From MIDWIFERY MATTERS, Issue No.108, Spring 2006
Introduction
CHANGING CHILDBIRTH, the report of the Expert Committee on Maternity Care (DoH,
1993) heralded the beginning of Government policy reform for the maternity services
that aimed to make maternity care more responsive to women's needs and improve
their ability to make informed choices about their care. Indeed, all registered
midwives now have a statutory duty to ensure that the needs of the woman or
baby are the primary focus of their practice (NMC, 2004).
Integral to the success of this woman-centred approach is the concept of continuity
of carer. The Report set the standard that 75% of women should know the midwife
who cares for them in labour as an indicator of success in achieving woman-centred
care, yet, despite the plethora of schemes intended to improve continuity of
care, most providers have failed to reach this particular standard (Audit Commission,
1997).
In several position papers, the Royal College of Midwives (2001) points out that while these policies still stand, they have been overtaken by new health policy agenda - such as the NHS Plan (DoH, 2000a), NHS Implementation Plan (2000b), Keeping the NHS Local (DoH 2003b) and National Service Frameworks (DoH 2004) - in a drive to modernise and improve services. This is placing increasing demands on managers and midwives to develop more effective means of delivering care within the financial constraints of the NHS.
The model of midwifery care currently practised in this Trust is that of team midwifery, whereby small teams of community-based midwives aim to provide antenatal, intrapartum and postnatal care for women, supported by core staff on the maternity ward, delivery suite and antenatal clinics. This model is based on evidence from trials showing clear advantages for women who receive care from a team of midwives (Homer et al, 2002; Homer et al, 2001; Waldestrom et al, 2000; Biro et al, 2000), although these trials are small.
A Cochrane systematic review of two larger trials, (Rowley et al, 1995; Flint et al, 1989) involving a total of 1,815 women found team midwifery to be associated with reduced antenatal admissions and labour interventions, increased attendance at antenatal education classes, greater satisfaction with care and feeling prepared and supported during labour. No differences in childbirth outcomes, such as caesarean section, induction of labour, instrumental delivery, breastfeeding rates or neonatal outcomes were identified. However, Hodnett (2004) points out that it is unclear whether these benefits are a result of increased continuity of carer, or the fact that care was midwife-led rather than traditional shared care.
While team midwifery benefits women, its effects on midwives are less advantageous. Many midwives in this Trust feel that true team midwifery is unachievable at present with an increasing number of staff having recently left the service, and are frustrated with this. Team midwifery has been associated with high levels of burnout due to low levels of control, fragmented relationships with women and the stressful nature of on-call team midwifery (Sandall, 1999; Barber, 1998; Sandall, 1997).
Caseload midwifery is becoming increasingly common in the UK and Lester (2005) argues that this model of care not only meets the standard of ensuring a known caregiver during labour for most women, but will also improve the quality and cost effectiveness of midwifery care in line with many of the key priorities of the current public health policy agenda. The expected result will be effective, woman-centred services with improved experience of birth and improved health outcomes for all women who access it. As such, caseload midwifery is considered to be the 'gold standard' of midwifery care for women and their families (Lester, 2005). This review intends to examine the implications of caseload midwifery for women and for midwives.
Caseload Midwifery
Caseload midwifery is described as an organisational model of care whereby
a midwife is responsible for the planning and execution of midwifery care for
an agreed number of women, with that midwife being the primary provider of midwifery
care wherever the woman is (Tiran, 1997; National Childbirth Trust, 1995).
In this model midwives' work centres around women, rather than being attached
to particular locations (Sandall, 2004), enabling improved continuity of care
and communication through building a relationship of trust. The size of a primary
caseload for one whole-time-equivalent midwife ranges from 36 (Lester, 2005;
Henty, 2004; Hutchings and Henty, 2002) to 40 women per year (Sandall, 2004;
Walsh, 1995), with a secondary caseload of similar size - allowing two midwives
to work as partners providing on-call cover for each other, ensuring that the
vast majority of women are cared for during labour by either their primary or
secondary midwife - both of whom they will have got to know during pregnancy.
Caseload midwives manage their own workload but work in group practices which provide mutual support and peer review, working flexibly to accommodate 24 hour cover for their caseload and have 12 weeks annual leave, negotiated within each practice (Lester, 2005; Henty, 2004; Sandall, 2001; McCourt, 1998).
Implications of Caseload Midwifery for Women
The latest annual statistics compiled by BirthChoiceUK (2004) reveal that only
46.4% of births in England last year were normal, with 'normal' categorised
here as birth not involving caesarean delivery (22.7%), instrumental delivery
(10.4%) or induction of labour (20.2%); epidural anaesthesia is also excluded.
