Caseload Midwifery: A Critical Analysis of Evidence-based Practice - Essay Example

?Caseload Midwifery: A Critical Analysis of Evidence-based Practice Introduction Caseloading has become one of the major trends in the midwifery practice (Tracy 2014). Issues relating to shortage of medical personnel and reduction in budget allocations for health care services have called for the adoption of other more efficient methods of health care delivery. Caseloading in midwifery has become a welcome alternative in this regard (Tracy, 2014). Caseload midwifery is a style of care where a patient is assigned a primary midwife who will secure care from pregnancy, birth, and the days following the delivery (Southern Health, 2011). Under these conditions, there is a continuity of care with the midwife, and backup care only called in where additional needs during the pregnancy or delivery emerge. The patient would meet with the allocated midwife for the prenatal examinations, including the delivery and initial postpartum care (Southern Health, 2011). Any additional tests or care shall be ordered by the midwife, including the need to refer the patient to medical staff where necessary. The primary midwife is available on call and would be supported by caseload midwives where the primary is not available. Caseload midwifery also seems to be synonymous with midwifery-managed care or one-on-one midwifery care (McCourt and Page, 1996; Farmer and Chipperfield, 1996). In different countries, midwifery care has been based on caseload and sustained care (Newman and Pearse, 2006). For countries like Australia and the UK where this type of care is often applied, caseload midwifery is a coordinated model for care within existing maternity services. This study now seeks to present a critical literature review of caseload midwifery model compared with standard models of practice. To pursue such goals, various aspects and perspectives in midwifery caseload shall be covered, including clinical outcomes, patient perspectives, midwife perspectives, and efficacy of the model. The Kotter model of change will be considered especially as it covers the leadership elements which can help ensure the effective implementation of change in maternal and child care. Discussion Clinical outcomes The available evidence from randomized controlled trials (Turnbull, et.al. 1996; Hatem, et.al. 2008) indicates how caseload midwifery is an option which helps decrease obstetric intervention (Hartz, et.al. 2011). It is also an intervention which helps ensure improved levels of satisfaction for women, with less unfavourable effects on mothers and their babies (Hartz, et.al. 2011). However, the randomized controlled trials on caseload midwifery including two comparative studies (Harvey, et.al. 1996; Pankhurst, 1997) did not specify differences in the style of delivery for the women under caseload management. Trends in other comparative cohort studies (Benjamin, et.al. 2001; Pankhurst, 1997) indicate that caseload midwifery may favourably impact on the outcomes of birth. However, no previous studies sought to evaluate the significance in the style of delivery. Comparative cohort studies and descriptive studies for caseload midwifery of care include low risk standards (Nixon, et.al. 2003; Johnson, et.al. 2005; Williams, et.al. 2005), including standards for women with low to moderate risks and women having high levels of risk (Nixon, et.al. 2003; Turnbull, et.al. 2009). There seems to be a contrast in the mode of birth outcomes in terms of comparative cohorts and descriptive Australian standards on caseload midwifery in terms of clinical trials and comparative cohort studies (Harvey, et.al. 1996; Pankhurst, 1997). The issue on why the contrast exists needs to be considered. Methodological differences would be under initial consideration. The levels of evidence relating to the efficacy of clinical remedies is hierarchical in nature with systematic reviews and some randomized controlled trials at the highest level of evidence (National Health and Medical Research Council, 2008). The Cochrane review of midwifery-centric against other interventions for delivering women indicates a meta-analysis of research for midwifery-supported care including the two RTCs under caseload midwifery (North Staffordshire Changing Childbirth Research, 2000; Turnbull, et.al. 1996). It is very much apparent that the credibility for evidence cannot reach as high a point for caseload midwifery and therefore, other evidence with lower levels of credibility from the UK and Australia have already been under consideration. Although a good number of these studies are indicated, the results must be evaluated in terms of their limits. The comparative cohort and descriptive studies provide an assessment of sampling and selection bias using a non-random sample of a population having the intervention. Such bias may have an unbalanced representation of respondents within a specific population being indicated in a study. In terms of comparative cohort studies for caseload midwifery, women may want to self-select the caseload models (Hartz, et.al. 2011). As such, the researcher is not sure if it is the type of care which impacts on the clinical results, or that the women wanting to use the model of care impact the outcomes because they are more inclined to be allocated the caseload model of care. Other elements