Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): Labor Support, Midwifery, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: To investigate the association between one-to-one midwifery care and birth outcomes with pain relief as the primary outcome. Secondary outcomes include obs

Intervention Results: Logistic regression analysis show that nulliparous women receiving one-to-one midwifery care in the active phase of labour are less likely to have an epidural analgesia, adjusted OR of 0.81 (95% CI 0.72,0.91), less likely to be given nitrous oxide, adjusted OR of 0.77 (95% CI 0.69,0.85), and they more often received massages, adjusted OR of 1.76 (95% CI 1.47,2.11), compared with women not receiving one-to-one midwifery care. Descriptive analyses show that women receiving one-to-one midwifery care in the active phase of labour are less likely to have a caesarean section (5.8% vs. 7.2%) and they are less likely to have an operative vaginal birth (16.5% vs. 23.7%). No significant differences were observed between the groups in terms of low Apgar scores at five minutes.

Conclusion: We found that one-to-one midwifery care in the active phase of labour may be associated with birth outcomes, including decreased use of epidural analgesia and a decreased rate of caesarean sections and operative vaginal birth. The results of this study could encourage midwives to be present during the active phase of labour to promote physiological birth.

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, HEALTH_CARE_PROVIDER_PRACTICE, Labor Support

Intervention Description: To compare labor outcomes in women accompanied by an additional support person (doula group) with outcomes in women who did not have this additional support person (control group).

Intervention Results: Significantly shorter length of labor in the doula group, greater cervical dilation at the time of epidural anesthesia, and higher Apgar scores at both 1 and 5 minutes. Differences did not reach statistical significance in type of analgesia/anesthesia or cesarean delivery despite a trend toward lower cesarean delivery rates in the doula group.

Conclusion: Providing low-income pregnant women with the option to choose a female friend who has received lay doula training and will act as doula during labor, along with other family members, shortens the labor process.

Study Design: RCT

Setting: 1 women’s ambulatory care center at a tertiary hospital in New Jersey

Population of Focus: Nulliparous women who gave birth after enrollment between 1998 and 2002

Data Source: Not specified

Sample Size: Total (n=586) Intervention (n=291) Control (n=295)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): Enabling Services, Expert Support (Provider), Labor Support,

Intervention Description: This research used a phenomenological approach, using data from in-depth individual interviews to explore the essence of 25 Black women's experiences.

Intervention Results: We identified three major themes from the data that together, show that PSPs served as communication bridges for their clients. Clients said their PSPs helped them to understand and feel seen and heard by their medical providers during their prenatal appointments. The third theme was the deep level of trust the clients developed for their PSPs which made the first two themes possible. PSPs' intervention resulted in reduced stress and uncertainty in medical interactions and increased women's trust in their providers' recommendations.

Conclusion: Including a trusted, knowledgeable advocate like a PSP may be an important intervention in improving Black women's prenatal care experiences, reducing stress associated with medical interactions, and ultimately reducing pregnancy-related health disparities.

Study Design: Qualitative

Setting: Community-based

Population of Focus: Black women

Sample Size: 25

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Childbirth Education Classes, PROVIDER/PRACTICE, Active Management of Labor, Labor Support, Midwifery

Intervention Description: Active management of labor is a multifaceted program that, as implemented at the National Maternity Hospital in Dublin, is associated with a lower rate of cesarean delivery than the rate usually found in the United States. We conducted a randomized trial to evaluate the efficacy of this approach in lowering the rate of cesarean section among women delivering their first babies.

Intervention Results: Rate of CS among protocol-eligible women lower in AMOL group vs. control group (10.9% vs. 11.5%; p>0.05) after adjustment for epidural use and adoption of final protocol (three hours for second stage of labor with epidural); (OR=0.9, 95% CI: 0.4–1.9)

Conclusion: Active management of labor did not reduce the rate of cesarean section in nulliparous women but was associated with a somewhat shorter duration of labor and less maternal fever.

Study Design: RCT

Setting: 1 women’s hospital

Population of Focus: Nulliparous women who gave birth between June 10, 1991 and October 17, 1993

Data Source: Not specified

Sample Size: Total (n=1,915) Intervention (n=1,009) Control (n=906)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): Labor Support, PROVIDER/PRACTICE, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: To compare the benefits of one-to-one nurse labor support with the benefits of usual intrapartum nursing care in women stimulated with oxytocin.

