Primary Midwife Research Articles

Continuity of care by a primary midwife (caseload midwifery): a cost analysis using results from the COSMOS randomised controlled trial

IntroductionCaseload midwifery (continuity of midwifery carer) offers benefits including lower caesarean section rates, lower risks of preterm birth and stillbirth, and improved maternal satisfaction of care. Despite these advantages, concerns...

Midwives’ experiences of professional learning when practicing collegial midwifery assistance during the active second stage of labour: data from the oneplus trial

BackgroundLearning is a lifelong process and the workplace is an essential arena for professional learning. Workplace learning is particularly relevant for midwives as essential knowledge and skills are gained through clinical work. A clinical practice known as ‘Collegial Midwifery Assistance’ (CMA), which involves two midwives being present during the active second stage of labour, was found to reduce severe perineal trauma by 30% in the Oneplus trial. Research regarding learning associated with CMA, however, is lacking. The aim was to investigate learning experiences of primary and second midwives with varying levels of work experience when practicing CMA, and to further explore possible factors that influence their learning.MethodsThe study uses an observational design to analyse data from the Oneplus trial. Descriptive statistics and proportions were calculated with 95% confidence intervals. Stratified univariable and multivariable logistic regression analysis were performed.ResultsA total of 1430 births performed with CMA were included in the study. Less experienced primary midwives reported professional learning to a higher degree (< 2 years, 76%) than the more experienced (> 20 years, 22%). A similar but less pronounced pattern was seen for the second midwives. Duration of the intervention ≥ 15 min improved learning across groups, especially for the least experienced primary midwives. The colleague’s level of experience was found to be of importance for primary midwives with less than five years’ work experience, whereas for second midwives it was also important in their mid to late career. Reciprocal feedback had more impact on learning for the primary midwife than the second midwife.ConclusionsThe study provides evidence that CMA has the potential to contribute with professional learning both for primary and second midwives, for all levels of work experience. We found that factors such as the colleague’s work experience, the duration of CMA and reciprocal feedback influenced learning, but the importance of these factors were different for the primary and second midwife and varied depending on the level of work experience. The findings may have implications for future implementation of CMA and can be used to guide the practice.

Clinical outcomes and financial estimates for women attending the largest private midwifery service in Australia compared to national data: a retrospective cohort study

Background and ProblemMultiple barriers to national scale-out of private midwifery practice in Australia exist. AimTo describe and compare maternal infant health outcomes of the largest private midwifery service in Australia with the national core maternity indicators and estimate the financial impact on collaborating public hospitals. MethodsA retrospective cohort of 2747 maternal health records from 2014 to 2022 were compared to national indicators. Financial calculations estimated the impact on hospitals. FindingsCompared to national data, women cared by private midwives were significantly: more likely to be 25–34 years and primiparous; less likely to be Indigenous, have diabetes, hypertension or multiple births. At birth, 5% required discussion with specialists, 25% required consultation and 39% were referred; 86% women had their primary midwife at birth; 12.5% birthed at home and 14.5% at a birth centre. Compared to national data, primiparous women had fewer inductions (22.9% vs 45.8%), caesarean sections (22.6% vs 32.1%), instrumental vaginal births (17.0% vs 25.7%), episiotomies (9.5% vs 23.9%) and more birthed vaginally after caesarean section (75.9% vs 11.9%). Significantly less babies were born with a birthweight <2750 g (0.5% vs 1.2%) and 83.7% babies were exclusively breastfed at six weeks. Collaborating hospitals would receive less DRG funding compared to public patients, require less intrapartum midwifery staff and receive a net benefit, even when bed fees were waived. ConclusionWomen attending My Midwives had significantly lower intervention rates when compared to national indicators although maternal characteristics could be contributing. Multidisciplinary care was evident. Financial modelling shows positive impacts for hospitals.

