Caseload Midwifery: The Reciprocal Midwife-Mother Relationship

The perception of what it would be like to be a caseload midwife is often that it involves working 24/7, lots of overtime, no work/life balance and the inability to spend any time with family, which admittedly does sound pretty awful. But you only have to speak to midwives working in this model to know it is far from the reality. Midwives working in a caseload model providing one to one midwifery care, with control over how and when they work have the high rates of job satisfaction and are much happier (McCourt and Stevens 2009, Newton et al 2014). The evidence shows that actually hospital based midwives are far more likely to work beyond their shifts than caseload midwives (Yoshida & Sandall 2013). Caseload midwifery also doesn’t mean you will only support home births, you support women’s choice, whether that be outside in nature, in the theatre for an elective caesarean section or at home in the pool. Having a named midwife, whom you know and trust helps women to feel confident in choosing the birth place that is right for them.

The key to this model of care being effective is supportive management that enables the caseload midwife to prioritise their caseload of women and also having a supportive team (Sandal et al 2016b). The absence of this control and the way in which this affects relationships and continuity, is one of the largest causes of stress and burn out (Sandall 1997, Yoshida & Sandall 2013). This stress and burnout is generally because of wanting to meet and exceed the expectations of the women whom they have developed meaningful relationships with through continuity, but being restricted because of shift patterns, lack of team support or lack of management support (McCourt and Stevens 2009).

When a midwife builds a positive relationship through the caseload model of care and it is reciprocated, this is emotionally rewarding for the midwife as well as the woman (Hunter 2006). The fulfilment felt by the midwife leads to them wanting to go the extra mile and sometimes because of the huge emotional rewards felt, putting the woman’s needs before anything else (Kirkham & Stapleton 2000, Jepson et al 2016). This was something I experienced as a student when I completed my continuity project within the caseload model of care. My dear Grandad passed away very suddenly and unexpectedly, very close to when one woman was due, so I was back home with my family miles away. I decided to return to London for 5 days before I was to go back for his funeral, because she expressed feeling anxious about the birth and worried she wouldn’t cope. I felt overwhelmingly responsible for her wellbeing and birth experience, which is a common feeling for student midwives undertaking the continuity project (Rawnson 2011) and so I returned so that she knew I was close by and could offer her an additional birth preparation appointment. I was aware of her desire to stay calm during birth, a common desire by women who see their ability to stay calm as a measurement of how positive their birth experience was (Huber & Sandall 2011) but also something that is more likely when the woman knows her midwife. As it happened I was at the birth and was able to support her, but I felt equally supported because offering support that could have a direct positive impact on the birth of a new life and then seeing that life enter the world, whilst preparing myself to say final goodbyes to someone that meant so much to me, had something so uniquely beautiful about it. Something  still can’t quite put into words. It gave me a sense of purpose at an incredibly emotionally challenging time and helped me to deal with my grief.

Lou and supporters

Wanting to and being able to go the extra mile led to an overwhelming sense of pride in my passion for my profession and subsequently felt like I had achieved something extraordinary. This sense of achievement that comes from feeling empowered as a student, has a positive impact on confidence and competence in practice (Rawnson 2011). The feedback received also highlighted how this positive relationship led to her own personal growth and self-confidence, the feeling of personal development and empowerment is true for both students and women when there is a meaningful relationship built (Dahlberg & Aune, 2013).

My experience of the caseload model of care, providing continuity to women from booking and into the postnatal period, attending every appointment including scans, was by far the most valuable of experiences as a student midwife and one that continues to inspire me and the way that I practice. It was the epitome of a reciprocal midwife-mother relationship.

