Você está na página 1de 6

Midwifery 28 (2012) e874–e879

Contents lists available at SciVerse ScienceDirect

Midwifery
journal homepage: www.elsevier.com/midw

A non-randomised trial investigating the cost-effectiveness of Midwifery


Group Practice compared with standard maternity care arrangements
in one Australian hospital
Jocelyn Toohill, MMid, Grad Dip Educ, Grad Cert Hlth Mgmt (Lecturer)a,n, Erika Turkstra,
PhD (Senior Lecturer)b, Jenny Gamble, PhD (Associate Professor, Deputy Head of School)a,
Paul A. Scuffham, PhD (Professor)c
a
School of Nursing and Midwifery, Research Centre for Clinical and Community Practice Innovation, Griffith University, University Drive,
Meadowbrook 4131, Australia
b
Health Technology Assessment, School of Medicine Griffith University, University Drive, Meadowbrook 4131, Australia
c
Health Economics, School of Medicine Griffith University, University Drive, Meadowbrook 4131, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Objective: to compare cost-effectiveness of two models of maternity service delivery: Midwifery Group
Received 9 December 2010 Practice (MGP) at a birth centre and standard care (SC).
Received in revised form Design: a prospective non-randomised trial.
10 October 2011
Setting: an Australian metropolitan hospital.
Accepted 31 October 2011
Method: women at 36 weeks gestation were approached in the birth centre or hospital antenatal clinics
between March and December 2008. Of 170 consecutive women who met birth centre eligibility
Keywords: criteria, 70% (n ¼119) were recruited to the study. Women (MGP n ¼ 52 or standard care n ¼50) were
Midwifery Group Practice followed through to 6 weeks postpartum. Publically funded care costs were collected from women’s
Birth centre
diaries, handheld pregnancy health records, medical records and the hospital accounting system. Main
Cost-effectiveness
outcome measures: health-care costs to the hospital and government.
Continuity of carer
Analysis: generalised linear models with covariates of age, nulliparity, private health insurance (yes/no)
and household income category.
Findings: women receiving MGP care were less likely to experience induction of labour, required fewer
antenatal visits, received more postnatal care, and neonates were less likely to be admitted to special care
nursery than those receiving standard care. Statistically significant lower costs were found for women
and babies receiving MGP care compared with women receiving standard care during pregnancy, labour
and birth and postpartum to 6 weeks. MGP resulted in lower costs for the hospital ($AUD4,696 vs.
$AUD5,521 po0.001) and the government ($AUD4,722 vs. $AUD5,641 po0.001). When baby costs were
excluded MGP care remained statistically significantly cheaper than standard care.
Conclusion: for women at low-risk of birth complications, Midwifery Group Practice was cost effective,
and women experienced fewer obstetric interventions compared with standard maternity care. The
evidence suggests Midwifery Group Practice is safe and economically viable.
& 2011 Elsevier Ltd. All rights reserved.

Introduction ratio, duration and number of visits, length of hospital stay, gestation
at booking and duration of care after birth. Consequently the most
Midwifery service delivery models have a philosophy to provide cost-effective model is unknown (Henderson and Petrou, 2008).
continuity of woman-centred care. However implementation of In Australia, team midwifery incorporating antenatal care in a
these models is inconsistent within countries, and throughout the community setting (Homer et al., 2001) and Midwifery Group
world. Variations include diversity in setting, midwife to woman Practice in a stand-alone unit have been found to be cost effective
(Tracy and Hartz, 2006). A comparison of birth centre care alongside
n
a tertiary level conventional delivery suite found no difference in
Corresponding author.
costs (Byrne et al., 2000). However, rostered team midwifery in
E-mail addresses: j.toohill@griffith.edu.au, jtoohill@yahoo.com.au (J. Toohill),
e.turkstra@griffith.edu.au (E. Turkstra), j.gamble@griffith.edu.au (J. Gamble), a stand-alone birth centre showed slightly higher birth costs
p.scuffham@griffith.edu.au (P.A. Scuffham). compared with public hospital birth (Senate Community Affairs

