Midwifery Team Research Articles

Stress in midwifery practice: an empirical study

This research was undertaken in a maternity unit in spring 2000. Team midwifery had been fully implemented, and midwifery-led care was expanding. The sickness levels attributed to stress had risen sharply in the unit since implementation of the changes in working practices resulting from the Cumberlege recommendations. The staff believed that ‘change’ had led to stress, and thus to sickness. The aim of the study was to identify the contribution that change and other external and internal factors have had on the stress levels of the midwives working within the unit. Questionnaires were issued to assess life changes and stress levels. The results indicate that the perception of stress is far greater than the reality. Only 6% of midwives scored high on their stress analysis questionnaire. Stress perception was increased by having children at home, working part-time and working in a team. Recurring life events were also present in the stressed group. Occupational stress can often be linked to the personality of the individual. Home related stress often resulted as a consequence of trying to juggle work and home commitments. Interpersonal coping mechanisms and individual personality had the greatest affect on perception of, and ability to cope with potentially stressful situations. The amount of change needed to produce a stress response will vary from person to person and is related to their personality rather than the amount of change per se. The appropriateness of organisational initiatives such as worker support schemes, stress counsellors, and stress awareness schemes are questioned. These measures have not been beneficial to this group. Greater input into personality awareness and self awareness, linked to coping strategies may provide a more constructive approach.

A comparison of partnership caseload midwifery care with conventional team midwifery care: labour and birth outcomes

Objectives: to compare the effects of partnership caseload midwifery care, with conventional team midwifery care. Comparisons of labour interventions and birth outcomes were made between the two models of care.Design: a prospective, non-randomised clinical trial.Setting: Women's Hospital at Leicester Royal Infirmary, Leicester, UK in 1998.Participants: 303 women from the experimental group and 308 from the control group (611 in total) matched for age, ethnicity, marital status, parity, gravida and height who gave birth between April 1997 and August 1998.Intervention: the control group received conventional team midwifery care during pregnancy, labour and birth, and the experimental group received care from midwives working in partnerships that provided continuity of care during pregnancy, labour and birth.Key findings: 21% of women in the experimental group had an epidural compared with 32% of the controls (OR 0.56 95%, CI 0.39–0.81, P=0.002). The normal vaginal birth rate (74% v 66%, OR 1.45, 95% CI 1.02–2.05, P=0.038), upright birth posture rate (60% v 14%, OR 9.64, 95% CI 5.96–15.61, P=<0.001), intact perineum rate (40% v 30%, OR 1.57, 95% CI 1.05–2.35, P=0.027), and physiological third stage rate (37% v 1.5%, OR 38.69, 95% CI 11.98–124.89, P=<0.001) were significantly higher in the experimental group. The induction of labour rate (16% v 23%, OR 0.66, 95% CI 0.44–0.98,P =0.042) was significantly lower in the experimental group. Women in the experimental group had more home births (17% v 1.3%, OR 15.38. 95% CI 5.48–43.14, P=<0.001); used the midwife-led birthing suite more often (28% v 12%, OR 2.77, 95% CI 1.82–4.22, P=<0.001); were more likely to take an early discharge (two to six hours) from hospital following birth (25% v 3%, OR 11.32. 95% CI 5.55–23.06, P=<0.001); and were attended in birth more often by either their named midwife (67% v 5%, OR 39.65, 95% CI 22.38–70.25, P=<0.001) or her partner (known midwife) (84% v 14%, OR 32.74, CI 20.96–51.14, P=<0.001).Implications for practice: partnership caseload midwifery care resulted in less interventionist labour and more normal birth than conventional team midwifery care. Women in the experimental group had more home births, birth in a midwife-led suite and opted for early discharge home postnatally more often than the controls. They also experienced much higher levels of continuity, particularly of a known midwife during labour and birth. The study findings should encourage other maternity units in the UK to pilot and evaluate the model to see if these benefits are transferable.

Made-to-measure midwives

Since the concept of domino care in the 1970s and the pioneering work of Caroline Flint in the 1980s, midwives have sought to deliver maternity care in a number of ways and patterns. Briefly, these include team midwifery, domino scheme, caseload managed care, shared care and midwifery-led care.

