Caseloading midwifery — an ever evolving model of care?

25-Oct-2015

MIDIRS Midwifery Digest 25:2 2015

Much has been written about the impact of the caseloading model on the work–life balance of midwives. On the one hand it can mean long hours leading to exhaustion and ‘burnout’, and on the other it can mean midwives having the opportunity to reach their full potential as autonomous practitioners. This can at times lead to conflict, with midwives balancing a job they love and that requires immense commitment, with the demands of their personal lives. The One to One model, providing caseload midwifery services for almost five years, has been adjusted many times to address the issue of burnout. It aims to stay true to the model of care where women and their families are central, but give midwives the flexibility within their caseload to have protected time off and annual leave that is proportionate to their time and commitment. With a different way of working comes added stress, and while One to One can adjust the model, what is more difficult to address and causes significant amounts of anxiety and low morale for midwives, is the clash of culture and models that midwives encounter as they try to interact with the multidisciplinary teams at local Trusts.

The One to One Model

One to One (North West) Limited is a community based caseloading model of midwifery commissioned by the NHS to provide the full care pathway to all women, regardless of risk factors. The One to One model is guided by humanistic principles, based on the normalcy of birth, with a fundamental respect for human rights at the core of the organisation’s vision. At One to One, the primary goal is not only to tackle inequalities that hinder a woman’s health, but also to challenge restrictive obstetric norms and empower all women to claim their right to self-determination in a responsive, high-quality maternity service. A service that applies a public health approach to care, that identifies the needs of different communities and cultures, values diversity, reduces health inequalities, and encourages women and their families to take a central role in their care. A service, which is accessible to all women at a time and place convenient to them, in a language they understand, thus removing barriers to care.

The One to One caseloading model is based on the concept of continuity, of choice and of a relationship that empowers women to take control of their pregnancy–birth journey. Its philosophy of care works from the premise that birth is a normal life event within the context of a social model of health and wellness, which includes emotional support for women and their families. Within the One to One model there are two key roles for midwives: firstly, that the midwife is the lead professional for women going through the normal physiological process, and secondly, that she is the care navigator for all women, including women defined as having additional needs or complex factors. In this second element the lead professional may change to be obstetric-led but the midwife will continue providing continuity and holistic care, thereby optimising the birth experience for women and their families. The named midwife will provide continuity of care throughout pregnancy, birth and the postnatal period, giving women care that is based on their individual needs. Women are cared for by a known and trusted midwife, care is flexible and delivered predominantly in the primary care setting over seven days a week, evenings and weekends. The majority of visits, including the booking visit, take place in the woman’s own home at a time convenient for her and her family. The amount of antenatal and postnatal care provided is flexible and will depend on need and choice; there are no upper limits on care or time spent at each visit. Ultrasound scanning, bloods, triage including antenatal CTGs, are all delivered in the community setting. Low-risk women booked with the service are offered a home assessment during labour and it is at this point that some women will decide on a place of birth. Others may have chosen their place of birth at an earlier point during their pregnancy.

One to One commenced providing services to women in 2010, and was initially based on the Wirral, Merseyside. The model evidenced outstanding outcomes for women and has therefore developed and expanded to other areas in the UK.

Caseloading is seen as the utopia of midwifery: it’s what midwives train for, to be with woman. However, the potential impact on midwives must also be given due consideration.

Images from Call the Midwife, harking back to how midwifery was in the 1950s, portray a romantic view of midwifery, a picture that midwives may envisage when they come into the profession. But it is not necessarily how it was. In 1947 the Ministry of Health (Ministry of Health, Department of Health for Scotland, Ministry of Labour and National Service 1949) undertook a survey of midwives in England and Wales; 16,374 midwives who had notified their intention to practise that year took part in the survey.The outcome of the study cited the challenges of long hours, lack of time off, being on call for 24-hours a day, and many midwives had left the profession or intended to leave. They resented the lack of free time to live their own lives and even when free time was available many said they had no security against interruption.

While caseloads today are smaller, and midwives do have more annual leave and protected time, the main issues are the same: long hours and on-call commitments. However the trade-off for midwives is increased autonomy and enhanced job satisfaction —the opportunity to truly be a midwife. Can midwives sustain the level of commitment? Is there a model of midwifery that can meet the needs of both mothers and midwives that will include caseloading? It certainly takes dedication to the job, a special type of person, a midwife who can sustain the level of commitment the work commands. It can be argued that midwives are special, or at least the job they do is special, extraordinary in fact: a job that gives midwives the privilege of being part of the life of a woman when she is at her most powerful. Midwives are trained to be with woman but the majority work within a restricted medical model that stifles autonomy. Caseloading midwifery is not only the gold standard for mothers but also the gold standard for midwives. A model delivered within a framework that is supportive, united, multidisciplinary and based in current evidence, is a model that can work for all midwives.

One to One have always strived to support the practice of midwifery, in a model that not only supports and empowers women, but supports and nurtures midwives to be the best that they can. This however does not come without challenges.