PENGARUH TEKNIK HYPNOBREASFEEDING TERHADAP PENGELUARAN ASI PADA IBU NIFAS DI KLINIK PRATAMA BIDAN MURNI SIBULUAN KABUPATEN TAPANULI ENGAH TAHUN 2023

Breastfeeding is one of the main task of mother in meeting the nutritional needs of her baby, but the success of exclusive breastfeeding in sibolga Regency was low ( 72 % ) because the failure of first breastfeeding for the babies and also because factors obstruct mother didn’t want to brasfeeding. First incessant produser campaign for milk and food replace ASI. Second, lack of cognition mother about giving food to child. Third, not care really from experts health to promote habit breasfeeding child. Forth, lack of program social welfare evident, which is conducted by several goverment agency.one of solution to help overcome it is hypnobreasfeeding. This research is study preexperiment with approach one group pretest posttes. Technique taking sample use perposive sampling in the puerperal mother with the number 30 person. This research conducted in april-june. statistic test use wilcoxon test. The results processing data with use wilcoxon test against expenditure ASI in the puerperal mother before and after intervetion, the results obtained sicnificancy p= 0,000 (p&lt; 0,05) which mean there is influence technique hypnobreasfeeding against expenditure ASI in the puerpural mother. The conclution from this research there is influence technique hypnobreasfeeding against expenditure ASI in the puerperal mother in Pure Tapanuli Primary Midwife Clinic in the middle of 2023.

Primary midwives' experiences of collegial midwifery assistance during the active second stage of labor: Data from the Oneplus trial.

Collegial midwifery assistance during the active second stage of labor that involves a second midwife being present has been shown to reduce severe perineal trauma (SPT) by 30%. The aim of this study was to investigate primary midwives' experiences of collegial midwifery assistance with the purpose of preventing SPT during the active second stage of labor. This study uses an observational design with data from a multicenter randomized controlled trial (Oneplus). Data consist of clinical registration forms completed by the midwives after birth. Descriptive statistics as well as univariable and multivariable logistic regression were used to analyze the data. The majority of the primary midwives felt confident (61%) and were positive (56%) toward the practice. Midwives with less than 2 years' work experience were more likely to completely agree they felt confident (aOR 9.18, 95% CI: 6.28-13.41) and experience the intervention as positive (aOR 4.04, 95% CI: 2.83-5.78) than those with over 20 years' work experience. Factors such as duration of time spent in the birthing room by the second midwife, opportunity for planning and if the second midwife provided support were further associated with the primary midwife's experience of the practice as being positive. Our findings indicate that having a second midwife present during the active second stage of labor was an accepted practice, with the majority of primary midwives feeling confident and positive toward the intervention. This was especially pronounced among midwives with less than 2 years' work experience.

P26 - My Mater Midwife: A Collaborative Private MGP Model

With the aim of increasing access to high quality continuity midwifery, Mater South Brisbane recently launched an innovative new model of collaborative private care called My Mater Midwife. Within this model, private clients of participating obstetricians have their care shared collaboratively between their chosen obstetrician and an endorsed midwife employed by the hospital. The primary midwife is on call for hospital presentations and eventually the birth, supported by a small midwifery team. Clients have their known midwife and known doctor present for their birth, enjoy the comfort of a private postnatal stay in hospital and receive the ongoing support of their primary midwife delivering homecare after discharge. The model will be explained in more detail including how we meet the needs and expectations of the various stakeholders and the challenges we have faced in establishing the model. This presentation has been developed in collaboration with one of the participating obstetricians, Di Poad whose contribution will be pre-recorded. Continuity midwifery models of care have been well established by research to improve client outcomes over a wide range of measurable factors. As a private hospital, Mater wanted to be able to offer this “gold standard” of care to private clients who were accessing their maternity care through private obstetricians. The model is aimed at people seeking the comfort of private maternity care along with the benefits of continuity midwifery. While challenging at times to establish mutually attractive terms of involvement for all stakeholders, the current model honours the professional contribution of both obstetricians and midwives while centring the birthing person and adapting care around their needs. Feedback from clients birthing in the model has been overwhelmingly positive.