0266-6138/$ - see front matter & 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.midw.2011.10.012
J. Toohill et al. / Midwifery 28 (2012) e874–e879 e875

References Committee, 1999). No study in Australia or internation- outcomes of MGP and standard care. A total study sample of 100
ally that we could find, has specifically investigated salaried Mid- ‘low obstetric risk’ woman, who met birth centre eligibility criteria,
wifery Group Practice (MGP) within a birth centre offering home was required for the study. Women self-selected for their model of
antenatal and postnatal visiting compared with standard care. care; but access to MGP was limited due to capacity. Women’s
Publicly funded midwifery models are becoming more prevalent, health records were reviewed to determine if they met the
albeit slowly, in response to consumer demand, research evidence, eligibility criteria for the study prior to seeking consent. This
and government reviews and inquiries (Senate Community Affairs included meeting the birth centre eligibility criteria, living within
References Committee, 1999; Maternity Coalition, 2002; Hatem the defined geographic catchment area, and commencing care at
et al., 2008; Department of Health and Ageing, 2009). In 2005, a the Gold Coast Hospital prior to 24 weeks gestation. Eligibility
review of maternity services in the Australian state of Queensland criteria were determined against a ‘well woman’ health checklist
called ‘Rebirthing’ echoed findings of previous state/territory and and meeting suitability for midwifery care (Australian College of
national reviews and recommended improving women’s access to Midwives, 2008). The groups were not matched for baseline
continuity of care and carer (Hirst, 2005). A priority area for action demographics. Recruitment occurred at the woman’s 36 week
was addressing the widespread poor quality of post birth care. antenatal appointment. Women were provided with verbal and
Consequently, in 2006 a birth centre was established at the Gold written information prior to consenting to participate in the study.
Coast Hospital (GCH), which has around 3,500 births/year. The birth
centre was staffed by midwives working within a Midwifery Group Measures and data collection procedures
Practice, founded on primary health-care principles (Thorogood,
2010). This study compares costs and maternal and newborn out- At recruitment, women completed baseline demographic
comes of MGP within the Gold Coast Birth Centre with standard information and were provided with a diary to record where
care at the same publicly funded hospital sharing one set of clinical and with whom maternity visits occurred. At 6 weeks post birth
guidelines. women returned their diary of care in a post paid envelope to the
research assistant.
Midwifery Group Practice (MGP) Costs were collected from two perspectives: the hospital
perspective and the federal government perspective in Australian
Three full-time midwives with a personal caseload of 40 dollars. The latter included costs for mother and baby primary
women per year work in each Midwifery Group Practice (MGP). care visits (antenatal and postnatal) with general practitioners.
Two MGPs operate within the birth centre with a total combined Using the medical record number for the mother and baby, the
caseload of 240 women annually. Midwives are not rostered to hospital Decision Support Services team provided all hospital
shifts, but within each group practice provide backup for each costs attributed to the woman and her baby by applying standard
other through an on-call arrangement. This arrangement ensures hospital processes in determining hospital costs. This process
women have their primary midwife or a known midwife available involves medical coders reviewing the medical record and align-
24 hrs a day from booking until 6 weeks postpartum. ing episodes of care and procedures to Australian-Refined Diag-
Most women in MGP give birth in the centre and are usually nostic-Related Groupings (Department of Health and Ageing,
home within 4 hrs of birth. Home-based care for pregnancy, early 2006). Any costs not attached directly to the maternity episode
labour and postnatal care to 6 weeks postpartum is a feature of were not used. All costs to the hospital from 36 weeks gestation
MGP. MGP spans the same geographic area as that of postnatal to 6 weeks postpartum were included. Regardless of change to
home visiting as part of standard care. Postnatal home care risk status or intended place of birth (birth centre or birth suite),
includes mother and baby physical and psychosocial health checks, women’s costs were analysed by intended mode of care.
promotion and support of breast feeding, early parenting and Research assistants cross-checked visits, admission, birth and
general health education, and linking families to appropriate discharge dates against the women’s diaries, medical records and
agencies according to their needs. A dedicated obstetrician is hospital activity system. The first author identified any cost
attached to each MGP and women attend that consultant’s antena- outliers in the data and a research assistant checked accuracy
tal clinic should complications arise. If women birth in the hospital against care received. Decision Support Services were alerted if
birth suite or operating theatre, continuity of care is maintained by care and cost did not align, with women removed from the study
her MGP midwife until 6 weeks postpartum. Women in this model if gross inaccuracies were confirmed.
experience 75% attendance of their primary midwife or 92% The number of general practitioner visits was extracted from
attendance of a MGP midwife for labour and birth (Toohill, 2008). each woman’s diary or pregnancy handheld record (PHHR).
The PHHR is a comprehensive booklet that the woman carries
throughout pregnancy to provide her with maternity information
Standard care
and ownership of her care, and a space for her to record her birth
plan. It is used by care providers to document the woman’s health
In standard care, women have the option of attending a
and obstetric history and care provided throughout pregnancy.
general practitioner, a hospital midwife at a community outreach
Each general practitioner visit was costed using Medicare Benefits
centre, a hospital midwife clinic or an obstetric clinic at the
Schedule item number 16,500 (Department of Health and Ageing,
hospital for pregnancy check-ups. Routine visits are scheduled in
2008) (Schedule July 2008, $AUD38.65 per visit).
the outpatient obstetric clinic at 36 and 41 weeks gestation.
Ethics approval was granted from the hospital and university
Intrapartum and postnatal care is provided by rostered midwifery
human research ethics committees.
and medical staff, with optional postnatal home visiting for up to
7 days postpartum. Services following discharge are provided by
Data analysis
community child health nurses and general practitioners.
All statistical analyses were performed using SPSS (version
Method 17.0). For baseline characteristics, Pearson w2 tests were used for
categorical data and Student’s t-tests were used for continuous
A non-randomised pilot study following the TREND statement data to assess differences in baseline characteristics between
(Des Jarlais et al., 2004) was designed to assess the costs and MGP and SC. For all outcomes, data were analysed using
e876 J. Toohill et al. / Midwifery 28 (2012) e874–e879

