Essays

Caseload intervention 

Introduction

Caseload intervention is slowly gaining momentum throughout the world. According to the definition of McLachlan et al. (2012), caseload refers to the care provided by a primary midwife with one or two back-up midwives throughout pregnancy, birth and the early postnatal period. It is also referred to as one-on-one midwifery because a midwife is assigned every client (expectant woman) throughout her pregnancy. Maree et al. (2005) defined the caseload midwifery as a woman under care of one midwife for 24 hours every day. The efficiency brought about by caseloads in maternal interventions has cultivated the connotation that women will survive throughout pregnancy and post pregnancy period.

Many challenges related to pregnancies have emerged because of new lifestyles adopted by women globally and this is evident through maternal deaths that occur either before or during delivery (Stevens & McCourt, 2002). For this reason, the role of midwives, through new intervention models, has been changing with time with the aim of reducing health challenges among expecting and lactating women globally. In this essay, caseload as a maternal intervention and the role of leaders as change agents in launching such intervention has been discussed. This discussion is made in the context of management and motivational theories.

Caseload Intervention Model Analysis

Caseload midwifery is not a new innovation per se because it existed in traditional societies only that the scope and efficiency could have been different. Owing to the efficiency found from caseloads since those immemorial times, many clients have had the urge to try in assurance of survival in their delicate expecting days (Bryant, 2009). It has been argued that caseloads, if introduced early, can help prevent health problems such as potential caesarean section delivery and maternal deaths (McLachlan et al., 2012). The intervention, according to Stevens and McCourt (2002) has also helped midwives control their time and build strong relationships and bonds with their clients. However, some people have also argued that caseload interventions have lacked the penetration ability because of affordability.

Caseload intervention means that an expecting woman is introduced to special care at an early onset of her pregnancy and her condition is closely monitored. Therefore, in introducing caseload to new midwives, change agents may be required to understand the three different models in the intervention and chose the most appropriate. These include one-on-one, partnership and team caseloads. One-on-one caseload according to Tracy et al. (2013) means that one physician is assigned to one client and monitors her condition for 24 hours a day, 7 days a week throughout the intervention period which probably starts at the onset of pregnancy through a few weeks after delivery. Using this strategy for caseload interventions means that the change leader is capable of spending much time with midwives and develop new bonds altogether.

The leader (change agent) may also choose to use partnership caseloads - situations where one client is under observation by one main physician who is assisted by other physicians (often between 2 and 5 physicians) (Varney, 2004). The adoption of this model of case would be applicable if the change agent is interested in information sharing and wishes that clients developed readiness for any midwife attending to them. In this case, the main doctor (midwife) may assign the assistants roles or the roles could be defined at the beginning of the intervention for each of the physicians. In this case, the physicians attend to the client in shifts but making sure that the client is attended to throughout the day. Not very different from partnership, team caseload model is whereby one client is attended to by a team of doctors who conduct their work simultaneous or through consultation and involvement of each other.

Studies have been conducted in relation to the significance of one-on-one, partnership and team caseloads models of midwifery intervention (Maree, et al. 2005; Craven, 2007; Greene, 2012; and Sandall et al, 2013). Maree, et al. (2005) studied 9148 women with interventions for women during labour and birth for two years. 20% of the study population was comprised of a control group that is the intervention was not administered at all. The intervention given comprised of electronic foetal monitoring, induction, analgesia in labour (epidural narcotics), augmentation, cases of episiotomy in maternal outcomes, operative delivery and infant outcomes. Continuity of care was given to these and any other emerging condition 24 hours a day through partnership, team caseload and one-on-one caseload.

Results were measured through the prevalence of complications, perinatal mortality (including stillbirths and neonatal deaths) and number of admissions to intensive care or special baby care units. The findings showed that team caseloads and partnership caseloads occurred through fewer interventions at labour and there was no observable difference in caesarean section rates. However, there was low episiotomy rate with high perineal tears rate. Moreover, there was no difference in terms of the number of babies born with Apgars less than seven and still, there was no difference in the number of babies admitted to special care units (Maree, et al., 2005). This suggests that there are many issues of maternity that team caseloads ignored and that is why results were not satisfactory. The issues could be probably poor coordination, communication, confusion or assumptions hence no much deviation from the standard interventions. From the results, one-on-one caseload model, if introduced by change leaders, would be easily adopted among women who cherish secrecy and confidentiality and therefore more applicable in wealthy clients who have fear for teams of doctors or associating with other patients.

