MIdwife-led care and caseload continuity may decrease risk for cesarean birth

摘要

There are myriad reasons subscribed to why the cesarean birth rate in the United States is on the rise, including frequent use of labor interventions and limited availability of vaginal birth after cesarean. Evidence suggests women highly value vaginal birth, and cesarean birth significantly contributes to maternal morbidity and health care expenditures, which are increasing at a rate that is unaffordable. The primary aim of this study was to assess if caseload midwifery significantly decreased the rate of cesarean birth compared with standard care that included midwives as providers. The authors acknowledge that an underlying objective in doing this study was to provide additional evidence for a recent Cochrane review that reported no significant difference in midwife-led care and risk for cesarean birth. Caseload midwifery is defined as one-to-one care in which women receive care from a primary midwife with potential to be seen by one or 2 backup midwives. Secondary outcomes assessed include evaluating the relative risks for induction of labor, instrumental vaginal birth, epidural analgesia, episiotomy, post-partum length of stay, and neonatal admission to special care. The setting was Melbourne, Australia, with 2314 low-risk women randomized to caseload or standard care. Women enrolled were less than 24 completed weeks' gestation with a singleton pregnancy and considered low risk at recruitment. The final sample size was established with a power analysis to detect a decrease in cesarean rate from 25% to 20% (with 80% power and 95% confidence) assuming fewer than 1% loss to follow-up.