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02/09/2012

Caseload Midwifery A Critical Review 10 Years on From Changing Childbirth


Caseload Midwifery

A Critical Review 10 Years on From Changing Childbirth

 

Outline

Abstract

            Caseload midwifery and its variations such as one-to-one, team and group approaches is a relatively new and evolving reality for midwife practice in the United Kingdom. From the launching of the Changing Childbirth in November of 1993, the recommendation of the Department of Health where the locus of the approach is to put the woman at the centre of care requires the necessity to have midwives that will practice caseload midwifery.

There are positives and negatives to caseload clinical practice for the midwives, the maternity patients and the hospitals. Midwives have indicated in numerous studies that caseload midwifery increases job satisfaction, autonomy, skills and the relationship between them and the patients. However, the logistics of juggling these multiple roles, while at the same time maintaining health and sanity, can be difficult, with role overload and role stress being possible outcomes.

The study suggested that there are several factors that need to be considered before adopting the caseload approach. While it may have generated positive responses from some parts of the population, it cannot be ignored that there were also studies suggesting that the traditional care is still a better mode of delivering childbirth.

1.0         Introduction

The roots of midwifery lie in the support given by one woman to another around the time of birth. Even after the professionalization of midwifery, most births in the United Kingdom took place at home, and the midwife was a part of the woman’s community (Page, 2003). Two themes are high on the agenda of maternity care throughout the UK at the moment (Walsh, McLean and Benjamin, 1999): Changing services to realize continuity of carer and promoting evidence-based practice. This is shown by the evidence that most pregnant women have their babies delivered by a stranger – one of up 40 midwives that they may see throughout their pregnancy (Shuttleworth, 1994). Moreover, wider consultation of consumer views and on issues related to quality of care concluded that maternity care needed to become more “women-focused”.

The UK Department of Health addressed these two issues through the Changing Childbirth which recommended that women should be the focus of maternity care and that every woman should have the name of a midwife, known to her, whom she can contact for advice (Department of Health, 1993). It set the target that within 5 years, 75% of women should be cared for by a midwife who they have come to know during their pregnancy. It is predominantly up to the midwives to make this possible, not only for the benefit of the women using the maternity services, but also for the benefit of midwives themselves.

These changes closely reflected midwifery practice and have led to dramatic changes in maternity services. Thus, the caseload midwifery approach emerged. Caseload midwifery essentially deviates from the traditional model of childbirth in that it specifically sets a caseload fro every midwife which they will focus on. In this manner, continuity of care is said to take place.

Midwives in the United Kingdom have always provided the majority of care for childbearing women. By law, midwives have always been entitled to care for women on their own responsibility. As more and more midwives were required to practice in the hospital setting, the traditional place of the midwife working within the woman’s home and community changed. However, this structure of care that evolved over time created complete fragmentation of care, with little possibility of a continuing relationship between individual women and their maternity care providers. Finally, a large scale, multi-disciplinary evaluation of the scheme, reported in September 1996, concluded that overall results had been encouraging and recommended that the scheme be extended in steps, under continuing evaluation, and tried out in other context (McCourt, 1998a). 

            In Changing Childbirth, the Expert Maternity Group states that the main role of maternity care is to meet the individual needs of the woman.  The evidence considered by the group when drawing up the Changing Childbirth indicators suggested that knowing a lead professional in charge of your maternity care, and knowing the people caring for you in labor, are priorities for many women.   However, it is vital that the ethos of Changing Childbirth is considered when evaluating maternity services, rather than relying on the shorthand of the indicators.

Criticisms on the Changing Childbirth

Lee (1994) stressed that the emphasis on continuity of intrapartum care as a priority for all women was misplaced. However, while it is considered as essential, it is not essential to satisfaction with care during labor (Fleissig and Kroll, 1996). Furthermore, Lewis (1996) argued that the financial repercussions of Changing Childbirth were not given sufficient consideration. In this trust the prioritization of intrapartum continuity by the maternity service in response to government and internal initiative was not borne out by the majority of local women’s preferences and priorities for continuity of care and service provision (Hart, Pankhurst and Sommerville, 1999). Hart, Pankhurst and Sommerville (1999) further argued that the benefit of the scheme to a minority of clients was not good enough to support further roll out of the scheme and the context of extreme financial constraints made such an event extremely likely throughout UK.

1.1         Overview of the Literature

            Most of England’s maternity services – and increasingly since 1980 – have been fragmented, with a division between community and hospital, and with a focus on medical rather than midwifery care (McCourt-Perring and Page, 1996).   To put the woman at the centre of care, to chance around the system so that the midwife follows the woman through rather than the woman progressing through an assembly line, to have midwives start to use all their skills and practice truly as practitioners in their own right requires fundamental change.

            Although the principles and targets for changes were clear, the report did not recommend any one model of care. The model introduced at Queen Charlotte’s and Hammersmith is similar to the way independent midwives practice and moves on from the earlier attempts to improve continuity of care through team midwifery.

It has always been hypothesized that continuity of carer will improve women’s satisfaction with their care, give midwives greater job satisfaction, increase their autonomy, and reduce intervention rates (Page, 2003). The evaluation of the One-to-One Midwifery practice is the only study to have evaluated all of these outcomes in the program.

