within an Indigenous research approach using a narrative inquiry framework. Participants were three Indigenous midwifery students who provided continuity of care to Indigenous women. Three interconnected themes; facilitating connection, being connected, and journeying with the woman. These themes contribute to the overarching finding that the experience of providing continuity of care for Indigenous women creates a sense of personal affirmation, purpose and a validation of cultural identity in Indigenous students. Midwifery philosophy aligns strongly with the Indigenous health philosophy and this provides a learning platform for Indigenous student midwives. Privileging Indigenous culture within midwifery education programs assists students develop a sense of purpose and affirms them in their emerging professional role and within their community. The findings from this study illustrate the demand for, and pertinence of, continuity of care midwifery experiences with Indigenous women as fundamental to increasing the Indigenous midwifery workforce in Australia. Australian universities should provide this experience for Indigenous student midwives.

Continuity of care by a primary midwife (caseload midwifery) increases women's satisfaction with antenatal, intrapartum and postpartum care: results from the COSMOS randomised controlled trial.

BackgroundContinuity of care by a primary midwife during the antenatal, intrapartum and postpartum periods has been recommended in Australia and many hospitals have introduced a caseload midwifery model of care. The aim of this paper is to evaluate the effect of caseload midwifery on women’s satisfaction with care across the maternity continuum.MethodsPregnant women at low risk of complications, booking for care at a tertiary hospital in Melbourne, Australia, were recruited to a randomised controlled trial between September 2007 and June 2010. Women were randomised to caseload midwifery or standard care. The caseload model included antenatal, intrapartum and postpartum care from a primary midwife with back-up provided by another known midwife when necessary. Women allocated to standard care received midwife-led care with varying levels of continuity, junior obstetric care, or community-based general practitioner care. Data for this paper were collected by background questionnaire prior to randomisation and a follow-up questionnaire sent at two months postpartum. The primary analysis was by intention to treat. A secondary analysis explored the effect of intrapartum continuity of carer on overall satisfaction rating.ResultsTwo thousand, three hundred fourteen women were randomised: 1,156 to caseload care and 1,158 to standard care. The response rate to the two month survey was 88 % in the caseload group and 74 % in the standard care group. Compared with standard care, caseload care was associated with higher overall ratings of satisfaction with antenatal care (OR 3.35; 95 % CI 2.79, 4.03), intrapartum care (OR 2.14; 95 % CI 1.78, 2.57), hospital postpartum care (OR 1.56, 95 % CI 1.32, 1.85) and home-based postpartum care (OR 3.19; 95 % CI 2.64, 3.85).ConclusionFor women at low risk of medical complications, caseload midwifery increases women’s satisfaction with antenatal, intrapartum and postpartum care.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN012607000073404 (registration complete 23rd January 2007).

Implementing caseload midwifery: Exploring the views of maternity managers in Australia - A national cross-sectional survey.

The benefits of caseload midwifery care are clearly documented, and many policy documents in Australia support its expansion. Despite this, little is known about the availability of caseload across Australia, nor about what proportion of women have access to a caseload model. This paper describes caseload midwifery in the public maternity system in Australia; its prevalence, and factors associated with implementation and sustainability. A cross-sectional online survey of maternity managers of public hospitals that provide birthing services throughout Australia. Sixty-three percent (149/235) of eligible participants responded. Respondents were from all states and territories, metropolitan, regional and remote areas, and from hospitals with very small to very large birth numbers. Only 31% reported that their hospital offers caseload midwifery, and an estimated eight percent of women received caseload care at the time of the survey, most of whom were considered to be of 'low obstetric risk'. Many respondents were planning to implement or expand caseload. Key factors associated with the implementation of caseload were funding to establish the model, the interest and availability of staff to work in the model, organisational support and perceived consumer demand. This is the first study to explore caseload implementation at a national level. Although the number of services offering caseload midwifery care has increased nationally, access remains relatively limited. Women who live in metropolitan areas and who are considered at 'low obstetric risk' are most likely to be able to access this model. Funding and support for establishing new models are the main barriers to implementation.