In another study to compare team (seven midwives) and standard care interventions in antenatal, intrapartum and postpartum support to a group of women with low risk, more satisfaction was realized especially in antenatal care and some aspects of continuity care (Edmondson and Walker, 2013). In this study, it seemed that when a group of women were subjected to the same intervention by a team of physician, they tended to gain support and encouragement not only from the medics but also from each other, hence the level of satisfaction. Thus, the aspect of group learning was highlighted as effective in interventions. Group learning can be most accepted in some communities and highly rejected in others. It is therefore the work of the change leader to study midwives before introducing this type of intervention to prevent resistance or rejection.

Another study that was conducted on one-to-one midwifery whereby one doctor executes the intervention to one client all the time showed better results than the above two studies (Hatem, et al., 2008). In this study, it was found that women were more satisfied with the services received in antenatal care, during birth and after birth. There were also very few cases of stillbirths which were anyway realized sometime earlier in the gestation period and the number of children admitted to the intensive care unit was minimal. It can be argued that one-on-one caseload is more effective than partnership or team caseloads (Gottvall, Waldenstrom, Tingstig, Grunewald, 2011). Change leaders in this intervention can therefore consider using one-on-one model for initial intervention and slowly adopt other models of midwifery caseload as this is deemed a better way to ensure the intervention faced little resistance.

The Pros and cons of caseload midwifery intervention

A number of benefits have been realized because of caseload interventions among women under low and high risk and may be realized still if change agents introduce this change in the right manner. According to the data collected in 2004 and 2005 about caseload interventions, it was found that one-on-one caseload was rated satisfactorily by majority of women who received the intervention (Hartz, Foureur & Tracy, 2012). One of the advantages and benefits of this intervention from the research was determined as the freedom of control by the mother such as the ability to choose the place of birth. Conventional care to expecting mothers do not allow freedom to choose the place of birth as this will ordinarily be at home. Although a midwife may assess the situation and advice on place of birth, the clients’ input is often given much consideration. The mother can choose to deliver from home if no complications are detected but should there be need for caesarean; the midwife may explain to the client the need for hospital delivery. From the research by Beake et al (2013), about 17% of patients chose home delivery after assessing their labour while more than 43% chose home delivery at initial stages of pregnancy.

Another advantage of one-on-one caseload has been found to be pain relief to clients. Caseload ensures that a woman receives analgesia on time relieving her of the pain intensity that would be felt under conventional conditions. Analgesia is often a treatment (hydrotherapy) composed of entonox and transcutaneous electrical nerve stimulation (TENS) formula that makes a person fails to recognize the presence of pain in their bodies (Williams et al., 2010). This service is usually presented when a woman under caseload is on labour. In public utilities, demand is usually higher than supply hence the probability of delivery under analgesia is often low. Besides, caseload midwifery, argues Tracy, et al (2011) has the advantage of personal control where a continued relation is created between a woman and the midwife. Thus, a woman is capable of calling her midwife any time she senses danger or a speculation for it during the pregnancy. She also gains more on pain relief management and makes the woman trust other midwives (and her ability to give birth) when she goes to the hospital.

Other advantages of caseloads have been identified as reduced mortalities among women receiving intervention with the number of babies and mothers admitted to intensive care units with birth related problems being lower than expected (Brown and Dietsch, 2012). Boutsikou and Malamitsi-Puchner (2011) also opine there are usually lower cases of caesarean section birth among women under caseload intervention because they are given advise about pregnancy is issues like lifestyles and nutrition early enough.

Although there are not many cons of caseload midwifery, Tracy, et al (2011) point out that in government initiated caseloads, many of the people targeted by the intervention are never reached because the service diverts to the wealthy and relative to the elites. Therefore, high-risk population remains under the risk of maternal complications despite the fact that the government has good plans for them. Another weakness pointed out is reflected in team midwifery caseloads where errors still occur despite special attention (Brown & Dietsch, 2012) thus; team caseload is highly feared by midwives and clients.