There is a growing body of evidence detailing the negative impact of medical
intervention during labour on women who give birth in hospitals (Laing, 2001;
Creedy et al, 2000; Beech, 2000; Hillan, 2000). The BirthChoiceUK figures provide
an average however, and closer scrutiny of the statistics reveal that, while
many maternity units are achieving normal birth rates roughly around the national
average, wide variation exists; several small, midwifery-led units achieved
between 90-100% normal births, while some larger, consultant-led units achieved
as few as 32% normal births. (Statistics for our Trust for 2004 are as follows:
normal birth 43.9%; caesarean delivery 22.4%; instrumental delivery 11.9%; and
induction of labour 24%).
However, even these figures overestimate the normal birth rate, as Downe et al, (2001) have demonstrated. The Association for Improvements in the Maternity Services (AIMS) found that many women who accessed their service felt their birth experience had been traumatic, yet was recorded as 'normal' or 'spontaneous' in their health records (Beech, 1997). Beech conducted a study to ascertain how many births within five consultant units were termed 'normal' or 'spontaneous' despite involving one or more of a specific set of interventions defined in the study as constituting an 'obstetric delivery', i.e. induction of labour, acceleration of labour, artificial rupture of the membranes, epidural anaesthesia and episiotomy.
While this set of interventions accounts for medical interventions not mentioned in the BirthChoice UK statistics, it remains limited. Nevertheless, Downe et al, (2001), found that 62% of the births recorded as 'normal' or 'spontaneous' in their sample fulfilled their own definition of 'obstetric delivery'. Quite apart from the major public health concern about escalating rates of intervention, Lester (2005) highlights the financial implications - every 1% increase in caesarean section rate costs the maternity services £5,000,000, the equivalent of 167 midwives. Thus, systems of care that reduce intervention rates and increase normal delivery rates are eagerly sought by women, midwives, NHS managers and politicians alike.
Comparing Caseload with Team midwifery
There are no large trials of caseload midwifery available to date, but there
is a growing body of evidence from non-randomised trials that caseload midwifery
is associated with improved vaginal delivery rates and less intervention during
childbirth (Benjamin et al, 2001; Page et al, 2001; Allen et al, 1997; Pankhurst,
1997). Benjamin's study (2001) was of particular interest to us because it compares
partnership caseload midwifery with team midwifery care. The trial compared
clinical outcomes and labour interventions for 611 women, matched for age, ethnicity,
parity, gravida and height.
The trial demonstrated that the 303 women in the caseload partnership group
experienced less interventional labour and more normal birth, having significantly
higher rates of vaginal birth (74% v 66%), upright birth posture (60% v 14%),
intact perineum ( 40% v 30%) and physiological third stage (37% v 1.5%), alongside
significantly lower rates of epidural (21% v 32%) and induction of labour (16%
v 23%) compared to the control group of 308 women receiving team midwifery care.
The experimental group also had significantly more home births (17% v 1.3%),
used the midwife-led birthing suite more often (28% v 12%), were more likely
to take early discharge from hospital (25% v 3%) and were attended during labour
more often by their primary midwife (67% v 5%) or their primary or secondary
midwife (84% v 14%).
A slightly larger, randomised trial by the North Staffordshire Changing Childbirth
Research Team (2000) compared clinical outcomes of caseload midwifery (770 women)
with traditional 'shared-care' (735 women), finding significantly increased
levels of 'known midwife' at delivery (94.7% v 6.7%) alongside a reduced epidural
rate (10% v 15%), and decreased augmentation rate (46% v 53%) in those women
receiving caseload midwifery care. No difference in the normal birth rate was
found, although women in the caseload group experienced labours lasting less
than eight hours more frequently than those receiving traditional care.
Although Benjamin's study could be considered less robust owing to the non-randomised
design, the results are encouraging and pertinent to our Trust as it compares
the current model of care with caseload midwifery. The more robust randomised
trial by the North Staffordshire Changing Childbirth Research Team (2000) failed
to include any explanation as to what 'shared-care' actually entailed - the
wide variations of care from one area of the country to another are well documented
(Audit Commission, 1997). Nevertheless, both found a reduction in labour intervention
and identified no disadvantages with the caseload midwifery model of care.