generalised linear models (univariate analysis of variance for in standard care, with postnatal costs statistically higher in MGP.
continuous data and logistic models for categorical data) with When compared overall there was a statistically significant lower
covariates of age, nulliparity, private health insurance (yes/no), cost associated with MGP compared to standard care (MGP
and household income category. These covariates were included $4,696 vs. SC $5,521, p o0.001) based on the hospital costing
as they may impact on outcomes. Statistical significance was system and when assessed against Federal government health
determined using p-value o0.05. funding arrangements (MGP $4,722 vs. SC $5,641, p o0.001)
(Table 3). After removing newborn costs, standard care remained
more expensive (MGP $4,418 vs. SC $4,871, po0.001).
Findings

A research midwife randomly attended birth centre or hospi-


tal antenatal clinics at an average of 1–2 4 hrs clinics per week to Discussion
recruit participants. Between March and December 2008, 170
consecutive women who met birth centre eligibility criteria For pregnant women at low-risk of birth complications, care
(MGP n ¼ 70, SC n ¼100) were approached for participation in provided through a Midwifery Group Practice model of service
the study. A non-randomised sample of 119 women (70%) were delivery was less costly and women experienced fewer birth
recruited to the study at 36 weeks gestation (MGP n ¼58 or interventions compared to a similar group of women receiving
standard care n ¼61). Seventeen women were not included in standard maternity care. There was no mortality and no signifi-
the final analysis (Fig. 1) for the following reasons: consent not cant morbidity for women or babies between the two groups. This
completed (n ¼2) did not give birth at GCH (n ¼ 2), withdrew is consistent with existing published research showing continuity
consent at follow-up (n ¼11), and other (n ¼2). This resulted in of midwifery care to be safe for women and babies, and satisfying
102 women remaining in the study (MGP n ¼52; SC n ¼50). for women (Hatem et al., 2008). Adopting a primary health model
Standard Care consisted of women receiving antenatal care with of care, providing women with home-based visiting across the
a GP n ¼29 (58%), obstetric clinic n ¼10 (20%) or midwives clinic continuum, and increasing postnatal care provided better out-
n ¼11 (22%). Participant characteristics were similar across the comes. Women entered spontaneous labour more often, were
two groups except women accessing MGP were more likely to home earlier, babies were admitted to nursery less often, and
have higher family income (p ¼ 0.003) and private health insur- there were fewer unplanned presentations to hospital.
ance (p o 0.001) (Table 1). Methods used to determine cost-effectiveness of midwifery
There were significant differences in the outcomes for women models of service delivery vary (Henderson and Petrou, 2008).
and their babies between the two models of service delivery. This is particularly so where there is a birth centre separate to
Women receiving standard care had more antenatal visits that of a hospital birth suite and where antenatal and postnatal
(p¼ 0.001), but fewer postnatal visits consistent with a reduced home visits are provided.
period of postnatal care in that model (po0.001) (Table 1). Fewer Difficulties in establishing comparative costs of midwifery
women in MGP used pharmacologic pain relief in labour compared models stem from different reporting and payment methods, skill
to women receiving standard care (pethidine, p¼0.058, epidural mix complements, contexts of care (team or caseload, birth centre
p¼0.001 and nitrous oxide po0.001) with epidural use three or freestanding centre, hospital or community care). Generally,