1.2         The Traditional Midwifery Care and Practice

The traditional or standard care in midwifery included care mostly by doctors, care mostly by midwives in collaboration with medical staff (midwives’ clinic), birth center care and shared care between local general practitioner and doctors in the hospital (Waldenstrom, McLachlan, Forster, Brennecke and Brown, 2001).

However, the widespread dissatisfaction with the “old country”, expressed not only by middle-class pressure groups and radical midwives but also by women in a wide range of social circumstances, by both establishment midwives and doctors, by health care leaders and government agencies, here and around the world (Page, 1996). The reasons for dissatisfaction as outlined by Page (1996) include: the institutionalization of birth and midwifery; the replacement of human support and clinical skills with technology; organization of care that artificially separate the phases or trimesters of pregnancy; fragmented systems that separate and alienate women and their families from the midwives and doctors who are their carers; the lack of a lead clinician who takes responsibility for ensuring that care is provided effectively and appropriately and; ward routines that separate mother and baby.

1.3         The Emergence of Caseload Midwifery

Smith and Jowett (2001) asserted that Caseload Midwifery emerged as a response to the negative effects of a fragmented service thus, prompting midwives to pilot what they term as a women-centered approach to care- Caseload Midwifery.

Page, Cooke and McCourt (1997) outlined the historical background of Caseload Midwifery as one stemming from the introduction into The Queen Charlotte’s and Hammersmith Hospitals Maternity Service in 1993, as a way of putting the principles of Changing Birth, the report of the Government expert maternity group, into practice, the new and unique way. The initial results in 1995 showed that in both hospitals, across the trust, more women were delivered normally and fewer had caesarean sections on the section that used one-to-one instead of the traditional way.

This approach provides one named midwife who provides most of the care for individual women has been tried by hospitals. In London alone, around 800 London women in 1997- approximately 16% of the local service- are provided with this form of care (Page, Cooke, and McCourt, 1997). One-to-one should not be take in the literal sense, Duff (1995) suggested that the case is not always one-to-one but rather, the system of each woman having a named midwife working with a partner means that over 76% of women have been delivered by the midwife they know best.

According to Walsh (1995a), the term named midwife immediately suggests the importance of the relationship between the midwife and her clients. This relationship is central to the midwifery practice. The phrase personalizes this relationship because women know the midwife’s name she cares for, and has a time frame that enables the relationship to be ongoing over the life of a pregnant woman.

Caseload midwifery (Duff, 1995) has the flexibility to provide continuity wherever the woman chooses to have her baby, and to respond to the individual needs of women either with a normal pregnancy or with complications.

The organization allowed midwives’ flexibility in work patterns and encouraged professional autonomy, and adequate managerial support was given. In the system of care, Page, McCourt, Beake, Vail and Hewison (1999) observed that midwives are actually communities or ward based and women progressed through the system, being cared for by a number of different professionals.

2.0         Caseload Midwifery

2.1         Definition and Focus Areas

Caseload midwifery has been defined clearly by the National Childbirth Trust as:  ‘When a midwife carries a caseload she is the primary provider of midwifery care (the named midwife) during pregnancy, birth and the early postnatal days for an agreed number of women.  She may be providing care to women wherever they are: at home, in the community, or in a maternity unit.  She has responsibility for the planning and monitoring of care throughout for the women on her list (McCourt, 1998b). She liaises with medical colleagues and social agencies as appropriate’ (McCourt, 1998b).

            Health purchasers are implementing a revolutionary midwifery pilot scheme, which has proved to be both cost-effective and popular with patients (Waters, 1996). The elements include: developing a caseload; relationships with other staff – perceived ‘elitism’; boundaries of care for high-risk mothers; long hours; isolation and; women’s unrealistic expectations of midwife, including overdependence (Farmer and Chipperfield, 1996).

The ethnographic who are not accustomed to working in this way need time – probably six to nine months - and good peer and management support to settle into this way of working (McCourt, 1998a). This workload analysis was conducted when the scheme had been in operation for almost three years.   At this point, a number of midwives were relatively newly recruited to the scheme but it is possible that these midwives benefited from the greater experience of those who had been caseload midwives since the inception of the scheme (McCourt, 1998a).”       “Individual caseload”: this phrase seems to pose a myriad of questions to midwives practicing within what has become over the last forty years or so, the conventional system of midwifery care (Reed, 2002). For many midwives who harbor a keen desire to get away from the fragmented hospital-based system that they have trained in and become accustomed to, the idea of practicing their own caseload is very tempting, but there are nagging doubts on its possibility (Reed, 2002).

2.2         Continuity of Care

The locus of the Changing Childbirth has been the emphasis on the lack of continuity of care on the traditional approach.

Homer, et al (2001) suggested that community-based continuity of care provided collaboratively by midwives and obstetricians could result in a decreased caesarean section rate. Moreover, women who develop complications during pregnancy can continue to be managed in a community setting without apparent detriment to their health.

Sandall (1997) examined the impact of Changing Childbirth (Department of Health, 1993) on midwife’s work and personal lives. It reports findings from a multiple site case study of community-based maternity care where each site represented a model of continuity of carer along a continuum from complete one-to-one continuity to continuity within a team.   The three sites represented the traditional model of GP-attached community midwives, a community team and a community-based group practice. Three key themes emerged from the data relating to sustainable practice, the avoidance of burnout and the provision of flexible woman-centered care. These were occupational autonomy, social support and developing meaningful relationships with women.

