***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background No midwifery-led units existed in Irel and before 2004 . The aim of this study was to compare midwife-led ( MLU ) versus consultant-led ( CLU ) care for healthy , pregnant women without risk factors for labour and delivery . Methods An unblinded , pragmatic r and omised trial was design ed , funded by the Health Service Executive ( Dublin North-East ) . Following ethical approval , all women booking prior to 24 weeks of pregnancy at two maternity hospitals with 1,300 - 3,200 births annually in Irel and were assessed for trial eligibility .1,653 consenting women were central ly r and omised on a 2:1 ratio to MLU or CLU care , ( 1101:552 ) . ' Intention-to-treat ' analysis was used to compare 9 key neonatal and maternal outcomes . Results No statistically significant difference was found between MLU and CLU in the seven key outcomes : caesarean birth ( 163 [ 14.8 % ] vs 84 [ 15.2 % ] ; relative risk ( RR ) 0.97 [ 95 % CI 0.76 to 1.24 ] ) , induction ( 248 [ 22.5 % ] vs 138 [ 25.0 % ] ; RR 0.90 [ 0.75 to 1.08 ] ) , episiotomy ( 126 [ 11.4 % ] vs 68 [ 12.3 % ] ; RR 0.93 [ 0.70 to 1.23 ] ) , instrumental birth ( 139 [ 12.6 % ] vs 79 [ 14.3 % ] ; RR 0.88 [ 0.68 to 1.14 ] ) , Apgar scores < 8 ( 10 [ 0.9 % ] vs 9 [ 1.6 % ] ; RR 0.56 [ 0.23 to 1.36 ] ) , postpartum haemorrhage ( 144 [ 13.1 % ] vs 75 [ 13.6 % ] ; RR 0.96 [ 0.74 to 1.25 ] ) ; breastfeeding initiation ( 616 [ 55.9 % ] vs 317 [ 57.4 % ] ; RR 0.97 [ 0.89 to 1.06 ] ) . MLU women were significantly less likely to have continuous electronic fetal monitoring ( 397 [ 36.1 % ] vs 313 [ 56.7 % ] ; RR 0.64 [ 0.57 to 0.71 ] ) , or augmentation of labour ( 436 [ 39.6 % ] vs 314 [ 56.9 % ] ; RR 0.50 [ 0.40 to 0.61 ] ) . Conclusions Midwife-led care , as practised in this study , is as safe as consultant-led care and is associated with less intervention during labour and delivery . Trial registration numberIS RCT N : IS RCT Background A community-based r and omized control prenatal care trial was performed in a rural county of China during 2000 - 2003 . The purpose of this paper is to describe the trial implementation and the impact of the trial on the utilization of prenatal care and perinatal outcomes . Material s and methods In the study county , 10 townships ( from a total of 55 ) were each paired with a control ( 20 study townships in total ) , with the criteria for pairing being the township 's socioeconomic development , perinatal health , and maternal care utilization and provision . One of each township pair was r and omly allocated to the intervention or control groups . The trial interventions were : 1 ) training township hospital midwives and instructing them in how to provide systematic maternal care , 2 ) informing women in the community of the importance of prenatal care , 3 ) if needed , providing basic medical instruments to the hospitals . A variety of data sources were used to describe the trial implementation ( observations , group discussion s , field notes , survey to women ) . The data on pregnancy and perinatal outcomes were from the original h and -written work-records in the village family planning centers of the study townships . Results Implementation of the intervention was deficient . The factors hindering the trial implementation included poor coordination between midwives and family planning officers , broader policy changes implemented by the provincial government during the trial , the de central ization of county governance , and the lack of government funding for maternal care . There was only little difference in the use of maternal care , in women 's opinions related to maternal care or content of prenatal care , and no difference in the perinatal outcomes between the intervention and control townships . Conclusions A community based r and omized controlled trial could not be fully carried out in rural China as planned due to the changing political l and scape , the complexity of the socio-economic situation and a lengthy planning stage . The study could not answer if perinatal outcomes could be improved by increased use of prenatal care . Trial registration NCT Please cite this paper as : McLachlan H , Forster D , Davey M , Farrell T , Gold L , Biro M , Albers L , Flood M , Oats J , Waldenström U. Effects of continuity of care by a primary midwife ( caseload midwifery ) on caesarean section rates in women of low obstetric risk : the COSMOS r and omised controlled trial . BJOG 2012;119:1483–1492 OBJECTIVE : To determine whether group prenatal care improves pregnancy outcomes , psychosocial function , and patient satisfaction and to examine potential cost differences . METHODS : A multisite r and omized controlled trial was conducted at two university-affiliated hospital prenatal clinics . Pregnant women aged 14–25 years ( n=1,047 ) were r and omly assigned to either st and ard or group care . Women with medical conditions requiring individualized care were excluded from r and omization . Group participants received care in a group setting with women having the same expected delivery month . Timing and content of visits followed obstetric guidelines from week 18 through delivery . Each 2-hour prenatal care session included physical assessment , education and skills building , and support through facilitated group discussion . Structured interviews were conducted at study entry , during the third trimester , and postpartum . RESULTS : Mean age of participants was 20.4 years ; 80 % were African American . Using intent-to-treat analyses , women assigned to group care were significantly less likely to have preterm births compared with those in st and ard