Midwifery 28 (2012) e874–e879

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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
Midwifery service delivery models have a philosophy to provide
continuity of woman-centred care. However implementation of
these models is inconsistent within countries, and throughout the
world. Variations include diversity in setting, midwife to woman
n
Corresponding author.
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),
p.scuffham@griffith.edu.au (P.A. Scuffham).
ratio, duration and number of visits, length of hospital stay, gestation
at booking and duration of care after birth. Consequently the most
cost-effective model is unknown (Henderson and Petrou, 2008).
In Australia, team midwifery incorporating antenatal care in a
community setting (Homer et al., 2001) and Midwifery Group
Practice in a stand-alone unit have been found to be cost effective
(Tracy and Hartz, 2006). A comparison of birth centre care alongside
a tertiary level conventional delivery suite found no difference in
costs (Byrne et al., 2000). However, rostered team midwifery in
a stand-alone birth centre showed slightly higher birth costs
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
References Committee, 1999). No study in Australia or internation-
ally that we could find, has specifically investigated salaried Mid-
wifery Group Practice (MGP) within a birth centre offering home
antenatal and postnatal visiting compared with standard care.
Publicly funded midwifery models are becoming more prevalent,
albeit slowly, in response to consumer demand, research evidence,
and government reviews and inquiries (Senate Community Affairs
References Committee, 1999; Maternity Coalition, 2002; Hatem
et al., 2008; Department of Health and Ageing, 2009). In 2005, a
review of maternity services in the Australian state of Queensland
called ‘Rebirthing’ echoed findings of previous state/territory and
national reviews and recommended improving women’s access to
continuity of care and carer (Hirst, 2005). A priority area for action
was addressing the widespread poor quality of post birth care.
Consequently, in 2006 a birth centre was established at the Gold
Coast Hospital (GCH), which has around 3,500 births/year. The birth
centre was staffed by midwives working within a Midwifery Group
Practice, founded on primary health-care principles (Thorogood,
2010). This study compares costs and maternal and newborn out-
comes of MGP within the Gold Coast Birth Centre with standard
care at the same publicly funded hospital sharing one set of clinical
guidelines.
Midwifery Group Practice (MGP)
Three full-time midwives with a personal caseload of 40
women per year work in each Midwifery Group Practice (MGP).
Two MGPs operate within the birth centre with a total combined
caseload of 240 women annually. Midwives are not rostered to
shifts, but within each group practice provide backup for each
other through an on-call arrangement. This arrangement ensures
women have their primary midwife or a known midwife available
24 hrs a day from booking until 6 weeks postpartum.
Most women in MGP give birth in the centre and are usually
home within 4 hrs of birth. Home-based care for pregnancy, early
labour and postnatal care to 6 weeks postpartum is a feature of
MGP. MGP spans the same geographic area as that of postnatal
home visiting as part of standard care. Postnatal home care
includes mother and baby physical and psychosocial health checks,
promotion and support of breast feeding, early parenting and
general health education, and linking families to appropriate
agencies according to their needs. A dedicated obstetrician is
attached to each MGP and women attend that consultant’s antena-
tal clinic should complications arise. If women birth in the hospital
birth suite or operating theatre, continuity of care is maintained by
her MGP midwife until 6 weeks postpartum. Women in this model
experience 75% attendance of their primary midwife or 92%
attendance of a MGP midwife for labour and birth (Toohill, 2008).
Standard care
In standard care, women have the option of attending a
general practitioner, a hospital midwife at a community outreach
centre, a hospital midwife clinic or an obstetric clinic at the
hospital for pregnancy check-ups. Routine visits are scheduled in
the outpatient obstetric clinic at 36 and 41 weeks gestation.
Intrapartum and postnatal care is provided by rostered midwifery
and medical staff, with optional postnatal home visiting for up to
7 days postpartum. Services following discharge are provided by
community child health nurses and general practitioners.