consider include the fact that caseload midwifery may also be the only style of care which women can have within her disposal or that there is limited data available for her to make specific choices on her care (Hartz, et.al. 2011). Moreover, health professionals may unknowingly have prejudice on the allocation of women to specific type of care. So, in contrast to randomized controlled trials where interventions relating to caseload midwifery are generally indicated to women, and is clinically more viable, the selection bias seen in cohort studies compromises the internal validity and impact on the general results. The selection impact of sampling or selection biases also impacts on the external validity of the research as the outcome measures may not be applied to the larger population of women within childbearing age (Hartz, et.al. 2011). This is usually seen for studies were the intervention group includes a limited sample. External validity can be included for cohort studies by applying a comparative control group. The application of comparative groups can support the intervention including caseload midwifery, impacting on different respondents seen as homogenous (Swanson, 2010). The clinical trials supporting some of the studies cited herein (Hatem, et.al. 2008) were carried out in a specific clinical context. Most of the studies published were seen in the 1990s where C-sections were not common procedures. During those times, the UK rates were only at 15.5% (Information Services Division, 2009). However, even considering these elements, the C-section rates for some countries on caseload care are still very much below the rates of previous years in Australia and the UK and no specific outcomes of caseload care in the UK for the 2000s have been uncovered (Hartz, et.al. 2011). Patient’s perspective on caseloading The favourable development of the caseload midwife and the patient’s relationship is a crucial aspect of the patient’s actual experiences relating to her pregnancy and delivery, eventually her role as a mother (Andrews, et.al. 2006). Various researches (Benjamin, et.al 2001; Hartz, et.al. 2001; Hatem, et.al. 2008; McCourt and Page, 1996; Johnson, et.al. 2008; and Tracy, et.al. 2005) established better experiences and outcomes for women under caseloading as compared to those who were under standard care. Benjamin, et.al (2001) emphasized that where there was poor antenatal care within small and ethnically diverse minority communities, higher maternal deaths were observed. In effect, caseload midwifery has a significant effect on the maternal and pregnancy outcomes within local populations especially in relation to monitoring for the progress of the pregnancy, early detection and prevention of pregnancy complications, postpartum recovery, infant vaccinations, as well as securing good breastfeeding rates (Pankhurst, 1997; North Staffordshire Changing Childbirth Research, 2000; Stevens and McCourt, 2001). Some issues have been observed in relation to the development of effective clinical management with the focus placed mostly on prenatal to intra-partum management. The postpartum phase does not seem to have as much attention and care development in terms of improving services for women following the completion of their pregnancy. The studies also indicate that how the patients felt that they were not provided sufficient tools in terms of the emotional, physical, and social impact of their delivery to their lives (Hatem, et.al. 2008; Fleming and Downe, 2007). The outcomes relating to infant care is nevertheless a crucial element in the experiences and women and these elements have to be aggressively addressed when considering possible midwifery-based models (Benjamin, et.al. 2001; Pankhurst, 1997). Midwife perspectives Midwives have a major role in ensuring high-quality maternity services for mothers and their infants, even if they are often subjected to various changes in the work practice. Retaining and recruiting highly-motivated midwives has become an important element in securing adequate and quality care (Department of Health, 2000). Shortages are associated with higher incidents of obstetric intervention and as a result can affect the care of the patients and the healthcare organization in general. It is therefore important to assess what is crucial for midwives. However, there are limited options in research methods on adequate assessments for determining what is crucial for midwives and their work. Most of the current studies have highlighted (Hundley, et.al., 1995; Stevens and McCourt, 2001) on a particular model of maternity care. Different models included schemes relating to different levels of flexibility from midwives, but this meant higher levels of emotional exhaustion (Sandall, 1998). Still, autonomy and increased responsibility are related also to decreased levels of emotional exhaustion. As leaders, it is important for a good deal of autonomy to be granted them in order to allow room for decision-making. Sandall (1998) also indicated how continuity in care and the chance to secure relationships with women was important to midwives and their clients. Earlier studies which evaluated 220 midwives perceptions (Garcia, 1997) indicated different advantages in working with teams, specifically in supporting midwifery skills, guaranteeing professional development, as well as protecting job