Monday, July 30, 2012

More evidence ...

... demanding action.

For many years the buzz word in maternity care has been 'evidence'.  'Evidence-based' maternity care guidelines can be found everywhere. 

Application of the evidence into mainstream maternity care is quite another matter.

From my perspective, it's great to see another piece of reliable evidence supporting midwifery continuity of care /caseload midwifery/ one-to-one midwifery.  This evidence is published in a respected professional journal, BJOG, and International Journal of Obstetrics and Gynaecology, reporting on research carried out under the strict rules of randomised controlled trials, by the La Trobe University team of midwifery academics, led by Associate Professor Helen McLachlan.

The title of the paper is:
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.
Authors: McLachlan et al, BJOG (2012).

The team of authors of this paper includes midwife academics who were prominent in the 'Team Midwifery' research from LaTrobe Uni more than a decade ago.  'Team midwifery' was adopted into many mainstream maternity units, in an attempt to reduce the huge number of midwives who provided care for individual women during their prenatal, intranatal, and postnatal experience.  Women were allocated to the 'Green team' or the 'Pink team'.  Midwives work ordinary hospital nursing shifts.  Women under 'team midwifery' are usually attended in labour by midwives who are strangers. 

Two papers addressing Team Midwifery, authored by Professor Ulla Waldenstrom and others, and Mary-Anne Biro and others in 2000 in the journal BIRTH presented the research findings, and a commentary was written by Karyn Kaufman.  Kaufman, a midwife academic and a member of a community-based midwifery practice in Canada highlighted in her review the lack of difference between the control or ‘standard care’ and the intervention, team midwifery.  Kaufman commented that “midwifery care that follows strict medical protocols is not the same as midwifery care that is enacted from a philosophy of normal birth and is individually negotiated with labouring women.”  This statement sounds logical, yet many Australian midwives at the time may not have realised that midwifery care for well women can be enacted from a philosophy of normal birth.

The primary outcome of the continuity of care by a primary midwife (caseload midwifery) trial is that
"In settings with a relatively high baseline caesarean section rate, caseload midwifery for women at low obstetric risk shows promise for reducing caesarean births."  
Besides having fewer caesareans, women allocated to 'caseload' were more likely to have a spontaneous vaginal birth, less likely to have epidural or episiotomy, and their babies were less likely to be taken to the special care nursery than those who received standard care.  

Good for mother, good for baby.
Good for the midwife, too.

In the highly formal language of academia, the authors have boldly come to the conclusion that the midwives with caseloads "can make a difference by reducing the caesarean section rate."

When a reduced likelihood of caesarean can be demonstrated for women at low risk of complications, it's time for the midwifery profession to celebrate.  

Evidence demands action.

This is reliable evidence.
This research was carried out under strict controls.

Midwives and maternity services must be challenged to apply the evidence to practice.  The usual practise of midwifery should be in a caseload model, working autonomously in their scope of practice to promote, protect and support physiological processes in birth whenever possible ('Plan A').  Not as shiftworker nurses in hospitals who work as assistants to obstetricians.  

Only when midwives are willing to take action on evidence will we see improvements in birth outcomes: healthier mothers and babies.

1 comment:

Midwife International said...

Hi Joy,
Thank you so much for sharing such significant information!

At Midwife International, we are taking action internationally to train midwives who are equipped to work in resource-constrained regions where maternal and child mortality is high and the need for professional midwives is greatest.

For more information, please be directed to

Yours in the pursuit of healthier mothers and babies,
Midwife International