Method
A non-randomised pilot study following the TREND statement
(Des Jarlais et al., 2004) was designed to assess the costs and
e875
outcomes of MGP and standard care. A total study sample of 100
‘low obstetric risk’ woman, who met birth centre eligibility criteria,
was required for the study. Women self-selected for their model of
care; but access to MGP was limited due to capacity. Women’s
health records were reviewed to determine if they met the
eligibility criteria for the study prior to seeking consent. This
included meeting the birth centre eligibility criteria, living within
the defined geographic catchment area, and commencing care at
the Gold Coast Hospital prior to 24 weeks gestation. Eligibility
criteria were determined against a ‘well woman’ health checklist
and meeting suitability for midwifery care (Australian College of
Midwives, 2008). The groups were not matched for baseline
demographics. Recruitment occurred at the woman’s 36 week
antenatal appointment. Women were provided with verbal and
written information prior to consenting to participate in the study.
Measures and data collection procedures
At recruitment, women completed baseline demographic
information and were provided with a diary to record where
and with whom maternity visits occurred. At 6 weeks post birth
women returned their diary of care in a post paid envelope to the
research assistant.
Costs were collected from two perspectives: the hospital
perspective and the federal government perspective in Australian
dollars. The latter included costs for mother and baby primary
care visits (antenatal and postnatal) with general practitioners.
Using the medical record number for the mother and baby, the
hospital Decision Support Services team provided all hospital
costs attributed to the woman and her baby by applying standard
hospital processes in determining hospital costs. This process
involves medical coders reviewing the medical record and align-
ing episodes of care and procedures to Australian-Refined Diag-
nostic-Related Groupings (Department of Health and Ageing,
2006). Any costs not attached directly to the maternity episode
were not used. All costs to the hospital from 36 weeks gestation
to 6 weeks postpartum were included. Regardless of change to
risk status or intended place of birth (birth centre or birth suite),
women’s costs were analysed by intended mode of care.
Research assistants cross-checked visits, admission, birth and
discharge dates against the women’s diaries, medical records and
hospital activity system. The first author identified any cost
outliers in the data and a research assistant checked accuracy
against care received. Decision Support Services were alerted if
care and cost did not align, with women removed from the study
if gross inaccuracies were confirmed.
The number of general practitioner visits was extracted from
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
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
and obstetric history and care provided throughout pregnancy.
Each general practitioner visit was costed using Medicare Benefits
Schedule item number 16,500 (Department of Health and Ageing,
2008) (Schedule July 2008, $AUD38.65 per visit).
Ethics approval was granted from the hospital and university
human research ethics committees.
Data analysis
All statistical analyses were performed using SPSS (version
17.0). For baseline characteristics, Pearson w2 tests were used for
categorical data and Student’s t-tests were used for continuous
data to assess differences in baseline characteristics between
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
continuous data and logistic models for categorical data) with
covariates of age, nulliparity, private health insurance (yes/no),
and household income category. These covariates were included
as they may impact on outcomes. Statistical significance was
determined using p-value o0.05.
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
recruit participants. Between March and December 2008, 170
consecutive women who met birth centre eligibility criteria
(MGP n ¼ 70, SC n ¼100) were approached for participation in
the study. A non-randomised sample of 119 women (70%) were
recruited to the study at 36 weeks gestation (MGP n ¼58 or
standard care n ¼61). Seventeen women were not included in
the final analysis (Fig. 1) for the following reasons: consent not
completed (n ¼2) did not give birth at GCH (n ¼ 2), withdrew
consent at follow-up (n ¼11), and other (n ¼2). This resulted in
102 women remaining in the study (MGP n ¼52; SC n ¼50).
Standard Care consisted of women receiving antenatal care with
a GP n ¼29 (58%), obstetric clinic n ¼10 (20%) or midwives clinic
n ¼11 (22%). Participant characteristics were similar across the
two groups except women accessing MGP were more likely to
have higher family income (p ¼ 0.003) and private health insur-
ance (p o 0.001) (Table 1).
There were significant differences in the outcomes for women
and their babies between the two models of service delivery.
