Maternity care and family services in the early years

Comparing Standard Maternity care with One to one midwifery Support (COSMOS): a randomised trial

Helen McLachlan, Della Forster, Mary-Ann Davey, Michelle Newton; in collaboration with Lisa Gold, Deakin University; Mary Anne Biro, Monash University; Tanya Farrell and Jeremy Oats, Royal Women's Hospital; Ulla Waldenström, Karolinska Institute;  Leah Albers, University of New Mexico

Continuity of carer in the provision of maternity care has been strongly recommended and encouraged in Victoria and throughout Australia.  Many hospitals responded by introducing caseload midwifery, a one to one midwifery model of care in which women are cared for by a primary midwife throughout pregnancy, birth and the early postnatal period. However, this model of care had not been subjected to rigorous evaluation.

The COSMOS trial compared caseload midwifery care with the standard options of care for women at low risk of medical complications at the Royal Women's Hospital in Melbourne. The trial which recruited over 2,300 women, found that women who were randomly allocated to receive caseload midwifery care (compared with women allocated to standard care), were less likely to have a caesarean birth, more likely to have a normal birth, and less likely to have epidural pain relief during labour. The study also found that babies of women who had caseload midwifery care were less likely to be admitted to the special care nursery or neonatal intensive care. Women allocated to caseload midwifery were also more satisfied with their care during pregnancy, birth, and after the birth in hospital and at home. They also had more positive experiences of labour and birth. The reduction in caesarean births and associated reduction in length of stay may also yield some cost savings. A full cost analysis and cost-effectiveness analysis will be completed based on these birth outcomes and data on service use and costs over the first six months after birth.

The study is the first randomised controlled trial of caseload midwifery in Australia and only the third internationally. It is also the largest study of its kind in the world.  The results have assisted policy-makers and maternity services in planning for future models of maternity care in Australia and internationally.

FUNDING: NHMRC project grant 2007-2010

STATUS: Three papers published; three in preparation

Davey M-A, McLachlan H, Forster D, Flood M. 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). Midwifery 2013; 29(12):1297–302
McLachlan HL, Forster DA, Davey MA, Farrell T, Gold L, Biro MA, Albers L, Flood M, Oats J, Waldenström U. 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;119(12):1483–92
McLachlan HL, Forster DA, Davey MA, Lumley J, Farrell T, Oats J, Gold L, Waldenstrom U, Albers L, Biro MA. COSMOS: COmparing Standard Maternity care with one-to-one midwifery support: A randomised controlled trial. BMC Pregnancy Childbirth 2008; 8: 35

COSMOS website

ECO – Exploring the introduction, expansion and sustainability of caseload midwifery in Australia

Michelle Newton, Kate Dawson, Della Forster, Helen McLachlan

Caseload midwifery is a maternity model of care which aims to provide women with continuity of carer from a known midwife. There is strong evidence that caseload care decreases interventions (e.g. caesarean births, analgesia in labour) as well as increasing women's satisfaction with care. Infant outcomes are also improved – our recent randomised controlled trial of caseload care compared with standard care found infants whose mothers were allocated to caseload were less likely to be admitted to the special care nursery and have low birthweight, and more likely to commence breastfeeding (McLachlan 2012).

In the caseload model each woman has a primary midwife, and each midwife carries a 'caseload' of women, to whom she provides care throughout the antenatal, intrapartum and postnatal periods. When the woman is in labour the midwife comes to provide care, unless she is on leave, on a scheduled day off, or if she has already worked the maximum hours in a 24-hour period. The midwife usually works with two or three other midwives to form a small group, with each providing back-up care for the others, to maintain known caregivers. A study we undertook in Victoria found that midwives working in caseload were more satisfied and less burnt out than their standard care counterparts (Newton, Australian Midwifery Models of Care conference, Adelaide 2012), however there was some evidence that not all midwives want to work in this way, suggesting that the sustainability of the model needs exploration.

The ECO study aims to explore the sustainability of caseload midwifery in Australia. This model of care is being promoted by many levels of government throughout Australia and an increasing number of hospitals are introducing the model in Australia. However, very little is known about the workforce implications of the model and therefore the possible scale and sustainability of this style of care. This cross-sectional study involved contacting all public maternity hospitals in Australia to invite management and midwives to participate. An online survey was sent to maternity managers of participating hospitals and then online or hard copy surveys were supplied to midwives around Australia.  A survey of Victorian graduating midwifery students was also conducted to elicit their intent to work in a caseload model.


STATUS: Data collection complete; one paper published, three others in preparation

PUBLICATION: Dawson K, Newton M, Forster D, McLachlan H. Exploring midwifery students׳ views and experiences of caseload midwifery: A cross-sectional survey conducted in Victoria, Australia. Midwifery 2015; 31(2):e7-e15

Enhanced care and support in early labour (ECSEL pilot study)

Mary‐Ann Davey, Rhonda Small, Maggie Flood

This project undertook feasibility work for a proposed rando­mi­sed controlled trial of modified care in early labour. Women attending the proposed study hospitals for maternity care completed questionnaires regarding their willingness to take part in a study like the one described to them. Key clinical staff were interviewed to identify facilitators and barriers to the introduction of the trial.