times higher in standard care (Table 2). Additionally women hospital administrators compare cost centre reports to determine
receiving standard care were more likely to have labour induced how budgets are running. With a birth centre operating alongside
(p¼ 0.026), and less likely to experience an operative vaginal birth a main birth suite, cost centre reports do not provide a compar-
(p¼ 0.024) (Table 2). More women receiving standard care experi- ison of cost-effectiveness due to the different activities, skill mix
enced a caesarean section (n¼7) compared with MGP (n¼3) but and context of care. Therefore, this study used the hospital’s
this difference was not statistically significant (p¼ 0.51). accounting system to track women’s care and costs. This study
Newborns to mothers receiving standard care were admitted to commenced comparison from 36 weeks gestation as this was a
special care nursery four times more frequently compared to MGP time when all women were reviewed at the hospital regardless of
(p¼ 0.028) (Table 2), and stayed in the nursery longer (SC¼42.3 hrs; model of service delivery. Consistent with a previous study, we
MGP¼23.6 hrs; p¼0.026). There was no difference between groups found that community or home antenatal visits through MGP
for duration of stay in the birthing environment (MGP¼9.6 hrs; were cost effective and women required less visits overall than
SC¼12.4 hrs; p¼0.164). However women using MGP went home women in SC (Young et al., 1997).
earlier (MGP¼18.0 hrs; SC¼53.1 hrs; po0.001), significantly redu- Compared with other studies, it has been suggested that
cing postnatal bed occupancy rates. There was insufficient data to salaried midwifery models in the UK NHS require a median
draw statistically significant conclusions on breast-feeding out- caseload of 39 women per midwife per year (Young et al.,
comes and this may have been due to lower reporting of this 1997), and in the USA that transfer rates from a free standing
outcome in the women’s records. The available data indicated that birth centre to obstetric care must remain below 62% (Stone and
women in MGP were more likely to fully breast feed following birth Walker, 1995) to be cost neutral. In our study, midwives were
(MGP n¼47, 92%; SC n¼38, 78%; p¼ 0.230), on discharge (MGP paid an annual salary under the state industrial award to care for
n¼45, 88%; SC n¼38, 76%; p¼0.065) and at 6 weeks postnatal 40 women per year across the maternity continuum (Queensland
(MGP n¼27, 82%; SC n¼13, 59%; p¼0.332). Only 55 women Industrial Relations Commission, 2006, p. 27), and there was a
reported on feeding patterns at 6 weeks (MGP n¼33, SC n¼22). 23% transfer from birth centre to collaborative obstetric care with
Postnatal readmissions were low (MGP n¼1; SC n¼3) with mean- MGP continuity. The cost findings indicated that the lower
ingful statistical analysis not able to be determined. Twenty-three hospital resource use and improved clinical outcomes in the
per cent of women required transfer from MGP to collaborative MGP model provided savings to support home visiting through-
obstetric care (n¼6, 11.5% in pregnancy, n¼6, 11.5% during labour, out pregnancy and up to 6 weeks following birth.
none postpartum) with continuity of midwifery care continued and Assumptions that midwives on annualised salaries increase
costs attributed to booked model of care. costs of maternity care are not borne out in this study. Impor-
A breakdown of care showed that antenatal costs across the tantly, cost must be assessed in context of the overall package of
two models were the same, labour costs were statistically higher care. While MGP postnatal homecare to 6 weeks following birth
J. Toohill et al. / Midwifery 28 (2012) e874–e879 e877