Written by Michala Marling – Midwife, Hypnobirthing teacher and campaigner

Please join the campaign for continuity of carer for all women, for the benefit not just of the women but for babies, for families and for the midwives too. You can do so by following the campaign on Facebook, sharing the campaign on social media using the hashtag #continuitymatters or you can email your story to share on the blog to continuitymatters@gmail.com

References

Dahlberg, U. and Aune,I. (2013) The womans birth experience – The effect of interpersonal relationships and continuity of care. Midwifery, 29 (4), 407-415. Available online http://www.sciencedirect.com/science/article/pii/S026661381200174X

Huber U, Sandall J, 2008, A qualitative exploration of the creation of calm in a continuity of carer model in London. Midwifery (2008)

Hunter, B. (2006). The importance of reciprocity in relationships between community-based midwives and mothers. Midwifery, 22(4), 308-322.

Jepsen, I., Mark, E., Nøhr, E., Foureur, M. and Sørensen, E. (2016). A qualitative study of how caseload midwifery is constituted and experienced by Danish midwives. Midwifery, 36, pp.61-69.

Kirkham, M. and Stapleton, H. (2000), Midwives’ support needs as childbirth changes. Journal of Advanced Nursing, 32: 465–472. doi:10.1046/j.1365-2648.2000.01497.x

McCourt, C., & Stevens, T. (2009). Relationship and reciprocity in caseload midwifery. Emotions in midwifery and reproduction, 17-23.

Newton, M., McLachlan, H., Willis, K. and Forster, D. (2014). Comparing satisfaction and burnout between caseload and standard care midwives: findings from two cross-sectional surveys conducted in Victoria, Australia. BMC Pregnancy and Childbirth, 14(1).

Rawnson, S. (2011). A qualitative study exploring student midwives’ experiences of carrying a caseload as part of their midwifery education in England. Midwifery, 27(6), 786-792.

Sandall J (1997) Midwives’ burnout and continuity of care. British Journal of midwifery 5(2): 106–11

Sandall, J., Coxon, K., Mackintosh, N. J., Rayment-Jones, H., Locock, L., & Page, L. (2016b). Relationships: the pathway to safe, high-quality maternity care: Sheila Kitzinger symposium at Green Templeton College, Oxford: Summary report. Green Templeton College, Oxford.

Yoshida, Y., & Sandall, J. (2013). Occupational burnout and work factors in community and hospital midwives: A survey analysis. Midwifery, 29(8), 921-926.

3 thoughts on “Caseload Midwifery: The Reciprocal Midwife-Mother Relationship

  1. Gemma says:

    I work in the NHS as a community midwife and we follow a caseload model but it certainly is not as idealistic as this sounds. As it is the NHS we don’t have ultimate control over our workload (although ultimately the work/life balance is better than the hospital). I do however miss having more days off and I take quite a bit of work home with me. I worry a lot about my women and feel ultimately responsible for them. I do not get to participate in their labour or birth unless I am on call at the time they labour (and only if they’re at home). I have 100+ women on my caseload across 2 GP surgery’s and it’s hard. I feel I’d give better care and be happier if my caseload was lessened but apparently this is appropriate numbers when you work full time 😔

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    • Michala Marling says:

      It’s not surprising you see my experience as ‘idealistic’ if you see the caseload model of care as what you described, that’s how I work currently and it’s impossible to provide continuity in that model with so many women. I have experience of the model I talk about in this post, it’s not at all idealistic but is a real model of care used in the NHS where I trained. Currently I work in the same model as you at a different trust, I provide continuity antenatally and postnatally and I do on call shifts, but that’s not the caseload model of midwifery care, I’m talking about continuity of carer. Better births describe the caseload model and is the same way many teams I know of work and work well, it’s so different and so wonderful! It’s so hard to envisage it if you haven’t worked in it before, but believe me it’s achievable. Hopefully when this is rolled out more and more of us will get the opportunity to work in this model of care, I can’t wait to do it again!

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  2. Rachhuk says:

    I’m a caseloading midwife and I have been since I qualified nearly 2 years ago. The job satisfaction I have is beyond what I imagine it would be if I worked in a hospital. Being with woman from booking to supporting a family is ultimately rewarding . Over these past 2 years I have supported women birthing their babies, built reciprocal relationships and most of all helped support positive experiences. There are times when my family do wonder who the strange woman is walking in the door 🤣 but mostly I have a well balanced life. Caseloading to me is midwifery at its core

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