Caseload midwifery: A Mixed Methods study

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Caseload midwifery: A Mixed Methods study

Ingrid Jepsen

Midwife, MPH, PhD

Lecturer at the Midwifery Department, University College North Denmark

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Plan

 Background, aim, design

 Results from Study1 - 4

 Integration

 Organisational changes

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Caseload Midwifery

• Focus:

Continuity of care during pregnancy and childbirth

• Continuity of care means:

A pair of midwives or a small group of midwives follow the woman through pregnancy- birth- and postnatal care

(Homer et al, 2008)

3

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Background for the Ph.d. study

 Caseload midwifery is expanding in Denmark

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

perspectives are varied

^1-3

 Women seem to prefer to know their midwife

^4-6

. We do not know about the partners…

 How Danish couples experience caseload midwifery is not known.

 Evidence shows that continuity of care promotes 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 midwives’

perspectives are varied

^1-3

 Women seem to prefer to know their midwife

^4-6

. We do not know about the partners…

 How Danish couples experience caseload midwifery is not known.

 Evidence shows that continuity of care promotes 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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The Mixed Methods research question for the Ph.d. study

What are the experiences and outcomes of caseload midwifery in a Danish context?

5

?

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Study design

6

Study 2 Quantitative

study Survey on

burnout

N=50 Midwives

Study 3 Qualitative

study

Participant observa- tions and interviews

N=10 Couples

Study 4 Quantitative

study Cohort

Study

N=13115 births Study 1

Qualitative study

Participant observa- tions and interviews

N= 13 midwives

INTEGRATION

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Study design

7

Study 2 Quantitative

study Survey on

burnout

N=50 Midwives

Study 3 Qualitative

study

Participant observa- tions and interviews

N=10 Couples

Study 4 Quantitative

study Cohort

Study

N=13115 births Study 1

Qualitative study

Participant observa- tions and interviews

N= 13 midwives

INTEGRATION

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Study 1

Aim

To advance knowledge about working and living conditions of midwives working in caseload midwifery

1

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Methodological approach

Ethnographically inspired field study followed up by dyadic interviews

 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

9

OBS ERV

ATIO NS

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Findingss - main themes

High degree of job-satisfaction Construction: “My own space”

The job as a midwife - a personalised professional To know each other was the glue of the model

Caseload Midwifery: An obligating but rewarding job

Philosophy of care: Shared decision making, family centered care

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Study design

11

Study 2 Quantitative

study Survey on

burnout

N=50 Midwives

Study 3 Qualitative

study

Participant observa- tions and interviews

N=10 Couples

Study 4 Quantitative

study Cohort

Study

N=13115 births Study 1

Qualitative study

Participant observa- tions and interviews

N= 13 midwives

INTEGRATION

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Study 2

Aim

To investigate the level of burnout among midwives

2

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Methodological approach

Survey on midwives’

burnout levels

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”The Copenhagen Burnout Inventory (CBI)”

Developed in Denmark 1999-2005 in

Project Burnout (Projekt Udbrændthed, Motivation og

Arbejdsglæde (PUMA) undersøgelsen).

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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

Mean burnout score in each domain for midwives in caseload midwifery

compared to midwives working in standard care

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Study design

15

Study 2 Quantitative

study Survey on

burnout

N=50 Midwives

Study 3 Qualitative

study

Participant observa- tions and interviews

N=10 Couples

Study 4 Quantitative

study Cohort

Study

N=13115 births Study 1

Qualitative study

Participant observa- tions and interviews

N= 13 midwives

INTEGRATION

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Study 3

Aim

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

17

OBS ER

VATI ON

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Findings

• The partner had a very positive experience of continuity of care

• All participants felt individually recognised because the midwives

knew their names, their personal stories and their wishes for birth

• The couples felt welcomed when they called the midwife

• The couples felt welcomed at the hospital

• They had a special relationship to their “own” midwife and felt disappointed if their midwife had to go home

The couples preferred fast births….

