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To clarify the sub-group analyses in the Cochrane Review on Midwife-led care vs other models of care states the following. The following outcomes were considered in the following subgroup analyses. It is hypothesised that differential effects and outcomes are due to the levels of continuity with care provider (caseload models of care offer higher levels of personal relationship continuity). Comparison 2: variation in midwifery models of care (caseload or one to one versus team) Two trials randomised 2804 women to compare a caseload model of care (defined as one midwife carrying responsibility for a defined caseload of women in partnership with a midwife partner) with other models of care (North Stafford 2000; Turnbull 1996). Caseload size was reported to be 35 to 40 women (North Stafford 2000) and 32.4 women per midwife (Turnbull 1996). Nine trials randomised 9472 women to compare team models of midwifery (defined as a group of midwives sharing responsibility for a caseload of women) with other models of care (Biro 2000; Flint 1989; Harvey 1996; Hicks 2003; Homer 2001; Kenny 1994; MacVicar 1993; Rowley 1995; Waldenstrom 2001). There was a statistically significant difference in the treatment effects between subgroups for 5-minute Apgar score less than 7 (interaction chi squared = 5.62, P = 0.02), and fetal loss and neonatal death at greater than or equal to 24 weeks (interaction chi squared 5.25, P = 0.02). The risk ratio for fetal loss or neonatal death greater than or equal to 24 weeks was 0.48 (95% CI 0.23, 1.03) in the two caseload trials and 1.44 (95% CI 0.86, 2.42) in the seven team trials. Interaction tests provide an appropriate test of differences between the subgroups, but need to be interpreted with caution because the number of outcome events in these analyses was low, subgroup analyses are by their nature observational (not randomised), and the increase in the number of analyses performed caused by subgroup analyses may have led to some statistically significant results arising by chance. The link to the review is below. http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004667/frame.html To summarise the above. The two trials of caseload midwifery had significantly fewer babies with low apgars, fetal loss and neonatal death at greater than 24 weeks. Bearing in mind the caveat about interaction tests, at the very least, such findings should inform further research and thinking about why such findings have occurred. Professor Jane Sandall Professor of Social Science & Women's Health Programme Director (Innovations) NIHR King's Patient Safety and Service Quality Research Centre Department of Public Health Sciences King's College London School of Medicine, Floor 7, Capital House, 42 Weston St London SE1 3QD, UK Tel: +44 (0)20 7848 6261/6604 e-mail:[log in to unmask] http://www.kingspssq.org.uk/ http://myprofile.cos.com/sandall ________________________________________ From: A forum for discussion on midwifery and reproductive health research. [[log in to unmask]] On Behalf Of Della Forster [[log in to unmask]] Sent: 13 October 2009 04:15 To: [log in to unmask] Subject: Re: team midwifery I think that it is important to keep in mind though that the two caselaod trial included in the hatem et al review do not on their on provide evidence of the safety outcomes of caseload models and I we can not say that caseload models are significantly safer than team odels - while this may well be the case we don't have this evidence at the moment Della Forster ________________________________ From: A forum for discussion on midwifery and reproductive health research. on behalf of Sandall, Jane Sent: Mon 12/10/2009 6:08 PM To: [log in to unmask] Subject: Re: team midwifery Dear Debra If you look at our Cochrane review midwife-led care vs other models of care, which had a range of positive outcomes, you will see that 2 studies offered caseload and 9 offered team care. No home birth care was offered in any trial in this review. Levels of intrapartum continuity ranged from 63-98% in the midwife led models of care vs 0.3-21% for other models of care. Caseload size was 32-40 women in the caseload models. So the evidence is there to support team midwifery, although when you compare outcomes between the two models, there were statistically significantly fewer babies with lower apgar scores, and fetal loss after 24 weeks in the caseload models. So there might be 'dose response' with the level of continuity. Hatem M, Sandall, J. (Joint First Author and Contact Author) Devane D, Soltani H. Gates,S. (2008) Midwife-led versus other models of care for childbearing women, Cochrane Database of Systematic Reviews 2008, Issue 4. We also did some work in London, assessing the implementation and impact of a move to caseload midwifery. http://www.kcl.ac.uk/projects/1to1caseload You can see the women's views about this model here. Finlay, S. Sandall,J. (in press online ) "Someone's rooting for you": Continuity