It is clear from the literature that there can be many significant advantages to caseload midwifery in terms of health outcomes for women and their babies. These advantages include reduced incidence of episiotomies (Benjamin et al, 2001), reduced rates of caesarean section (Hartz et al, 2012), fewer neonatal unit admissions (Rayment-Jones et al, 2015) and higher breastfeeding rates (Huber and Sandall, 2009; Homer et al, 2017). These advantages have the potential to positively affect women, babies and families throughout their life (McAra-Couper et al, 2014).
In Scotland, while there have been improvements in continuity of carer in antenatal services, there are still significant issues in postnatal provision and the elusive known care giver at birth is arguably further away than it was when promoted in Changing Childbirth (Department of Health, 1993); the rising number of planned caesarean sections, continued high percentage of hospital births (Cheyne et al, 2015) and the dominant care model all being barriers to continuity of carer. This has led to a focus on continuity of carer in the recently published 5 year plan for maternity services in Scotland (Scottish Government, 2017), which points to caseloading and a reconfiguration of the existing midwifery and obstetric workforce as a route to this.
From the perspective of a new student midwife, this article discusses the benefits of the caseloading approach and reflects on some of the challenges in applying the Nursing and Midwifery Council (NMC) Code (NMC, 2015) in the absence of caseloading and continuity of carer. It suggests ways in which student midwives might draw from the caseload model, bringing some of its strengths into existing mainstream workplaces.
Prioritise people
The first pillar of the Code, Prioritising People, is the essence of person-centred care: treating people as individuals, listening and responding appropriately, and respecting and upholding their rights, including their right to choice (NMC, 2015). In this regard, a caseload approach to midwifery excels.
Studies that have focused on women's experiences of maternity care start to tell us why the caseload model yields such good outcomes. Looking at a range of studies, several key themes emerge that point to an enabling and supportive relationship between the woman and the midwife (Williams et al, 2010; Josif et al, 2014; Forster et al, 2016; McLachlan et al, 2016). Compared to other models of care, caseload midwifery appears to increase women's sense of control, increase their confidence, improve communication and manage expectations. This all affects the woman's choice of birth place and helps her to have a positive pregnancy, birth and early parenthood experience. Together, these studies demonstrate that an individualised, mutually trusting and supportive relationship between the midwife and the woman and her family can have a direct and positive impact on how well women engage with their maternity care. Women with a caseload midwife appear to take greater control of their own care rather than deferring responsibility and judgement to health professionals. Consequently, midwives in a caseload system are more able to work in partnership with the women in their care; better understanding and responding to their needs holistically and contributing positively to their health outcomes. This model of care, which prioritises people by its nature, must be the woman-centred care envisioned by Changing Childbirth back in 1993 (Department of Health, 1993).
Caseloading is particularly powerful where the needs or situation of the woman are complex and difficult to identify and assess. Rayment-Jones et al (2015) for example, looking specifically at socially disadvantaged women, found that women under one-to-one care were more likely to be booked earlier and be referred by the midwife to relevant extra support services, such as psychiatry or domestic violence support groups, which is likely to be in part responsible for better outcomes, such as reduced caesarean section rates. Although they do not attempt to explain how the caseload approach achieves this, they point to the importance of trust and support in their recommendations for further research. In Scotland, it has been found that continuity of carer is particularly important for women with medically complex pregnancies, who are more in need of an advocate and tire of repeating information about their situation to innumerable health professionals (Cheyne et al, 2015).
Prioritising people in practise
Student midwives learning, then working, in mainstream care models in the UK with reduced continuity of carer, should therefore focus on recognising the limits and potential negative affects of the care model in which they work, and find ways to compensate with respect to prioritising people. One way would be through good communication and cooperative working, which are important in any environment, as per the Code (NMC, 2015), but become even more so in a situation where the continuity of carer is reduced (Haggerty et al, 2003). Improved communication would, in turn, help in preserving safety in cases where knowledge of a women's situation is distributed among a range of midwives and other professionals such as health visitors, GPs, specialist consultants and social services. It is important that student midwives have the opportunity to try caseloading within their education programme. Caseloading can increase student confidence and competence, as well as exposing them to an alternative approach to practice and the range of benefits that this brings—not least feeling like a ‘proper midwife’ and a greater sense of responsibility to women because of a more meaningful relationship (Fry et al, 2011; Rawnson, 2011).
Student midwives should remain abreast and aware of surveys and more involved studies that shed light on how women experience care. They should reflect on and remember this in practice, always asking themselves how they would like to be treated. Students should also watch colleagues and mentors to find good examples of language and approaches that put women and their families at ease and facilitate a productive relationship—no matter how short the contact. At the very least, as per the ‘Hello my name is…’ campaign (Granger and Pointon, 2017), student midwives should remember to introduce themselves, to smile, and to listen—no matter how busy they are.