Control over work and continuity of care are as important to midwives in how well they balance their work and home life as they are to women experiencing childbirth (Sandall, 1997). Models of care such as personal caseloads that incorporate these factors may be more sustainable in terms of less burnout and greater personal accomplishment than team caseloads.

2.3         Less intervention labor and birth

One of the most effective midwifery interventions is social support in labor (Hodnett, 1995). Hodnett’s meta-analysis reports that the continuous presence of a support person reduces: the duration of labor and the use of pain-relieving drugs; the incidence of an operative vaginal delivery; and a 5-minute Apgar score of less than 7. Midwives were able to manage their own time, had increased responsibility and accountability, and made decisions (Bissett, 1996).

2.4         A Comparative Analysis on the Traditional Midwifery Care

Women’s perception and experiences are predominantly influenced by the relationships they had with their midwives who they described as “friends” (Walsh, 1995b). All other themes are filtered through this relationships, including previous negative experiences of maternity care, the valuing of a known midwife for labor and birth, their positive birth experiences, expressions of delight at their care, their liking of home antenatal care, and the appreciation of their existing children and partners meeting their midwives.

2.4.1     Community and hospital based care

Community and Hospital-based care differs primarily in the location where childbirth is delivered. The result of several studies also suggested that women had been shown to be generally happier on the care they receives from their community, describing hospital based care as inconvenient and inflexible, routine and impersonal (McCourt, 1996). Aside from the positive patient assessment on community-based care, it will also be convenient for midwives who could organize flexible working hours to their own advantage, and did not have a set routine everyday (Bissett, 1996). Moreover, in the approach, the skills of midwives provided them the opportunity to gain greater experience working with a caseload and all spoke positively on how caseload practice had improved their knowledge base, confidence and judgment. Caseload practices also appeared to increase the midwives’ scope for reflective practice – all felt that the care they had offered in the hospital system lags behind that of what they can offer in a community-based care as practiced in a caseload approach (Bissett, 1996).

2.4.2     Relationship with Different Care Professionals

There was also an improved working relationship between midwives and medical staff.  Working closely with other midwives promoted good working relationships, and sharing experiences gave additional knowledge and support. It was also mentioned that there was increased respect from the medical staff (Bissett, 1996).

Women also prefer midwives rather than any other medical professional knowing however that they had access to doctors as needed. This preference stems from knowing that their midwives have access to their personal and medical history thereby understanding their needs (McCourt, 1996). This is in lieu with the lack of visits they get from their doctors, who cannot grant the relationship they sought for. 

The North Staffordshire Changing Childbirth Research Team (2002) posited that it is possible to achieve very high levels of “knowing your midwife” for pregnancy and childbirth using a caseload model. Furthermore, within the findings were demonstrable benefits for the mother receiving caseload care in terms of the outcomes measured.

2.4.3     Communication and Care

Women using birth services tended to view the communication and support in care as essentially linked (McCourt, 1996). A professional who provides information and involves her throughout helps the women to gain confidence, and cope with fear and pain during labor and birth. In the caseload practice, the women are confident about the role played by the midwives compared with other professionals. In the traditional setting however, there were uncertainties as to the care and communication they receive from the midwives.

            The women benefit from a named midwife who provides community of care throughout the pregnancy (Sweet, 1995) by providing an individual service to the women which also gives job satisfaction for the practitioners. This type of service involves extra accountability and organization of time. However, effective time management is crucial to managing a caseload successfully while having enough time for personal rest and relaxation.

In order to address the problems, small call groups of 3-5 people can provide a reasonable amount of stability and continuity as well as minimizing communication problems (Reid, 1998).  This size a group would make it relatively easy for women and their partners to meet other members of the call group.   Larger call groups, while they may provide more protected time, may make communication more complex and significantly reduce continuity of care. 

2.4.4     Care during early labor and for induction of labor

Due to staff time pressures and the assumption that they were not in active labor, they received little professional care. In some cases, due to rapid progress and shortage of delivery suite beds, they remained in this situation for the first stage (McCourt, 1996). However, in the caseload setting, the women were able to access advice from their midwife through the telephone and the midwife usually visited them at home at an appropriate stage, to assess progress, offer care and advise on transfer to hospital.

2.4.5     Care During Labor and Birth

Partnership caseload midwifery practice has a significant positive impact on women’s experience of childbirth (Walsh, 1999). In addition, this relationship has evolved in the context where both parties value each other as opposed to the traditional setting. Compared to traditional care, women receiving one-to-one care felt more supported and confident during labor and were more likely to understand and support any intervention they had experienced. Furthermore, they were able to cope with pain through the support offered by their midwife, including massage, touch and relaxation, and appeared less reliant on pain relief, particularly epidural anaesthesia (McCourt, 1996).

Cooper (1997) posited that women cared by midwives on a one-to-one basis need fewer epidurals or other pain relief during childbirth. This is in connection with reports between care rendered by traditional midwives and half-cared by midwives in the One-to-one project where a woman can have up to 40 people caring for her during her pregnancy and is unlikely to have her baby delivered by a midwife.

Generally, women expressed more positive views about the experience of labor and birth (McCourt and Hewison, 1998). Furthermore, McCourt and Hewison’s study showed that women who delivered using the caseload approach relied particularly on their named midwife or her partner for support, encompassing clinical care, companionship, information giving, and advocacy.  Women in the traditional approach gave more varied views of midwifery care, with some women highly dissatisfied.   Some women in both groups were critical of the role of doctors, but those in the study group had a midwife to mediate in this relationship if necessary, to explain the doctor’s views, and to advocate the woman’s view when needed.