P21 - Mobile Midwives Transforming Midwifery Care

Despite abundant research demonstrating the benefits of ‘continuity of care, Australian women are still receiving fragmented care in a system that does little to reduce their anxiety. What can we do to make a difference to women’s satisfaction with their birth experience? How can we increase the number of women having joyful birth experience? It has been a hot topic for midwifery researchers for many years and yet progress has not been sustained. Continuity of Care models such as Midwifery Group Practice (MGP), Caseloads, and even Maternal Antenatal and Postnatal Care (MAPS provide a great deal of promise. Sometimes the ability for the teams to provide continuity is limited because of rostering, leave workloads and staff availability. There are some Community Midwifery Programs being run through the public system which provide continuity of care and choice of birthplace (home or hospital). These are ideal and can truly provide women with the same midwives throughout the pregnancy and at birth. It would be optimal if these systems could be replicated around the country. Services need to optimize their efforts and gain efficiencies. It is beneficial for hospitals to examine options. Satisfied midwives result in less downtime. My book Mobile Midwives Transforming Birth Options describes a way four midwives developed a business providing antenatal care, birthplace of choice and postnatal care with continuity of care from the same primary midwife with a known backup midwife. Midwives in each of your areas should look for opportunities to make change, keeping women central to your thoughts and design innovative programs that will help.

The effect of two midwives during the second stage of labour to reduce severe perineal trauma (Oneplus): a multicentre, randomised controlled trial in Sweden

Severe perineal trauma (SPT) affecting the anal sphincter muscle complex is a serious complication following childbirth, associated with short-term and long-term maternal morbidity. Effective preventive strategies are still scarce. The aim of the Oneplus trial was to test the hypothesis that the presence of a second midwife during the second stage of labour, with the purpose of preventing SPT, would result in fewer injuries affecting the anal sphincter than if attended by one midwife. In this multicentre, randomised, controlled parallel group, unmasked trial done at five obstetric units in Sweden, women were randomly assigned to be assisted by either one or two midwives in late second stage. Nulliparous women and women planning the first vaginal birth after caesarean section who were age 18-47 years were randomly assigned to an intervention when reaching the second stage of labour. Further inclusion criteria were gestational week 37+0, carrying a singleton live fetus in vertex presentation, and proficiency in either Swedish, English, Arabic, or Farsi. Exclusion criteria were a multiple pregnancy, intrauterine fetal demise, a planned caesarean section, or women who were less than 37 weeks pregnant. Randomisation to the intervention group of two midwives or standard care group of one midwife (1:1) was done using a computer-based program and treatment groups were allocated by use of sealed opaque envelopes. All women and midwives were aware of the group assignment, but the statistician from Clinical Studies Forum South, who did the analyses, was masked to group assignment. Midwives were instructed to implement existing prevention models and the second midwife was to assist on instruction of the primary midwife, when asked. Midwives were also instructed to complete case report forms detailing assistance techniques and perineal trauma prevention techniques. The primary outcome was the proportion of women who had SPT, for which odds ratios (ORs) and 95% CIs were calculated, and logistic regression was done to adjust for study site. All analyses were done according to intention to treat. The trial is registered with ClinicalTrials.gov, NCT0377096. Between Dec 10, 2018, and March 21, 2020, 8866 women were assessed for eligibility, and 4264 met the inclusion criteria and agreed to participate. 3776 (88·5%) of 4264 women were randomly assigned to an intervention after reaching the second stage of labour. 1892 women were assigned to collegial assistance (two midwives) during the second stage of labour and 1884 women were assigned to standard care (one midwife). 13 women in each group did not meet the inclusion criteria and were excluded. After further exclusions, 1546 women spontaneously gave birth in the intervention group and 1513 in the standard care group. 1546 women in the intervention group and 1513 in the standard care group were included in the intention-to-treat analysis of the primary outcome. There was a significant reduction in SPT in the intervention group (3·9% [61 of 1546] vs 5·7% [86 of 1513]; adjusted OR 0·69 (0·49-0·97). The presence of two midwives during the active second stage can reduce SPT in women giving birth for the first time. The Swedish Research Council for Health, Working Life and Welfare; Jan Hains Research Foundation; and Skane County Council's Research and Development Foundation.

