ArticlesRandomised, controlled trial of efficacy of midwife-managed care
Introduction
The movement to implement change in maternity services so that the individual needs of women are more central to the provision of care has gathered pace in several western countries during the 1990s.1, 2, 3, 4, 5 In the UK, the predominant model of shared care–divided among midwives, hospital doctors, and general practitioners (family physicians)—has been called into question.1, 2, 3 The UK initiatives call for a lead role and greater responsibility for midwives, and support the development of programmes of care in which midwives hold their own caseloads and provide care throughout the antenatal, intrapartum, and postnatal periods. Such programmes are currently being implemented,6, 7 but there have been few randomised controlled trials of their efficacy.8 Published trials have concentrated on the intrapartum9 or antenatal and intrapartum periods.10
The Midwifery Development Unit (MDU) project at Glasgow Royal Maternity Hospital aimed to address this issue by implementing and assessing a midwife-managed programme of care for healthy women. Care was provided by a group of 20 midwives who volunteered to join the unit from the hospital's existing complement of midwives.11 Each pregnant woman had a named midwife whom she met at the first antenatal visit and who aimed to provide the majority of planned episodes of care from booking to discharge to the health visitor. When the named midwife was unavailable, the woman was cared for by an associate midwife from the MDU team; women were referred to the obstetric medical team when there was deviation from normal, rather than at routinely specified times. The programme of care and its comparison with shared care have been described in detail elsewhere12, 13 (available from the MDU).
Since alternative models of maternity care are being widely implemented, they must be subjected to rigorous evaluation. The aim of this study was to compare midwife-managed care and shared care in terms of clinical efficacy and women's satisfaction. The randomised controlled trial was designed to address the hypothesis that compared with shared care, midwife-managed care would result in fewer interventions, similar (or more favourable) outcomes, similar complications, plus greater satisfaction with care and enhanced continuity of care and carer.
Section snippets
Design and participants
The study was carried out at Glasgow Royal Maternity Hospital, a major urban teaching hospital with around 5000 deliveries per year, serving a largely disadvantaged community.14 Between Jan 11, 1993, and Feb 25, 1994, all women booking for care at routine hospital-based consultant clinics were screened for eligibility; the criteria were residence within the hospital's catchment area, booking for antenatal care within 16 completed weeks of pregnancy, and absence of medical or obstetric
Results
Of the 1586 eligible women, 1299 (81·9%) consented to take part in the study. 651 women were assigned shared care and 648 midwife-managed care. Case records were available for 635 (97·5%) of the shared-care group and 643 (99·2%) in the midwife-managed group. The baseline characteristics of women in the two study groups were similar (table 1).
Women in the midwife-managed group were more likely than those in the shared-care group to return the third-trimester questionnaire (534 [85·3%] vs 487
Discussion
Our study examined the efficacy of midwife-managed care from booking to discharge to the health visitor and women's satisfaction with such care. The study was done in an inner-city community, and about two-thirds of women were from very deprived backgrounds. The analysis was by intended care group, which makes the comparison of types of care more realistic.
We found that compared with shared care, the midwife-managed care programme resulted in similar or reduced rates of interventions, similar
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