2.4.6     Postnatal Care

The early times after birth were a time when the women needed time and sensitive support for their physical and psychological recovery from birth, whilst at the same time establishing their role as new mothers. It is also this time that women felt more vulnerable (McCourt, 1996). In the traditional midwifery care, the women lack the support coming from their midwives (McCourt, 1996). However, with the emergence of the caseload midwifery, this issue has been addressed more efficiently.

2.4.7     Women’s Experiences

Women receiving one-to-one care were very positive about the experience of having a named midwife who took the main responsibility for co-coordinating their care, and who was usually the main provider. They felt their care was consistent, supportive and as a result enhanced their confidence rather than making them feel more dependent on the maternity services (McCourt, 1996).

2.5         Elements of Caseload Midwifery

Stevens and McCourt (2002a) divided the elements of caseload midwifery in terms of the adjustments done by the midwives into two: the visible and tangible adjustments and the second level adjustments.

In the adoption of caseload midwifery, some visible and tangible adjustments have to be done. Come immediate adaptations were obvious to everyone as being part of the job: case load midwives wore their own clothes and the requirement to practice all aspects of midwifery, in varying locations, according to the needs of the women on their caseloads (Stevens and McCourt, 2002a). Stevens and McCourt (2002a) also noted the change in the territory, as multi-dimensional in terms of place, time and organization of work. In a hospital service the parameters of where, when and how midwives work are clear, with rotational placements, shifts and protocols offering minimal flexibility.

In the caseload practice, the parameters are defined by the actual caseload and not the institution, who usually defines the limitations and restrictions on the midwives’ role, load and work specifications. (Stevens and McCourt, 2002b). Consequently, the caseload practice demanded that each midwife be competent in all areas of practice on a daily basis and with women with a wide range of needs and levels of risk. The second level of adjustment included factors that are not visible yet considered as more important over time (Stevens and McCourt, 2002b): Resource networks, relationships, partnership and group, professional colleagues, women and families, responsibility and boundaries.

3.0         Approaches to Caseload Midwifery

3.1         One-to-one midwifery

Lesley Page, professor of midwifery, and her team, as a way of putting into practice the policies stemming from Changing Childbirth, developed One-to-One midwifery practice. Cooke (1996) argued that One-to-One has developed a supportive learning environment, which encourages practice development. This can be done by the preparation for caseload practice includes reviewing experience and skills, leading to personal development planning.

            The One-to-One project is based on the requirement of the British Government report Changing Birth which has created a new policy for the maternity services in Britain. It was introduced in 1993 as a service innovation within the Hammersmith Hospital NHS Trust in November 1993 (McCourt, 1996). The key themes include: continuity of care and carer; community versus hospital based care; relationships with different care professionals; care during early labor and for induction of labor; care during labor and birth and postnatal care (McCourt, 1996).

            One-to-one practice provided the main components, which Sandall (1996) identified as of importance in avoiding burnout and creating sustainability for midwives carrying a caseload. These are occupational autonomy, social support and developing meaningful relationships with women (Page, 1996).

Evaluation was seen as integral to the One-to-One project from its earliest development stages (McCourt–Perring and Page, 1996). Hence, planning and support: Right from the start of the One-to-One project research was on the agenda, and the steering group pulled together a group of people with relevant experience.

Team Midwifery

            The implementation of team midwifery has been a popular response by maternity service managers to the challenges set by Changing Childbirth (Department of Health, 1993). However, the long-term prospects of many team midwifery schemes hang in the balance of limited resources and operational complexities (Hart, Pankhurst and Sommerville, 1999).

One-to-one midwifery differs from many of the innovations tried in other services, such as the team midwifery. Many team midwifery developments have comprised large teams of midwives, with responsibility for the care of individual women being taken by the team rather than one or two named midwives (Page, Beake, Vail, McCourt and Hewison, 2001). In this way, the woman has to meet a potentially large group of midwives and how far this signifies “getting to know” them needs further examination. In some cases continuity has been decreased rather than increased by these developments and midwives involved have perceived reduced control of their workload (Page, Beake, Vail, McCourt and Hewison, 2001).

            Research confirmed that the term “team midwifery” has a variety of interpretations, and identified three main models of team midwifery (Stock, 1994):

1.)  teams of midwives providing hospital care only;

2.)  teams of midwives providing community care only;

3.)  teams of midwives providing care in both hospital and community.

Team midwifery is seen as a partial solution to providing continuity while accommodating a range of practical difficulties.

Three factors are particularly relevant (Stock, 1994):

1.      The historical development of institutional births which has led to the growth of hospital based midwifery services, and in turn to the increased numbers of, and specialization of midwives. This specialization has continued to the extent that midwives’ skills in some areas are said to have become “compartmentalized”. The separation of hospital and community midwifery, and the further specialization of hospital midwives does not fit easily with the concept of team midwifery, where individual midwives are ostensibly capable of providing “total midwifery care”.

2.      The job roles are (in principle at least) specified within the framework of national grading criteria.   Greater continuity demands greater flexibility in terms of shifts, input and levels or responsibility than the widespread interpretation of national conditions and grading criteria suggest.