The midwife and role of supervisors in caseload midwifery interventions

Once a caseload intervention is set and introduced among targeted midwives, it is important for midwives to work under supervision. Supervisors and midwives play a salient role in ensuring that expecting women are healthy and free from dangers during their engagement period. Some of the dangers that could be associated with lack of intervention include cases of unrealized ectopic pregnancies that may turn wild to the mother at a future date within the pregnancy, miscarriages due to infections in the reproductive system, still births, complications at birth (often solved through caesarean although this can be prevented if earlier discovered) and many others (Yoshida & Sandall, 2013). Midwives in particular are charged with the responsibility of taking care after women and offering support to them whenever needed to protect the life of the mother and her unborn child.

First, a midwife is to offer care and support to the client. According to Ortega, and Tropman (2009), a midwife is a recognized professional who is not only accountable for his/her actions in partnership with women but also responsible for support, advice and care during pregnancy. This primary role of a midwife should be observed at an individual and customized level in relation to caseloads. This includes diagnosis of any problems and complications related to the pregnancy and provision of care in relation to labour and postpartum periods. Besides, the midwife is charged with the responsibility of conducting births to the client and taking care of the infant. In all, a midwife is to make sure that a mother experiences a normal delivery by detecting complications in the mother/child early. This means that the midwife is required to carry out any emergency measures and access medical assistance to the mother.

The second role of midwives in caseloads is to deliver counselling and education to clients. Under caseload, a midwife also has the role of educating the client about childcare at the end of the intervention such as need to immunize the child against all immunizable diseases, breastfeeding advantages, feeding for self and the baby (Hartz, Foureur & Tracy, 2012). Since pregnancy comes about with several ambiguities and stress not only for a woman but also within the community and family, it is the role of the midwife to counsel the woman until everything looks normal to her. Thirdly, the role of the midwife includes building positive relations and engaging families: according to the research of one, Sandall et al. (2013), a one-on-one caseload intervention should ensure easiness and confidence of the mother. This is through engaging the community and family. It is the responsibility of the midwife to ensure that an expecting mother does not get tension, stress or other forms of health challenges from the external environment since this can also be a distress to the health of the unborn child.

A supervisors’ role in all caseload interventions is to provide leadership. Indeed, the supervisor works with many midwives and has to coordinate their functionality. For instance, the supervisor has to make sure that all clients are attended to by making appropriate schedules for home or hospital care and making sure that the services provided are customized to the client as much as possible. Thus, because of the 24 hour services required, there is always need for shift management, a role given to the supervisor (Edmondson & Walker, 2013). If shifts are not well coordinated, midwives may be overwhelmed and may not carry out their functions effectively.

It is also the work of the supervisor to train the midwives and prepare them for field experiences especially when clients are those of high risk because they may require specialized care and support. Training involves a restatement of work ethics especially to midwives deployed to homes of their clients. In fact, midwife supervisors need to train and engage their staff as means to workload management and reducing turnover because as Edmondson and Walker (2013) argue, midwives with big workloads often get away from the maternal facilities and care centres. The training is also a move to make workers (midwives) deliver quality educating them on the need to observe timeliness, quality of service and continuity. According to Juby and Scannapieco (2007), good supervision is helpful to midwives as it helps them gain requisite knowledge and skills for efficiency. Zlotnik et al. (2005) adds that supervisors in case loads improve caseload intervention through coaching initiatives, training, feedback communication, and offering mentoring opportunities.

Conclusion

This study was conducted to explore the caseload model of midwifery intervention among vulnerable and high-risk women during their pregnancy period. From the analysis of the models, leadership and change management theories, this study found out that caseload intervention of much benefit among women for promoting equity and equality in medical service provision especially among women who would have otherwise suffered pregnancy complications. Caseloads have also been found effective in reducing maternal related deaths and increasing the scope for which women make decisions regarding childbirth. With the efficiency of the model, it is a noble idea if it spread to as many communities as possible. As much as this study supports caseload adoption in as many communities as possible, it also calls upon for support from government machineries for a smoother adoption process.

Reference List

Beake, S., Acosta, L., Cooke, P., & McCourt, C. 2013. Caseload midwifery in a multi-ethnic community: The women's experiences. Midwifery, 1(1), p.1-19

Boutsikou, T, Malamitsi-Puchner, A. 2011. Caesarean section: impact on mother and child. Acta Paediatr; 100, p.1518–22.

Brown, M., & Dietsch, E., 2012. The feasibility of caseload midwifery in rural Australia: A literature review. Women and Birth.

