Collaboration in maternity care: a randomised controlled trial comparing community-based continuity of care with standard hospital care.

OBJECTIVE: To test whether a new community-based model of continuity of care provided by midwives and obstetricians improved maternal clinical outcomes, in particular a reduced caesarean section rate. DESIGN: Randomised controlled trial. SETTING: A public teaching hospital in metropolitan Sydney, Australia. Sample 1089 women randomised to either the community-based model (n = 550) or standard hospital-based care (n = 539) prior to their first antenatal booking visit at an Australian metropolitan public hospital. MAIN OUTCOME MEASURES: Data were collected on onset and outcomes of labour, antenatal, intrapartum and postnatal complications, antenatal admissions to hospital and neonatal mortality and morbidity. RESULTS: There was a significant difference in the caesarean section rate between the groups, 13.3% (73/550) in the community-based group and 17.8% in the control group (96/539). This difference was maintained after controlling for known contributing factors to caesarean section (OR = 0.6, 95% CI 0.4-0.9, P = 0.02). There were no other significant differences in the events during labour and birth. Eighty babies (14.5%) from the community-based group and 102 (18.9%) from the control group were admitted to the special care nursery, but this difference was not significant (OR 0.75, 95% CI 0.5-1.1, P = 0.12). Eight infants died during the perinatal period (four from each group), for an overall perinatal mortality rate of 7.3 per 1000 births. CONCLUSION: Community-based continuity of maternity care provided by midwives and obstetricians resulted in a significantly reduced caesarean section rate. There were no other differences in clinical outcomes.

What do women feel about community-based antenatal care?

OBJECTIVE: This study evaluated women's perceptions of a new community-based model of continuity of antenatal care, the St George Outreach Maternity Project (STOMP). The model was established in an attempt to address some of the ongoing concerns and criticisms regarding antenatal care in Australia: lack of continuity of care and caregiver; prolonged waiting times; and inaccessible clinics. METHODS: A randomised controlled trial was conducted with 1,089 women (550 in the experimental group and 539 in the control group). The experimental group (the STOMP group) received antenatal care from small teams of midwives and an obstetrician in community-based settings. Data were collected using a questionnaire administered at 36 weeks' gestation, with a response rate of 75%. RESULTS: Women in the STOMP group reported waiting significantly less time for antenatal visits with easier access to care. STOMP group women also reported a higher perceived 'quality' of antenatal care compared with the control group. STOMP group women saw slightly more midwives and fewer doctors than control group women did. CONCLUSION AND IMPLICATIONS: This model of care has implications for the planning and provision of antenatal services within the Australian public health system, which is increasingly moving towards a community-based emphasis. Antenatal care is a service that can be successfully transferred into community-based settings with benefits for women.