Philosophy of the Practice

  • Pregnancy and birth are seen as a normal part of a woman’s life
  • Midwifery care is a trusting, mutually respectful partnership between the woman and her carers
  • Each woman is entitled to get to know the midwives caring for her throughout her pregnancy and childbirth regardless of recognised risk factors, complications or place of birth
  • Women should be able to give birth to their babies in a safe and satisfying way in the place of their choice
  • The midwife ‘follows the woman’, thereby enabling care either at home or in hospital, appropriate to the woman’s needs and choices
  • Women have the right to be given research based information in order to make informed choices throughout pregnancy, birth and the postnatal period

We offered continuity of midwifery care with two known midwives for each woman. These midwives provided antenatal and intrapartum care and postnatal care for up to 28 days.

One mother who had a vaginal birth at home following a previous Caesarean section, made some comments that illustrate the importance to women of this model of care:

Seeing the same person … you’re not afraid. With [my first child] I didn’t know who was going to knock at my door. It’s nice to see the same friendly face. You can also express your feelings more about any problems you may have. Just to know that you know who to contact, and you know who you’re contacting at the same time.

The caseload was generated by local GP practices, with occasional self-referrals, and some referrals from consultant obstetricians at the hospital. We looked after all the women referred to us, regardless of their perceived obstetric, medical, or social risk. Each whole caseload midwife looked after 36 women per year as a primary midwife and a further 36 women as a second midwife; 18 ‘primaries’ and 18 ‘seconds’ for each of the two half caseload midwives. We were on call for our own caseload at all times unless we were on holiday; we had 12 weeks holiday a year, organised well in advance in order to facilitate the allocation of bookings. The women knew that they could contact their midwives at any time if they needed to, but were asked not to call with non-urgent messages after 8 pm or at weekends. We arranged time off between ourselves and liaised with each other for cover for special, unmissable, social or family events. Fundamental to the model were the two support workers, who between them ensured both the smooth day-to-day running of the practice and its continued place in the wider midwifery world. The practice administrator handled referrals and general secretarial work for the midwives, while the manager dealt with media requests, organised workshops, and was the contact point for national and international interest in the Practice.

The practice administrator, who coordinated the bookings according to the midwives’ holidays as the referrals arrived, allocated each woman booked with the Practice a primary and a second midwife. The primary midwife was responsible for the woman’s midwifery care and aimed to keep an overview of her individual situation. This midwife met the woman at home for a first visit during which she took all the booking details and discussed a pattern of care appropriate to the individual woman, including relevant referrals and screening tests. Further antenatal visits were usually at the Practice at a time that was convenient for both the woman and her midwife. The second midwife also built up a relationship with the woman, sharing her antenatal care and attending the Birth Talk visit at around 36 weeks in the woman’s home. The primary midwife arranged any necessary consultations with other professionals and always accompanied a woman on an obstetric visit to act as her advocate. We had a link Consultant Obstetrician with whom we worked very closely, meeting regularly over lunch to review ongoing practices and discuss different aspects of care.

Choice of place of birth was discussed at the booking visit, and women with healthy normal pregnancies were encouraged to keep their options open until labour was established. Home birth was always presented positively, as we knew that for most women this option would optimise their likelihood of having a normal birth and provide an empowering start to their lives as mothers. Throughout the pregnancy the midwives continued to discuss the safety and benefits of home birth, illustrating this with stories and photographs from previously attended births.

Both of the woman’s named midwives planned to attend the birth, the primary midwife calling the second when the birth was near or at any time she felt in need of support. The midwives carried their equipment with them at all times, and planned to visit all women at home in labour, giving them the opportunity to make a final choice about place of birth at this time. In a long labour we shared the care, and tried to ensure that the woman’s primary midwife was with her when her baby was born. The primary midwife provided the majority of the postnatal care, with the second midwife usually doing one visit. We were on call for the women up to 28 days postnatally, and arranged to visit them at home when appropriate during this time, encouraging them to start attending the postnatal group at the Practice when they felt ready.

This model ensured a very high level of continuity of carer: our statistics from the last five years of the Practice show that 84% of women were attended by their primary midwife in labour and a further 10% were attended by their second midwife if their primary midwife was unable to be there (for example if she was with another woman in labour or if the woman was having her baby unexpectedly early or late). 2% of women were cared for in labour by another Albany midwife who was not one of their original named midwives; 2% women gave birth before their midwife arrived, usually at home with a very rapid birth; and 2% either gave birth at another hospital or were attended by a hospital midwife (giving birth very quickly after arriving and perhaps before the Albany midwife arrived).

We each worked with different midwives in the group, which enabled us to develop and maintain a shared philosophy and approach. We enjoyed the opportunity to be together at births, in order to learn from each other and to be able to debrief together. Each midwife organised her own working week depending on births and domestic commitments. Every week we all attended our two Practice meetings and we each had a weekly session at the Practice where we saw the women in our caseload for their antenatal visits. A midwife with a full caseload would attend on average 8 births a month; some would obviously be more difficult or more time-consuming than others, but the total workload eventually evened out.

In this model each midwife is only on call for the women in her own caseload, ensuring that the women know their midwives and the midwives know the women who will be calling them. In the “team” model of care a group of midwives jointly share the care of a large number of women. Women in the team system do not identify with a particular midwife, and often see midwives they haven’t met before. The team model doesn’t provide a high level of continuity of carer, and is associated with high levels of burnout for midwives (Sandall 1997). With an individual caseload model a trusting, respectful relationship is built up between the midwives and the women. This ensures that women rarely call unnecessarily at any time of day or night, making it much easier for their midwives to be on call all the time. One mother said:

But you know the main thing is trust, that’s the main thing. If you meet someone on a regular basis you build this trust within each other, ‘cos to give birth you need to trust the person. Your life is in the midwife’s hands in a way. If I didn’t trust (my midwife) I wouldn’t have listened to her, and I wouldn’t have felt safe to give birth at home, specially after the CS and the way that whole thing went.

We always held regular meetings for support, peer review, skill sharing and to discuss organisational matters with each other and the practice manager. At the start of each week all the midwives and the practice manager met to discuss any Practice business and organisational issues. During this meeting we also had a “How are we?” session where we all shared what had been happening and how we were feeling; this was very important as we were working so closely together. The midwives also met over lunch later in the week to share skills and discuss any interesting clinical issues.

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