Exploring the impact of midwife-led group antenatal care on caesarean section rates and infant health: a multi-site randomised controlled trial

Intervention: Pregnancy care in 'Group Care' - Midwife-led group antenatal care and education (Group Care) integrates antenatal care, childbirth preparation, and early parenting education into group sessions that occur at regular intervals throughout pregnancy, facilitated by two midwives who remain with the group. It includes continuity of midwife carer; increased education and information sharing about childbirth, breastfeeding and early parenting; and peer support. The aim is to help women to choose health-promoting behaviours, and be active participants in their care. Clinical care for women in both groups will be as per the clinical guidelines in operation at the respective study site. All women will have access to support services normally available to them, and medical input as appropriate. Women allocated to 'Group Care' will receive all their antenatal care in small groups of 10 to 12 women of a similar gestation. Women will be offered a choice of group times and locations based on their due date, with each group including women due in the same 2 to 3 week period to maximise peer support potential, and optimise timing of education and discussions. The group-based approach enables pre-set appointment schedules, with no waiting time for pregnancy visits. Group session dates and times are booked for a woman’s entire pregnancy. Groups meet for two hours six times in pregnancy at the standard pregnancy appointment gestations. Each group is run by the same two midwives every session, to provide continuity and to allow flexibility with information provision over the course of any particular group, so timing of information/discussions can be altered to suit group needs. Physical assessments e.g. fundal height and fetal heart rate take place individually, in the group space, but in a private screened area to maintain privacy. Physical assessments are completed during the session in the private area while the group is ongoing. All sessions include routine clinical care and assessment, along with childbirth education, preparation for parenting, and peer support. Timing of 'Group Care' appointments, summary of content and appointment duration. 26 weeks gestation: Introductions/group formation goals/care plans, pregnancy issues, breastfeeding, expectations (2 hours) 30 weeks gestation: Normal newborn behaviour, breastfeeding, labour and birth, feelings, expectations, worries, concerns (2 hours) 33 weeks gestation: Labour and birth, postnatal care, breastfeeding, parenting ((2 hours plus, 2 hour hospital tour) 36 weeks gestation: Preparing for home, community supports, Group B Streptococcus testing, complications, concerns (2 hours) 38 weeks gestation: Early postnatal care, labour and birth, expectations, worries (2 hours) 40 weeks gestation: Labour, birth, induction, breastfeeding (2 hours) Physical and online information materials provided will be those given during standard pregnancy care (hospital developed, reviewed and promoted materials). Emphasis is placed on engaging women in their own health care and empowering them to be proactive. Women can bring a partner or support person, with some groups available for women-only for those who prefer. Women in Group Care who need additional obstetric or other care during pregnancy will remain in the group, with additional care as required. Women at higher risk initially will have concurrent collaborative medical care as is usual practice in midwife-led models at the study sites. Adherence of participants to sessions will be monitored using hospital data (e.g. checked into appointment, Did Not Attend etc.). Observations of sessions will be conducted ad hoc by research team as required but as it is woman-led and proactive there may be deviations from the planned content schedule to address the groups individual needs, as decided by the groups.