satisfaction. Moreover, working in teams as midwives implied greater autonomy in terms of decision-making when compared to non-team members. Still, issues were seen in terms of the lack of new skills gained and isolated working (Lavender, et.al., 2004). The team midwives were often also inclined to express how their past impacted on the care of their dependents including their social life. UK midwives have been challenged with different role changes in the past few decades, still it seems that they have stayed receptive to change if it would eventually mean that they would be able to secure quality and sustained services (Lavender, et.al. 2002). They are however concerned about their basic functions on supporting pregnant women sometimes being dismissed or devalued. A survey on midwife perceptions on changes in midwifery indicated that midwives are starting to recognize the gap of midwifery functions with equal impact (Lavender, et.al. 2004). Still, midwives who want to support women with basic care must also be attributed with same status as those who provide care for women with complicated births. As provided in various studies, caseload care for women regardless of their possible risks within the hospital setting is feasible and very much cost-effective. There does not seem to be any difference between caseload midwifery and standard maternity care within primary care setting. However, as discovered by Tracy, et.al. (2013), there is a significant difference in the overall medial cost of birth for women seeking caseload midwifery care. Neonatal results of 7 or less, admission to neonatal care, and preterm birth incidents did not present contrasting results for the groups being studied. Not many women under the caseload group had C-sections (Tracy, et.al. 2013). Caseload midwifery care is a complicated process which requires different elements which can work with and through each other. Such complicated elements can have significant effects on how processes are carried out and how they function. Performance and function are impacted by different elements including higher senior manager support, governance structures, clinical engagement, and cooperation between professionals. These were the different elements in reorganization for the two hospitals in the Tracy, et.al. (2013) study. Efficacy of the model Caseload midwifery is different from standard midwifery care. Caseload midwifery care seems to function well in the maternity structure by supporting and changing the different possibilities which can impact on obstetric intervention (Tracy, et.al. 2013). It functions based on the concept that if women have the chance to work with their midwives as partners, they will likely labour more effectively, stay in hospital for fewer days, and have a better sense of personal control and satisfaction in their delivery. Due to the better interrelationship between the patient and the midwife, the caseload system works better as the system for primary care and for the tertiary setting. Allowing for continuity of care can be difficult process to secure, especially where midwives have become used to working in schedules, and midwifery as well as birth has become accepted partners in care (Tracy, et.al. 2013). For this review, it is revealed how many women under the caseload group have secured their midwives for their care, more so than their standard practice counterparts. While midwives have different levels of discovery, the overall goal has always been consistent. Midwives have long wanted to secure autonomous practice within the setting which allowed for equity in care for most women and job satisfaction for the midwives. Midwives admit that they do not always present the proper picture as role models for students; however, consultant midwives must play a huge role in supporting evidence-based practice under the context of normality. Ball, et.al. (2002) considered close to 2000 midwives who did not notify the Royal Council of Midwifery and Nursing of their desire to practice. The study discovered dissatisfaction in midwifery as a major reason for midwives leaving the profession. Limited communication and clinical support emerged as major issues in the midwifery practice (Ball, et.al. 2002). These midwives discussed limited confidence for women in opting for straightforward pregnancy within the home setting. This, they recognized, was having an impact on their morale. The present desire to secure normal birth (Newburn, 2002) and individuals is very much apparent (Downe, 2001). Still to ensure normal childbirth, midwives must ensure that their confidence is up to par with the confidence of autonomous practitioners. Within the planning stage, different action possibilities were suggested in order to secure an ideal. This was heartening with midwives admitting local issues and also actively wanting to secure solutions. Until these possibilities are indicated, the end-goal would be secured. Some of the action points indicated are often easy to secure. For instance, midwives wanting added support for supervisory and clinical activities. These results also match the project by Garcia (1997) who indicated that about majority of midwives thought that non-midwives must participate more under the postnatal settings. Kotter Change Management Model can be used in order to provide a pathway for change in the midwifery practice, incorporating