Midwifery students׳ experiences of an innovative clinical placement model embedded within midwifery continuity of care in Australia

Backgroundmidwifery continuity of care experiences can provide high quality clinical learning for students but can be challenging to implement. The Rural and Private Midwifery Education Project (RPMEP) is a strategic government funded initiative to (1) grow the midwifery workforce within private midwifery practice and rural midwifery, by (2) better preparing new graduates to work in private midwifery and rural continuity of care models. Aimthis study evaluated midwifery students׳ experience of an innovative continuity of care clinical placement model in partnership with private midwifery practice and rural midwifery group practices. Methoda descriptive cohort design was used. All students in the RPMEP were invited to complete an online survey about their experiences of clinical placement within midwifery continuity models of care.Responses were analysed using descriptive statistics. Correlations between total scale scores were examined. Open-ended responses were analysed using content analysis. Internal reliability of the scales was assessed using Cronbach׳s alpha. Findingssixteen out of 17 completed surveys were received (94% response rate). Scales included in the survey demonstrated good internal reliability. The majority of students felt inspired by caseload approaches to care, expressed overall satisfaction with the mentoring received and reported a positive learning environment at their placement site. Some students reported stress related to course expectations and demands in the clinical environment (e.g. skill acquisition and hours required for continuity of care).There were significant correlations between scales on perceptions of caseload care and learning culture (r=.87 p<.001) and assessment (r=.87 p<.001). Scores on the clinical learning environment scale were significantly correlated with perceptions of the caseload model (rho=.86 p<.001), learning culture (rho=.94 p<.001) and assessment (rho=.65 p<.01) scales. Conclusionsembedding students within midwifery continuity of care models was perceived to be highly beneficial to learning, developed partnerships with women, and provided appropriate clinical skills development required for registration, while promoting students׳ confidence and competence. The flexible academic programme enabled students to access learning at any time and prioritise continuity of care experiences.Strategies are needed to better support students achieve a satisfactory work-life balance.

An investigation of the relationship between the caseload model of midwifery for socially disadvantaged women and childbirth outcomes using routine data – A retrospective, observational study

Objectivethe objective of this study was to describe and compare childbirth outcomes and processes for women with complex social factors who received caseload midwifery care, and standard maternity care in the UK. Backgroundwomen with complex social factors experience high rates of morbidity, mortality and poor birth outcomes. A caseload team was established to support these women throughout pregnancy and childbirth by providing continuity and individualised care. Methodsdata was collected from computerised birth details of 194 women with complex social factors who presented for maternity care between May 2012 and June 2013; 96 received standard care and 98 caseload care. SPSS v21 was used to calculate descriptive and inferential statistics. Logistic regression modelling found no differences in demographics, therefore unadjusted statistics are presented. Comparative analysis between women receiving caseload care and those receiving standard care was accomplished using χ2 test, relative risk (RR) and 95% confidence intervals (CI). Resultsthe relationship between type of care and outcome was not changed by the inclusion of confounding factors. Women receiving caseload care were more likely to experience; spontaneous vaginal childbirth (80% versus 55% RR 1.88, 95% CI 1.27–2.77, P=<0.001), use water for pain relief (32% versus 10%, RR 4.10 95% CI 1.95–8.64, p=<0.001), birth in the midwife led centre (26% versus 13% RR 1.48 95% CI 1.12–1.95, p=0.023), assessment by 10 weeks gestation (24% versus 8% RR 1.61 95% CI 1.24–2.10, p=0.008), shorter postnatal stay (1 day versus 3 days SD 1.2 versus 2.2, p=<0.001), and know their midwife (90% versus 8% RR 8.98 95% CI 4.97–16.2, p=<0.001). More women in the caseload group were referred to multidisciplinary support services; psychiatry (56% versus 19% RR 2.06 95% CI 1.59–2.65, p=<0.001), domestic violence advocacy (42% versus 18% RR 1.68 CI 1.31–2.15, p=<0.001) and other services (56% versus 31% RR 1.58 95% CI 1.15–2.16, p=0.03). They were less likely to have a caesarean section (11% versus 33% RR 0.26 95% CI 0.12–0.55, P=<0.001), an epidural/spinal for pain relief (35% versus 56%, RR 0.64 95% CI 0.46–0.86, p=0.004), give birth on the labour ward (70% versus 88% RR 0.63 95% CI 0.49–0.83, p=0.006), and had fewer antenatal admissions (0.9(SD 1.1) versus 1.3(SD1.5), p=0.036) and neonatal unit admissions (4% versus 18%, RR 0.35 95% CI 0.15–0.85, p=0.005). Conclusioncaseload midwifery care appeared to confer increased benefit and reduced harmful outcomes. Findings for individual outcomes differed from previous literature depending on outcome, suggesting caseload care may affect women in different ways depending on their individual needs.