Similar findings are cited elsewhere. The Weston Shore Midwifery Group Practice
in Southampton works as part of the Sure Start Initiative, aimed at improving
health and reducing inequalities related to health and social environment and
using the caseload model of care (Henty, 2004; Hutchings and Henty, 2002). When
compared to women receiving traditional care in non Sure Start areas of the
same NHS Trust, the birth and intervention statistics demonstrate improved outcomes
for those women who receive caseload midwifery care in terms of normal birth
rate (82% v 69%), intact perineum (62% v 38%), physiological third stage (37%
v 1%), alongside a reduced caesarean section rate (6 % v 23%), fewer inductions
of labour (12% v 23%), less epidural analgesia (8% v 27%), fewer episiotomies
(6% v 14%) and less use of pethidine (5% v 12%). Like those in Benjamin's study,
women receiving caseload midwifery care from this practice also had more homebirths
(23% v 2%) and attended the midwife-led unit more frequently (30% v 8%).
These figures replicate those of Sandall et al (2001) in their extensive evaluation
of the Albany Midwifery Practice (a thorough, 120 page document - available
online - which should be read by all professionals involved in maternity care
at all levels who are considering implementing caseload midwifery practice).
The Albany Practice has been running for several years now and it is unique
in that it consists of self-employed midwives working under contract from King's
College Hospital NHS Trust, South East London, to provide care for some of the
most materially and socially deprived women in that area.
Compared with women who received care from the hospital trust during the same
period of time, women who received caseload midwifery from the Albany Practice
had a higher normal birth rate (77% v 63%), more home births (42% v 7%), fewer
inductions of labour (5% v 11%), fewer caesarean sections (18% v 25%), fewer
instrumental deliveries (5% v 10%), less augmentation (0% v 20%), fewer episiotomies
(3% v 15%) a lower epidural rate (17% v 35%), used less pethidine (1% v 29%)
and were more likely to use no pain relief at all (69% v 16%). In addition to
this the Albany Practice boasts a 93% breastfeeding rate at birth, with 70%
of women still fully breastfeeding at 28 days postpartum. 98% of these women
were attended by their primary or secondary midwife during labour.
The available evidence so far has consistently found advantages in terms of
clinical outcomes and labour interventions and no disadvantages have been identified.
The implications of such figures on women's health and maternity service budgets
are self-evident. However, if services are to be truly woman-centred, then caseload
midwifery cannot be considered on clinical outcomes alone. Indeed, the role
of the midwife is to provide psychological and social, as well as physical care
to women during the entire childbearing period (NMC, 2004).
Satisfaction of women and professionals
To complete their evaluation, Sandall et al (2001) not only interviewed all
midwives from the Albany Practice and 11 from King's College Hospital Trust,
they also interviewed seven medical staff at varying grades, five hospital managers,
two GPs who accessed the practice and two health visitors to discover their
views and experiences of caseload midwifery in action. More significantly, they
consulted women who had received both Albany's services and that of King's College
Hospital NHS Trust, surveying 447 women - 299 who had hospital births, 42 who
had home births excluding Albany women and 106 women who were cared for by Albany
midwives. The overall response rate was 52%, with a 58% response from Albany
women compared to 46% from other women in the Trust. Surveyed on multiple aspects
of antenatal, intrapartum and postnatal care, the findings are too lengthy to
discuss here but it is clear that while most women spoke favourably of their
experiences, women who received caseload midwifery thought very highly of the
care they received.
This is echoed in McCourt and Pearce's research (2000) in which 20 women from
ethnic minority groups took part in a semi-structured interview; ten received
caseload midwifery and ten received traditional shared care. Those women who
received caseload midwifery were found to hold more positive views, showed greater
trust and confidence in the professional they met and in the personal transition
of giving birth, whereas those receiving conventional care were disappointed
with their care, particularly care given in hospital settings, and did not feel
it was focused on them as a person.
This study is very small however and sadly, due to its qualitative nature would
not be considered authoritative in the hierarchy of most evidence lists endorsed
by the Government (Cluett 2000, Humphris 1999). Yet, as Walsh (2000) points
out, human experience cannot be quantified, standardised or rationalised through
quantitative methods, and if midwives are to provide care responsive to individual
need - as is their statutory obligation (NMC 2004) - then this kind of research
is essential in informing practice to enable woman centred, rather than professionally
controlled care.
