title: An investigation of the relationship between the caseload model of midwifery for socially disadvantaged women and childbirth outcomes using routine data--a retrospective, observational study.
abstract: OBJECTIVE
  the objective of this study was to describe and compare childbirth outcomes and processes for women with complex social factors who received caseload midwifery care, and standard maternity care in the UK.
  
  
  BACKGROUND
  women with complex social factors experience high rates of morbidity, mortality and poor birth outcomes. A caseload team was established to support these women throughout pregnancy and childbirth by providing continuity and individualised care.
  
  
  METHODS
  data was collected from computerised birth details of 194 women with complex social factors who presented for maternity care between May 2012 and June 2013; 96 received standard care and 98 caseload care. SPSS v21 was used to calculate descriptive and inferential statistics. Logistic regression modelling found no differences in demographics, therefore unadjusted statistics are presented. Comparative analysis between women receiving caseload care and those receiving standard care was accomplished using χ2 test, relative risk (RR) and 95% confidence intervals (CI).
  
  
  RESULTS
  the relationship between type of care and outcome was not changed by the inclusion of confounding factors. Women receiving caseload care were more likely to experience; spontaneous vaginal childbirth (80% versus 55% RR 1.88, 95% CI 1.27-2.77, P=<0.001), use water for pain relief (32% versus 10%, RR 4.10 95% CI 1.95-8.64, p=<0.001), birth in the midwife led centre (26% versus 13% RR 1.48 95% CI 1.12-1.95, p=0.023), assessment by 10 weeks gestation (24% versus 8% RR 1.61 95% CI 1.24-2.10, p=0.008), shorter postnatal stay (1 day versus 3 days SD 1.2 versus 2.2, p=<0.001), and know their midwife (90% versus 8% RR 8.98 95% CI 4.97-16.2, p=<0.001). More women in the caseload group were referred to multidisciplinary support services; psychiatry (56% versus 19% RR 2.06 95% CI 1.59-2.65, p=<0.001), domestic violence advocacy (42% versus 18% RR 1.68 CI 1.31-2.15, p=<0.001) and other services (56% versus 31% RR 1.58 95% CI 1.15-2.16, p=0.03). They were less likely to have a caesarean section (11% versus 33% RR 0.26 95% CI 0.12-0.55, P=<0.001), an epidural/spinal for pain relief (35% versus 56%, RR 0.64 95% CI 0.46-0.86, p=0.004), give birth on the labour ward (70% versus 88% RR 0.63 95% CI 0.49-0.83, p=0.006), and had fewer antenatal admissions (0.9(SD 1.1) versus 1.3(SD1.5), p=0.036) and neonatal unit admissions (4% versus 18%, RR 0.35 95% CI 0.15-0.85, p=0.005).
  
  
  CONCLUSIONS
  caseload midwifery care appeared to confer increased benefit and reduced harmful outcomes. Findings for individual outcomes differed from previous literature depending on outcome, suggesting caseload care may affect women in different ways depending on their individual needs.
authors: Florence Nightingale Faculty of Nursing and Midwifery, Kings College London, 57 Waterloo Road, London SE1 8WA, United Kingdom. Electronic address: Hannah.8.jones@kcl.ac.uk.
authors: Hannah
authors: H
authors: Rayment-Jones
authors: Florence Nightingale Faculty of Nursing and Midwifery, Kings College London, 57 Waterloo Road, London SE1 8WA, United Kingdom. Electronic address: Trevor.Murrells@kcl.ac.uk.
authors: Trevor
authors: T
authors: Murrells
authors: Women׳s Health Academic Centre, King׳s College London, St. Thomas׳ Hospital, London SE1 7EH, United Kingdom. Electronic address: jane.sandall@kcl.ac.uk.
authors: Jane
authors: J
authors: Sandall
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D008880:Midwifery / Q000379:methods* / Q000706:statistics & numerical data*; D009017:Morbidity; D036801:Parturition; D011247:Pregnancy; D012189:Retrospective Studies; D012923:Social Class; D035862:Vulnerable Populations / Q000706:statistics & numerical data
keywords: Caseload; Complex social factors; Continuity; Disadvantage; Inequalities; Vulnerable