Comparing views and experiences of caseload and standard care midwives

Comparing views and experiences of caseload and standard care midwives Michelle Newton *, Della Forster , Helen McLachlan , Karen Willis 4 1 School of Nursing & Midwifery, La Trobe University, Melbourne, Australia 2 Judith Lumley Centre, La Trobe University, Melbourne, Australia 3 The Royal Women’s Hospital, Melbourne, Australia Australian Catholic University, Melbourne, Australia *Corresponding author.

Collaborating together to provide pregnancy and parenting education to youth

Comparing views and experiences of caseload and standard care midwives Michelle Newton *, Della Forster , Helen McLachlan , Karen Willis 4 1 School of Nursing & Midwifery, La Trobe University, Melbourne, Australia 2 Judith Lumley Centre, La Trobe University, Melbourne, Australia 3 The Royal Women’s Hospital, Melbourne, Australia Australian Catholic University, Melbourne, Australia *Corresponding author.

Midwives' perceptions of organisational structures and processes influencing their ability to provide caseload care to socially disadvantaged and vulnerable women

Objectivethis study examined midwives' perceptions of organisational structures and processes of care when working in a caseload model (Midwifery Group Practice MGP) for socially disadvantaged and vulnerable childbearing women. Designthis study used Donabedian's theoretical framework for evaluating the quality of health care provision. Of the 17 eligible midwives, 15 participated in focus group discussions and two others provided written comments. Thematic analysis was guided by three headings; clinical outcomes, processes of care and organisational structure. Findingsmidwives believed they provided an excellent service to socially disadvantaged and vulnerable childbearing women. Midwives gained satisfaction from working in partnership with women, working across their full scope of practice, and making a difference to the women. However the midwives perceived the MGP was situated within an organisation that was hostile to the caseload model of care. Midwives felt frustrated and distressed by a lack of organisational support for the model and a culture of blame dominated by medicine. A lack of material resources and no identified office space created feelings akin to ‘homelessness’. Together these challenges threatened the cohesiveness of the MGP and undermined midwives' ability to advocate for women and keep birth normal. Key conclusionsif access to caseload midwifery care for women with diverse backgrounds and circumstances is to be enhanced, then mechanisms need to be implemented to ensure organisational structures and processes are developed to sustain midwives in the provision of ‘best practice’ maternity care. Implications for practicewomen accessing midwifery caseload care have excellent maternal and newborn outcomes. However there remains limited understanding of the impact of organisational structures and processes of care on clinical outcomes.

Influence of timing of admission in labour and management of labour on method of birth: Results from a randomised controlled trial of caseload midwifery (COSMOS trial)

Objectiveto explore the relationship between the degree to which labour is established on admission to hospital and method of birth. Backgrounda recent randomised controlled trial found fewer caesarean sections (CS) in women allocated to caseload midwifery (19.4%) compared with standard care (24.9%). There is interest in exploring what specific aspects of the care might have resulted in this reduction. Settinga large tertiary-level maternity service in Melbourne, Australia. ParticipantsEnglish-speaking women with no previous caesarean section at low risk of complications in pregnancy were recruited to a randomised controlled trial. Trial participants whose management did not include a planned caesarean and who were admitted to hospital in spontaneous labour were included in this secondary analysis of trial data (n=1532). Methodsthis secondary analysis included women admitted to hospital in spontaneous labour who were randomised to caseload midwifery compared with those randomised to standard care with regard to timing of admission in labour, augmentation of labour and use of epidural analgesia. In a further analysis randomised groups were pooled to examine predictors of caesarean section for first births only using multiple logistic regression. Resultsnulliparous women randomised to standard care were more likely to have labour augmented than those having caseload care (54.2% and 45.5% respectively, p=0.008), but were no more likely to use epidural analgesia. They were admitted earlier in labour, spending 1.1 hours longer than those in the caseload arm in hospital before the birth (p=0.003). Parous women allocated to standard care were more likely than those in the caseload arm to use epidural analgesia (10.0% and 5.3% respectively, p=0.047), but were no more likely to have labour augmented. They were also admitted earlier in labour, with a median cervical dilatation of 4cm compared with 5cm in the caseload arm (p=0.012).Pooling the two randomised groups of nulliparous women, and after adjusting for randomised group, maternal age and maternal body mass index, early admission to hospital was strongly associated with caesarean section. Admission before the cervix was 5cm dilated increased the odds 2.4-fold (95%CI 1.4, 4.0; p=0.001). Augmentation of labour and use of epidural analgesia were each strongly associated with caesarean section (adjusted odds ratios 3.10 (95%CI 2.1, 4.5) and 5.77 (95%CI 4.0, 8.4) respectively. Conclusionthese findings that women allocated to caseload care were admitted to hospital later in labour, and that earlier admission was strongly associated with birth by caesarean section, suggest that remaining at home somewhat longer in labour may be one of the mechanisms by which caseload care was effective in reducing caesarean section in the COSMOS trial.