Women receiving standard care had more antenatal visits
(p¼ 0.001), but fewer postnatal visits consistent with a reduced
period of postnatal care in that model (po0.001) (Table 1). Fewer
women in MGP used pharmacologic pain relief in labour compared
to women receiving standard care (pethidine, p¼0.058, epidural
p¼0.001 and nitrous oxide po0.001) with epidural use three
times higher in standard care (Table 2). Additionally women
receiving standard care were more likely to have labour induced
(p¼ 0.026), and less likely to experience an operative vaginal birth
(p¼ 0.024) (Table 2). More women receiving standard care experi-
enced a caesarean section (n¼7) compared with MGP (n¼3) but
this difference was not statistically significant (p¼ 0.51).
Newborns to mothers receiving standard care were admitted to
special care nursery four times more frequently compared to MGP
(p¼ 0.028) (Table 2), and stayed in the nursery longer (SC¼42.3 hrs;
MGP¼23.6 hrs; p¼0.026). There was no difference between groups
for duration of stay in the birthing environment (MGP¼9.6 hrs;
SC¼12.4 hrs; p¼0.164). However women using MGP went home
earlier (MGP¼18.0 hrs; SC¼53.1 hrs; po0.001), significantly redu-
cing postnatal bed occupancy rates. There was insufficient data to
draw statistically significant conclusions on breast-feeding out-
comes and this may have been due to lower reporting of this
outcome in the women’s records. The available data indicated that
women in MGP were more likely to fully breast feed following birth
(MGP n¼47, 92%; SC n¼38, 78%; p¼ 0.230), on discharge (MGP
n¼45, 88%; SC n¼38, 76%; p¼0.065) and at 6 weeks postnatal
(MGP n¼27, 82%; SC n¼13, 59%; p¼0.332). Only 55 women
reported on feeding patterns at 6 weeks (MGP n¼33, SC n¼22).
Postnatal readmissions were low (MGP n¼1; SC n¼3) with mean-
ingful statistical analysis not able to be determined. Twenty-three
per cent of women required transfer from MGP to collaborative
obstetric care (n¼6, 11.5% in pregnancy, n¼6, 11.5% during labour,
none postpartum) with continuity of midwifery care continued and
costs attributed to booked model of care.
A breakdown of care showed that antenatal costs across the
two models were the same, labour costs were statistically higher
in standard care, with postnatal costs statistically higher in MGP.
When compared overall there was a statistically significant lower
cost associated with MGP compared to standard care (MGP
$4,696 vs. SC $5,521, p o0.001) based on the hospital costing
system and when assessed against Federal government health
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).
Discussion
For pregnant women at low-risk of birth complications, care
provided through a Midwifery Group Practice model of service
delivery was less costly and women experienced fewer birth
interventions compared to a similar group of women receiving
standard maternity care. There was no mortality and no signifi-
cant morbidity for women or babies between the two groups. This
is consistent with existing published research showing continuity
of midwifery care to be safe for women and babies, and satisfying
for women (Hatem et al., 2008). Adopting a primary health model
of care, providing women with home-based visiting across the
continuum, and increasing postnatal care provided better out-
comes. Women entered spontaneous labour more often, were
home earlier, babies were admitted to nursery less often, and
there were fewer unplanned presentations to hospital.
Methods used to determine cost-effectiveness of midwifery
models of service delivery vary (Henderson and Petrou, 2008).
This is particularly so where there is a birth centre separate to
that of a hospital birth suite and where antenatal and postnatal
home visits are provided.
Difficulties in establishing comparative costs of midwifery
models stem from different reporting and payment methods, skill
mix complements, contexts of care (team or caseload, birth centre
or freestanding centre, hospital or community care). Generally,
hospital administrators compare cost centre reports to determine
how budgets are running. With a birth centre operating alongside
a main birth suite, cost centre reports do not provide a compar-
ison of cost-effectiveness due to the different activities, skill mix
and context of care. Therefore, this study used the hospital’s
accounting system to track women’s care and costs. This study
commenced comparison from 36 weeks gestation as this was a
time when all women were reviewed at the hospital regardless of
model of service delivery. Consistent with a previous study, we
found that community or home antenatal visits through MGP
were cost effective and women required less visits overall than
women in SC (Young et al., 1997).