Intervention Results: A beneficial trend because of one-to-one nurse support, with a 56% reduction in risk of total cesarean deliveries [RR of experimental vs. control = 0.44 (95% confidence interval = 0.19 to 1.01)].

Conclusion: The beneficial trend in reducing cesarean deliveries attributed to one-to-one nursing in women stimulated with oxytocin suggests that continuous support by intrapartum nursing staff may benefit women stimulated with oxytocin during labor.

Study Design: RCT

Setting: 1 women’s hospital

Population of Focus: Nulliparous women who gave birth between January 17, 1993 and July 17, 1994

Data Source: Not specified

Sample Size: Total (n=413) Intervention (n=209) Control (n=204)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Labor Support, Midwifery, HOSPITAL, Peer Review, Quality Improvement

Intervention Description: In efforts to help reduce the primary C-section rate, the hospital participated in the American College of Nurse-Midwives Healthy Birth Initiative. Strategies employed included use of intermittent auscultation, upright labor positioning, an early labor lounge, one-to-one labor support, and team huddles.

Intervention Results: The baseline nulliparous, term, singleton, vertex cesarean rate in 2015 was 29.3%. In 2016, after 1 year of implementation of the project, the hospital decreased nulliparous, term, singleton, vertex cesarean rate to 26.1%-a reduction of 10%. In 2017, the rate was decreased to 25.3%-a reduction by 3.7%.

Conclusion: The multicomponent bundle incorporated proven quality improvement strategies and engaged numerous champions and stakeholders, including midwifery students.

Setting: Urban academic hospital in the Midwest

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Continuity of Care (Caseload), Labor Support, POPULATION-BASED SYSTEMS, STATE, Place of Birth, HEALTH_CARE_PROVIDER_PRACTICE, Midwifery

Intervention Description: The aim of this study was to investigate the effects of modified birth center care on obstetric procedures during delivery and on maternal and neonatal outcomes.

Intervention Results: The modified birth center group included fewer emergency cesarean sections (primiparas: OR: 0.69, 95% CI: 0.58-0.83; multiparas: OR: 0.34, 95% CI: 0.23-0.51), and in multiparas the vacuum extraction rate was reduced (OR: 0.42, 95% CI: 0.26-0.67). In addition, epidural analgesia was used less frequently (primiparas: OR: 0.47, 95% CI: 0.41-0.53; multiparas: OR: 0.25, 95% CI: 0.20-0.32). Fetal distress was less frequently diagnosed in the modified birth center group (primiparas: OR: 0.72, 95% CI: 0.59-0.87; multiparas: OR: 0.45, 95% CI: 0.29-0.69), but no statistically significant differences were found in neonatal hypoxia, low Apgar score less than 7 at 5 minutes, or proportion of perinatal deaths (OR: 0.40, 95% CI: 0.14-1.13). Anal sphincter tears were reduced (primiparas: OR: 0.73, 95% CI: 0.55-0.98; multiparas: OR: 0.41, 95% CI: 0.20-0.83).

Conclusion: Midwife-led comprehensive care with the same medical guidelines as in standard care reduced medical interventions without jeopardizing maternal and infant health.

Study Design: Retrospective cohort

Setting: 1 large, public hospital

Population of Focus: Nulliparous women admitted to the modified birth center between March 2004 to July 2008 who gave birth at either the modified birth center or in standard delivery ward2

Data Source: Not specified

Sample Size: Total (n=6,141) Intervention (n=1,263) Control (n=4,878)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Labor Support, POPULATION-BASED SYSTEMS, State — Place of Birth, STATE, Place of Birth, Childbirth Education Classes, Midwifery, PATIENT_CONSUMER, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: We evaluated the effect on perinatal outcomes of an interdisciplinary program designed to promote physiologic birth and encourage active involvement of women and their families in maternity care.

Intervention Results: Compared with women receiving standard care, those in the birth program were more likely to be delivered by a midwife (41.9% v. 7.4%, p < 0.001) instead of an obstetrician (35.5% v. 69.6%, p < 0.001). The program participants were less likely than the matched controls to undergo cesarean delivery (relative risk [RR] 0.76, 95% confidence interval [CI] 0.68-0.84) and, among those with a previous cesarean delivery, more likely to plan a vaginal birth (RR 3.22, 95% CI 2.25-4.62). Length of stay in hospital was shorter in the program group for both the mothers (mean ± standard deviation 50.6 ± 47.1 v. 72.7 ± 66.7 h, p < 0.001) and the newborns (47.5 ± 92.6 v. 70.6 ± 126.7 h, p < 0.001). Women in the birth program were more likely than the matched controls to be breastfeeding exclusively at discharge (RR 2.10, 95% CI 1.85-2.39).