3.      Continuity has an associated cost to be borne either by the service as a whole, or by individual midwives.   It has been suggested that in order to provide a full “named midwife” service, each midwife would either have a smaller workload (in terms of numbers or complexity) than the current national average caseload, or would have to work longer hours and be highly flexible.

 

Partnership caseload midwifery care resulted in less interventionist labor and more normal birth than conventional team midwifery care  ( Benjamin, Walsh and Taub, 2001). They also experienced much higher levels of continuity, particularly of a known midwife during labor and birth.  

Several scholars found higher levels of maternal satisfaction with the partnership caseload model when compared with conventional care  (Benjamin, Walsh and Taub, 2001). Maternal satisfaction is an important dimension of evaluations of service developments and should be appraised alongside clinical outcomes when decisions are made regarding the “roll-out” of pilot schemes. However, the absence of published data in this area for this project weakens its generalisability. Thus, although the implications for other UK maternity units are mitigated by the research design, the results should encourage them to set up and evaluate their own partnership caseload schemes  (Benjamin, Walsh and Taub, 2001).

Another variation is the one practiced at The Wessex Maternity Centre in Southampton’s where midwives practiced a paired caseload system, which means that a woman is allocated a partnership of midwives, one of whom is the primary midwife (Coe, 1997). The practice had been successful due mainly to the ability of the midwives to be a clinician and a practitioner of midwifery.

Group Midwifery      

The Group Practice Model was piloted in a few places in the UK (Leap, 1994). It describes a team of midwives (up to six or seven) who are community based, with an individual caseload of women from their particular geographical area.

The Wistow project (Walsh, 1995b) adopted the model of midwifery group practices, each with their own caseload, to achieve intrapartum continuity of carer. The result showed that large caseloads, referral pattern anomalies, inappropriate grade mix and hospital core cover all complicate the setting up of intrapartum continuity of carer schemes. The anomalies highlighted the difficulty in achieving continuity of carer with cross-boundary referrals. Thus, with the overwhelming obstacles, the project concluded that intrapartum continuity of carer could not be achieved in the lifetime of the project.

In another variation, Kenner (2001) accounted that in Carmarthenshire, there have been “Teams” since 1995. They are community-based, with four midwives in each one and who are not necessarily full load. Their caseload ranges from 110-160 births a year. The teams all work to the same brief, that is, to provide antenatal care; intrapartum care, at home or in the hospital, and including less usual situations such as Caesarean sections and inductions of labor; post-natal care at home; and a 24-hour on-call service for all women who booked them. Unlike however in the Wistow project, the strategy had been successful.

3.2         Caseload Midwifery in Hospital Setting

3.2.1     Albany Practice

The Albany Midwifery Practice (Reed, 2002) is a self-employed, self-managed partnership of seven midwives and a practice manager, working within the National Health Service offering continuity of midwifery care to women in Peckham, South East London. The set-up encourages the individual caseload where a midwifery manager oversees the activity of the members. This arose out of the discontent among midwives and women at the lack of continuity of service provided and the too many different models of working for the midwives in their respective trusts.

Thus, the Albany Midwifery Practice used the individual caseload in addressing these problems. The results have been successful normal deliveries, a lower Cesarean section rate and a lower forceps/ventouse rate were achieved (Reed, 2002). Moreover, the midwives stress their role as primarily guardians of normality, during pregnancy, labor and postnatal period. They also emphasize the need for a support group such as the family or the husband in order to make the process easier.

3.2.2     Oakwood Practice

The Oakward Practice is based on the BUMPS scheme in Leicester.   This means the Practice has six WTE midwives who work in pairs. Randle (2002) documented and illustrated the Oakward Practice where each pair books 6-8 women a month, looks after those women antenatal and postnatal and attends their birth, whether home or hospital.   The caseload is generated by one GP practice in South East London, and the Practice is based there.  One member of the Practice has the job of allocating women as they are referred; this is done according to due date, midwives’ annual leave, etc.

Each partnership works slightly differently within this framework.   Some have small antenatal clinics in the GP surgery, whereas others do all antenatal care in the women’s home. Being on call is the most stressful thing about working this way and it takes most midwives a long time (we’re talking years here) to get used to the pager and, sometimes, to get a good night’s sleep when on call.

Good communication within the team about the whole caseload is important, so that you know about your colleague’s clients, when you are holding their pager for the night.   The other factor that helps this system to work is good support from your colleagues. Nobody expects their colleagues to be with women for hours on end; this is counterproductive for everybody. If any midwife has had enough and needs to get some rest, or if a fresh perspective is needed, she can call on her colleague to come and take over-and she will.

The most important issues that have emerged over the years to make this team work are  (Randle, 2002):

-           Midwives need to look after themselves first and support each other

-           Midwives need to be free to choose a way to work that suits them.

-           Good communication between the Practice members is vital.

3.2.3     The St. George Outreach Maternity Project (STOMP)

The St. George Outreach Maternity Project (STOMP) is a new model of care seeking to provide of care during labor, that is care from one of the STOMP team midwives. The set-up includes that one midwife from each of the STOMP team will always be on call to provide care during labor or to give telephone advice. It was designed primarily to enable women to be better-informed and have more choices during labor and to feel in control during labor and birth. It was hypothesized that continuity of care and carer would deliver these important elements of maternity services more effectively than the standard care. The findings of Homer, Davis, Cooke and Barclay (2002) demonstrated that the STOMP model was associated with more positive experiences of childbirth compared with standard care.