The effectiveness of the caseload approach is in no small part due to the fact that it allows midwives to better prioritise people and be ‘with woman’ through the development of a constructive relationship. The reality of practice, however, is unlikely to match this ideal model of care, making it all the more important that student midwives are mindful of this pillar of the Code at every encounter with a woman; remembering to humanise the women in their care, and themselves with warmth, empathy and compassion.
Practise effectively
The second pillar of the Code, Practising Effectively, requires midwives to ensure timely and appropriate treatment or advice, good communication, a reflective and continuous learning approach to expertise and cooperation with colleagues (NMC, 2015). Effective practice is fundamental to making the caseload system work and perhaps because of this, seems to be more apparent in caseload systems.
The need for cooperative environments and good communication is urgent, given the recent report by the Royal College of Midwives (RCM) into why midwives leave (RCM, 2016). This report points to staffing pressures and a lack of time to do the job properly, as well as a lack of support from colleagues and a bullying culture that forces many competent midwives to leave. This must have an impact on safety and maternal and infant outcomes (Smith et al, 2009). Sadly, this was brought to the fore in the report into Morecambe Bay maternity service failings, where poor communication and a lack of collaborative working across professional boundaries, along with poor standards in practice, were found to be significant factors in some cases of maternal and infant mortality (Kirkup, 2015). Furthermore, a recent report by The King's Fund on discrimination within the NHS in England found high levels of discrimination from managers and colleagues as well as from patients, particularly for black and disabled staff (West et al, 2015), leading to questions about the ability of the NHS to deliver inclusive care from an environment that is discriminatory. Perhaps this is in part why Hall et al (2016), looking at the human rights and dignity experience of disabled women using maternity services, found that more than half of the women surveyed thought that the attitudes they experienced towards disability were inappropriate. It should be noted that women's experience varied by individual, not disability, highlighting the importance of prioritising people and of individualised care.
Conversely, research into the highly successful Albany Practice which, when it existed, operated a caseload system, found autonomy for individual midwives, but active cooperation among the team. Midwives in the Albany Practice met twice weekly for support, peer review, skills sharing and to raise any organisational concerns (Huber and Sandall, 2009). In New Zealand, which has an almost exclusively midwife-led caseload approach to maternity services, research has found good relationships with colleagues and a shared philosophy of midwifery, born out of good communication, to be of high importance for workforce morale (McAra-Couper et al, 2014). In both cases, midwives remained passionate and enthused by their job because of the partnership developed with women. It could be said that effective practice is both generated by, and facilitates, a caseload model of care and that effective working is less prominent where care models with reduced relational continuity are adopted. This could be why a change in care model is seen by some as a potential solution to the problems of workplace culture, lack of job satisfaction and safety issues in the UK (Smith et al, 2009; RCM, 2016). Indeed, according to MacLellan (2014), the institutionalisation of midwifery practice and, with this, the loss of individualised care, can lead to peer-to-peer bullying, attempts to dominate, rather than partner, women and an emotional detachment from women and their care. It could well be that this is what we see at work in Kirkup (2015) and RCM (2016) and why caseload approaches that maintain individualised care yield happy midwives (concerns around work-life balance not withstanding) and women.
Effective practice for student midwives
It would appear that student midwives entering the mainstream maternity services in the UK may need to learn resilience in the face of the workplace culture. If they do find a negative environment, they should try to respond positively, by finding ways to replicate examples of good practice found in the caseload model; seeking out supportive and enabling relationships with those whom they have a shared philosophy (potentially, but not necessarily their mentor); being open and finding opportunities to discuss practice, evidence and guidelines in order to learn; and using reflection days offered by universities, personal development tutors and relationships with peers to best effect. Importantly, student midwives must ensure that they do not carry any negative experience into practice with them, or let it affect how they engage with the women in their care.
Creating an open and cooperative working environment, with good communication and a focus on continual learning and improvement of practice, appears to be essential for effective and safe midwifery practice. Without it, morale and standards inevitably drop, to the detriment of women and their families. Good working relationships and well-conceived approaches to cooperation can sustain midwives working in a caseload model of care and fuel its success. Student midwives may need to take some of the elements of caseload approaches into practice with them and be proactive in seeking change in workplace practices where there is low morale.