Conclusion: Women attending a collaborative program of interdisciplinary maternity care were less likely to have a cesarean delivery, had shorter hospital stays on average and were more likely to breastfeed exclusively than women receiving standard care.

Study Design: Retrospective cohort

Setting: 1 women’s hospital

Population of Focus: Nulliparous women who gave birth between April 2004 to October 20102

Data Source: Not specified

Sample Size: Total (n=1,660) Intervention (n=830) Control (n=830)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Labor Support

Intervention Description: Patients were randomly assigned to receive usual care (n = 3461) or continuous labor support by a specially trained nurse (n = 3454) during labor.

Intervention Results: Data were received for all 6915 women and their infants (n = 6949). The rates of cesarean delivery were almost identical in the 2 groups (12.5% in the continuous labor support group and 12.6% in the usual care group; P =.44). There were no significant differences in other maternal or neonatal events during labor, delivery, or the hospital stay. There were no significant differences in women's perceived control during childbirth or in depression, measured at 6 to 8 postpartum weeks. All comparisons of women's likes and dislikes, and their future preference for amount of nursing support, favored the continuous labor support group.

Conclusion: In hospitals characterized by high rates of routine intrapartum interventions, continuous labor support by nurses does not affect the likelihood of cesarean delivery or other medical or psychosocial outcomes of labor and birth.

Study Design: RCT

Setting: 13 hospitals with annual CS rates of at least 15%

Population of Focus: Nulliparous women who gave birth after enrollment between May 1999 to May 20012

Data Source: Not specified

Sample Size: Total (n=3,395) Intervention (n=1,701) Control (n=1,694)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Labor Support

Intervention Description: The continuous presence of a supportive companion (doula) during labor and delivery in two studies in Guatemala shortened labor and reduced the need for cesarean section and other interventions.

Intervention Results: Continuous labor support significantly reduced the rate of cesarean section deliveries (supported group, 8%; observed group, 13%; and control group, 18%) and forceps deliveries. Epidural anesthesia for spontaneous vaginal deliveries varied across the three groups (supported group, 7.8%; observed group, 22.6%; and control group, 55.3%). Oxytocin use, duration of labor, prolonged infant hospitalization, and maternal fever followed a similar pattern.

Conclusion: The beneficial effects of labor support underscore the need for a review of current obstetric practices.

Study Design: RCT

Setting: 1 public, university hospital in Texas

Population of Focus: Nulliparous women who gave birth during study period (dates not specified)

Data Source: Not specified

Sample Size: Total (n=616) Intervention (n=212) Observed (n=200) Control (n=204)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Labor Support

Intervention Description: We compared rates of preterm and cesarean birth among Medicaid recipients with prenatal access to doula care (nonmedical maternal support) with similar women regionally. We used data on this association to mathematically model the potential cost-effectiveness of Medicaid coverage of doula services.

Intervention Results: Women who received doula support had lower preterm and cesarean birth rates than Medicaid beneficiaries regionally (4.7 vs 6.3%, and 20.4 vs 34.2%). After adjustment for covariates, women with doula care had 22 percent lower odds of preterm birth (AOR 0.77 [95% CI 0.61–0.96]). Cost‐effectiveness analyses indicate potential savings associated with doula support reimbursed at an average of $986 (ranging from $929 to $1,047 across states).

Conclusion: Based on associations between doula care and preterm and cesarean birth, coverage reimbursement for doula services would likely be cost saving or cost-effective for state Medicaid programs.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Active Management of Labor, Labor Support, HOSPITAL, STATE, Quality Improvement, Policy/Guideline (State), Collaboratives, Policy/Guideline (Hospital)

Intervention Description: California hospitals whose nulliparous, term, singleton, vertex cesarean delivery rates were above the Healthy People 2020 goal of 23.9% in 2015 were invited to participate in the Supporting Vaginal Birth collaborative led by the California Maternal Quality Care Collaborative (CMQCC). The participating hospitals were organized into small teams of six to eight hospitals each led by a physician and a nurse mentor who provided clinical expertise and quality-improvement coaching. The mentors were from other hospitals and had experience in prior CMQCC quality collaboratives. The collaborative focused on implementation of ACOG–SMFM guidelines for labor management and on increasing nursing labor support. A modified Institute for Healthcare Improvement Breakthrough Series collaborative model was used with monthly team check-in phone calls and sharing of implementation ideas and materials. Hospitals received training materials, Grand Rounds for physicians and nurses, educational webinars, and on-site assistance from their mentors.