Inclusion Criteria:

• Booked at hospital ≤ 24 weeks of pregnancy Exclusion Criteria:


• Living within geographical home visiting • Did not meet birth centre
area
criteria at 36 weeks of
• Met birth centre criteria at booking pregnancy
appointment
• Plans to birth elsewhere
• Able to read, write and understand English
• ≥ 18 years and ability to consent to study

Assessed for eligibility: consecutive ‘low risk’ women attending 36 week antenatal appointment in
Birth Centre and Antenatal Clinic on random days March to December 2008 (n= 170)

Excluded prior to
Screening

Midwifery Group Practice enrolment (n=51) Standard Care


(MGP) Group (n=70) Declined to participate: (SC) Group (n=100)
MGP (n=11) SC (n=38)
Planning homebirth:
MGP (n=1) SC (n=1)
Recruitment

Midwifery Group Practice Excluded at 6 week Standard Care


(MGP) Group (n=58) postnatal follow-up (n=4) (SC) Group (n=61)
Incomplete consent:
MGP (n=1) SC (n=1)
Birthed elsewhere:
MGP (n=1) SC (n=1)
Follow-up
6 week

Midwifery Group Practice Excluded at Analysis Standard Care


(MGP) Group (n=56) (n=13) (SC) Group (n=59)
Withdrew consent:
MGP (n=3) SC (n=8)
Other:
MGP (n=1) SC (n=1)
Analysis

Midwifery Group Practice


Standard Care
(MGP) Group (n=52)
(SC) Group (n=50)

Fig. 1. Study flow diagram.

was more expensive than postnatal standard care to 1 week, the 2001). An Australian study reported a relative increase in birth
overall cost of MGP care was less. This provides reassurance to cost of 50% for low risk primiparous women and 36% for low risk
support women in their home whilst they adapt to early parent- multiparous women as labour interventions accumulate (Tracy
ing, and addresses concerns raised in maternity services reviews and Tracy, 2001).
of women receiving inadequate postnatal support within stan- In light of increasing maternity care costs associated with
dard care arrangements. The longitudinal benefits in both social intervention rates such as epidural pain relief and caesarean
and economic terms may be substantial. sections (Tracy and Tracy, 2001) and a reduction in obstetric
Moreover, MGP midwives manage clinical and administration interventions when women receive midwifery continuity of care
functions associated with their caseload. This increases continuity (Hatem et al., 2008; Scherman et al., 2008), it is important to
of care and streamlines services through reducing the number of know how the reduction in resources and interventions translate
carers involved and the risks of fragmented care, as well as to an economic value. This study endeavours to provide an
reduces duplication. It is reported women can experience more economic evaluation at a local level and is consistent with
than 30 carers across their maternity episode (Homer, 2006). previous Australian (Byrne et al., 2000; Homer et al., 2001;
Important to note is the decrease in interventions and improved Tracy and Hartz, 2006), UK (Young et al., 1997) and USA (Stone
care for women receiving continuity of carer (Benjamin et al., and Walker, 1995) continuity of midwifery cost analyses.
e878 J. Toohill et al. / Midwifery 28 (2012) e874–e879

