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�Clinical outcomes for women cared for by private midwives in collaborative agreement in a regional public hospital: a retrospective comparison with national and state standards and public midwives  outcomes. 


R. McDonald MBBSa
A. Kassab MBBCh, MRCOG, FRCS, FRANZCOGb                                           
Dr Gehan El-Bialy MRCOGc 
a Monash Medical Centre, Clayton, VIC, 3021 Australia
bDepartment of Obstetrics & Gynaecology, Toowoomba Hospital, QLD, 4350 Australia
cCoffs Harbour Health Campus, NSW, 2450.


There are no relevant funding supports or relationships to declare.
The views expressed in the submitted article are the authors' and not an official position of either institution.  

Total words excluding abstract and references: 1237. 
Total tables: 1
Title
Clinical outcomes for women cared for by private midwives in collaborative agreement in a regional public hospital: a retrospective comparison with national and state standards and public midwives  outcomes. 
 
Authors
R. McDonald MBBSa
A. Kassab MBBCh, MRCOG, FRCS, FRANZCOGb,                                            
a Monash Medical Centre, Clayton, VIC, 3021 Australia
bDepartment of Obstetrics & Gynaecology, Toowoomba base hospital, QLD, 4350 Australia

Abstract
Background:  There is debate on the various merits of different models of pregnancy care. Women in Australia may choose between public hospital based midwife care with obstetrician support, private obstetrician care, shared general practitioner and hospital based care and private midwife care. Toowoomba Hospital has recently implemented a model of care involving private midwives with public obstetrician support. The current study aimed to compare outcomes obtained using this new model with the national averages and with standard public midwife care to demonstrate non-inferiority and find areas of superiority. 

Method: This was a retrospective observational study in Toowoomba Hospital, QLD, Australia. It involved 160 pregnant women who were under private midwife care and delivered between January 2011 and April 2013. A comparison group was used of the 2176 pregnant women receiving standard care at the same hospital in 2012. Primary outcome measures were mode of delivery, postpartum haemorrhage and perineal tears. Secondary measures were method of analgesia and measures of early neonatal morbidity.  Differences were expressed as relative risk (RR) and significance was assessed using chi square analysis. 

Results: Patients under private midwife care were more likely to deliver vaginally than both comparators but no less likely to undergo an instrumental delivery or emergency caesarean. They experienced a comparable number of postpartum haemorrhages and perineal tears overall. However, they suffered significantly more 3rd or 4th degree tears than both comparators. They were much less likely to use pharmacological analgesia and were less likely to delivery preterm. 

Conclusions: This new model of care is a valid one. On nearly all measures of maternal and infant outcomes, women cared for by private midwives in Toowoomba Hospital fared as well as the average Australian woman or woman receiving standard care at Toowoomba Hospital. 

Key words
Private midwives
Independent midwives
Collaboration
Midwifery 
Private obstetrics 


Background
There is long standing debate on the various merits of different models of pregnancy care. Women in Australia may choose between public hospital based midwife care with obstetrician support, private obstetrician care, shared GP and hospital based care and private (independent) midwife care. 

It has been previously demonstrated that caseload midwifery or midwife-led continuity models of care is safe and cost effective for women with a variety of risk profiles1, 2, 3, 4. A recent Cochrane review1 found women under such models made less use of pharmacological analgesia and were less likely to undergo an instrumental delivery. There were no differences found in the rate of caesarean births. Their babies experienced less morbidity or mortality. It has been argued that this model of care a more effective labour and less time spent in hospital by allowing women to get to know their midwife and to build a trusting relationship with them2. 

It follows that similar advantage in labour characteristics should be seen in women employing private midwives. Private or independent midwives traditionally operate outside the public health system. This cultural and physical separation from medical facilities and expertise raises a number of safety concerns and to date there is a paucity of data regarding this model's effectiveness and safety. Toowoomba Hospital has recently implemented a model of care involving private midwife led care with delivery in hospital with public obstetrician support where needed. This model aims to ameliorate safety concerns while supporting women s agency in choosing a model of care and retaining benefits associated with it. 

The current study aims to compare outcomes obtained using this new model with the national/state standards and with standard public midwife care in order to demonstrate non-inferiority and find areas of superiority.  

 
Materials and Method
As this study was a clinical audit measuring against local guidelines, it did not require ethical review according to local guidelines (Darling Downs Hospital and Health Services Human Research Ethics Committee). 

This was a retrospective observational study in Toowoomba Hospital, QLD, Australia. It involved 166 pregnant women who were under private midwife care (PM) and delivered between January 2011 and April 2013. A comparison group was used of the 2176 pregnant women who received standard care (SC) at the same hospital from in 2012. Outcomes were also compared to national data (ND). 

This study was not sufficiently powered to assess mortality or severe morbidity. Therefore, primary outcome measures were potential predictors of long term or severe maternal morbidity namely mode of delivery, postpartum haemorrhage (PPH) and perineal tears. Secondary measures were method of analgesia and measures of early neonatal morbidity. Differences are expressed as relative risk (RR) and significance was assessed using chi square analysis with post hoc analysis 


Results 
Results are summarised in the table below. 