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Study design

19

Study 2 Quantitative

study Survey on

burnout

N=50 Midwives

Study 3 Qualitative

study

Participant observa- tions and interviews

N=10 Couples

Study 4 Quantitative

study Cohort

Study

N=13115 births Study 1

Qualitative study

Participant observa- tions and interviews

N= 13 midwives

INTEGRATION

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Study 4

Aim

To describe and compare labour outcomes in caseload midwifery and standard care

4

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Study design

Register- based cohort study

• 13115 singleton, all-risk

pregnancies were included in the study

2679 caseload midwifery 10436 standard care

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The overall result

Compared to international findings, both standard care and caseload midwifery in this region had better outcome

- and even better outcome than international outcomes in caseload midwifery

- Locally, there was something to think about

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Results

Outcome Adjusted Odds Ratio - 95% CI

Laceration 1 or 2 0,86 (0,77;0,95)

Labour length <=10 hours 1.26 (1.13;1.42)

Augmentation (syntocinon) 1.20 (1.06;1.35)

Apgar <=7 in 1. minute 1.32 (1.09;1.60)

Apgar <=7 in 5. minute 1.57 (1.11;2.23)

Emergency CS* 1.17 (0.96;1.42)

Most outcomes showed no difference between caseload midwifery and

standard care (eg: transfer to NCU, Umb. art. pH, instrumental birth, epidural analgesia, time for hospitalization)

*same as women in standard care with similar distance to hospital

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Integration of the results from the 4 studies

The midwives experienced high job satisfaction and low levels of burnout compared to standard care.

The women appreciated caseload midwifery and their partners also benefitted from it, as they all felt that the midwives

acknowledged and treated them as individuals.

This good relationship led to a positive cycle in which mutual recognition and consideration supported the sense of coherence.

The experience of working in caseload midwifery seemed to depend on the midwives’ ability to handle the strong obligation

always to perform well and to be there for all, and this could lead to

a more active approach to labour and therefor a negative cycle

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• Midwives’ heavy obligations to be there for all might constrain the time

spent in each labour and consequently, and lead midwives to adopt a more active approach.

• The couples’ clear wish for their known midwife to stay during labour and birth

• The couples’ preferences for a short duration of labour

• The undefined and long working hours

“In the middle of the night – after a long day – 7 days on call - a multiparous with weak contractions – inpatient couple who want you to stay….. - then you get tempted to try to fasten labour – and they appreciate that you do something ….” (a midwife)

²⁵

Dette bi llede efter Uk endt f

orfatte r er l icens eret u nder CC B Y

A positive cycle, but also a negative cycle in

caseload midwifery… why a negative?

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Changes in the organisation of Caseload Midwifery

What have changed

?

Before this

study After this

study Why? What study/studies contributed

Days on call Up till 7 days 3-4 days

To avoid fastening the labors without professional reasons - and to avoid jet-lac in the end of a time period on call

Study 1: the midwives want to be present for all of their known couples.

The time period is experienced to be very long.

Stud 3: The couples want the midwife to be there no matter how long time she has been at work

Study 4: the findings of a more active approach

Hours on

call Up till 24 hours or more - the midwives

decided..

After 12 hours:

consider..

after 16 hours:

expect to go home

To avoid loosing concentration To be able to remain the ability to make

professional judgement

Study 1: Difficult to go home when you have a reputation to care for in a small town - and when you want to be present.

Study 2: A non-existing client-related burnout

Study 3: The couples get disappointed if the midwife leaves

Study 4: Higher rate of augmentation and low Apgar

Number of midwives in

each caseload?

Most often 2 midwives

Most often 3 midwives

To avoid getting too dependent on the presence of a specific midwife – a too close

relationship where professionalism is

Study 1: The midwives cannot bear to leave the woman

Study 2: Very low degree of all burnout Study 3: The couples experience a very tight relationship to the midwife

Study 4: A more active approach and shorter births.

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Methodological strengths and limitations

Strengths:

•All studies investigated the same phenomenon from different perspectives

•The findings from the qualitative studies could partly explain the results from the cohort study

•The findings were discussed with the midwives who recognized the findings and were able to explain some of the unexpected findings

•Women were not self-selected into caseload midwifery

Limitations:

•Observational design of the Cohort study

•Geographical allocation to caseload midwifery

•Organisation of caseload midwifery was different from that of international studies which make comparison difficult

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Acknowledgements

The Research- and Development program ”Technologies Closely Connected to Citizens’

Health” at the University College Northern Denmark (UCN)

The Midwifery Department, University College Northern Denmark (UCN)

Department of Obstetrics and Gynecology and The Clinical Nursing Research, Unit Aalborg University Hospital

Department of Clinical Medicine, Aalborg University

The Danish Association of Midwives, the Research and Development foundation

The University Hospitals Centre for Health Research, Lundbeckfoundation Knud Højgaards foundation

Cristian og Ottilia Brorsons foundation

Familien Hede Nielsens foundation

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Thank you for your attention!