Table 1 Table 3
Characteristics of participants. Costs per woman, mean (SE).

Midwifery Group Standard care p-Value Antenatal Midwifery Group Standard care p-Value
Practice (n ¼52) (n ¼50) Practice (n ¼52) (n ¼ 50)

Age, years (SD) 30.5 (4.7) 28.5 (5.7) 0.060 Obstetric team $18 ($24) $191 ($25) o0.001
Labour onset (weeks) 39.5 (1.3) 39.6 (1.1) 0.675 Midwife $370 ($32) $68 ($33) o0.001
(SD) Other hospital based $40 ($16) $64 ($16) 0.005
Nulliparous, n (%) 20 (38%) 25 (50%) 0.241 visits
Education, n (%) 0.737 GP $3 ($9) $83 ($9) o0.001
o Year 12 12 (23%) 11 (22%) Total antenatal costs $432 ($45) $405 ($46) 0.290
Year 12 14 (27%) 17 (34%) Labour
Diploma/apprenticeship 10 (19%) 11 (22%) Obstetrics $535 ($319) $3,840 ($326) o0.001
Bachelors degree/ 16 (31%) 11 (22%) Midwives $2,233 ($172) $70 ($176) o0.001
postgraduate Total labour Costs $2,769 ($308) $3,911 ($315) o0.001
In paid work, n (%) 40 (77%) 40 (80%) 0.706 Baby $303 ($112) $771 ($114) o0.001
Household income per 0.003 Postnatal
annum, n (%) Obstetric team $37 ($31) $6 ($32) 0.080
Prefer not to tell 1 (2%) 6 (12%) Midwife $1,134 ($58) $320 ($59) o0.001
$20,000–$39,999 3 (6%) 14 (28%) Other hospital based $24 ($84) $191 ($86) 0.281
$40,000–$59,999 15 (29%) 13 (26%) visits
$60,000–$79,999 17 (33%) 10 (20%) GP $23 ($9) $37 ($10) 0.869
4$80,000 16 (31%) 7 (14%) Total postnatal costs $1,218 ($101) $554 ($103) 0.001
Private health insurance 19 (37%) 3 (6%) o 0.001 Total cost
Occasions of service, mean (SE) Hospital perspective $4,696 ($395) $5,521 ($404) o0.001
Antenatal visits* 2.77 (0.36) 4.96 (0.37) 0.001 (excludes GP)
Postnatal visits* 8.84 (0.44) 3.95 (0.45) o 0.001 Government health $4,722 ($394) $5,641 ($403) o0.001
perspective
n
Adjusted for the covariates of age, nulliparity, private health insurance yes/no, Government cost minus $4,418 ($345) $4,871 ($353) o0.00
and household income. baby cost 1

