Caseload midwifery: A Mixed Methods study.

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Ingrid Jepsen

Midwife, MPH, PhD

Lecturer at the Midwifery Department University College North Denmark

Caseload midwifery: A Mixed Methods study.

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Plan

 Definition of Caseload Midwifery

 Description of Caseload Midwifery in Northern Jutland

 Background

 Aim

 Design

 Study1

 Study 2

 Study 3

 Study 4

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 Continuity of care in focus

 The midwife or a small group of midwives follow the woman through pregnancy- birth- and postnatal care

(Homer et al, 2008)

Definition of Caseload Midwifery

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How is caseload midwifery

organised in the northern part of Denmark?

How is caseload midwifery

organised in the northern part of

Denmark?

(5)

Geographical illustration of caseload midwifery in the North Denmark region

Birthplace A = Consultations =

Birthplace B = Consultations =

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Definition of caseload midwifery and standard care

Caseload midwifery

Continuity of care is in focus

Midwives work in pairs (or small groups of 3) succeeding each other with one week on call and one week off work

The midwives are backed up by hospital midwives

The midwives attend 60 all-risk pregnant women a year

The midwives provide antenatal consultations

Standard care

Continuity of care during pregnancy

Midwives are rostered to work 37 hours a week. The work scheme in known 4 weeks ahead

The midwives share the workload

The midwives attend on average 75 all-risk women a year

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Background for the thesis

 Caseload midwifery is expanding in Denmark

 How midwives cope with this model of care needs more attention, as international studies indicate that midwivies’ perspectives are varied

^1-3

 Women prefer to know their midwife

^4-6

But how does the partner experience caseload midwifery?

 Evidence shows that continuity of care seems to promote uncomplicated births

^7-11

 Caseload midwifery is expanding in Denmark

 How midwives cope with this model of care needs more attention, as international studies indicate that midwivies’ perspectives are varied

^1-3

 Women prefer to know their midwife

^4-6

But how does the partner experience caseload midwifery?

 Evidence shows that continuity of care seems to promote uncomplicated births

^7-11

1-3: (Newton et al., 2014; Fleming, 2006; Chenerey-Morris, 2010))

4-6:(Dove and Muir-Cochrane, 2014; Edmondson and Walker, 2014; Beake et al.,2013)

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Aim and research question

Aim

The overall aim of this mixed methods study was to expand the understanding of caseload midwifery by integrating findings from both qualitative and quantitative studies

Mixed metode research question:

What are the experiences and outcomes of caseload midwifery in the

?

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Mixed methods study design

Figur 1: Illustration of design: Illustration of mixed methods study design: A multistage framework where a core convergent design is supplemented by an exploratory sequential phase

Core convergent design

Study 1 Qualitative

study Participant observations and interviews

N= 13 midwives

Study 2 Quantitative

study Survey on

burnout N=50 Midwives

Study 3 Qualitative

N=10 Couples

study Cohort

Study N=13115

births ESF

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Mixed methods study design

Core convergent design

Study 1 Qualitative

N= 13 midwives

study Survey on

Study 3 Qualitative

N=10 Couples

study Cohort

Study N=13115

births ESF

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Aim and research questions

Aim

The aim was to advance knowledge about the experienced working and living conditions of midwives in

caseload midwifery,

Methodology

 An ethnographically inspired field study followed up by interviews

1

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Participant and methods

 13 Midwives participated - all working in caseload midwifery

 The midwives were observed during antenatal consultations for 1 or 2 days

 Observations were followed up by interviews

Participant observations inspired the interview guide

OBSERV ATIONS

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Analytical process

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Findings - main themes

 High degree of job-satisfaction

 A personalised professional

 Posibility of creating ”my own space”

 Cohesiveness was created because of “knowing”

 An obligating but rewarding job

 Philosophy of care: Shared decision making

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Conclusion

Caseload midwifery is a model of care with an embedded and inevitable commitment and obligation that

brings forward the midwife’s desi re to do her utmost and in return get

appreciation, social recognition and high job satis faction.

There is a balance between the meaningful job and the effects on personal life, but midwives wor king in caseloads found the benefits to

outweigh the disadvantages.

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Mixed methods study design

Core convergent design

Study 1 Qualitative

N= 13 midwives

study Survey on

Study 3 Qualitative

N=10 Couples

study Cohort

Study N=13115

births ESF

(18)

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Study 2: Aim and research questions

Aim: The aim of this study was to investigate burnout among

midwives.

2

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Methodological approach

Survey on midwives level of burnout

”The Copenhagen Burnout Inventory (CBI)”

Developed in Danmark 1999-2005

Project Burnout (Projekt Udbrændthed,

Motivation og Arbejdsglæde (PUMA)

undersøgelsen).

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Definition of burnout

The PUMA investigation’s definition of burnout:

Tiredness, exhaustion or ”flat batteries”.