3.2.4 Weston Shore Midwifery Group Practice

In September 2000, the Weston Shore Midwifery Group Practice (WSMGP) was set up to work in partnership with one such initiative --- Sure Start Weston in Southampton. The aim of the practice is to provide total midwifery care for all women from booking until six weeks postnatal, with a named midwife providing continuity of carer (Weston, 2002). The philosophy, aims and objectives of the practice were inspired by the Albany Midwifery Practice, which has successfully demonstrated the benefits of caseload midwifery in a socially deprived group of women. The achievements of WSMGP and the women they have cared for since the practice was established in September 2000 have been very encouraging and positive and the practice is now well established within the local community (Weston, 2002).  This provides the opportunity for care to be responsive to local needs especially in addressing health inequalities and social exclusion.

3.3         Summary

The study conducted by McCourt and Hewison (1998) demonstrated that women were more satisfied with the one-to-one model of care. Taken together with the results of clinical and economic audit and professional responses, the evaluation suggests that this model should be developed and evaluated further to gain a greater understanding of women’s needs of the maternity service. (McCourt and Hewison, 1998).

4.0         Caseload Midwifery Effectiveness in One-to-One, Team and Group Approaches

4.1         Highlighting the Role of the Midwives

Taking responsibility for a caseload provides midwives with the opportunity to utilize and develop their skills in all spheres of midwifery practice (Bissett, 1995).

            When a midwife carries a caseload, she is the primary provider of  midwifery care (the named midwife) during pregnancy, birth and the early postnatal days for an agreed number of women (Nolan, 1995). She may be providing care to women wherever they are: at home, in the community, or in a maternity unit, the responsibility for the planning and monitoring of care throughout, for the women on her list and liaises with medical colleagues and social agencies as a appropriate (Nolan, 1995).

Lavender, Bennett, Buldell and Malpass (2002) asserted the need by midwives to have the opportunity to contribute to preconception care, extended postnatal visiting that would gain potential benefits in terms of psychological care and breastfeeding and that the postnatal examination is best carried out by the midwives themselves. Furthermore, increased contact with the women will allow them to assess their patients individually to determine the optimum duration of visiting, and of eliciting parental views on all aspects of care (Lavender, et al, 2002). Leap (1994) in his study showed that many midwives saw the caseload practice as a way of ensuring that midwives utilize their skills in the full potential.

The experience and meaning of caseload practice was strongly influenced by personal characteristics, past experiences and current social support mechanisms (Stevens and McCourt, 2001). However, from the evidence four key themes emerged.

4.2         Midwife and Maternal Relationship

The provision of true continuity of carer is difficult to achieve in maternity services where most midwives have become accustomed to working shifts, and where midwifery as well as birth has been institutionalized. There has been a tendency to perceive the needs of women and midwives as being different, with continuity of carer being believed to present a problem rather than an opportunity for midwives. Yet, a number of studies, including the evaluation on one-to-one midwifery have shown that what is best for women may be best for many midwives (Page, 2003).

            Women turn to midwives for expertise (Leap, 1997). In the past the professionalisation of midwifery has led to exclusivity and attitudes that can be described as authoritarian and oppressive (Leap, 1997).   In rejecting this style of working, they have created a movement that talks about’ equal partnership’ with women. 

            Facilitating friendships and support amongst women is one of the main purposes of the antenatal and postnatal groups (Leap, 1997). Women can come to antenatal groups at any stage of their pregnancy. There is no fixed agenda at these groups but most weeks someone comes back with a new baby and tells their birth story.

Strong friendships are formed among the women, which continue to develop in the postnatal group where the women support each other through all the potential loneliness and isolation of new motherhood (Leap, 1997). In all of these groups there is a midwife there, coordinating the group, available for information giving where appropriate, but she is not the central focus of the group since the bulk of the learning comes from the sharing of ideas and experiences by women in the group.

4.3         Caseload Midwifery as a Support Group

Community-based caseload midwifery is a way of reorganizing care that increases social support for women by offering continuity of care and facilitating antenatal and postnatal groups where women can build their own support networks.

However, close relationships formed between mothers and midwives so that midwives often felt guilty if they were not present for the delivery (Bisett, 1996) is also a concern. Some thought that the problem arose because the women became too dependent on them; others felt that the midwife was overprotecting the women (Bisett, 1996).  The solution is to explain to the women how the on-call system works within the partnership, and to ensure that the women meet both partners.

4.4         Barriers to Midwife and Maternal Relationship: One-to-One, Team and Group Approaches

Waldenstrom, McLAchlan, Forster, Brennecke and Brown (2001) indicate however that there are actually no statistical differences between team midwife care and the standard care in medical interventions, maternal health and infant health. Moreover, their analysis illustrates that in perinatal mortality and to the evidence suggesting that models of team midwife care is actually not associated with a reduction in safety.

There was a vast transition from working in the hospital system to working with a caseload. The midwives had to adjust not only to a different type of work, but also to managing their own time. This included ensuring that they had adequate time off work. Thus, many midwives regard caseload practice with skepticism because of the extra commitment and the prospect of on-call work (The North Staffordshire Changing Childbirth Research Team, 2002). 

4.5         The Arguments Against Caseload Midwifery

A frequently expressed reservation about caseload practice is that it leads to burn out and that it is unfair to expect midwives with families to work that way (Leap, 1996).