Intervention Results: Among collaborative hospitals, the nulliparous, term, singleton, vertex cesarean delivery rate fell from 29.3% in 2015 to 25.0% in 2017 (2017 vs 2015 adjusted OR [aOR] 0.76, 95% CI 0.73-0.78). None of the six safety measures showed any difference comparing 2017 to 2015. As a sensitivity analysis, we examined the tercile of hospitals with the greatest decline (31.2%-20.6%, 2017 vs 2015 aOR 0.54, 95% CI 0.50-0.58) to evaluate whether they had greater risk of poor maternal and neonatal outcomes. Again, no measure was statistically worse, and the severe unexpected newborn complications composite actually declined (3.2%-2.2%, aOR 0.71, 95% CI 0.55-0.92).

Conclusion: Mothers and neonates participating in a large-scale Supporting Vaginal Birth collaborative had no evidence of worsened birth outcomes, even in hospitals with large cesarean delivery rate reductions, supporting the safety of efforts to reduce primary cesarean delivery using American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine guidelines and enhanced labor support.

Setting: 56 California hospitals

Population of Focus: Nulliparous women with term singleton vertex gestations

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Labor Support, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: The objective of this randomized controlled trial was to examine the perinatal effects of doula support for nulliparous middle-income women accompanied by a male partner during labor and delivery.

Intervention Results: The doula group had a significantly lower cesarean delivery rate than the control group (13.4% vs 25.0%, p = 0.002), and fewer women in the doula group received epidural analgesia (64.7% vs 76.0%, p = 0.008). Among women with induced labor, those supported by a doula had a lower rate of cesarean delivery than those in the control group (12.5% vs 58.8%, p = 0.007). On questionnaires the day after delivery, 100 percent of couples with doula support rated their experience with the doula positively.

Conclusion: For middle-class women laboring with the support of their male partner, the continuous presence of a doula during labor significantly decreased the likelihood of cesarean delivery and reduced the need for epidural analgesia. Women and their male partners were unequivocal in their positive opinions about laboring with the support of a doula.

Study Design: RCT

Setting: University Hospitals in Ohio

Population of Focus: Nulliparous women who gave birth after enrollment in childbirth education classes between 1988 and 2002

Data Source: Not specified

Sample Size: Total (n=420) Intervention (n=224) Control (n=196)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Labor Support, Midwifery, HOSPITAL, Chart Audit and Feedback, Peer Review, Quality Improvement

Intervention Description: This quality improvement initiative involved multiple interventions that were monitored over time by statistical process control charts. Components included a nested case-control review of local risk factors, provider and patient education, multidisciplinary reviews based on published guidelines with feedback, provider report cards, commitment to labor duration guidelines, and a focus on natural labor. The nursing team received training and certification in holistic nursing, and certified nurse-midwives were employed and given delivery privileges. The six-bed Karmanos Center for Natural Birth (NBC) was opened in November 2014 for low-risk women who were managed without continuous fetal monitoring, epidural analgesia, and obstetrical interventions.

Intervention Results: Control chart analysis demonstrated that the institutional cesarean delivery rate was due to culture and not "outlier" obstetricians. The primary singleton vertex cesarean rate decreased from 23.4% to 14.1% and the NTSV rate decreased from 34.5% to 19.2% (both p < .0001). There was a decrease in NICU admission but no significant changes in postpartum hemorrhage, chorioamnionitis, stillbirth, or neonatal mortality.

Conclusion: Structured quality improvement initiatives may decrease primary cesarean deliveries without increasing maternal or perinatal morbidity.

Setting: Beaumont Hospital, Royal Oak, an academic-community hybrid facility in southeastern Michigan

Population of Focus: Nulliparous women with term singleton vertex gestations

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Labor Support, Provider Training/Education, HOSPITAL, Guideline Change and Implementation, Quality improvement

Intervention Description: This was a quality improvement project and practice change was part of the Reducing Primary Cesarean Learning Collaborative from the American College of Nurse-Midwives. It was designed to increase nurse self-efficacy and the use of continuous labor support and to reduce the rate of primary cesarean births among nulliparous women with low-risk pregnancies. The multi-component intervention, called the “Comfort in Labor Safety Bundle,” included updating existing labor policies, providing nurse education and training workshops, modifying the documentation of care, and procuring labor support equipment. Nurse confidence and skill in labor support techniques was measured using the Self-Efficacy Labor Support Scale. The study also tracked how many women were provided continuous labor support and the primary cesarean birth rate among women who were nulliparous and low risk.