Preserve safety
The third pillar of the Code obliges midwives to protect patient and public safety, to not exceed the limits of their competence and to share information if they believe that someone may be at risk from harm (NMC, 2015). This section of the Code is arguably the most challenging, potentially causing the most cognitive dissonance for midwives working in the mainstream care model as opposed to caseload systems. For those already working in caseload systems, such as independent midwives, it can affect their ability to practice.
Safety is a significant and legitimate concern within maternity services. The impact of simple, proven measures within the caregiver's control, such as handwashing, could and should be an automatic part of everyone's practice—as should responding quickly and appropriately when safety concerns arise. When considering safety though, perceptions of ‘normal’ and ‘risk’, and therefore what is appropriate in terms of preserving safety, become very important. The view of childbirth as a natural physiological event, for which medical intervention is looked to only when necessary, leads to a different approach to care than the view of childbirth as inherently risk laden, needing medical management (Cahill, 2001). In the 2015 Having a Baby in Scotland survey, 98% reported having a hospital birth (Cheyne et al, 2015). That the overriding number of births continue to be in hospitals rather than any other setting tells us which of these two philosophies currently dominates. This is despite the Department of Health's report on maternity services stating in 1993 that the evidence did not support across-the-board promotion of hospital birth on the grounds of safety (Department of Health, 1993).
The evidence on the safety of midwife-led care and birth outside of hospital has grown since the Changing Childbirth report and continues to grow (Sandall et al, 2009; Tracy et al, 2013; Bowles et al, 2016). It is interesting that non-medical approaches, the foundation of the midwifery profession, need to continually demonstrate their safety for validity, yet medical interventions do not have to demonstrate their necessity. Indeed, Rayment-Jones et al (2015) demonstrate that a caseload approach can reduce caesarean section rates, among other interventions, in socially disadvantaged women. This is significant because it is these women who are most likely to have high levels of medical intervention under other models of care. This finding suggests that these interventions are not always medically necessary and that some women are more susceptible to unnecessary medical interventions than others, raising serious ethical concerns. For this reason, the authors recommend that free caseload midwifery should be targeted at vulnerable women in the UK.
Selecting appropriate interventions
Importantly for student midwives, caseload approaches that operate alongside the medical system, rather than from within it, appear better able to actively promote practices such as homebirth with positive outcomes (One to One, 2016; Reed, 2016). Midwives in the mainstream maternity services, conversely, appear to be positioned between a professional desire to limit unnecessary interventions for women, and an institutionalised and societally dominant view of safety in pregnancy and childbirth that has a very low tolerance for risk. Increasing application of the precautionary principle in antenatal advice, as per Winter (2016), is an example of this. It is pertinent that at this time the professional registration of independent midwives (the main opportunity for midwives to practice caseloading), is under threat due to rulings on the adequacy of their indemnity insurance (Nagendran, 2017).
Student midwives will need to regularly revisit their professional philosophy of ‘normal birth’ and how they communicate with women. This is important to ensure that they are being balanced, alleviating, rather than feeding into, unwarranted fear and anxiety, and offering properly informed choice. It is very probable that the level of experience of ‘normal birth’—and indeed the nature of that experience—inadvertently affects how individual midwives present information on safety. A lack of experience of positive normal physiological births will alter engagement with it, with potential implications for women's choice. As MacLellan (2014) states, the more confident and empowered the midwife, the more she can instil confidence in her women. In this regard, it is important for student midwives to seek out opportunities to observe and engage in normal physiological births in order to properly develop these skills and gain confidence in their promotion.
Preserving safety is undoubtedly of extreme importance and a necessary part of practice but is a very challenging area, raising tensions for the midwife. The caseload model of care better allows midwives to challenge the dominant view of safety but many existing caseload practitioners are under threat, arguably because they practice outside of the medicalised view of childbirth. Student midwives working in the NHS will need to ensure that everything they do is based in evidence, and to resist any temptations to see risk where it does not exist, while also ensuring they are responding appropriately and quickly where it does.
Conclusions
The Pillars of the Code, as the nomenclature suggests, are interrelating and mutually supporting for the benefit of the health and wellbeing of those in midwifery care. However, balancing the different elements of the Code is not always easy, and tensions arise that student midwives will need to learn to navigate. Furthermore, care models with reduced relational continuity do not necessarily facilitate good application of the Code in practice. The role of a student midwife, as well as to learn, is to be an agent of change. Student midwives can encourage the reflective practice required by the Code and challenge, where possible, some of the assumptions and structures of our existing maternity services. Student midwives can take much from the caseloading approach with them into their day-to-day practice while also calling for the more fundamental changes that are necessary to improve continuity of carer and allow proper and conscientious application of the Code for the benefit of pregnant women and babies.