caseload midwifery into mainstream practice. The first step in this change management process would be to increase the urgency for change. This would entail lobbying on the part of the midwives for change with their administrators and political leaders (Kotter and Cohen, 2002). Providing information to news and the media can also bring much needed attention to the issues surrounding the midwifery practice and how caseloading can help resolve the issue. Media attention can prompt swift action from leaders (Silverstein and Kornacki, 2003). The next step would be to build guiding teams. Such teams would be made up of experts in the field of caseloading. These teams would help guide the midwives and the administrators towards the development of standards in the practice which can later help implement change (Cohen, 2005). It is also important to get the vision right. Under these conditions, specific aims and activities which can map out the changes are a necessary part of the process towards change (Cohen, 2005). As such, caseloading midwifery has to include the specific tasks of the midwives, the tools they would need to improve their practice, and the goals they would have to achieve in order secure change. Communication for buy-in is also an important aspect of the change management model in caseloading midwifery (Bridges, 2003). This would necessitate communicating with the other midwives as well as the patients about their vision and goals and how it can improve their lives. It is important to setup meetings and trainings with midwives under these conditions and to clearly discuss with mothers what caseloading would imply for them (Bridges, 2003). The next step would be difficult as it would require the enabling of action. Plans are easy enough to make, but enabling them to move forward can be difficult. This would require all the members of the team understanding their role in the plan (Cohen, 2005). The aggressive and active participation as well as the willingness of mothers to cooperate and to participate in this program is also essential to the implementation of change. Despite the difficulties expected, smaller goals can be secured with the creation of short-term wins (Silverstein and Kornacki, 2003). This would include the need to break down the bigger goals into smaller ones. The goal of mainstreaming caseload midwifery can be broken down to the passage of legislation for the widespread practice of caseload midwifery. Other short-term wins include the allocation of funds towards the training of midwives in caseloading, this can be followed by the conduct of trainings for midwives in caseloading (Silverstein and Kornacki, 2003). Staying relentless and not letting up in these goals and the achievement of short-term wins would call for the commitment and dedication of midwives and other health advocates, especially mothers who are very much affected by caseloading (Cohen, 2005). In the end, these changes can be made to stick through the specific achievement of goals as well as the cooperation of the teams involved. The assistance of health administrators and legislators can also provide legitimacy to caseload midwifery, ensuring that it can be sustained for a long period of time. Conclusion In general, caseloading supports midwives towards ensuring that the priorities of healthcare would be achieved and the continuity of care would be secured. Moreover, this model of care allows greater autonomy for the midwife and allowing for a deeper relationship with her patients, which ultimately helps mothers make better informed choices about their care. Leadership for the midwife as the primary caregiver for the delivering mothers is important. The Kottberg model provides important steps and activities in which the midwife must participate in order to provide improved patient outcomes. The need and urgency for change must be increased, teams must then be guided towards the appropriate directions for change. Communication for buy-in is also important. Finally, the relentlessness and dedication of the midwife towards change is also important in order to secure the details for caseloading. The sustainability of this model is dependent on clinical efficacy, as well as the profession’s ability to secure an effective place for it to secure change. There is a place for caseload midwifery with effective models like that by Kottberg providing guidelines for implementation, change management, as well as sustainability. References Ball, L., Curtis, P. and Kirkham, M. 2002. Why Do Midwives Leave? London: RCM Publications. Benjamin, Y., Walsh, D. and Taub N. 2001. A comparison of partnership caseload midwifery care with conventional team midwifery care: labour and birth outcomes. Midwifery, pp. 234-240 [online]. Available from: Science Direct. http://0-www.sciencedirect.com.lispac.lsbu.ac.uk/ [Accessed 07 December 2013]. Bridges, W. 2003. Managing Transitions: Making the Most of Change. Cambridge, MA: Perseus Publishing. Cohen, D. 2005. The Heart of Change Field Guide: Tools and Tactics for Leading Change in Your Organization. Boston, MA: Harvard Business School Press. Department of Health, 2000. The NHS Plan: A Plan for Investment, a Plan for Reform. London: HMSO. Downe, S. 2001. Defining normal birth. MIDIRS Midwifery Digest 11, S31–S33. Farmer, E. and Chipperfield, C. 1996. One-to-one midwifery. Modern Midwife, 6(4), pp. 