Table. Comparison of results with private midwifery care to public midwives and national/state wide averages. 
Outcome measurePrivate midwivesStandard careNational averages5N = 160N = 2176RRRRN%N%p%pMode of delivery
Vaginal
Instrumental
LSCS
Elective
Emergency
125
8
33
9
24
78.1%
5.0%
20.1% 
5.6%
15.0%
1367
132
639
253
386
64% 
6% 
30% 
12% 
18%
1.24
0.82
0.70
0.48
0.85< 0.001
< 0.01
NS
< 0.01
< 0.05
NS
60.8%
17.6%
31.6%
18.6%
13.0%
1.29
0.28 
0.65
0.30
1.15< 0.001
< 0.001
< 0.001
< 0.01
< 0.001
NSMaternal morbidity 
PPH
Genital tears
Total 
1st degree
2nd degree�
3rd/4th degree
7

57
14
33
7
4.4%

35.6% 
8.75%
20.6% 
4.4%
209

752
123
564
36
9.7%

33.6%
5.8% 
26.2% 
1.6%
0.46

1.03
1.55
0.80
2.64
< 0.05
< 0.05
NS
NS
NS
< 0.01
5.9%

71.7%
23.0%
39.7%
1.8%
0.74

0.50
0.38
0.52
2.43
NS

< 0.001
< 0.001
< 0.001
< 0.01Analgesic use 
Non-pharm
Regional
Opiate 
91
17
14
56.9% 
10.6% 
8.8% 
Not available
24.4%
32.9%
21.2%
2.33
0.32
0.41< 0.001
< 0.001
< 0.001
< 0.001Neonatal morbidity 
Preterm del
Postterm del
Low APGAR at 5min
5
0
2
3.1% 

1.3% 
187
42
57
9%
2%
2.6%
0.36

0.48< 0.01
< 0.01
-
NS
8.3%
0.8%
1.6%
0.38

0.63< 0.05
< 0.05
-
NS5Australian Institute of Health and Welfare. Australia s mothers and babies, 2010.
RR = relative risk for PM in comparison to SC or state/national data with 95% confidence intervals 
NS = not significant
� includes tears, episiotomies and combined tears and episiotomies. 
Patients under PM care were more likely to delivery vaginally that those under SC (78.1% vs 64%, RR = 1.24, p < 0.01) or compared to national averages but no less likely to undergo an instrumental delivery or emergency caesarean. They experienced fewer PPHs in comparison to SC but not in comparison to national averages (PM = 4.4%, SC = 9.7%, p < 0.05, ND 5.9%). They suffered a comparable number of total tears to SC (35.6% vs 33.6%) but fewer than national averages (71.7% p < 0.001). PM resulted in significantly more 3rd or 4th degree tears than either comparator (PM = 4.4%, RRSC = 2.64, RRND = 2.43, p < 0.01). They were much less likely to utilise pharmacological analgesia in favour of non-pharmacological methods (PM = 56.9%, ND = 24.4%, RR 2.33, p < 0.001). PM was associated with smaller numbers of preterm deliveries compared to SC (3.1% vs 9%, p < 0.01) but numbers overall were small for measures of neonatal morbidity. There were no cases of maternal or perinatal mortality recorded in this study. 


Discussion 
The women in this study under PM care made less use of pharmacological analgesia which is in keeping with previous studies' on caseload midwifery1. In difference to the recent Cochrane review1, a lower rate of caesareans was found overall. However, the Cochrane study did not differentiate elective from emergency cases. The difference found in this study was due lower rate of elective caesareans with no difference in the rate of emergency caesarean delivery. This is in keeping with other studies that have separated elective and emergency caesareans2, 3.  

This study found significant improvements in both the rate of instrumental delivery and minor perineal injury in comparison to national data. However, rates were similar to those obtained under standard care suggesting that these differences may reflect hospital or population differences. Previous study results have been rather heterogeneous1, 2, 3, 4. A surprising difference was found in the incidence of 3rd and 4th degree tears which were more than double that of comparators. A reason for this difference is not suggested by the current study or previous research and may be a reflection of small cell size and type one error.

Women under PM care had a similar need for obstetrician intervention for instrumental or operative deliveries and for paediatric support as women with hospital based delivery care although numbers in these categories were small. 

Relative risk estimates demonstrate a favourable comparison for private midwife care with both comparators on nearly all measures. This demonstrates clear non-inferiority overall. The only exception to this finding was the incidence of 3rd and 4th degree tears. 

Future studies powered to analyse infrequent and rare adverse outcomes are needed to conclusively demonstrate the non-inferiority and safety of this model of care particularly with regard to the incidence of severe perineal trauma. 

Acknowledgements
The authors of the present study would like to acknowledge the staff of Toowoomba Hospital's Obstetric and Gynaecology department and the Activity and Costing Evaluation Service. 
References
Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev. 2013 Aug 21; 8. doi: 10.1002/14651858.CD004667.pub3
Tracy SK, Hartz DL, Tracy MB, Allen J, Forti A, Hall B, White J, Lainchbury A, Stapleton H, Beckmann M, Bisits A, Homer C, Foureur M, Welsh A, Kildea S. Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial. The Lancet. 2013 Nov 23; 382 (9906): 1723-1732. doi:10.1016/S0140-6736(13)61406- 3. 
Tracy SK, Welsh A, Hall B, Hartz D, Lainchbury A, Bisits A, White J, Tracy MB. Caseload midwifery compared to standard or private obstetric care for first time mothers in a public teaching hospital in Australia: a cross sectional study of cost and birth outcomes. BMC Pregnancy and Childbirth. 2014; 14: 48. doi: 10.1186/1471-2393-14-46 
Shaw-Battista J, Fineberg A,�Boehler B,�Skubic B,�Woolley D,�Tilton Z. Obstetrician and nurse-midwife collaboration: successful public health and private practice partnership. Obstet Gynecol.�2011 Sep;118(3):663-72. doi: 10.1097/AOG.0b013e31822ac86f.
Li Z, Zeki R, Hilder L, Sullivan E. Australia s mothers and babies. Australian Institute of Health and Welfare, Canberra (ACT): 2010.
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