Midwife-led continuity of care increases women’s satisfaction with antenatal, intrapartum, and postpartum care: North Shoa, Amhara regional state, Ethiopia: A quasi-experimental study

BackgroundThe provision of midwife-led continuity of care (MLCC) is effective in high-resource settings in improving maternal satisfaction. This study aimed to evaluate the effect of MLCC on women’s satisfaction with care in a low-income/resource setting. MethodA study with a quasi-experimental design was conducted from August 2019 to September 2020 in four primary hospitals in the north Shoa zone, Amhara regional state, Ethiopia. A total of 1178 low-risk women were allocated to one of two groups; the MLCC (intervention group) that received all antenatal, intrapartum, and immediate postnatal care from a primary midwife or backup midwife) (n = 589) and the shared model of care (SMC) group that received care following established practice in Ethiopia, care from different staff members at different times) (n = 589). Data for this paper were collected using face-to-face interviews at the women’s home at the end of the postpartum period. The study’s outcome was the mean sum-score of satisfaction with care through the antenatal, intrapartum, and postnatal period continuum, where mean sum-scores range from 1 (lowest) to 5 (highest). FindingsCompared with SMC, MLCC was associated with statistically significantly higher satisfaction with all continuity of care (4.07 vs. 2.79 adjusted mean difference 1.27, 95% CI 1.18–1.35; p < 0.001), during antenatal care (4.14 vs. 2.81 adjusted mean difference 1.33 (95% CI 1.22–1.52), intrapartum care (3.83 vs. 2.71 adjusted mean difference 1.06 (95% CI 0.88–1.23) and postnatal care (5.46 vs. 3.71 adjusted mean difference 1.75 (95% CI 1.54–1.94)). ConclusionMLCC increased women's satisfaction with maternity care for women at low risk of medical complications. These findings confirm that the MLCC model will be applicable in the Ethiopian health care system with similar settings.

Process lessons from evaluating a combined continuity of carer and home birth scheme.

Continuity of midwifery carer improves outcomes, but there is significant variation in how such schemes are implemented and evaluated cross-culturally. The Angus home birth scheme in Scotland incorporates continuity of carer throughout pregnancy, labor, birth, and the postnatal period. Manual maternity case note review to evaluate the 80% continuity of carer and 3% planned home birth rate targets. Of 1466 women booking for maternity care, 69 joined the scheme. Forty-four had a planned home birth (3% overall), of whom seven were originally deemed ineligible. Of the 44, eight (18%) also achieved 80% continuity of carer with the primary midwife; by including a home birth team colleague, the continuity rate rose to 73%. Women whose care achieved home birth and continuity targets had lower deprivation scores. Eligibility issues, women's changing circumstances, and data recording lapses were complicating issues. Targets must be both feasible and meaningful and should be complemented by assessing a broad range of outcomes while viewing the scheme holistically. By expanding eligibility criteria, the home birth rate target was met; including input from a home birth team colleague in the calculation meant the continuity target was nearly met. With dedicated and competent staff, adequate resource and political support, and when considered in the round, the scheme's viability within local services was confirmed. Other generalizable learning points included the need to standardize definitions and data recording methods. Comparability across schemes helps grow the evidence base so that the links between processes and outcomes can be identified.

Continuity of midwifery carer moderates the effects of prenatal maternal stress on postnatal maternal wellbeing: the Queensland flood study.

Poor postnatal mental health is a major public health issue, and risk factors include experiencing adverse life events during pregnancy. We assessed whether midwifery group practice, compared to standard hospital care, would protect women from the negative impact of a sudden-onset flood on postnatal depression and anxiety. Women either received midwifery group practice care in pregnancy, in which they were allocated a primary midwife who provided continuity of care, or they received standard hospital care provided by various on-call and rostered medical staff. Women were pregnant when a sudden-onset flood severely affected Queensland, Australia, in January 2011. Women completed questionnaires on their flood-related hardship (objective stress), emotional reactions (subjective stress), and cognitive appraisal of the impact of the flood. Self-report assessments of the women's depression and anxiety were obtained during pregnancy, at 6weeks and 6months postnatally. Controlling for all main effects, regression analyses at 6weeks postpartum showed a significant interaction between maternity care type and objective flood-related hardship and subjective stress, such that depression scores increased with increasing objective and subjective stress with standard care, but not with midwifery group practice (continuity), indicating a buffering effect of continuity of midwifery carer. Similar results were found for anxiety scores at 6weeks, but only with subjective stress. The benefits of midwifery continuity of carer in pregnancy extend beyond a more positive birth experience and better birthing and infant outcomes, to mitigating the effects of high levels of stress experienced by women in the context of a natural disaster on postnatal mental health.