FUNDING: Healthy Motherhood Program Grant 2012

STATUS: analysis underway

Evaluation of Victorian Homebirthing Pilots

Helen McLachlan, Della Forster, Heather McKay, Rhonda Small, Mary-Ann Davey, Ya-Seng (Arthur) Hsueh, and Michelle Newton; in collaboration with Fiona Cullinane, Royal Women's Hospital, Colleen White, Southern Health, and Susan Gannon, Western Health

The care women receive after having a baby is likely to have a significant impact on their health and well-being. With the rising number of births, many health services in Victoria (including tertiary referral hospitals) have had to respond by discharging women much earlier than planned or expected. Women receive one or two home visits by a hospital midwife, yet there has been very little evaluation of the provision of home-based postnatal care in Victoria, and there is very little evidence to guide care. The aim of the project was to explore home-based postnatal care in terms of what is currently provided; what women expect; and how prepared midwives are to provide home-based postnatal care. This project included three components: focus groups (with midwives), semi-structured interviews with postpartum women and a survey of public hospital managers of maternity services.

The project was the first to provide urgently needed information regarding the structure and content of home-based postnatal care. It is our intention that this study will provide valuable data to inform clinical practice as well as policy. It will also guide future research and if appropriate, may inform a future randomised controlled trial to explore the association between different types of postnatal care provision and clinical outcomes.

FUNDING: Victorian Department of Health

STATUS: Report completed; papers in preparation

Improving the reporting and collection of rural obstetrics data

Mary-Ann Davey, Angela Taft, Rosemary Warren

The Judith Lumley Centre was successful in winning the tender to complete this project for the Department of Health. It covers a number of areas:

  • Exploration of the extent and quality of data collected around maternity care in rural areas
  • Identification of gaps in data or its use
  • Analysis of characteristics of women accessing maternity care in rural areas and their outcomes
  • Suggestions regarding modifications to data items collected and Performance Indicators relating to maternity care
  • Recommendations related to rural obstetrics data.

FUNDING: Department of Health

STATUS: Final report submitted

Davey M-A, Taft AJ, Warren R. Improving the reporting of rural obstetrics data: Final report. Report to Maternity and Newborn Program, Department of Health. Melbourne, Australia: Judith Lumley Centre, La Trobe University; 2014

Validation study of data in the 2011 Victorian Perinatal Data Collection

Mary-Ann Davey, Maggie Flood; Sue McDonald, Mercy Hospital for Women/La Trobe University; Wendy Pollock, School of Nursing and Midwifery, La Trobe University; Rosemary Warren, Sonia Palma

This program of research includes a project based on data in the Victorian Perinatal Data Collection. In order to quantify the accuracy of the data, we are also conducting a validation study of the 2011 Perinatal Data, in collaboration with the Clinical Councils Unit, Victorian Department of Health, and the Consultative Council on Obstetric and Paediatric Mortality and Morbidity.

Data collection for the validation study of a random sample of 1% of births in Victoria was completed on September 2014. 737 mother/baby pairs of records at the three tertiary hospitals and a random sample of other hospitals were checked and validated. The audit included 15 hospitals and two homebirths at seven rural sites, four inner metropolitan and four outer metropolitan sites. The research team comprised Maggie Flood (PhD candidate) and research assistants Rosemary Warren and Sonia Palma

FUNDING: La Trobe University Faculty of Health Sciences Research Grant, Australian College of Midwives Victorian Branch Higher Degree Research Scholarship, Nurses Memorial Scholarship

STATUS: data collection completed; data cleaning has commenced; reports and papers are being prepared

Collaborative work

Birthplace in Australia: a prospective cohort study

Caroline Homer, University of Technology Sydney; David Elwood, Canberra Hospital; Jeremy Oats, Royal Women's Hospital; Maralyn Foureur, University of Technology Sydney; David Sibbritt, University of Technology Sydney; Helen McLachlan and Della Forster; Hannah Dahlen, University of Technology Sydney

More than 7,500 babies are born outside conventional labour wards, either in birth centres or at home in Australia each year. However, there is limited evidence on the safety of these alternative settings, with concerns being raised about increased risk of stillbirth, early neonatal death, neonatal encephalopathy, meconium aspiration, brachial plexus injury, and fractured humerus or clavicle. High quality evidence about the risks and benefits associated with giving birth in different settings should be available to women, policy makers and those responsible for service provision.

Birthplace in Australia is a prospective cohort study which aims to compare the safety of planned birth at home, in birth centres and in stand-alone midwifery units with standard labour wards in Australia, for women at 'low risk' of complications at labour onset.

FUNDING: NHMRC Project Grant 2012-2015

STATUS: Data collection in progress

PUBLICATION: Catling-Paull C, Coddington RL, Foureur MJ, Homer CSE, on behalf of the Birthplace in Australia Study and the National Publicly-funded Homebirth Consortium. Publicly funded homebirth in Australia: a review of maternal and neonatal outcomes over 6 years. Med J Aust 2013;198(11):616-20