Caseload midwifery in a multi-ethnic community: The women's experiences

Objectiveto evaluate caseload midwifery in a relatively deprived and ethnically diverse inner-city area. Design and settingsemi-structured interviews were undertaken with 24 women from diverse ethnic backgrounds, 12 of whom had received caseload care and 12 women from an adjacent area who had received conventional maternity care in a large inner-city maternity unit. Framework analysis was adopted drawing on links with the authors' previous work on women's views of caseload midwifery. Findingskey themes from previous work fitted well with the themes that emerged from this study. Themes included ‘knowing and being known’, ‘person-centred care’, ‘social support’, ‘gaining trust and confidence’, ‘quality and sensitivity of care’ and ‘communication’. Key conclusions and implicationswomen from this socially and ethnically diverse group of women had similar views and wanted similar care to those in previous studies of caseload midwifery. Many of the women receiving caseload care highlighted the close relationship they had with the midwives and as a result of this felt more able to discuss their concerns with them. This has the potential not only for improved quality of care but also improved safety.

Measuring the best outcome for the least intervention: can the Optimality Index-US be applied in the UK?

Objective to pilot the Optimality Index-US (OI-US) for the first time within a UK maternity setting in a sample of women at mixed risk. Design a multidisciplinary group reviewed the items and evidence base of the OI-US. A pilot study was undertaken to compare the availability and quality of data from maternity records to complete the OI-US. Data were collected from maternity records. Setting a maternity unit of an inner city teaching hospital in England. Participants clinical midwives, research midwives, midwifery lecturers and consultant obstetricians ( n=10) reviewed the items and evidence base of the OI-US. Data were collected from the maternity records of 97 women receiving caseload care and 103 women receiving standard care. Measurements and findings when the multidisciplinary group reviewed the items and evidence base of the OI-US, it was noted that some social and clinical factors should be considered for inclusion as part of the Perinatal Background Index (PBI) and OI. The results suggest that the inclusion of women at higher risk in this sample within the UK maternity setting has not been captured by the OI-US. Key conclusions the following social and clinical factors should be included as part of the PBI and OI for the UK setting: measure of social deprivation, woman's ability to speak and understand English in relation to accessing maternity care, mental health problems during pregnancy and history of domestic violence during pregnancy Implications for practice availability of items in electronic records is poor and it is recommended that the OI-UK version is a useful research tool in prospective data collection. The development of an international version would be valuable for comparision of background risk and outcomes across a range of care settings.

“Someone's rooting for you”: Continuity, advocacy and street-level bureaucracy in UK maternal healthcare

Continuity and advocacy are widely held to be important elements in maternal healthcare, yet they are often lacking from the care women receive. In order to understand this disparity, we draw upon interviews and ethnographic observational findings from The One-to-One Caseload Project, a study exploring the impacts of a caseload model of maternity care within an urban National Health Service provider in Britain. Drawing on Lipsky's (1980) and Prottas's (1979) theories of street-level bureaucracy, this paper attempts to understand how midwives, working on the frontline within caseload and standard care models, manage the competing demands of delivering a personalised service within a bureaucratic organisation. The caseload care model serves as a case study for how a client-centred model of working can assist street-level bureaucrats to manage the administrative pressures of public service organisations and provide their clients with a personalised, responsive service. Nevertheless, despite such benefits, client-centred models of working may have unintended consequences for both health carers and healthcare systems.