Over the Christmas period, standards for continuity of carer in maternity services were published by NHS England (2017), against a backdrop of reports of A&Es in crisis and routine operations being cancelled as the NHS struggled to cope (Donelly, 2018).
For women, continuity of carer is the gold standard in midwifery care, and evidence (Sandall, 2014) shows the effect of such a simple act on a women who experiences this as her maternity pathway. The outcomes of a woman having midwifery care as part of a caseload are manifold: women have a higher chance of having a vaginal delivery, less chance of preterm birth, shorter labours and higher rates of satisfaction with their birth experience (Sandall, 2014). We only have to see the outrage over the decisions by the Nursing and Midwifery Council (NMC) (2017) regarding independent midwives' insurance and the work of the Albany Midwifery Practice, to see the kind of passion and outcomes that caseloading can bring (Association for Improvements in the Maternity Services, 2014). Better Births (National Maternity Review, 2016) recommends that every woman has an individualised care plan, with her at the centre of it.
As a student, I have caseloaded women and seen to their care from the beginning of pregnancy to their discharge—and no experience has come close to the joy I have when caring for these women. Seeing them bring their babies into the world made me as proud and as excited as if it was a member of my own family. Yes, I was their midwife, but it's different when you caseload: I knew the women and their families, and they knew me. It takes time to build that kind of relationship, and to be able to do that is an immense privilege.
As amazing as caseloading is, however, I wonder how it will be implemented with the NHS as it stands. While maternity services exist in their own bubble in the NHS, we are not in isolation. The Royal College of Midwives (RCM) reported that, for every 100 student midwife places commissioned, the profession gained only one overall (Bonar, 2016). There is a deficit of both midwives (RCM, 2017) and doctors, and this problem is not going away. If anything, Brexit will only exacerbate the issue: according to some reports, recruitment of nurses from overseas is at an all-time low (Siddique, 2017). Services such as school nurses, health visitors and social care are being cut to the bone (Asthana, 2017), and as a society, we are struggling to provide even the most basic of services for those in need. It is this that makes me feel low when I see new documents and standards—how do we hope to provide services with the little we have?
Caseloading as a model has been shown to be cost effective (Tracy et al, 2014), yet in the circumstances that the NHS finds itself in, implementation feels impossible.
However, I will end with a thought from a former community team leader. She told me recently during a clinic that, while the big picture is important, it is made up of thousands of individual women. When things go wrong, a life can be affected in a multitude of ways, many of which we may never see. So we should be working hard for each expectant mother, to help make a difference, to change the outcomes for that one woman for the better and make her care the best we can.