Bryant, R., 2009. Improving Maternity Services in Australia: The report of the Maternity Services Review. Canberra: Commonwealth of Australia.

Children’s Bureau, U.S. Department of Health and Human Services., 2008. Arizona Child and Family Services Review: Final report. [PDF] Available at https://www.azdes.gov/InternetFiles/Reports/pdf/az_child_family_services_review_2008.pdf. [Accessed 25 November, 2013]

Craven, C., 2007.  A “Consumer’s Right” to Choose a Midwife: Shifting Meanings for Reproductive Rights under Neoliberalism. American Anthropologist. 109(4), p.701–712.

Edmondson, M. C., and Walker, S.B., 2013. Working in caseload midwifery care: The experience of midwives working in a birth centre in North Queensland. Women and Birth, p.1-12

Gottvall, K, Waldenstrom, U., Tingstig, C. and Grunewald, C., 2011. In-hospital birth center with the same medical guidelines as standard care: a comparative study of obstetric interventions and outcomes. Birth 38, p.120–8.

Greene, M.F., 2012. Two Hundred Years of Progress in the Practice of Midwifery. New England Journal of Medicine 367(18): p.1732–1740.

Hartz, D.L., Foureur, M., & Tracy, S. K., 2012. Australian caseload midwifery: The exception or the rule. Women and Birth, 25(1), p.39-46.

Hatem, M., Sandall, J., Devane, D., Soltani, H. and Gates, S., 2008. Midwife-led versus other models of care for childbearing women. Cochrane Database System Review 4: CD004667.

Juby, C., & Scannapieco, M., 2007. Characteristics of workload management in public child welfare agencies. Administration in Social Work, 31(3), p.95-109

Kritsonis, A., 2005. Comparison Of Change Theories. International Journal Of Scholarly Academic Intellectual Diversity, 8(1) 2004-2005. Available at < http://qiroadmap.org/?wpfb_dl=12 > [Accessed 4^th Dec 2013]

Lawler, E. and Christopher, G. W., 2006. Winning Support for Organizational Change: Designing employee reward system that keeps on working. Ivey Business Journal Online. March-April 2006.

Lippitt, R., Watson, J., Westley, B., & Spalding, W. B. 1958. The dynamics of planned change: a comparative study of principles and techniques. Harcourt, Brace & World.

Maree, J., et al., 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), p.21-27

McLachlan H, Forster D, Davey M, Farrell T, Gold L, Biro M, Albers L, Flood M, Oats J, Waldenstro¨m, U., 2012. Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomized controlled trial. BJOG. DOI: 10.1111/j.1471-0528.2012.03446.x.

Sandall, J., Soltani, H., Gates, S., Shennan, A. and Devane, D., 2013. Midwife-led continuity models versus other models of care for childbearing women. In Sandall, J., Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD004667.pub3.

Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D., 2013. Midwife-led continuity models versus other models of care for childbearing women. British Journal of Midwifery, 14(4) p.101-117

Tracy, S., Hartz, D., Hall, B., Allen, J., Forti, A., Lainchbury, A. and Kildea, S., 2011. A randomised controlled trial of caseload midwifery care: MANGO (Midwives New Group practice Options). BMC pregnancy and childbirth, 11(1), p.82.

Tracy, S.K. et al., 2013. Caseload midwifery care versus standard maternity care for women of any risk: MANGO, a randomised controlled trial. The Lancet 382 (9906), p.1723.

Varney, H. 2004. Varney's midwifery (4th ed.). Sudbury, Mass.: Jones and Bartlett. p. 7.

Williams, K., Lago, L., Lainchbury, A., and Eagar, K., 2010. Mothers’ views of caseload midwifery and the value of continuity of care at an Australian regional hospital. Midwifery, 26(6), p.615-621.

Yoshida, Y. and Sandall, J., 2013. Occupational burnout and work factors in community and hospital midwives: A survey analysis. Midwifery 1(1).

Zlotnik, J.L., DePanfilis, D., Daining, C. and Lane, M.M., 2005. Factors influencing retention of child welfare staff: A systematic review of research. [PDF] available at the Institute for the Advancement of Social Work Research website <www.charityadvantage.com/iaswr/FinalReportCWWI.pdf> [Accessed 25 November 2013]