care : 9.8 % compared with 13.8 % , with no differences in age , parity , education , or income between study conditions . This is equivalent to a risk reduction of 33 % ( odds ratio 0.67 , 95 % confidence interval 0.44–0.99 , P=.045 ) , or 40 per 1,000 births . Effects were strengthened for African-American women : 10.0 % compared with 15.8 % ( odds ratio 0.59 , 95 % confidence interval 0.38–0.92 , P=.02 ) . Women in group sessions were less likely to have suboptimal prenatal care ( P<.01 ) , had significantly better prenatal knowledge ( P<.001 ) , felt more ready for labor and delivery ( P<.001 ) , and had greater satisfaction with care ( P<.001 ) . Breastfeeding initiation was higher in group care : 66.5 % compared with 54.6 % , P<.001 . There were no differences in birth weight nor in costs associated with prenatal care or delivery . CONCLUSION : Group prenatal care result ed in equal or improved perinatal outcomes at no added cost . CLINICAL TRIAL REGISTRATION : Clinical Trials.gov , www . clinical trials.gov , NCT00271960 LEVEL OF EVIDENCE : OBJECTIVES To assess the practicality , acceptability to patients and salary costs of the antenatal care of low risk obstetric patients by midwives . DESIGN A r and omised controlled trial . SETTING The antenatal clinic at Westmead Hospital , a teaching hospital of the University of Sydney in western Sydney . PATIENTS From January 1989 until November 1990 , 89 women booking for full antenatal care at Westmead Hospital and classified as low risk were r and omly allocated to one of two groups . Group 1 ( 43 patients ) had their antenatal care provided by registered midwives .  Group 2 ( 46 patients ) had their antenatal care provided by an obstetrician ( either Visiting Medical Officer or Staff Specialist ) in a routine hospital antenatal clinic . INTERVENTIONS Patients in the midwives ' clinic were seen by an obstetrician at their first visit to the antenatal clinic and again at 30 weeks and at 40 weeks . MAIN OUTCOME MEASURES These were the salary costs of each clinic and the patients ' levels of satisfaction . Maternal and neonatal indicators , delivery details and analgesic requirements were also considered . These indicators were planned before data collection commenced . RESULTS The major differences found were a 28 % to 68 % salary cost saving and that patients cared for by midwives showed appreciation of the continuity of care and information given at the midwives ' clinic . CONCLUSIONS The care of low risk obstetric patients by midwives in a midwives ' clinic showed salary cost savings and high patient acceptance A team of four midwives provided the majority of care during pregnancy , labour and the puerperium to 503 women at low obstetric risk , over a 2-year period . Compared with st and ard hospital care r and omly allocated to 498 women this  ' Know Your Midwife ' scheme was associated with greater continuity in all phases of maternity care . The scheme appeared very acceptable to women : they spent less time in the antenatal clinic , and overall , felt more satisfied , better prepared and better able to discuss problems . The scheme was characterised by less obstetric intervention particularly in respect of augmentation of labour and intrapartum analgesia ; labours tended to be longer . Neonatal outcome was generally similar in the two groups but the size of the trial did not allow a precise assessment of differential effects in these terms . The ' Know Your Midwife ' scheme is feasible . It should now be introduced more widely but in a way which allows continuing evaluation OBJECTIVES To evaluate caseload midwifery care in comparison to traditional ' shared care ' . DESIGN Comparative study with area r and omisation . SETTING District general hospital in Engl and . MAIN OUTCOME MEASURES  ' Known carer at delivery , ' ' normal vaginal delivery ' and ' obstetric intervention ' . SUBJECTS All pregnant women delivering in the six areas chosen for the study . MAIN FINDINGS A highly significant difference was found between caseload and traditional care groups in terms of level of ' known carer at delivery ' ( 696/770 94.7 % ; cf . 52/735 ( 6.7 % ) , p < 0.001 ) . However , no differences in ' normal vaginal delivery ' rates were found ( 542/770 ( 70 % ) cf . 509/735 ( 69 % ) . There were fewer ' obstetric interventions ' in the caseload group , particularly  epidural analgesia  ( 80/770 ( 10 % ) cf . 110/735 ( 15 % ) p = 0.01 ) and  oxytocin augmentation  ( 351/77 ( 46 % ) cf . 387/735 ( 53 % ) , p = 0.01 ) . There were no significant differences found in terms of neonatal outcome . CONCLUSIONS Caseload midwifery results in high levels of ' known carer at delivery ' which appears to be associated with a reduction in augmentation and epidural rates but which were not associated with an increase in normal vaginal delivery rate Objective To test whether a new community‐based model of continuity of care provided by midwives and obstetricians improved maternal clinical outcomes , in particular a reduced caesarean section rate 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 women 's satisfaction . METHODS We carried out a r and omised controlled trial of 1299 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 question naires . 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 
    Output:
    
Description of care model characteristics was lacking in many studies , but was better reported for the intervention arms .
Organisation of care was the best-described component .
Underlying values and philosophy of care were poorly reported .
Conclusions The QMNC framework facilitates assessment of the characteristics of antenatal care models .