title: 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.
abstract: OBJECTIVE
  To determine whether primary midwife care (caseload midwifery) decreases the caesarean section rate compared with standard maternity care.
  
  
  METHODS
  Randomised controlled trial.
  
  
  METHODS
  Tertiary-care women's hospital in Melbourne, Australia.
  
  
  METHODS
  A total of 2314 low-risk pregnant women.
  
  
  METHODS
  Women randomised to caseload received antenatal, intrapartum and postpartum care from a primary midwife with some care by 'back-up' midwives. Women randomised to standard care received either midwifery or obstetric-trainee care with varying levels of continuity, or community-based general practitioner care.
  
  
  METHODS
  
  
  
  METHODS
  caesarean birth. Secondary outcomes included instrumental vaginal births, analgesia, perineal trauma, induction of labour, infant admission to special/neonatal intensive care, gestational age, Apgar scores and birthweight.
  
  
  RESULTS
  In total 2314 women were randomised-1156 to caseload and 1158 to standard care. Women allocated to caseload were less likely to have a caesarean section (19.4% versus 24.9%; risk ratio [RR] 0.78; 95% CI 0.67-0.91; P = 0.001); more likely to have a spontaneous vaginal birth (63.0% versus 55.7%; RR 1.13; 95% CI 1.06-1.21; P < 0.001); less likely to have epidural analgesia (30.5% versus 34.6%; RR 0.88; 95% CI 0.79-0.996; P = 0.04) and less likely to have an episiotomy (23.1% versus 29.4%; RR 0.79; 95% CI 0.67-0.92; P = 0.003). Infants of women allocated to caseload were less likely to be admitted to special or neonatal intensive care (4.0% versus 6.4%; RR 0.63; 95% CI 0.44-0.90; P = 0.01). No infant outcomes favoured standard care.
  
  
  CONCLUSIONS
  In settings with a relatively high baseline caesarean section rate, caseload midwifery for women at low obstetric risk in early pregnancy shows promise for reducing caesarean births.
authors: Mother and Child Health Research, La Trobe University, Melbourne, Vic., Australia. h.mclachlan@latrobe.edu.au
authors: H L
authors: HL
authors: McLachlan
authors: D A
authors: DA
authors: Forster
authors: M A
authors: MA
authors: Davey
authors: T
authors: T
authors: Farrell
authors: L
authors: L
authors: Gold
authors: M A
authors: MA
authors: Biro
authors: L
authors: L
authors: Albers
authors: M
authors: M
authors: Flood
authors: J
authors: J
authors: Oats
authors: U
authors: U
authors: Waldenström
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000706:statistics & numerical data*; D003266:Continuity of Patient Care / Q000458:organization & administration*; D004841:Episiotomy / Q000706:statistics & numerical data; D005113:Extraction, Obstetrical / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D008880:Midwifery / Q000458:organization & administration*; D011181:Postnatal Care / Q000458:organization & administration*; D011247:Pregnancy; D011295:Prenatal Care / Q000458:organization & administration*; D012306:Risk; D014739:Victoria