Email irj@ucn.dk

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Results

Paper submitted to BMC pregnancy and childbirth Is the midwife known?

Caseloa d

midwife ry %

Stand ard care

% Proportion of births

where the woman saw only one midwife during labour and birth

78% 49%

Proportion of births where the woman saw two midwives during labour and birth

95% 82%

Mean number of

Midwives

Mean number

of Midwives

Average number of

midwives during birth

1,3 1,8

Yes, but standard

care also prioritize

continuity of care

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Result: Statistically significant outcomes

Outcome

Adjusted Odds Ratio - 95% CI

Laceration 1 or 2 0,86 (0,77;0,95) No lacerations 1,17 (1,06;1,29)

Augmentation (syntocinon) 1.20 (1.06;1.35)

Labour length <=10 hours 1.26 (1.13;1.42) Mean difference in length of

labour (minutes) - 28 (-45;-10)

Fewer

lacerations and shorter birth

- But more

augmentation…?

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Result: Emergency Caesarean Section

Caseload midwifery- compared to

standard care (without women with similar distance)

Adjusted Odds Ratio, 95%

CI

Women in

standard care with similar transport time - compared to the remaining

standard care women

Adjusted Odds Ratio, 95% CI

Emergenc y CS

1.21 (1.05;1.39)

1.17 (0.96-1.42)

Caseload midwifery

compared to standard care

Adjusted Odds Ratio, 95% CI

Emergen

cy CS 1.17 (1.03; 1.34)

The same

higher rate of

CS as other

women with

similar distance

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Result: Apgar score was negatively influenced

Outcome Adjusted Odds Ratio

- 95% CI

Apgar <=7 in 1. minute

1.32 (1.09;1.60) Apgar <=7 in 5. minute

1.57 (1.11;2.23) Lower Apgar

score in caseload midwifery

compared to

standard care

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Result: primi- or multiparous

Multiparous are more negatively influenced by caseload midwifery Outcome

Primiparou s

Adjusted Odds Ratio, 95% CI

Multiparou s

Adjusted Odds Ratio, 95% CI Augmentation (syntocinon) 1.05 (0.90;1.21) 1.49 (1.24;1.80) Emergency CS 1.11 (0.93;1.32) 1.28 (1.04;1.56) Apgar <=7 in 1. minute 1.18 (0.91;1.54) 1.35 (1.03;1.78) Apgar <=7 in 5. minute 1.43 (0.89;2.29) 1.69 (1.01;2.83 Umb. art. pH<7.05 1.02 (0.62;1.69) 1.41 (0.81;2.46) Transfer to NICU 1.33 (1.01;1.74) 0.98 (0.74;1.31)

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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?

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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 in small, local clinics

• At labour onset the woman phones one of her midwives directly

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

• The midwives provide antenatal in a centralised clinic

• The woman phones the labour ward at the onset of labour

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Results Paper submitted to BMC pregnancy and childbirth

All participants Primiparous Multiparous

Adj. OR* 95% CI Adj. OR* 95% CI Adj. OR* 95% CI

Augmentation 1.20 1.06; 1.35 1.05 0.90;1.21 1.49 1.24;1.80

Emergency CS 1.17 1.03;1.34 1.11 0.93;1.32 1.31 1.04;1.56

Apgar=<7 (5 min.) 1.57 1.11; 2.23 1.43 0.89;2.29 1.69 1.01;2.83

Umb. art. pH<7.05 1.21 0.84; 1.75 1.02 0.62;1.69 1.41 0.81;2.46

Transfer to NICU 1.20 0.97; 1.47 1.33 1.01;1.74 0.98 0.74;1.31

Labour<=10 hours 1.26 1.13; 1.42 1.29 1.12;1.49 1.22 1.02; 1.46