Caseload Midwifery: A family friendly way of working

‘Having it all’ is a myth yet still to be fully debunked, 35 years after it emerged as a cultural concept. Being a hands-on mother (there is rarely another kind) and a worker, whether wage-slave or career-woman, is full-on. We’re still edging towards a cultural understanding of how busy life is for working parents, and for mothers in particular; marketing for Caroline Criado Perez’s brand-new book, Invisible Women (‘exposing bias in a world designed for men’), focusses on the fun fact that husbands create an extra seven hours of housework a week for women, and I see that as a win. Go figure.
EJB Family

Anyway…. Before I was a midwife, I was an academic. I worked 0.8 whole time equivalent, meaning I worked 4 scheduled days, and like my academic colleagues who worked full-time, the work spilled over; an accepted aspect of the job. You write papers, you write grant applications – those things require time and space and thought, and don’t always fit neatly between teaching sessions, course admin, student supervision, pastoral support and marking. So I worked four days a week, starting at 8am so I could finish at 4.30pm, so I could collect my daughter from after-school club by 6pm (building in contingency time, since the trains I pick up once I get off the tube go every 15 minutes, and the cost of a late pick-up is £10 for every 5 minutes). My partner dropped my daughter off in the mornings and was home long after she went to bed; I left without seeing her for more than a few minutes every morning, but picked her up, fed her, bathed her and read her a story and snuggled her in bed every night. Then I went downstairs, washed up, made dinner for two, and felt guilty about the work that I was now too tired – and too disconnected from – to do. When she was five, I decided that without a partner who could take some of the evening burden off me, to allow me some evenings to stay in the office just to keep going with the work I was doing, rather than clock-watch from 4 and down-tools at 4.28; and maybe without a little more ambition, or drive, or energy, to mitigate the short days and fragmentation, I couldn’t be an academic any more. It wasn’t having a baby that interfered with my career; it was having a child.

So I retrained as a midwife, had a second baby during training, and started work in the NHS. I requested 0.6 whole time equivalent so I could see my kids as much as possible, limit the night shifts I worked, and try to make life feel a bit less unpredictable for them. Working full-time means working thirteen 11.5hour shifts a month – 3 weeks of 3 shifts and a week of four. As a newly qualified band 5 midwife in a rotational post (a few months in each part of the hospital maternity service), I expected to be a slave to my rota (difficulty putting in rota requests on time in the next area, difficulty getting annual leave in school holidays as it’s already been taken, no flexible working as you seem to have to earn that, by coming back from maternity leave, rather than arriving with a family) so I exerted what seemed to be the only choice available to me – working part-time enough to mitigate that (so, goodbye healthy salary and chunky pension contributions). 0.8wte means three shifts a week. Sounds manageable until you do it – up at 5.40am and home at 9.20pm three times a week is hard on the kids and exhausting for you. Throw in some night shifts randomly across the month and you have a disorientating life of never quite knowing where you are in the week and rarely feeling on top of things. (“But you’re only working 3 shifts a week! You’ve got four days off!”…. “Yeah, it doesn’t really work like that…”).

I enjoyed my preceptorship, for the most part. Some days and nights were scary, stressful, exhausting. Many days, I struggled to sleep long enough before or long enough after a night shift; but I enjoyed the work, enjoyed gaining competence and confidence, and enjoyed discovering I really liked Antenatal Ward, and I probably could work on Postnatal Ward (even if I was always barked at by the midwife in charge and some of the fathers for not discharging women early enough. Seriously, I just don’t know how you give good care and feeding support to 8 women and ~8 babies and write your notes and do the three meds rounds and discharge half the women before you get barked at). But on days I was out from 6.15am to 9.20pm, and on nights I left the kids eating dinner at 6.15pm and missed seeing them the next morning every time, as I got off the train at 9am as the school bell was ringing. And working two long days back-to-back meant putting them to bed one night and seeing them in the morning three days later.

As a full-time caseload midwife, however, I dropped my five-year-old to school every morning. I managed my own diary so that I saw my first client around 9.30, I was usually home for kids’ teatime at 5.15, I was able to take my 10 year old to swimming three times a week, I put them both to bed every night, and sometimes I got a call in the evening or the early hours and went out to a home assessment and/or birth. Occasionally I wasn’t home at breakfast time and had to send texts or make a call to remind the household of the things that mothers seem to keep track of so everyone else doesn’t bother; and occasionally I wasn’t home at teatime so I had to call or send a text to say ‘I’ll be late but I’ll make it for bedtime’, or very, very occasionally, ‘I’ll be late but I’ll see the kids in the morning’. Some days I had two appointments and was home in the middle of the afternoon. I was learning not to feel guilty about that – it mitigates the on-calls. Some days I had to call a client to say ‘I’m at a birth, I won’t make it to you today. Let’s rearrange, I’ll work around you.’ Some weeks I had to work at the weekend because some postnatal visits are non-negotiable, but I quite like driving on the quiet streets on a Sunday morning. Some weeks I chose to work weekends – it worked better for the woman, my partner would be at home so the kids wouldn’t feel short-changed and I quite like driving on the quiet streets on a Sunday morning.