Caring for disadvantaged women
What is emerging from the findings already discussed is that caseload midwifery
is of particular value when targeted at disadvantaged women, dispelling the
myth that such a model is associated with middle-class women, (Sandall et al,
2001), and is of particular interest considering the increased morbidity and
mortality women from poorer socio-economic backgrounds experience. The Report
on Confidential Enquiries into Maternal Death in the UK (CEMACH, 2003) found
that maternal mortality rates are highest for women who are disadvantaged materially
or socially compared with the most advantaged women. Lester (2005) argues that
enabling midwives to practise caseload midwifery targeted at such vulnerable
groups will enable them to fulfill the public health role that is expected of
them (DOH 2000a; 1999). However, there is a danger that this could result in
further inequalities if a two-tier system of care develops with some but not
all women receiving caseload midwifery care - as is the case at King's College
Hospital NHS Trust, (Sandall et al, 2001)
All maternity services that increase continuity of carer are associated with
high levels of satisfaction for women and lower levels of intervention (Hodnett,
2004; Biro et al, 2003; Page et al, 2001; Tinkler and Quinney, 1998; McCourt
et al, 1998). Indeed, Gould (2002) believes that when a midwife knows a woman
there is no chance of depersonalising her, especially if she is vulnerable and
Brodie (1996) found that where midwives and women were allowed to develop closer
relationships, the needs of the women became paramount.
"What is must be best"
Green et al (2000) point out that women are strongly disposed to express satisfaction
when they have just given birth to a healthy baby with a tendency to show loyalty
to what they have experienced. This is what Porter and Macintyre (1984) have
termed, 'What is must be best'. In their literature review entitled: 'Continuity
of carer - What matters to women'.
Nevertheless, if services are to be truly woman-centred then women's views
and experiences must be sought. Walsh (1999) helped to tackle this dilemma of
'What is must be best', by interviewing ten multiparous women who received team
midwifery care with their first pregnancies, but received caseload midwifery
care for their second. The women were interviewed individually and at length
at eight and 12 weeks postnatally and included women who had hospital and home
births, normal and assisted births and caesarean section. Such an approach may
be considered to be open to memory bias (Wagstaff, 2000), although Simkin (1992),
demonstrated considerable agreement between short and long-term recall of women's
first birth experiences, even after 15-20 years. Walsh (2000) found that women's
perceptions and experiences were predominantly influenced by the relationships
they had with their midwives and that caseload midwifery practice had a significant
positive impact on women's experiences of childbirth. His study provides detailed
and valuable insight into the experience of maternity care from the perspective
of women who have received it.
To summarise, there is a growing body of evidence suggesting that caseload midwifery has no disadvantages for women and their babies compared to other models of care. Caseload midwifery is also associated with less labour intervention and, with the exception of one study, higher rates of normal birth. It appears to be of particular benefit for women from disadvantaged or deprived groups - those who are most at risk of poorer health and even death, but traditionally less likely to access services. Women from all socio-economic backgrounds appear to value caseload midwifery highly, with the relationship between midwife and woman playing an important part in women's overall experiences of pregnancy and childbirth and the transition to motherhood. As such, caseload midwifery is worthy of consideration for implementation as a safe and cost-effective approach that promotes pregnancy and birth as a normal life event and enables midwives to fulfil many key priorities of the current public health agenda through the provision of continuity of carer and woman-centred care.
Implications of caseload midwifery for midwives
Any re-organisation of maternity services must consider the implications of
such changes for midwives. New ways of working not only need to be safe, cost-effective
and woman-centred, but essentially, they must also be sustainable. As already
stated, team midwifery has been associated with high levels of burnout owing
to low levels of control, fragmented relationships with women and the stressful
nature of on-call team midwifery (Sandall, 1999; Barber, 1998; Sandall, 1997).
According to the Independent Midwives Association (2005) team midwifery and
other (often well intentioned) initiatives have contributed to the national
shortage of midwives; there has been constant change within the structure of
services throughout the last decade, leaving midwives feeling stressed, disillusioned
and demoralised. This view is supported by research by Ball et al (2002), who
found that, while midwives are leaving because of dissatisfaction with midwifery,
over two thirds say they would return if the conditions were right.
Lester (2005) argues that caseload midwifery works for midwives because it
enables truly autonomous practice, allowing midwives to free themselves from
the constraints of 'the system' and to focus on the women in their care. On
entry to the NMC register all midwives are deemed capable of autonomous practice,
yet Stafford (2001) argues that a range of hierarchical and organisational factors
make the concept of truly autonomous practice an illusion.