The motivation and capacity to go ‘above and beyond’: Qualitative analysis of free-text survey responses in the M@NGO randomised controlled trial of caseload midwifery

Objectiveto explore whether women allocated to caseload care characterise their midwife differently to those allocated to standard care. Designmulti-site unblinded, randomised, controlled, parallel-group trial. Settingthe study was conducted in two metropolitan teaching hospitals across two Australian cities. Populationwomen of all obstetric risk were eligible to participate. Inclusion criteria were: 18 years or older, less than 24 week’s gestation with a singleton pregnancy. Women already booked with a care provider or planning to have an elective caesarean section were excluded. Interventionsparticipants were randomised to caseload midwifery or standard care. The caseload model provided antenatal, intrapartum and postnatal care from a primary midwife or ‘back-up’ midwife; as well as consultation with obstetric or medical physicians as indicated by national guidelines. The standard model included care from a general practitioner and/or midwives and obstetric doctors. Measurements and findingsparticipants’ responses to open-ended questions were collected through a 6-week postnatal survey and analysed thematically. A total of 1748 women were randomised between December 2008 – May 2011; 871 to caseload midwifery and 877 to standard care. The response rate to the 6-week survey including free text items was 52% (n=901). Respondents from both groups characterised midwives as Informative, Competent and Kind. Participants in the caseload group perceived midwives with additional qualities conceptualised as Empowering and ‘Endorphic’. These concepts highlight some of the active ingredients that moderated or mediated the effects of the midwifery care within the M@NGO trial. Key conclusioncaseload midwifery attracts, motivates and enables midwives to go Above and Beyond such that women feel empowered, nurtured and safe during pregnancy, labour and birth. Implications for practicethe concept of an Endorphic midwife makes a useful contribution to midwifery theory as it enhances our understanding of how the complex intervention of caseload midwifery influences normal birth rates and experiences. Defining personal midwife attributes which are important for caseload models has potential implications for graduate attributes in degree programs leading to registration as a midwife and selection criteria for caseload midwife positions.

How optimal caseload midwifery can modify predictors for preterm birth in young women: Integrated findings from a mixed methods study

Objectiveto identify possible mechanisms by which caseload midwifery reduces preterm birth for young childbearing women. Designa mixed methods triangulation, convergence design was used to answer the research question ‘How does the way maternity care is provided affect the health and well-being of young women and their babies?’ The project generated quantitative and qualitative findings which were collected and analysed concurrently then separately analysed and published. The research design enabled integration of the quantitative and qualitative findings for further interpretation through a critical pragmatic lens. Settinga tertiary maternity hospital in Australia providing care to approximately 500 pregnant young women (aged 21 years or less) each year. Three distinct models of care were offered: caseload midwifery, young women's clinic, and standard 'fragmented' care. Participantsa cohort study included data from 1971 young women and babies during 2008–2012. An ethnographic study included analysis of focus group interviews with four caseload midwives in the young women's midwifery group practice; as well as ten pregnant and postnatal young women receiving caseload midwifery care. Findingsintegrated analysis of the quantitative and qualitative findings suggested particular features in the model of care which facilitated young women turning up for antenatal care (at an earlier gestation and more frequently) and buying in to the process (disclosing risks, engaging in self-care activities and accepting referrals for assistance). We conceptualised that Optimal Caseload Midwifery promotes Synergistic Health Engagement between midwife and the young woman. Key conclusionsoptimal Caseload Midwifery (which includes midwives with specific personal attributes and philosophical commitments, along with appropriate institutional infrastructure and support) facilitates midwives and young clients to develop trusting relationships and engage in maternity care. Health engagement can modify predictors for preterm birth that are common amongst pregnant adolescents by promoting earlier maternity booking, sufficient antenatal care, greater emotional resilience, ideal gestational weight gain, less smoking/drug use, and fewer untreated genito-urinary infections. Implications for practicethe institutional infrastructure and managerial support for caseload midwifery should value and prioritise the philosophical commitments and personal attributes required to optimise the model. Furthermore the location of visits, between appointment access to primary midwife, and back-up system should be organised to optimise the midwife-woman relationship in order to promote the young woman's engagement with maternity care.

