Continuity of care by a primary midwife (caseload midwifery) increases women’s satisfaction with antenatal, intrapartum and postpartum care: results from the COSMOS randomised controlled trial

Continuity of carer has been strongly recommended and encouraged in maternity services in Australia [1], and many hospitals have responded by introducing caseload midwifery. In the caseload model women are cared for by a primary midwife throughout pregnancy, birth and the early postpartum period. We conducted a randomised controlled trial (RCT) comparing caseload midwifery care with standard care and found that women allocated to caseload midwifery were less likely to have a caesarean birth, analgesia during labour, and an episiotomy; that fewer infants were admitted to the special care nursery; and that mother and infant safety outcomes did not differ statistically between the study groups [2]. These findings confirm those of other RCTs of midwife-led care [3], suggesting that these models reduce interventions without jeopardising health outcomes.

Many of the RCTs of midwife-led care report increased satisfaction associated with being allocated to the midwife-led care trial arm [4‐6]. However, a lack of consistency in measuring women’s satisfaction means that the Cochrane review Midwife-led versus other models of care for childbearing women was only able to report on satisfaction outcomes using a narrative approach [7]. While nine studies reported on maternal satisfaction, there was ambiguity around the concept of satisfaction, and inconsistency in the tools used to measure satisfaction [7]. Overall, although the included studies showed a higher level of satisfaction among women who had midwife-led care compared with those who did not, the reviewers could not identify which aspects of care increased women’s satisfaction. Other studies have reported associations between positive ratings of satisfaction and different aspects of care, such as conveniently located care [8], safe care with skilled professionals [8, 9], positive staff attitudes and behaviours (e.g. respectful, kind, empathetic) [8‐11], being remembered between visits [12], having an active say in decision making [13], having enough information [8, 10, 13], perceiving care providers as helpful [13], and a consistent philosophy of care [11]. Both team midwifery models (that include four to 12 midwives) and caseload midwifery models (where women are allocated a primary ‘known’ midwife) have been shown to increase women’s satisfaction [4, 6, 14].

The type of continuity that matters to women has been extensively discussed; whether it is seeing the same care provider at each visit (continuity of carer) that is important, or if it is continuity in a broader sense, including the same team of midwives during all episodes of care, staff sharing the same philosophy of care, or consistency regarding guidelines, information and advice. The Cochrane review included ten trials in which midwife-led care was provided by teams, and only three trials of caseload midwifery, where there is a higher degree of continuity of carer [7]. The difference between team midwifery and caseload midwifery relates to the question of continuity of carer, and whether or not it is important to women.

A review by Green et al. [15] found no difference in satisfaction between women who had a known care provider during labour compared with those who had not. This review suggests that there is no evidence that women who are cared for in labour by a midwife they have already met are more satisfied than those who have not. The authors argue that other aspects of care, such as trust and consistent advice, may be more important to women than being cared for by a midwife with whom a relationship has developed over time. They also argue that although most of the schemes that aimed to achieve continuity of care did so, there should be caution in assuming that continuity is the specific component that explains the higher rates of satisfaction observed in the new models. Their concerns were based on the inconsistencies regarding the definitions of continuity; that studies evaluated packages of care rather than continuity as such; that while results showed that, as a group, women in models with higher continuity were more satisfied with their care, these results had not been analysed to examine whether the women who were more satisfied were also the ones who received higher levels of continuity; and finally, the potential bias caused by disappointment with the randomisation outcome in women allocated to standard care. A critical review by Freeman [16] found that the content of care was a higher priority for women than continuity of carer, and Waldenström found that continuity of carer was less important in a birth centre setting, where satisfaction was more likely to be associated with the attitudes of carers, the philosophy of care, and the environment, as opposed to knowing the individual midwife well [11]. In contrast to these findings, a summary of the literature by McCourt et al. [9] pointed to qualitative studies which all found continuity of carer to be important to women, particularly in labour.