Team Approach

Farquhar, Camilleri-Ferrante and Todd (2000) conducted a study comparing team midwifery and the traditional models of midwifery care. The result indicated that women cared for under the team scheme exhibited no overall advantages in terms of satisfaction with various aspects of their care. Women cared for under the traditional model of care were the most satisfied with antenatal care. Moreover, they had reported the highest percentage of named midwives, the highest continuity of carer antenatal and were the most likely to say they had formed a relationship with their midwives. In the team scheme, attempts to increase continuity of carer throughout the pregnancy, labor and the post-natal period appear to have occurred at the expense of continuity in the ante and postnatal periods. The study concluded that the smaller the size of midwifery teams, the better the delivery.

Similarly, in a study by Biro, Waldenstrom and Pannifex (2001), they concluded that compared to the standard care, team midwifery did not increase the rate of spontaneous vaginal delivery, but was associated with reductions in the proportions of women receiving epidural and narcotic analgesia, augmentation of labor, electronic fetal monitoring, and episiotomy.

According to (Sandall, 1998) this occurrence can be attributed to factors such as midwives who worked for teams had less control over their decision-making and work pattern, were on lower occupational grades, and worked longer hours than midwives who worked in traditional patterns of care. The implications are that if midwifery is to continue towards a more flexible way of working, then these predictors of burnout need to be taken into account when planning organizational changes.

However, Haith-Cooper (1999) in her study comparing team and non-team midwives’ opinions showed that there is actually confusion and conflicting opinions among midwives who works in teams. It suggests that some midwives enjoy the pattern of work associated with team midwifery, but that it does not suit all midwives. However, despite these contentions, the study indicated that although midwives felt undervalued in terms of grading, and on calls created major problems of tiredness for the, it resulted to the utilization of a wide rang e of midwifery skills compensated for this and contributed to a higher level of job satisfaction. Consequently, going back to the traditional model of midwifery was considered undesirable.

4.6         The Future of Caseload Midwifery

The lack of difference in clinical outcomes between standard care and caseload midwifery is puzzling and inconsistent with other trials of midwifery-led care that included continuity of care (Kaufman, 2000). It is possible that some differences may have been detected if the standard care group have been less heterogeneous and had not included women who received care from a team of birth center midwives (Kaufman, 2000). However, although dilution of effect may have occurred, the small number of control participant from the birth centers are unlikely to have obscured any large effects resulting to intervention.

Evaluation at frequent intervals demonstrated high levels of consumer satisfaction, better maternal and neonatal outcomes, less perineal trauma, lower use of analgesia, greater levels of breastfeeding and increased job satisfaction and greater autonomy for the midwives (Walker, 1999). Walker asserted that there have been changes of midwives within the scheme, but a strong bond of commitment and ownership runs between current and past members of the group, rather like a unique club. Midwives were able constantly to evaluate their practice, and follow up the women over a long period; indeed some women are in their second and third pregnancy within the scheme.  In addition, women’s experiences of labor and childbirth are much more positive and they are stronger, more knowledgeable, more assertive and better supported than ever before. One surprising factor for the midwives was that the home birth rate increased dramatically (Walker, 1999). This is thought to be because the women have greater belief in their ability to give birth, have increased confidence in their own body, and develop coping strategies for labor.   This is aided by having home visits in early labor, knowing midwives are easily contactable, and are strong supporters of home birth.

4.7         Issues Relating to Caseload Midwifery

Difficulty in the Transition Period

The essence of the transition period can be summed up as the coming to terms with the realities of the job and learning to make it work for the midwives (Stevens and McCourt, 2002b). The midwives account of this period paralleled with the phenomenon of culture shock: the strangeness of everything and the disorientation experienced could lead to feelings of extreme tiredness and inadequacy (Gardner, 1991). Major life changes as in the case of the traditional practice to caseload midwifery can be highly stressful even when they are desired (Marris, 1974; Perkins, 1997). However, any initial exhaustion experienced by the participants is likely to be attributed to the hours worked and being on call than to the adaptation.

            Recognition of the types of adaptations demanded may be helpful in enabling suitable preparation, both mental and practical, for midwives contemplating movement into case load practice (Stevens and McCourt, 2002). Comprehension of the pressures encountered might also encourage an understanding and supportive attitude from the colleagues. Such knowledge would be useful for managers developing appropriate support mechanisms, and for the preparation of pertinent in-service education.

Recruitment and Retention

Recruitment and retention in midwifery in the United Kingdom are at the lowest ebb ever, according to Page (2003). The majority of midwives laving the service are young and highly educated. Many seek recognition of their role and responsibility, and alongside the understandable need for more flexible hours, career progression, and stimulation, they also seek meaningful relationship with the women they care for (Page, 2003). Hence, the One-to-One practice significantly addresses these issues.

Generally, groups work well together, but sometimes there are interpersonal conflicts within a group. In general, the organizational and interpersonal problems of standard care in the United Kingdom are greater than appropriately managed One-to-One or caseload midwifery; they tend to be unnoticed because people have grown used to them (Page, 2003).

Stress and time management

The main disadvantage of caseload practice was the difficulty associated with sharing on-call work with only one other midwife (Bisett, 1996). Difficulties sometimes arose when one midwife was on sick leave, study leave, annual leave or maternity leave. This meant that the remaining partner had more on-call work and had to rely on support from group practice members to provide cover for time off.