Intervention Results: Nurses' mean self-efficacy scores increased from 76.67 in 2016 to 86.96 in 2019 (p < .001). The proportion of women who were provided continuous labor support increased from a baseline of 4.38% (47/1,074) in January 2015 through March 2016 to 18.06% (82/454) in July through December 2019 (p < .001). The primary cesarean birth rate for nulliparous women with low-risk pregnancies remained stable, at approximately 18% from 2015 to 2019.

Conclusion: Implementation of the Comfort in Labor Safety Bundle improved nurse self-efficacy in labor support techniques and increased the frequency of continuous labor support.

Setting: Level II regional hospital in Virginia

Population of Focus: Nulliparous women with low risk pregnancies

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Active Management of Labor, Labor Support, Midwifery, Prolonged Second Stage of Labor, HOSPITAL, Chart Audit and Feedback, Guideline Change and Implementation

Intervention Description: 419 consecutive patients were divided into two groups, with one group (216 patients) receiving “standard management” (with medical acceleration of labor commencing at the ‘‘action line’’ in the case of arrested or protracted labor) and the other group (203 patients) receiving “comprehensive management” (CM) where arrested or protracted labor was considered a warning sign promoting further diagnostic assessment prior to considering intervention. Comprehensive management included the daily audit and discussion of clinical cases by medical and midwifery staff; the introduction of intrapartum ultrasonography alongside traditional clinical assessment to determine fetal head and trunk position accurately; one-on-one labor support facilitated by midwives and/or labor partners; and attention to the psychological well-being of the patient throughout labor and delivery.

Intervention Results: his study included 3283 and 3068 women in the before and after periods, respectively. The groups had similar general and obstetric characteristics. The global cesarean delivery rate decreased significantly from 9.4% in the preguideline to 6.9% in the postguideline period (odds ratio, 0.71; 95% confidence interval, 0.59-0.85; P < .01). The cesarean delivery rate for arrest of first-stage labor fell by half, from 1.8% to 0.9% (odds ratio, 0.51; 95% confidence interval, 0.31-0.81; P < .01) but was significant only among nulliparous women. The cesarean delivery rate for second-stage arrest of labor decreased but not significantly between periods (1.3% vs 1.0%; odds ratio, 0.73; 95% confidence interval, 0.44-1.22; P = .2), and the cesarean delivery rate for failure of induction remained similar (3.7% vs 3.5%; odds ratio, 1.06; 95% confidence interval, 0.06-13.24; P = .88). The median duration of labor before cesarean delivery also became significantly longer among nulliparous women during the later period. Maternal and neonatal outcomes did not differ between the 2 periods, except that the rate of 1 minute Apgar score <7 fell significantly in the later period (8.4% vs 6.9%; odds ratio, 0.80; 95% confidence interval, 0.66-0.97; P = .02).

Conclusion: The modification of our protocol by implementing the new consensus recommendations was associated with a reduction of the rate of primary cesarean delivery performed for arrest of labor with no apparent increase in immediate adverse neonatal outcomes in nulliparous women at term with singleton pregnancies in vertex presentation and with epidural anesthesia. Further studies are needed to assess the long-term maternal and neonatal safety of these policies.

Setting: Obstetric Unit of Sesto San Giovanni Hospital, Milan, Italy, an urban community hospital

Population of Focus: nulliparous women with a single fetus in cephalic presentation, in spontaneous labor at term or induced labor post term.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Labor Support, Continuity of Care (Caseload), HOSPITAL, Chart Audit and Feedback, Quality Improvement

Intervention Description: Using data from Robson classification, a novel labor–ward management protocol termed Comprehensive Management (CM) was carried out at the Obstetric Unit of the Cà Granda Niguarda Hospital in Milan, Italy, from 1 January 2012 to 31 December 2013. CM included regular labor monitoring, documentation of events, audit and feedback, the use of intrapartum ultrasound, mobility in labor and birth posture of choice, a partograph conceived as a screening tool, continuity of care; respectful labor and childbirth care; oral fluid and food intake, and emotional support from a person of choice. The CM “framework” provides tools to make medical interventions performed during childbirth quantitatively measurable and comparable.