19—21. Fleming, A. and Downe, S. 2007. Narratives from the Blackburn West caseholding team: building up, British Journal of Midwifery, 15 (5), pp. 298-302. Garcia, J. 1997 Changing Midwifery CareFThe Scope for Evaluation: Report of an NHSE-funded Project. Evaluation of New Midwifery Practices. National Perinatal Epidemiology Unit, Oxford. Hartz, D. L., Foureur, M. and Tracy, S. K. 2011. Australian caseload midwifery: The exception or the rule. Women and Birth, 25(1), pp. 39-46. Harvey, S., Jarrell, J., Brant, R., Stainton, C. and Rach D. 1996. A randomized, controlled trial of nurse-midwifery care. Birth, pp. 128—135. Hatem, M., Sandall, J., Devane, D., Soltani, H. and Gates, S. 2008. Midwifery-led versus other models of care delivery for childbearing women. Cochrane Database of Systematic Reviews, 4 Hodnett, E. 2000. Attaining and Maintaining Best Practices in the Use of Caesarean Sections, an Analysis of Four Ontario Hospitals, Report of the Caesarean section Working Group of the Women’s Health Council Hundley, V.A., Cruickshank, F.M. and Milne, J.M. 1995. Satisfaction and continuity of care: staff views of care in a midwife-managed delivery unit. Midwifery 11, pp. 163–173. Information Services Division 2009. Births & Babies. NHS, National Services Scotland. Johnson, M. Stewart, H. Langdon, R. Kelly, P. and Yong, L. 2005. A comparison of the outcomes of partnership caseload midwifery and standard hospital care in low risk mothers. Australian Journal of Advanced Nursing, 22(3), pp. 21—7. Kotter, J. and Cohen, D. 2002. The Heart of Change: Real Life Stories of How People Change Their Organization. Boston, MA: Harvard Business School Press. Lavender, T., Bennett, N., Blundell, J. and Malpass, L. 2002. Redefining the midwifery role: midwives general views. British Journal of Midwifery 10, pp. 72–77. Maternity Services Inter-jurisdictional Committee 2008. Primary Maternity Services in Australia — a framework for implementation. Australian Health Ministers’ Advisory Council. McCourt, C. and Page, L. 1996. Report on the evaluation of one-to-one midwifery. London: Hammersmith Hospitals NHS Trust and TVU. National Health and Medical Research Council 2008. NHMRC additional levels of evidence and grades for recommendations for developers of guideline: Stage 2 consultation. In: Council. NHaMR, editor.: Commonwealth of Australia. National Health Service 1992. Parliamentary Regulations affecting General Practice. General Medical Services (GMS) Amendment Regulations No. 2412. Newburn, M. 2002. A birth policy for the National Childbirth Trust. MIDIRS Midwifery Digest 12, pp. 122–126. Newnham, H. and Pearse, J. 2006. Legal frameworks for practice in Australia and New Zealand. In: Pairman S, Pincombe J, Thoroughgood C, Tracy SK, editors. Midwifery: preparation for practice Marrickville, N.S.W.. Elsevier Churchill Livingstone. Nixon, A., Byrne J. and Church, A. 2003. An evaluation of the set-up of the Northern Women’s Community Midwives Project. South Australia: Northern Metropolitan . Community Health Service. North Staffordshire Changing Childbirth Research 2000. A randomized study of midwifery caseload care and traditional ‘sharedcare’. Midwifery, pp. 295—302. Pankhurst, F. 1997. Caseload midwifery: an evaluation of a pilot scheme. The impact on women, practitioners and practice. Part 2: final report. University of Brighton. Sandall, J. 1998. Occupation burnout in midwives: new ways of working and the relationship between organisational factors and psychological health and well-being. Risk Decision and Policy 3, pp. 213–232. Sandall, J., Davies, J. and Warwick, C. 2001. Evaluation of the Albany midwifery practice: final report, March 2001. London: Florence Nightingale School of Nursing & Midwifery, King’s College. Silversin, J. and Kornacki, M. 2003. Implementing change: from ideas to reality. Fam Pract Management, 10(1), pp. 57-62. Southern Health 2011. Caseload Midwifery. Available at: http://www.monashhealth.org/icms_docs/5699_Caseload_midwifery_care.pdf [Accessed 05 December 2013]. Stevens, T. and McCourt, C. 2001. One-to-one midwifery practice part 1: setting the scene. British Journal of Midwifery 9, pp. 736–740. Swanson, KM. 2010. Introduction to quantitative research. In: LoBiondo-Wood G, Haber J, editors. Nursing research: methods and critical appraisal for evidence-based practice. 7th ed. St. Louis, MO: Mosby/Elsevier. Tracy, S., Hartz, D., Nicholl, M., McCann, Y. and Latta, D. 2005. An integrated service network in maternity; the implementation of a midwifery-led unit. Australian Health Review, 3, pp. 332—339. Tracy, S. K., Hartz, D. L., Tracy, M. B., Allen, J., Forti, A., Hall, B. and Kildea, S. 2013. Caseload midwifery care versus standard maternity care for women of any risk: M@ NGO, a randomised controlled trial. The Lancet, 382(9906), pp. 1723-1732. Turnbull, D., Baghurst, P., Collins, C., Cornwell, C., Nixon, A. and Donnelan-Fernandez, R. 2009. An evaluation of Midwifery Group Practice. Part I: clinical effectiveness. Women and Birth, 22(1), pp. 3—9. Williams, K., Lainchbury, A. and Eagar, K. 2005. The Illawarra Midwifery Group Practice Program; the evaluation of a pilot program to introduce a safe and continuous model of care. Centre for Health Service Development, University of Wollongong. Young, G. 1995. GPs and Home Birth. The Association for Community-based Maternity Care Newsletter, Congleton Read More