In 2010, One to One started the journey by setting out to create positive health changes and excellent outcomes in maternity care. The service began as a pilot in a deprived area on the Wirral. The pilot was run by two midwives, who each worked with a caseload of up to 70 women — at this time only antenatal care was provided as One to One had no intrapartum insurance. The pilot was very successful and both the clinical outcomes and women’s satisfaction levels were impressive. Subsequently, One to One was given a three year contract across the whole of the Wirral. In Autumn 2011, One to One secured commercial insurance and started to provide community-based intrapartum care, consisting of home assessments for low-risk women in labour and facilitation of home births for those women who chose it. Caseloads were set to 35 at any one time, with a good mix of antenatal, intrapartum and postnatal women. The outcomes continued to be impressive, with the inclusion now of intrapartum data. One to One’s first year outcomes have been published in the British Journal of Midwifery (Collins & Kingdon 2014).

The model at this time included an on-call rota for the midwives within teams — this afforded the midwives protected time off, and set on-call hours. This was seen as a positive way of allowing midwives to manage their own diaries and maintain continuity for women, antenatally and postnatally, with the benefit of protected time away from the job. The result of this was that actually the vast majority of staff would fulfil their on-call commitments, but would also remain on-call for their caseload — a clear indication that they were yearning to practise midwifery and be ‘with woman’ — their woman. This brought with it the real risk of midwives burning out from the model, but not at the hands of the organisation, at the hands of midwives wanting to be with women. With the desire to practise this way evident, the organization went through a consultation process in 2013, which saw it move away from the on-call commitment to a full caseloading model with midwives having responsibility for the women in their care. This change brought an increase in caseload from 35 to 40 women, and an increase of annual leave from eight to 12 weeks. This was based loosely on the Albany model (Sandall et al 2001), but midwives could take their annual leave as desired across the 12 months.

Initially this brought great relief to midwives who wanted to provide this care, but who had also been committed to an on-call rota for the team. Inevitably, a few midwives decided that this model of caseloading was not for them, or their families, and they moved on to alternative areas of employment. For the midwives who remained, they embraced the role and became truly autonomous caseloading midwives.

Fast forward to the present day when midwives are contracted to care for 40 women at any one time at differing stages of their pregnancy, birth journey, and for up to six weeks postnatally. The vast majority of midwives only reach the capacity of their caseload at busy periods, and during rapid growth in new areas. Each locality has a coordinator who ensures that community events are shared equally, provides support to their teams and makes sure all midwives have protected time available to them. Women are not routinely allocated to midwives who will be on leave around the time of their due date, and leave is now restricted to two weeks at a time, except in special circumstances due to midwives finding longer periods detrimental to continuity, and finding shorter more frequent breaks more preferable. The outcomes remain good (see Table 1), and One to One now have Clinical Negligence Scheme for Trust (CNST) insurance, in line with their NHS counterparts.

Table 1. The latest maternity data for the One to One model illustrated below is based on 520 women who started birth at home from a total of 1449 births, between April 1st 2014 – 31st March 2015



We have seen the evidence around long working hours, which can cause midwives to feel resentful about the lack of uninterrupted personal time, and burnout is often attributed to the caseloading model. Midwifery is a vocation however, a way of life and something that sits within the heart of many women, and also a growing number of men. Are we really suggesting that midwives in the hospital or traditional shift-led employment never become tired, despondent, resentful, or burnt out, and inevitably think of leaving the profession? Ball et al (2002) acknowledge that a major reason for midwives leaving the profession is not being able to practise in the way that they want to, due to the constraints of the system they work in. Kirkham (2015) concurs with this and suggests that the majority of midwives in the NHS work part-time so that they have enough time to recover from the ever-demanding vocation they have chosen. One to One foster autonomy and flexible working so that midwives do not feel constrained by the system and are free to practise midwifery in its truest sense. This is coupled with generous annual leave, and protected time throughout the working weeks, as it is acknowledged that midwifery, in whatever guise, is a demanding vocation.

What we do know is that midwives are incredibly fulfilled by practising in this way, even when the hours can be long, and the work challenging — physically and emotionally. This is midwifery in its truest form, requiring a strong constitution and a passionate heart.

One of the biggest challenges midwives face within the One to One model is continued and relentless unprofessional treatment by their peers across organisations. There can be a disregard for their clinical expertise and a lack of professional respect — this is extremely detrimental not only to the profession of midwifery, but also for the caseloading midwives to experience. As a predominately woman-led profession, striving to support, empower and advocate for our fellow female population at their most vulnerable time, why is it deemed okay for our (predominantly) female peers to treat us with such contempt, for the main part over misinformed views on the privatization of the NHS? What makes this even more disturbing is that the women under our care can be privy to this discord. This discord and fragmentation between hospital staff and community staff is of course, an age old problem — this happens in the NHS every day and midwives continue to work, at times in opposition, with their peers and colleagues, to achieve the best outcomes for women and their babies. This however, is heightened for One to One caseloading midwives when encountering their NHS peers, largely due to misconceptions around practice and standards of care. One to One midwives have all trained in the NHS and as an organisation, are under the same regulations and robust processes as their NHS counterparts. Every registered midwife in the UK, regardless of place of work, is bound by their regulatory body — the Nursing and Midwifery Council (NMC), which states in The Code (NMC 2015) that midwives must promote professionalism and trust. This comes under question when considering the apprehension among our peers.