All the midwives I’ve spoken to worry about work-life balance when providing care in a continuity model; caseloading meaning not seeing their kids; multiple on-calls meaning multiple call-outs. But for me, life is better this way. Better for my family, more manageable for me, better for the women, better for their families. It just means we might (in maternity services) have to review what work looks like when it’s focused around a caseload rather than around a hospital. But autonomous working for a salary is much more empowering than working for what amounts to an hourly wage, and makes you realise the other way is hierarchical, untrusting and maybe pretty infantilising. Of course there will be weeks where you’re working and working and working and feel like you need some help and a break – that’s where your team comes in, as well as the knowledge that not every week is like this. I don’t want to be able to have it all – it reeks of the greedy, selfish ’80s when the term was coined. But I do want to be able to do it all – do my best for women and for my family, and therefore, actually, also for me: I want to be a caseload midwife.

 

All the midwives I’ve spoken to worry about work-life balance when providing care in a continuity model; caseloading meaning not seeing their kids; multiple on-calls meaning multiple call-outs. But for me, life is better this way. Better for my family, more manageable for me, better for the women, better for their families. It just means we might (in maternity services) have to review what work looks like when it’s focused around a caseload rather than around a hospital. But autonomous working for a salary is much more empowering than working for what amounts to an hourly wage, and makes you realise the other way is hierarchical, untrusting and maybe pretty infantilising. Of course there will be weeks where you’re working and working and working and feel like you need some help and a break – that’s where your team comes in, as well as the knowledge that not every week is like this. I don’t want to be able to have it all – it reeks of the greedy, selfish ’80s when the term was coined. But I do want to be able to do it all – do my best for women and for my family, and therefore, actually, also for me: I want to be a caseload midwife.

4 thoughts on “Caseload Midwifery: A family friendly way of working

  1. Mel says:

    My problem is childcare and what do I do if I am called out to a birth but my partner isn’t home yet, or I have picked the children up and then called out. It’s fine if you have a relative just around the corner who can come and take over tea time/ bath/ bed but otherwise it doesn’t work for me I’m afraid. I worked in a true caseloading homebirth team as a student midwife and I loved it, but I can’t see how it would be possible for me with young children.

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    • Michala Marling says:

      It won’t work for everyone, no one is suggesting it will, but there are ways that people are making it work, which is what is so important when so many are saying it won’t work at all. I think what’s important in this post is that it’s demonstrating that, contrary to popular belief, shift work isn’t family friendly either and that for some it is possible to work this way when there is support from your partner/team/family to provide back up if you’re not available. If you had childcare for 3x 12 hour shifts in hospital then it is no different to childcare for 3 days of on call shifts.

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    • Eleanor says:

      without wishing to sound controversial (and I am definitely not having a go at you) – but why does childcare always seem to fall to the woman? Why does the mum always have to organise the childcare? I think women do all the ‘mental work’ of organising family life (childcare, meals, organising play dates etc) even though they work full time? Would this even be thought of, if the father was the caseload midwife? I doubt it.

      Case-loading doesn’t work for everyone at every stage of their life or career – but children grow up and then you may have space in your life to caseload? I have caseloaded whilst a single parent, but I had excellent family support and could literally ‘drop everything’ and go. There are various models out there that have a rota system for caseloading or protected time off call – there is no perfect solution to any of this – but surely we should try?

      Liked by 1 person

  2. Jan Hinson says:

    I have been working with NZ continunity of carer (CoC) model for 28 yrs. (Known here as LMC ,Lead Maternity Carer).It wasn’t available until my kids were older . My son was 13 and his sisters 15 &17 so mostly all very capable , I was a solo parent . One advantage of CoC was that I didn’t have a run of ‘late’ shifts and night work was not out every night. I could control the workload by taking a certain number of clients per month . I worked with a small group of 2 other midwives who had the same work philosophy which is essential . We had a plan of ‘oncall’ and ‘back-up’ for homebirths. I have learned so much from continunity and looking after ‘repeat’ families and seen the highs and lows. From watching behaviour and progress I have learned the early and warning signs of cardiac problems , cystic fibrosis, secondary infection+++. I have been privileged to assist a mum of 2 ELSCS to go on to have 3VBACS and catch the 32w baby at home because mum ‘wasn’t feeling ok ‘. Just knowing people and their environment of home and family is a great learning curve. The diversity of ethnicity has taught me that every culture has positive ways of birthing and support and ‘western ways’ are not the ‘only’ way.. I could go on but its been a lifestyle that I will miss as I retire …

    Liked by 1 person

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