Tree domains of burnout:

 Personal burnout

 Work-related burnout

 Client-related burnout

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Participants

 61 midwives received the questionnaire

 50 midwives (82%)

responded

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Results

Burnout in caseload midwifery

(n=6)

Mean score (SD)

Burnout in standard care

(n=44)

Mean score (SD)

P value

Personal burnout 25.7 (12.0) 39.3 (16.1) 0.04

Work-related

burnout 19.2 (9.8) 37.2 (15.1) 0.004

Client-related

burnout 10.3 (6.0) 28.8 (16.2) <0.001

Table 1 ) Mean burnout score in each domain for midwives in caseload midwifery and midwives working in standard care

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Conclusion

Working in Caseload midwifery was associated with lower

burnout scores compared to

the scores of midwives working

in other models of care

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Mixed methods study design

Core convergent design

Study 1 Qualitative

N= 13 midwives

study Survey on

Study 3 Qualitative

N=10 Couples

study Cohort

Study N=13115

births ESF

(26)

(27)

Aim and research-questions

Aim

The aim was to explore how women and

their partners experience caseload midwifery 3

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Methodological approach

Ethnographically inspired field study followed up by dyadic interviews

• 10 couples from caseload midwifery participated

• Labour and birth were observed

• The couples were interviewed one to four days after birth

OBSER VATION

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Analytical process

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Findings

 The partner is involved

 The partner and the woman experience to be more than numbers because the couple and the midwife are known to each other

 Disappointment - if expectations are not met

Research question: How are the early phases of labour influenced?

 A welcoming first contact by phone

Research question: What does caseload midwifery mean for the woman and

her partner?

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Findings

 A relationship with a professional friend

 A relationship characterised by equality and inclusiveness

 A relationship creating a connecting thread

 A navigator on the ship

 The couples preferred fast births

Research question: What characterises the relationship with the midwife?

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Conclusion: Study 3

From the perspective of women and their

partners, attending caseload midwifery meant being recognised and cared for as individuals.

The partner felt included. He acknowledged and experienced working in a team with the midwife.

Caseload midwifery was able to solve problems

concerning labour onset and especially gaining

access to the labour ward

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Mixed methods study design

Core convergent design

Study 1 Qualitative

N= 13 midwives

study Survey on

Study 3 Qualitative

N=10 Couples

study Cohort

Study N=13115

births ESF

(34)

Aim and hypothesis

Aim

To describe and compare labour outcomes between caseload midwifery and

standard care

4

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Study design

Register- based cohort study

Two maternity units were included

Data for a three-year period (2013, 2014, 2015) were obtained from the electronic obstetric database of the North Denmark Region

13115 singleton, all-risk pregnancies were included in the study

 2679 caseload midwifery

 10436 standard care

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Potential confounders

Information about the following potential confounders, selected a priori, was retrieved from the database:

• maternal age,

• parity (nulliparous vs multiparous)

• maternal pre-pregnancy body mass index (BMI)

• smoking habits (non-smoker, smoker, stopped during pregnancy)

• need for an interpreter

• maternity unit (A or B),

• infant birthweight (<3,000 g, 3,000-3,999 g, ≥4,000 g)

• infants’ birth year (2013, 2014, 2015)

• mothers years in school

• level of education

• former intrauterine growth restriction, caesarean section, or preterm birth,

• Risk factors/complications in the present pregnancy including:

• malformations,

• alcohol or drug abuse,

• in vitro fertilization,

• preeclampsia,

• hypertension,

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The results are deleted from this version, because

they are not published, yet.

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Mixed methods study design

Core convergent design

Study 1 Qualitative

N= 13 midwives

study Survey on

Study 3 Qualitative

N=10 Couples

study Cohort

Study N=13115

births ESF

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1. Mixed methods finding

Concept Integrated interpretation A positive

cycle The close relationship between caseload midwives, colleagues, women, and their partners seemed to reinforce each other, and created an

atmosphere of respect and mutual empathy.

This mutual empathy led to kind and

thoughtful acts that again strengthened the relationship and

developed a positive cycle.

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2. Mixed methods finding

Concept Integrated interpretation A

negative cycle

The discovery of a negative cycle in caseload midwifery might be attributable to the fact that midwives’

heavy obligations to be there for all - might

constrain the time spent in each labour and

consequently, laed the midwives to adopt a more active approach.

Moreover, the shared decision approach and the couples’ preferences

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Strengths and limitations

Strength:

- High number of participants

- Women were not self-selected into caseload midwifery Limitations:

- The observational design of the study

- The geographical allocation to caseload midwifery

- The organisation of caseload midwifery was different from international studies which makes it hard to compare

- Continuity of care during labour was also found in standard care

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Implications for practise

- Further research in other caseloading models in Denmark is needed

We need to consider:

How many days on call?

For how many hours is it safe to let a midwife work?

The number of midwives in each caseload?

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Thank you to my supervisors:

Erik Elgaard Sørensen

RN, MScN, PhD, ass. Professor, head of Clinical Nursing Research Unit,

Aalborg University Hospital, Department of Clinical Medicine, Aalborg University.

Ellen Aagaard Nøhr

RM, MHSc, PhD, Professor of Midwifery Sciences and Reproductive Epidemiology

Edith Mark

RN, MScN, PhD, Clinical Researcher, Medical Center, Aalborg University Hospital, North Denmark Region

Svend Juul

Cand. med., epidemiolog, ekstern lektor ved Aarhus universitet

Maralyn Foureur

RM, RN, BA, Grad Dip Clin Epidem, PhD Professor of Midwifery in the Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney

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