Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial

Background Women at low risk of pregnancy complications benefit from continuity of midwifery care, but no trial evidence exists for women with identified risk factors. We aimed to assess the clinical and cost outcomes of caseload midwifery care for women irrespective of risk factors. Methods In this unblinded, randomised, controlled, parallel-group trial, pregnant women at two metropolitan teaching hospitals in Australia were randomly assigned to either caseload midwifery care or standard maternity care by a telephone-based computer randomisation service. Women aged 18 years and older were eligible if they were less than 24 weeks pregnant at the first booking visit. Those who booked with another care provider, had a multiple pregnancy, or planned to have an elective caesarean section were excluded. Women allocated to caseload care received antenatal, intrapartum, and postnatal care from a named caseload midwife (or back-up caseload midwife). Controls received standard care with rostered midwives in discrete wards or clinics. The participant and the clinician were not masked to assignment. The main primary outcome was the proportion of women who had a caesarean section. The other primary maternal outcomes were the proportions who had an instrumental or unassisted vaginal birth, and the proportion who had epidural analgesia during labour. Primary neonatal outcomes were Apgar scores, preterm birth, and admission to neonatal intensive care. We analysed all outcomes by intention to treat. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12609000349246. Findings Publicly insured women were screened at the participating hospitals between Dec 8, 2008, and May 31, 2011. 1748 pregnant women were randomly assigned, 871 to caseload and 877 to standard care. The proportion of caesarean sections did not differ between the groups (183 [21%] in the caseload group vs 204 [23%] in the standard care group; odds ratio [OR] 0.88, 95% CI 0.70-1.10; p=0.26). The proportion of women who had elective caesarean sections (before onset of labour) differed significantly between caseload and standard care (69 [8%] vs 94 [11%]; OR 0.72, 95% CI 0.52-0.99; p=0.05). Proportions of instrumental birth were similar (172 [20%] vs 171 [19%]; p=0.90), as were the proportions of unassisted vaginal births (487 [56%] vs 454 [52%]; p=0.08) and epidural use (314 [36%] vs 304 [35%]; p=0.54). Neonatal outcomes did not differ between the groups. Total cost of care per woman was AUS$566.74 (95% 106.17-1027.30; p=0.02) less for caseload midwifery than for standard maternity care. Interpretation Our results show that for women of any risk, caseload midwifery is safe and cost-effective.