Adjusted for the covariates of age, nulliparity, private health insurance yes/no and
household income.
Table 2
Birth outcomes.
Limitations
Midwifery Group Standard care p-Value
Practice (n ¼52) (n¼ 50)
Limitations include the sample size and selection bias as
Place of birth o 0.001 women self-selected for MGP in the birth centre, although a
Birth centre, n (%) 40 (77%) 0 (0%) number of women in standard care wanted, but were unable to
Hospital, n (%) 12 (23%) 50 (100%) access MGP due to capacity. However ensuring all women met
Induction, n (%) 5 (10%) 17 (34%) 0.026 physical and psychosocial birth centre entry criteria reduces self-
Pain relief methods in labour
Non-pharmacological 30 (58%) 11 (22%) 0.004
selection bias but does not eliminate this. Women in MGP care
Pethidine 0 (0%) 7 (14%) 0.058 had a higher household income and this was addressed by
Nitrous oxide 4 (8%) 28 (56%) o 0.001 including covariates in the analysis. More women in SC withdrew
Epidural 4 (8%) 14 (28%) 0.001 their consent compared to women in MGP. The impact of this
Pudendal block 1 (2%) 1 (2%) 0.224
difference is unknown. The return rate of women’s diaries was
Water immersion 20 (38%) 0 (0%) o 0.001
Mode of birth 0.016 71% overall with non-return from SC n ¼20 and MGP n ¼10,
Spontaneous, n (%) 45 (87%) 40 (80%) which was used for estimating general practitioner’s cost. This
Forceps/vacuum, n (%) 4 (8%) 3 (6%) is relevant to both antenatal and postnatal care, and potentially
Caesarean, n (%) 3 (6%) 7 (14%) underestimates cost in the SC group. Insufficient data was
Neonatal outcome
Birth weight, g (SE) 3,520 (81)* 3,538 (84)y 0.083
recorded in hospital records and in women’s diaries in respect
Paediatrician visits, n (%) 1 (2%) 8 (16%) 0.241 of baby feeding patterns, or women’s personal costs in attaining
Admitted to SCNz, n (%) 3 (6%) 13 (26%) 0.028 health care. This restricted analysis of these parameters. The non-
randomised sample may also have limited identification of
Adjusted for the covariates of age, nulliparity, private health insurance yes/no and
unknown confounders affecting the between-groups comparison.
household income.
n
n¼ 51.
y
n ¼48.
z
Special Care Nursery. Conclusion

Recommendations In this study, MGP Birth Centre care inclusive of antenatal and
postnatal home visiting resulted in fewer obstetric interventions,
Multicentre studies are required to provide comprehensive better clinical outcomes and was less costly compared to standard
analysis of maternity costings that include primary and secondary care. Additional savings and clinical benefits may be readily
clinical outcomes, staff and consumer satisfaction, and compar- anticipated by expanding MGP and increasing the proportion of
ison of any impact that local policies or organisational culture births in the Birth Centre for women with low risk pregnancies.
have on success of midwifery models. Identification and composi-
tion of various continuity midwifery models and application of
these in diverse maternity settings will provide for greater Conflict of interest statement
generalisability for health administrators. Also, the reasons well
women access antenatal care more frequently within standard The four authors have no conflict of interest in the study. The
care compared with MGP warrants enquiry. primary author (JT) managed Antenatal and Birthing Services at
J. Toohill et al. / Midwifery 28 (2012) e874–e879 e879