An overview of the first 'no exit' midwifery group practice in a tertiary maternity hospital in Western Australia: Outcomes, satisfaction and perceptions of care.

Midwifery group practice (MGP) is a care model offered by a primary midwife in a small team. Evidence confirms MGP is acceptable to women, safe and cost effective. We aimed to provide a systematic overview of the first 'no exit' MGP in a Western Australian (WA) tertiary maternity hospital, using a mixed methods approach, involving four phases. Between July 2013 and June 2014: phase one assessed MGP characteristics, obstetric and neonatal outcomes by parity; phase two examined women's satisfaction by mode of delivery; and phase three qualitatively explored perceptions of care. Phase four compared the proportion of MGP women and the 2012 WA birthing population. Phase one included 232 MGP women; 87% achieved a vaginal birth. Phase two included 97% (226 of 232) women, finding 98% would recommend the service. Phase three analysis of 62 interviews revealed an overarching theme 'Continuity with Midwives' encompassing six sub-themes: only a phone call away; home away from home; knowing me; a shared view; there for me; and letting it happen. Phase four compared the MGP cohort to 33,393 WA women. Intrapartum MGP women were more likely than the WA population to have a vaginal birth (87% vs 65%, P≤0.001) and intact perineum (49% vs 36%, P≤0.001) and less likely to use epidural/spinal analgesia (34% vs 59%, P≤0.001), or have a caesarean (13% vs 35%, P≤0.001). Mixed methods enabled systematic examination of this new 'no exit' MGP confirming safety and acceptability. Findings contribute to our knowledge of MGP models.

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).

The effect of primary midwife-led care on women's experience of childbirth: results from the COSMOS randomised controlled trial.

To determine the effect of primary midwife-led care ('caseload midwifery') on women's experiences of childbirth. Randomised controlled trial. Tertiary care women's hospital in Melbourne, Australia. A total of 2314 low-risk pregnant women. Women randomised to caseload care received antenatal, intrapartum and postpartum care from a primary midwife, with some care provided by a 'back-up' midwife. Women in standard care received midwifery-led care with varying levels of continuity, junior obstetric care or community-based medical care. The primary outcome of the study was caesarean section. This paper presents a secondary outcome, women's experience of childbirth. Women's views and experiences were sought using seven-point rating scales via postal questionnaires 2 months after the birth. A total of 2314 women were randomised between September 2007 and June 2010; 1156 to caseload and 1158 to standard care. Response rates to the follow-up questionnaire were 88 and 74%, respectively. Women in the caseload group were more positive about their overall birth experience than women in the standard care group (adjusted odds ratio 1.50, 95% CI 1.22-1.84). They also felt more in control during labour, were more proud of themselves, less anxious, and more likely to have a positive experience of pain. Compared with standard maternity care, caseload midwifery may improve women's experiences of childbirth. Primary midwife-led care ('caseload midwifery') improves women's experiences of childbirth.

Practitioner and Practice Characteristics of Certified Professional Midwives in the United States: Results of the 2011 North American Registry of Midwives Survey.