Sandall (1997) interviewed 48 midwives who worked in either the traditional
model of GP attached community midwifery, the team midwifery model, or in a
group practice delivering the caseload midwifery model. The interviews were
designed to ascertain the impact of different models of care on midwives' work
and personal lives. Analysis of the interviews identified three key factors
involved in sustainable practice, avoiding burnout and providing woman-centred
care. These factors were: occupational autonomy, social support, and developing
meaningful relationships with women. All midwives saw a high level of autonomy
as vital in managing the balance between work and home life. Those who had most
control over their workload - those who practised caseload midwifery - reported
significantly lower levels of stress than midwives providing other models of
care, particularly team midwifery. Caseload midwives also had more flexibility
to respond to women's needs. Sandall's study adds weight to Lester's claim that
carrying a caseload is a viable way of working.
Coping with on-calls
Despite the 24-hour, on-call commitment of caseload midwifery, anecdotal evidence
from midwives practising this way further supports Lester's argument that caseholding
is not as onerous as it seems (Hutchings and Henty, 2002; Sandall et al, 2001).
Lester (2005) and Davis (2003) point out that although the on-call commitment
is constant, it is less stressful because midwives will be called out only for
their 'own' women - a view which is confirmed by many midwives who work in this
way. Stevens (2002) collected data from 35 caseload midwives over 46 months
using a variety of qualitative methods. Contrary to expectation, she found that
midwives were disturbed less frequently during unsocial hours once the women
on their caseloads had learned when out of hours contact was appropriate.
Steven's published work is a synopsis of a paper she presented to the Triennial
Congress of the International Confederation of Midwives, and we cannot assess
fully the rigour and reliability of her research method as the necessary information
is unavailable. Nevertheless, further evidence is available from McCourt (1998)
who conducted a four-week diary analysis of 16 caseload midwives to assess the
range of activities involved in their work and the time spent doing this. She
demonstrated that midwives were working close (37.9) to their contracted 37.5
hours each week with a balance of activities as follows: 5.1 hours antenatal
community; 4.3 hours antenatal hospital; 11.2 hours labour/birth; 3.2 hours
postnatal community; 1.6 hours postnatal hospital; 4.1 hours travel; 2.3 hours
administration; 1.9 hours meetings; 1.1 hours study; 0.6 hours waiting; 1.4
hours telephone; 1.1 hours other; a total of 37.9 hours of which 6.5 hours were
worked during unsocial hours. It is worth noting, however, that these figures
represent average times only and do not demonstrate the fluctuating and unpredictable
workload associated with childbirth.
The whole issue of on-call commitment therefore needs to be addressed carefully
prior to implementation. (Henty, 2004). Without support, both at home and in
the work place, many midwives may feel unable to commit to this way of working.
Indeed, in their evaluation of the Albany Midwifery Practice, Sandall et al
(2001), found that two of the three midwives who left the practice cited 24-hour
on-call as the main reason. However, there is a range of ways to organise on-call,
for example, caseload partners could work alternately, two weeks on-call then
two weeks planned work. Sandall, (2004) argues that the key to success is for
managers to devolve the organisation of working patterns to the midwives, thus
enabling them to stay in control of their own workload.
Other benefits for midwives
Other advantages of caseloading are that it enables midwives to keep their
skills up to date in all areas in ways not achievable while rotating around
hospitals, and is associated with high levels of job satisfaction, attributed
to forming relationships with women (Lester, 2005; Henty, 2003; Davies, 2003;
Stevens, 2002; Sandall et al, 2001). Anthropological and psychosocial perspectives
suggest that these relationships have reciprocal benefits, reflecting a balance
in a relationship and the potential for psychological benefits for both mother
and midwife. This may be an important factor in preventing stress and burn-out
(Stevens, 2002). Indeed, the inability to form meaningful relationships with
women has already been associated with stress and burnout (Sandall, 1997), which
suggests that midwives value continuity of carer as much as women do.
It seems, therefore, that what is good for women is also good for midwives.
Caseload midwifery is associated with improved autonomy and control over working
patterns alongside increased job satisfaction derived from forming meaningful
relationships and achieving continuity of carer with 'their' women. All this
is achieved despite the demanding on-call commitments necessary to ensure continuity
of carer for a primary and secondary caseload of women. Formal research and
anecdotal evidence both suggest that women tend to call midwives out less than
might be expected and that, on average, midwives working this way spend an average
of 6.5 hours per week working unsocial hours - and this is only to visit their
own women - although this time may vary from week to week owing to the unpredictable
nature of childbirth.
In light of this review, the caseload model of midwifery is worthy of careful consideration as a means of being 'with woman' by providing truly woman-centred, safe, cost-effective and sustainable midwifery care.
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