Compared with other studies, it has been suggested that
salaried midwifery models in the UK NHS require a median
caseload of 39 women per midwife per year (Young et al.,
1997), and in the USA that transfer rates from a free standing
birth centre to obstetric care must remain below 62% (Stone and
Walker, 1995) to be cost neutral. In our study, midwives were
paid an annual salary under the state industrial award to care for
40 women per year across the maternity continuum (Queensland
Industrial Relations Commission, 2006, p. 27), and there was a
23% transfer from birth centre to collaborative obstetric care with
MGP continuity. The cost findings indicated that the lower
hospital resource use and improved clinical outcomes in the
MGP model provided savings to support home visiting through-
out pregnancy and up to 6 weeks following birth.
Assumptions that midwives on annualised salaries increase
costs of maternity care are not borne out in this study. Impor-
tantly, cost must be assessed in context of the overall package of
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
overall cost of MGP care was less. This provides reassurance to
support women in their home whilst they adapt to early parent-
ing, and addresses concerns raised in maternity services reviews
of women receiving inadequate postnatal support within stan-
dard care arrangements. The longitudinal benefits in both social
and economic terms may be substantial.
Moreover, MGP midwives manage clinical and administration
functions associated with their caseload. This increases continuity
of care and streamlines services through reducing the number of
carers involved and the risks of fragmented care, as well as
reduces duplication. It is reported women can experience more
than 30 carers across their maternity episode (Homer, 2006).
Important to note is the decrease in interventions and improved
care for women receiving continuity of carer (Benjamin et al.,
2001). An Australian study reported a relative increase in birth
cost of 50% for low risk primiparous women and 36% for low risk
multiparous women as labour interventions accumulate (Tracy
and Tracy, 2001).
In light of increasing maternity care costs associated with
intervention rates such as epidural pain relief and caesarean
sections (Tracy and Tracy, 2001) and a reduction in obstetric
interventions when women receive midwifery continuity of care
(Hatem et al., 2008; Scherman et al., 2008), it is important to
know how the reduction in resources and interventions translate
to an economic value. This study endeavours to provide an
economic evaluation at a local level and is consistent with
previous Australian (Byrne et al., 2000; Homer et al., 2001;
Tracy and Hartz, 2006), UK (Young et al., 1997) and USA (Stone
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
Multicentre studies are required to provide comprehensive
analysis of maternity costings that include primary and secondary
clinical outcomes, staff and consumer satisfaction, and compar-
ison of any impact that local policies or organisational culture
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
generalisability for health administrators. Also, the reasons well
women access antenatal care more frequently within standard
care compared with MGP warrants enquiry.
In this study, MGP Birth Centre care inclusive of antenatal and
postnatal home visiting resulted in fewer obstetric interventions,
better clinical outcomes and was less costly compared to standard
care. Additional savings and clinical benefits may be readily
anticipated by expanding MGP and increasing the proportion of
births in the Birth Centre for women with low risk pregnancies.
Conflict of interest statement
The four authors have no conflict of interest in the study. The
primary author (JT) managed Antenatal and Birthing Services at
 J. Toohill et al. / Midwifery 28 (2012) e874–e879
Gold Coast Hospital during the initial period of the study, from
February to September 2008. Another author (JG) is a visiting
scholar at Gold Coast Hospital. However these roles do not
conflict with the study.
Acknowledgements
We appreciate support for this study provided by the Research
Centre for Clinical and Community Practice Innovation at Griffith
University and a small grant from the Gold Coast Hospital
Foundation. Personnel assisting data collection were Sandra Ryan
& Natasha Pryde (Decision Support Services, Gold Coast Hospital),
and research assistants Faith Hohaia, Cas McCulloch, Judy Batkin,
Julie Fickel, Di Craig and Karen Milner. In addition, the comments
received from Prof Debra Creedy (School of Nursing, National
University of Singapore) on an earlier draft are greatly appre-
ciated and have helped refine the presentation of this manuscript.
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