Randomised, controlled trial of efficacy of midwife-managed care

Background Midwife-managed programmes of care are being widely implemented although there has been little investigation of their efficacy. We have compared midwife-managed care with shared care (ie, care divided among midwives, hospital doctors, and general practitioners) in terms of clinical efficacy and womenʹs satisfaction. Methods We carried out a randomised controlled trial of 1 299 pregnant women who had no adverse characteristics at booking (consent rate 81·9%). 648 women were assigned midwife-managed care and 651 shared care. The research hypothesis was that compared with shared care, midwife-managed care would produce fewer interventions, similar (or more favourable) outcomes, similar complications, and greater satisfaction with care. Data were collected by retrospective review of case records and self-report questionnaires. Analysis was by intention to treat. Findings Interventions were similar in the two groups or lower with midwife-managed care. For example, women in the midwife-managed group were less likely than women in shared care to have induction of labour (146 [23·9%] vs 199 [33·3%]; 95% CI for difference 4·4–14·5). Women in the midwife-managed group were more likely to have an intact perineum and less likely to have had an episiotomy (p=0·02), with no significant difference in perineal tears. Complication rates were similar. Overall, 32·8% of women were permanently transferred from midwife-managed care (28·7% for clinical reasons, 3·7% for non-clinical reasons). Women in both groups reported satisfaction with their care but the midwife-managed group were significantly more satisfied with their antenatal (difference in mean scores 0·48 [95% CI 0·41–0·55]), intrapartum (0·28 [0·18–0·37]), hospital-based postnatal care (0·57 [0·45–0·70]), and home-based postnatal care (0·33 [0·25–0·42]). Interpretation We conclude that midwife-managed care for healthy women, integrated within existing services, is clinically effective and enhances womenʹs satisfaction with maternity care.