Although evaluations of a ‘package’ of care such as caseload midwifery do not allow conclusions about which specific aspects of care contribute to the outcomes [2], secondary analyses of the data can contribute to the ongoing debate regarding the significance of continuity of carer, and whether or not it is associated with satisfaction.

The primary aim of this paper was to investigate the effect of caseload midwifery on women’s assessment of their satisfaction with antenatal, intrapartum, and postpartum care in hospital and at home. We investigated overall satisfaction with these episodes of care, as well as specific aspects of care, such as perception of emotional support, information and decision making, and whether care was provided in a competent way. A secondary aim of this paper was to explore the association between continuity of carer – being one of the key components of the caseload midwifery model – and satisfaction with care.

In this large randomised controlled trial with high response rates at two months postpartum, women allocated to caseload midwifery care had higher satisfaction ratings for all aspects of care. These findings are in keeping with many of the RCTs [4‐6, 14], other studies [4, 6, 8‐14], and the Cochrane review of midwife-led care [7]. The ratings of care reported by women allocated to caseload midwifery were generally higher than those we have reported in RCTs of team midwifery care in similar populations [4, 6].

Many of the studies included in the Cochrane review did not identify what aspects of care increased women’s satisfaction [7]. In this trial, we evaluated a ‘package’ of care, and cannot draw conclusions about which specific aspects of care contributed to women’s increased satisfaction outcomes, given there were a number of aspects of care likely to have been different, including known care provider, shorter clinic waiting times, continuous support in labour, and more postnatal home visits. We did not seek to identify any one measure associated with satisfaction, but have presented comprehensive data on a range of aspects of care that together have contributed to women’s increased overall satisfaction, as well as data on individual factors associated with increased satisfaction.

In terms of exploring if continuity of carer increases women’s satisfaction, it may be that it is individual providers’ approaches to care rather than a known care provider that lead to increased satisfaction, as suggested by Green et al [15]. In this study, as in all trials in the Cochrane review of midwife-led care, midwives self-selected to caseload and may have differed in some ways to standard care midwives; the caseload midwives might have had different personal attributes or philosophies of care. The secondary analyses we presented here on continuity of carer contribute to the debate, however these analyses were not conducted by intention to treat, so the results should be interpreted with caution. In the standard care group there was no association between knowing the intrapartum care provider and satisfaction with care, however this may be due to small numbers; only 9.0 % of women in standard care reported having previously met a midwife who provided labour care. We also explored the ‘dose response’ to continuity of carer during labour and birth in the caseload care group. The sample size in each category was inadequate to provide sufficient statistical power for comparisons, however there was a suggestion that the more times a woman has previously met a midwife providing labour care (compared to not having met any of the midwives), the higher the overall satisfaction with care, up to a point where the woman has met one of the midwives four times previously. After this point there appeared to be no increase in satisfaction; however the study is underpowered to reach a conclusion on this.

On balance it seems reasonable to conclude that continuity of carer helps in part to explain the increased satisfaction in the caseload arm; however group allocation had a stronger effect than having a known care provider in the analysis we presented on overall rating of labour and birth care. Other factors are also likely to have an impact, for example women’s views and experiences of any interventions, and caseload midwives’ personal attributes [2].

The study findings need to be interpreted in context. This was a single site trial, including English-speaking women who were low risk at the time of pregnancy booking. The women in the study were more likely to be married or living with a partner or expecting their first baby and less likely to be born in Australia than the overall Victorian population [22, 23]. The survey responders were also slightly less likely to have a low family income and to be receiving government benefits as the main family income than the trial sample overall, and slightly more likely to be born in Australia and to have English as a first language.

For women at low risk of medical complications, caseload midwifery increases women’s satisfaction with antenatal, intrapartum and postpartum care. Further work could explore the complex issue of the ‘dose’ of continuity of carer that is required to affect women’s satisfaction with care, at the same time ensuring the sustainability of the model from the workforce (midwife) perspective.