No data describing certified professional midwives (CPMs) currently exist in the literature, although CPMs attend the majority of home births in the United States. This study addresses this gap by assessing the demographics, education levels, routes to certification, and practice characteristics of currently practicing CPMs. Data were collected from a survey of CPMs conducted by the North American Registry of Midwives (NARM) between July and October 2011. In order to assess generalization to the entire population of practicing CPMs, we also completed a nonresponse bias analysis. We examined midwives' demographic, education, certification, and practice characteristics using descriptive and nonparametric, bivariable statistics. More than 90% of the 568 respondents attended at least some college, and 47.1% hold a bachelor's degree or greater. CPMs spent a median of 3 years (interquartile range, 2-5 years) in training before attending births as a primary midwife. However, 38.9% of currently practicing CPMs had less than 3 years of training. Regarding pathways to certification, 48.5% utilized the portfolio evaluation process (PEP); 36.9% graduated from a Midwifery Education and Accreditation Council (MEAC)-accredited school; 14.5% were already licensed by a state as a direct-entry midwife; and 0.7% were already a certified nurse-midwife or certified midwife, although many CPMs reported a blended education pathway. One-fifth (21%) of respondents identified as midwives of color. Whereas nearly one-third (31.8%) of CPM respondents reported that 95% or more of their clients were white, 5.2% serve populations that are 90% or more nonwhite. CPMs of color are significantly more likely to serve clients of color (P < .001). Training and nonmidwifery education levels of most CPMs practicing in the United States align with the Global Standards for Midwifery Education established by the International Confederation of Midwives, although there are still clear areas for improvement.

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

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Changing models of public antenatal care in Australia: Is current practice meeting the needs of vulnerable populations?

Objectiveto investigate women's views and experiences of public antenatal care. Designpopulation-based survey in two states. SettingSouth Australia and Victoria, Australia. Participants4366 women surveyed at 5–6 months post partum. Findingsof 8468 eligible women mailed the survey, 52% returned completed questionnaires. Fifty-seven per cent of women (2496/4339) received public antenatal care. Of these, half attended a GP for some/all antenatal visits, 38% attended a public hospital clinic or midwives clinic, and 12% had primary midwife care, mostly in a midwifery group practice. Women with complex needs – young women, those experiencing multiple social health problems, women of non-English speaking background, and women at higher risk of complications in pregnancy – were the least likely to say that care met their needs. Women attending a GP or midwife as a primary caregiver were the most positive about their antenatal care: 69% and 74% respectively describing their antenatal care as ‘very good’. Women attending a standard public hospital clinic were the least positive about their antenatal care with only 48% rating their care as ‘very good’. Women enroling in GP shared care or attending a midwives clinic at a public hospital gave intermediate ratings. Conclusion and implications for practiceModels of public antenatal care involving a designated lead primary caregiver (GP or midwife) came closest to meeting women's need for information, individualised care and support.

Mobile technologies and communication strategies in an urban Midwifery Group Practice setting. An exploratory study

Around-the-clock access to a known midwife is a distinct feature of Midwifery Group Practice (MGP) and caseload midwifery settings; although the literature suggests this aspect of working life may hinder recruitment and retention to this model of care. Mobile technologies, known as mHealth where they are used in health care, facilitate access and hence communication, however little is known about this area of midwifery practice. Which communication modalities are used, and most frequently, by MGP midwives and clients? A prospective, cross sectional design included a purposive sample of MGP midwives from an Australian tertiary maternity hospital. Data on modes of midwife-client contact were collected 24h/day, for two consecutive weeks, and included: visits, phone-calls, texts and emails. Demographic data were also collected. Details about 1442 midwife-client contacts were obtained. The majority of contact was via text, between the hours of 07:00 and 14:59, with primiparous women, when the primary midwife was on-call. An average of 96 contacts per fortnight occurred. The majority of contact was between the midwife and their primary clients, reiterating a key tenet of caseload models and confirming mobile technologies as a significant and evolving aspect of practice. The pattern of contact within social (or daytime) hours is reassuring for midwives considering caseload midwifery, who are concerned about the on-call burden. The use of text as the preferred communication modality raises issues regarding data security and retrieval, accountability, confidentiality and text management during off-duty periods. The development of Australian-wide guidelines to inform local policies and best practice is recommended.