The midwives mentioned that planning in advance was essential, to arrange weekends away or holidays. Other difficulties mentioned were being unable to relax totally when on call, disruptions to their social life and not being able to drink alcohol (Bisett, 1996). Long working hours were also mentioned; however, when the midwife no longer feels safe to practice she calls on the support of her partner or group practice members.

Peer Review Groups

Peer review is a strategy which develops practice knowledge. Cheyne, McGinley and Turnbull (1996) discussed the principles of peer review as an integral element in the midwifery practice. They suggested that the balance between peer support and peer evaluation must also coincide with confidentiality in order to increase the level of efficiency and competence of the practitioners; as such, it is a useful tool for midwives and their supervisors in the development of reflective practice.

4.8         Summary

            In focusing on what CLP meant to the midwives concerned it is important to consider why they originally joined the caseload midwifery service (Stevens and McCourt, 2002).

Holistic practice: developing all skills and impact on learning

            Another theme involved the midwives’ ability to practice a more ‘holistic’ form of midwifery than previously experienced. They valued the experience of delivering all aspects of care for both high-and low-risk pregnancies on a family basis.  Nevertheless, it was not merely the attainment of specific midwifery skills and research-based knowledge that was highlighted as important, but the application of these to meet the needs of individual women.  Also, the continuous feedback received and opportunity to reflect on their practice proved central to their professional development. The midwives talked of at last being able to practice ‘real midwifery’.

Relationship with the women

            The relationship the midwives were able to form with their clients proved a major source of satisfaction to them, and was often quoted as an important reward of the job. Working with ‘difficult’ or demanding women proved particularly tiring for the less experienced and achieving the right balance, to act as facilitator and enabler rather than inadvertently creating dependency, took time and skill to master.

Orientation: autonomy and responsibility

The effect of such features of CLP changed the midwives’ attitude towards their work, clients, colleagues, and the service.   The issues central to the change in the midwives’ orientation are ones of authority and control, involving management to midwives and midwives to women.

Sikorski, et.al  (1995) highlighted the fact that team midwifery has many variations, and that the continuity achieved depends greatly on the size of the team. The concept of team midwifery can therefore have diverse interpretations, depending on the size of the team of midwives, where they are based and the type of care they provide.

5.0       Conclusion and Recommendations

5.1         Conclusion

The clinical evaluation described here, using a case note study, was part of a larger study evaluating the changes made to part of the maternity services in one NHS Trust, in response to the recommendations of Changing Childbirth (Department of Health, 1993). Results of the audit showed no evidence of a lowering of clinical standards and provided reassurance that a radical change in the model of care, with greatly enhanced continuity of carer, an emphasis on community-based and midwifery-led care, and some reductions in labor interventions, could be implemented without compromising safety of care (Beake, McCourt and Page, 1998). 

The study suggested that there are several factors that need to be considered before adopting the caseload approach. While it may have generated positive responses from some parts of the population, it cannot be ignored that there were also studies suggesting that the traditional care is still a better mode of delivering childbirth.

However, predominantly the caseload practice is seen by scholars, practitioners and the maternity patients to be highly efficient in rendering the maternity services across the different stages in the childbirth process. The Changing Childcare report has been instrumental in instituting and thereby relieving the burden by most women on giving birth.

5.2         Recommendations for Practice

A multidisciplinary approach, integrating clinical, sociological, and anthropological knowledge and methodology, was valuable in gaining a thorough and valid understanding of women’s experiences and needs (McCourt and Hewison, 1998).  Satisfaction surveys are wrought with difficulties, from defining, or deconstructing, the concept of satisfaction to deciding how questions should be asked (McCourt and Hewison, 1998). On the whole, responses to consumer surveys tend to be neutralized by the use of broad satisfaction questions. Ambiguities, mixed feelings, and variations in the service itself are necessarily averaged out to arrive at a view that may provide little insight or information.

The audit process raised a number of methodological problems, which will need to be addressed in developing audit approaches, which are able to reflect quality of care.   It is important to recognize that the record of care is not a direct mirror of the care provided but a secondary source, kept for different purposes and designed to cover a different set of priorities from those which audit may seek to capture. The audit approach used in evaluating case load midwifery study will be modified in continuing evaluation of the service as it moves from a pilot stage towards providing a mainstream service. Additional methods, including direct observation of care, will be employed in a sample of cases in order to assist in interpretation of audit findings.

The differences in the results of the study can be pinpointed to the difference in perceptions of the practitioners in childbirth. It is important for instance to recognise and address the different views of midwives, obstetricians and general practitioners at this time when major changes in the organization of antenatal care are being planned and implemented. Thus, the differences in attitudes between health professionals need to be addressed when planning changes in the provision of antenatal care (Sikorski, Clement, Wilson, das and Smeeton, 1995). Clinical Audit can be a very valuable tool for research and continuing development and may appear very straightforward (Beake and Mulvaney-Carberry, 1996). The audit of case notes is a measure of the care recorded rather than a direct measure of the care provided.  

It is also important to bear in mind the context of this particular scheme. Despite a great deal of information and consultation, there was some resentment and a perception of the group as an elite, adding to the difficulties of transition. The intense scrutiny of research and the setting of organisational targets may have raised both expectations and fears of failure.

The midwife having much to offer in the field of education can also stress his/her role by providing health education to schools (Ong, 1994). They could foster links with local schools in order to encourage adequate teaching on interpersonal relationships, contraception and responsible sexual behavior and realistic preparation for family life.

 

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