Gold Coast Hospital during the initial period of the study, from Department of Health and Ageing, 2009. Report of the Maternity Services Review.
February to September 2008. Another author (JG) is a visiting Australian Government, Canberra.
Des Jarlais, D.C., Lyles, C., Crepaz, N., 2004. Improving the reporting quality of
scholar at Gold Coast Hospital. However these roles do not nonrandomized evaluations of behavioral and public health interventions: the
conflict with the study. TREND statement. American Journal of Public Health 94 (3), 361–366 (last
accessed 29 September 2011).
Hatem, M., Sandall, J., Devane, D., Soltani, H., Gates, S., 2008. Midwife-led versus
Acknowledgements other models of care for childbearing women. Cochrane Database of Systema-
tic Reviews 4. doi:10.1002/14651858.CD004667.pub2 art. no.: CD004667.
Henderson, J., Petrou, S., 2008. Economic Implications of home births and birth
We appreciate support for this study provided by the Research centers: a structured review. Birth 35, 136–146.
Centre for Clinical and Community Practice Innovation at Griffith Hirst, C., 2005. Rebirthing—Report of the Review of Maternity Services in Queens-
University and a small grant from the Gold Coast Hospital land. Brisbane, Queensland Government Printer.
Homer, C., Matha, D., Jordan, L., Wills, J., Davis, K., 2001. Community-based
Foundation. Personnel assisting data collection were Sandra Ryan continuity of midwifery care versus standard hospital care: a cost analysis.
& Natasha Pryde (Decision Support Services, Gold Coast Hospital), Australian Health Review 24, 85–93.
and research assistants Faith Hohaia, Cas McCulloch, Judy Batkin, Homer, C., 2006. Challenging midwifery care, challenging midwives and challen-
Julie Fickel, Di Craig and Karen Milner. In addition, the comments ging the system. Women & Birth 19, 79–83.
Maternity Coalition, 2002. Australian Maternity Action Plan. Birth Matters 6, 4–25.
received from Prof Debra Creedy (School of Nursing, National Queensland Industrial Relations Commission, 2006. Nurses (Queensland Health)
University of Singapore) on an earlier draft are greatly appre- Certified Agreement (EB6) /http://www.health.qld.gov.au/eb/agreements/
ciated and have helped refine the presentation of this manuscript. nurses.pdfS (last accessed 30 November 2010).
Scherman, S., Smith, J., Davidson, M., 2008. The first year of a midwifery-led model
of care in far north Queensland. Medical Journal of Australia 188, 85–88.
References Senate Community Affairs References Committee, 1999. Rocking the Cradle. A
Report Into Childbirth Procedures. Commonwealth Government, Canberra.
Stone, P., Walker, P., 1995. Cost-effectiveness analysis: birth center vs. hospital
Australian College of Midwives, 2008. National Midwifery Guidelines for Con-
care. Nursing Economics 13, 299–308.
sultation and Referral. 2nd edn. Australian Capital Territory. /http://mid
Thorogood, C., 2010. Challenges to women’s health. In: Pairman, S., Tracy, S.,
wives.rentsoft.biz/lib/pdf/ConsultationandReferralGuidelines2010.pdfS (last
accessed 30 August 2010). Thorogood, C., Pincombe, J. (Eds.), Midwifery Preparation for Practice. , Else-
Benjamin, Y., Walsh, D., Taub, N., 2001. A comparison of partnership caseload vier, Australia, pp. 128–161.
midwifery care with conventional team midwifery care: labour and birth Toohill, J., 2008. Gold Coast Birth Centre—First 12 Month Review. Queensland
outcomes. Midwifery 17, 234–240. Health, Australia.
Byrne, J., Crowther, C., Moss, J., 2000. A randomised controlled trial comparing Tracy, S., Tracy, M., 2001. Costing the cascade: estimating the cost of increased
birthing centre care with delivery suite care in Adelaide, Australia. Australian obstetric intervention in childbirth using population data. BJOG—An Interna-
and New Zealand Journal of Obstetrics & Gynaecology 40, 268–274. tional Journal of Obstetrics and Gynaecology 110, 717–724.
Department of Health and Ageing, 2006. Australian Refined Diagnosis Related Tracy, S., Hartz, D., 2006. The Quality Review of Ryde Midwifery Group Practice,
Groups (AR-DRGs) AR-DRG V5.2. Australian Government (last accessed September 2004 to October 2005: Final Report. Sydney, Northern Sydney and
4 October 2010)/http://www.health.gov.au/internet/main/publishing.nsf/ Central Coast Health.
Content/health-casemixardrg1.htmS. Young, D., Lees, A., Twaddle, S., 1997. The costs to the NHS of maternity care:
Department of Health and Ageing, MBS online July 2008 /http://www.health.gov. midwife managed vs. shared. British Journal of Midwifery 5, 465–472.
au/internet/mbsonline/publishing.nsf/Content/Medicare-Benefits-Schedule-
MBS-1S (last accessed 4 October 2010).