Intervention Results: Following CM a substantial reduction was observed in the Overall Treatment Ratio, as well as in the ratios for augmentation (amniotomy and synthetic oxytocin use) and for caesarean section ratio, without any increase in neonatal and maternal adverse outcomes. The key component of this reduction was the dramatic decline in the proportion of women progressing to augmentation, which resulted not only the most practiced intervention, but also the main door towards further treatments.

Conclusion: The proposed framework, once combined with Robson Classification, provides useful tools to make medical interventions performed during childbirth quantitatively measurable and comparable. The framework allowed to identifying the key components of interventions reduction following CM. In its turn, CM proved useful to reduce the number of medical interventions carried out during childbirth, without worsening neonatal and maternal outcomes.

Setting: Obstetric Unit of the Cà Granda Niguarda Hospital in Milan, Italy

Population of Focus: Nulliparous or multiparous women, at term, with single cephalic baby in either spontaneous or induced labor

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Continuity of Care (Caseload), Labor Support, Midwifery

Intervention Description: a cross sectional study examining the risk profile, birth outcomes and cost of care for women booked into one of the three available models of care in a tertiary teaching hospital in Australia between July 1st 2009 December 31st 2010.

Intervention Results: First time ‘low risk’ mothers who received caseload care were more likely to have a spontaneous onset of labour and an unassisted vaginal birth 58.5% in midwifery group practices (MGP) compared to 48.2% for Standard hospital care and 30.8% with Private obstetric care (p < 0.001). They were also significantly less likely to have an elective caesarean section 1.6% with MGP versus 5.3% with Standard care and 17.2% with private obstetric care (p < 0.001). From the public hospital perspective, over one financial year the average cost of care for the standard primipara in MGP was $3903.78 per woman. This was $1375.45 less per woman than those receiving Private obstetric care and $1590.91 less than Standard hospital care per woman (p < 0.001). Similar differences in cost were found in favour of MGP for all women in the study who received caseload care.

Conclusion: Cost reduction appears to be achieved through reorganising the way care is delivered in the public hospital system with the introduction of Midwifery Group Practice or caseload care. The study also highlights the unexplained clinical variation that exists between the three models of care in Australia.

Study Design: Retrospective cohort

Setting: 1 large teaching hospital

Population of Focus: Nulliparous women who gave birth between July 2009 and December 20102

Data Source: Not specified

Sample Size: Total (n=1,406) Intervention (n=482) Control (n=674)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, HEALTH_CARE_PROVIDER_PRACTICE, Midwifery, Labor Support

Intervention Description: A hospital in Belgium introduced "the cocoon," an alongside midwifery-led care unit. Low-risk pregnant women had the option of choosing the midwifery pathway or attending the traditional care pathway. Patients who chose the Cocoon pathway (62.2 percent nulliparous and 37.8% multiparous) had their pregnancy followed up almost exclusively by midwives, and their care was reviewed by a gynecologist at least twice during their pregnancy. The visits at the Cocoon lasted 45 minutes instead of the standard 20 minutes in the “classic” clinic. Women and their birth partners were encouraged to attend classes provided by midwives from the Cocoon and were given the opportunity to participate in a maximum of seven classes, six of which were group classes.

Intervention Results: In this setting, the cesarean birth rate was 10.3% compared with 16.0% in the traditional care pathway (adjusted odds ratios [aOR] 0.42 [95% CI 0.25-0.69]), the induction rate was 16.3% compared with 30.5% (0.46 [0.30-0.69]), the epidural analgesia rate was 24.9% compared with 59.1% (0.15 [0.09-0.22]), and the episiotomy rate was 6.8% compared with 14.5% (0.31 [0.17-0.56]). There was no increase in adverse neonatal outcomes. Intrapartum and postpartum transfer rates to the traditional pathway of care were 21.1% and 7.1%, respectively.

Conclusion: Women planning their births in the midwifery-led unit, the Cocoon, experienced fewer interventions with no increase in adverse neonatal outcomes. Our study gives initial support for the introduction of similar midwifery-led care pathways in other hospitals in Belgium.

Setting: Alongside midwifery‐led unit within a Belgian hospital

Population of Focus: Nulliparous and multiparous women with low-risk pregnancies