and Advocacy in Bureaucratic Maternal Health Care Systems, Social Science and Medicine, doi:10.1016/j.socscimed.2009.07.029 http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VBF-4X26XPX-4&_user=10&_coverDate=10%2F31%2F2009&_alid=1044081259&_rdoc=2&_fmt=high&_orig=search&_cdi=5925&_sort=r&_docanchor=&view=c&_ct=7&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=14c392461040fbe84f3538bc5d8f327e Three community based group practices working in deprived areas offered total midwifery care to women at all risk levels. Six midwives were in the groups and ended up doing 35 births a year each. They booked more women than this and this varied by level of mobility of women. The midwives carried their own caseload, and did the majority of births in home or hospital and antenatal and postnatal care in office hours but shared on call for out of hours in different ways. The outcomes - more home births, more births in MW led unit, higher breastfeeding and reduction of DNA rates. Access and experience and some safety issues improved. See attached poster. So lessons- women want to know who their midwife is, who to contact and to feel that the midwife knows them. teams larger than 8 have very little evidence to support them and plenty against in terms of very fragmented care. Most caseloads are around 40 women booked per midwife depending on level of complexity, It is possible for midwives to carry responsibility for their own caseload of women, provide care during office hours and share out of hours care with the team. It is better for women to develop a relationship with a midwife in the antenatal period rather than try to get her to see a different midwife each time. Expectations have to be managed about what can be offered in the intrapartum period. caseload size has to be managed otherwise they tend to creep up. Sticky areas to be addressed are - managing inductions, still having to cover GP clinics, making sure performance is audited and monitored by process and outcome rather than time sheets, training of midwives (see our web site for some audit and training assessment materials), managing on call incl different methods of payment. Hope this is helpful Jane Professor Jane Sandall Professor of Social Science & Women's Health Programme Director (Innovations) NIHR King's Patient Safety and Service Quality Research Centre Department of Public Health Sciences King's College London School of Medicine, Floor 7, Capital House, 42 Weston St London SE1 3QD, UK Tel: +44 (0)20 7848 6261/6604 e-mail:[log in to unmask] http://www.kingspssq.org.uk/ http://myprofile.cos.com/sandall <http://www.kcl.ac.uk/about/campuses/guys.html> ________________________________ From: A forum for discussion on midwifery and reproductive health research. [[log in to unmask]] On Behalf Of Maggie Banks [[log in to unmask]] Sent: 12 October 2009 05:19 To: [log in to unmask] Subject: Re: team midwifery Hello Deborah. Caseloads when midwives are employed by District Health Boards in NZ tend to be 40-50 women a year per midwife too - usually 40 - and they tend to work in pairs with someone from another pair providing the relief for holidays. I know when midwives work in shifts there are 4.5 midwives needed to cover 3 midwives for relief, holidays, education etc and 1.5 do not carry a caseload. As far as I know large teams have been abandoned in NZ because continuity of carer is so hit and miss and women are dissatisfied with large teams. kind regards Maggie Banks Check out Birthspirit Midwifery Journal <http://www.birthspirit.co.nz/BirthspiritMidwiferyJournal/Issue2.php> 15 Te Awa Road, RD 3, Hamilton, New Zealand 3283 Ph 64 7 8564612 Fax 64 7 8563070 www.birthspirit.co.nz <http://www.birthspirit.co.nz/> [log in to unmask] <mailto:[log in to unmask]> ________________________________ From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Della Forster Sent: Monday, 12 October 2009 2:31 p.m. To: [log in to unmask] Subject: Re: team midwifery We go on 40 women per eft for teams of about 8 - that covers antenatal, most birth suite shifts and some postnatal coverage on shifts (at least one per day) with some ability to do dom care So not that dissimilar to caseload numbers Della Forster (Victoria, Australia) ________________________________ From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Debra Kroll Sent: Monday, 12 October 2009 10:05 AM To: [log in to unmask] Subject: team midwifery We are reconfiguring out community teams. Does anyone have up to date numbers on how many women should be allocated per midwife if the midwives: a) work in teams b) and provide antenatal, intrapartum (on shifts) and postnatal care I do not appear to find this information for teams (only for caselaoding) Thanks Debra Kroll Midwifery Lecturer in Practice UCLH /City University Supervisor of Midwives __________ Information from ESET NOD32 Antivirus, version of virus signature database 4427 (20090915) __________ The message was checked by ESET NOD32 Antivirus. http://www.eset.com <http://www.eset.com/>