The RWH COSMOS study has been completed, and shows that continuity of care from a known midwife reduces caesarean section rates and improves outcomes.
Objective To determine whether primary midwife care (caseload midwifery) decreases the caesarean section rate compared with
standard maternity care.
Design Randomised controlled trial.
Setting Tertiary-care women’s hospital in Melbourne, Australia.
Population A total of 2314 low-risk pregnant women.
Methods Women randomised to caseload received antenatal,
intrapartum and postpartum care from a primary midwife with
some care by ‘back-up’ midwives. Women randomised to
standard care received either midwifery or obstetric-trainee care
with varying levels of continuity, or community-based general
Main outcome measures Primary outcome: caesarean birth.
Secondary outcomes included instrumental vaginal births,
analgesia, perineal trauma, induction of labour, infant admission
to special/neonatal intensive care, gestational age, Apgar scores
Results In total 2314 women were randomised–1156 to caseload
and 1158 to standard care. Women allocated to caseload were less
likely to have a caesarean section (19.4% versus 24.9%; risk ratio
[RR] 0.78; 95% CI 0.67–0.91; P = 0.001); more likely to have a
spontaneous vaginal birth (63.0% versus 55.7%; RR 1.13; 95% CI
1.06–1.21; P < 0.001); less likely to have epidural analgesia (30.5%
versus 34.6%; RR 0.88; 95% CI 0.79–0.996; P = 0.04) and less
likely to have an episiotomy (23.1% versus 29.4%; RR 0.79; 95%
CI 0.67–0.92; P = 0.003). Infants of women allocated to caseload
were less likely to be admitted to special or neonatal intensive care
(4.0% versus 6.4%; RR 0.63; 95% CI 0.44–0.90; P = 0.01). No
infant outcomes favoured standard care.
Conclusion In settings with a relatively high baseline caesarean
section rate, caseload midwifery for women at low obstetric
risk in early pregnancy shows promise for reducing caesarean
Keywords Caesarean, caseload midwifery, continuity of care,
randomised controlled trial.
Please cite this paper as: McLachlan H, Forster D, Davey M, Farrell T, Gold L, Biro M, Albers L, Flood M, Oats J, Waldenstro¨m U. Effects of