It is evident that not all midwives can, or want, to work in the caseloading model but for the sake of women, and the profession, we should be working together, driving forward maternity care in the UK to be the best in the world delivering gold standard collaborative care.

One to One is an organisation with the strap line ‘Learning, Growing, Changing’ — we strive to listen to our staff and be innovative and reactive to challenges. In December 2014, One to One undertook a full survey of all their staff, clinical and non-clinical — with similar results to many historical studies, citing the challenges as long hours, the need for protected time and reduction of caseloads. These seem to be recurrent themes, no matter what caseloads are set, or protected time and annual leave given. What does shine through in the survey is that midwives love being midwives, despite the challenges.

‘I love working within a caseloading model of care. One to Ones ethos supports me to practice the philosophy of midwifery I always wanted to’ (One to One midwife, Staff Survey 2014).

When asked what one thing they would change about One to One, a midwife stated:

‘Nothing, I love my job and how One to One provide gold standard care’ (One to One midwife, Staff Survey 2014).

Understandably, midwives requested lower caseloads, more protected time and more pay; this is to be expected. Yet 61.54% of the midwives were enthusiastic about their job, and 67.19% felt that their role makes a difference to their service users.

Of the midwives surveyed 83.87% believed in the One to One Core values — ‘Excellence, safety, woman centred, professionalism, integrity’.

Following the recent staff survey, the midwives voices have been heard — the caseloads are set to reduce and a more structured approach to protected time is set to come in to force in the near future, reflecting the views of the midwives in the survey.

With the new National Institute for Health and Care Excellence (NICE) intrapartum guidelines (NICE 2014) Promoting low-risk birth in out of hospital settings, it is growing increasingly important that midwives are confident to deliver this type of care, which not only improves outcomes for mothers and babies, but also satisfaction. This challenge is compounded by the knowledge that between 2001 and 2012 there was a 4% drop in the numbers of midwives in the north west of England, with an ever increasing birth rate (Royal College of Midwives (RCM) 2013).

So, for midwives to practise true midwifery, the impact on their personal lives should be considered, but with the understanding that midwifery in its purest sense is not ‘just a job’ but a way of life.

Is there a perfect model of caseloading? We know that this is a gold standard of care for women and their families — can it ever be that for midwives? Kirkham (2015) suggests that women being looked after in the traditional NHS system often feel that they cannot express or discuss their concerns with midwives, due to time constraints and the midwives being so busy. One to One midwives manage their own diaries and build strong relationships with women and families on their caseloads to empower them and afford them the time and space to address any concerns and nurture confident parents and strong family units.

Women are strong, and will continue to express themselves through their choice of care provider. Knowing that a woman and her family, at one of the most vulnerable times of their lives, chooses such a model of midwifery to provide a superior level of care, based on trust, relationships and continuity, shows the continued demand for such care.

Midwives want to be part of reclaiming the profession and driving forward changes within the ebb and flow of the maternity arena. One to One are inundated with student midwives and prospective students wanting to work within the model to see it delivered first hand — a continued thirst for true midwifery.

Conclusions

It must therefore be contemplated that for models of care such as caseloading to become successful, more protected time and annual leave should be incorporated into the work pattern, thus reducing ‘burnout’ and ultimately producing the utopia of midwifery care. At the same time, mutual respect from the profession, recognition of the care provided and collaborative partnerships is what will achieve the greatest results and job satisfaction.

2015 to 2016 is set to be an exciting year for One to One with further expansion and a further ‘tweak’ to the model. Thus, the caseloading model continues to ever evolve.

‘Learning, growing, changing’ — something One to One do, and will continue to do — indeed it is the only way to stay current, honest, and effective.

Katie Wainwright, Consultant Midwife, One to One (North West) Limited

Maureen Collins, Clinical Governance Lead, One to One (North West) Limited

References

Ball L, Curtis P, Kirkham M (2002). Why do midwives leave? London: Royal College of Midwives.

Collins M, Kingdon C (2014). One to one midwives: first-year outcomes of a midwifery-led model. British Journal of Midwifery 22(1):15-18, 20-21.

Kirkham M (2015). Midwives working time: propping up the system within the NHS. Midwifery Matters 144:11-12.

Ministry of Health, Department of Health for Scotland, Ministry of Labour and National Service (1949). Report of the Working Party on Midwives. London: HMSO.

National Institute for Health and Care Excellence (2014) Intrapartum care: care of healthy women and their babies during childbirth. London: NICE.

Nursing and Midwifery Council (2015). The Code: professional standards of practice and behaviour for nurses and midwives. London: NMC

Royal College of Midwives (2013). State of maternity services report 2013. London. RCM.

Sandall J, Davies J and Warwick C (2001). Evaluation of the Albany Midwifery Practice: final report March 2001. London:Florence Nightingale School of Nursing and Midwifery King’s College London.

Wainwright K, Collins M. MIDIRS Midwifery Digest, vol 25, no 2, June 2015, pp 186–189.