Continuity of care in maternity services: women's views of one team midwifery scheme

Objective: to describe the views of women using one team midwifery scheme and compare them with women using more traditional models of midwifery care.Design: postal and interview survey of 1482 consecutive women delivering over a six-month period.Setting: Hospital and community in the South-East of EnglandSamples: three groups of women were surveyed: (1) the Study Group consisted of women who delivered either at Hospital A or at home, and who received their antenatal, intrapartum and postnatal care from one of seven midwifery teams; (2) Comparison Group A consisted of women who received their antenatal and postnatal care from traditionally organised community midwives who were delivered by hospital midwives at Hospital A; and (3) Comparison Group B consisted of women who received their antenatal and postnatal care from traditionally organised community midwives who were delivered by hospital midwives at Hospital B.Methods: postal questionnaires and interviews, and an audit of midwife contacts.Main outcome measures: process of care and satisfaction with care.Findings: 88% of women responded. Women cared for under the team scheme exhibited no overall advantages in terms of satisfaction with various aspects of their care. Women cared for under the traditional model of care were the most satisfied with antenatal care. They had reported the highest percentage of named midwives, the highest continuity of carer antenatally and were the most likely to say that they had formed a relationship with their midwives. The majority of women who had met their delivering midwives previously did report that it made them feel more at ease, however, the majority of those who had not met their delivering midwives previously reported that it did not affect them one way or the other.Conclusion: in the team scheme, attempts to increase continuity of carer throughout pregnancy, labour and the postnatal period appear to have occurred at the expense of continuity in the ante- and postnatal periods. From the women's perspective the findings of this study support the view that the smaller the size of midwifery teams the better. The current focus on continuity throughout pregnancy and childbirth and the postnatal period may be misguided, if it is provided at the expense of continuity of carer in pregnancy and the postnatal period.

The impact of team midwifery on GPs

Many GPs in the UK have faced changes in midwifery service provision following the publication of Changing Childbirth (Department of Health, 1993). However, there is little documented evidence of how new midwifery schemes have affected the work of GPs. This study investigated: GPs' satisfaction with the current maternity and midwifery services; their views of the effects of team midwifery on GPs, midwives and women and whether it improved the maternity service; and assessed their training needs in relation to team midwifery. All GPs received a survey. Ten GPs associated with the team midwifery scheme were also interviewed. A total of 87 (50%) surveys were returned. Most GPs who responded were satisfied with current maternity and midwifery service provision. Most surgeries (66%) mainly provided shared care, the preferred mode of care delivery for 74% of respondents. Similar aspects for praise and criticism of either midwifery scheme were raised with communication figuring prominently at both extremes. Views of team midwifery ranged from support of the philosophy behind the scheme to anxieties about the GPs' role in maternity care. Fewer respondents thought team midwifery was better for GPs (48%), than for midwives (59%) or women (60%). Those without direct experience of team midwifery were more likely to think that GPs needed training in response to the implementation of team midwifery.

An evaluation of team midwifery

This article describes an evaluation of a pilot scheme of team midwifery which was implemented in response to a local drive to improve care within a budget and the recommendations set out in Changing Childbirth (Department of Health, 1993). the main focus of the paper is on women's perspectives of the pilot scheme and the traditional midwifery system regarding continuity of care and satisfaction with the service. The findings of the evaluation revealed ambivalence toward continuity of intrapartum care and equivalence in most satisfaction ratings between the two systems. The future of team midwifery at this trust remains uncertain within this context of differing priorities and prteferences of women for continuity of care and service provision in addition to limited financial resources.

Team midwifery: The views and job satisfaction of midwives

Objective: as part of an evaluation of a team midwifery scheme we assessed the satisfaction of community and hospital midwives and their views about working practices and care provided. Design: survey of complete enumeration of community midwives (most working in teams) and hospital midwives providing antenatal, intrapartum and postnatal care to a population of women. Setting: community and district general hospital, in the UK. Measurements: socio-demographic data about midwives, ratings on Likert-type scales of job satisfaction, quality of care variables, relationships with other professionals and women; Glasgow Midwifery Process Questionnaire. Findings: 80 out of 92 midwives (87%) responded. Community midwives were younger, more recently qualified, employed on lower grades, less likely to be married and have children than hospital midwives. The Glasgow Midwifery Process Questionnaire revealed that midwives, particularly hospital midwives, had low morale. Community midwives were more likely to report that their job was satisfying, offered a variety of work, enabled them to use skills and knowledge fully, and offered opportunities for professional development. Hospital midwives were more likely to report following strict guidelines. Community midwives, however, disliked the long on call and unsociable hours, and reported disruption to family/social life. Forty-one per cent of hospital midwives (12) and 28% of community midwives (14) reported regularly working beyond their shift. Whilst midwives thought that team midwifery was, in theory, a good idea, in practice it was not working well because of the size of teams and caseload. About half the community midwives felt that teams had detrimentally affected the quality and continuity of care. Conclusions: whilst team midwifery aims to improve continuity of maternity care, in this instance, it does not appear to achieve this aim. Many midwives reported it had adversely affected care. Team midwifery is a source of disillusionment for midwives, since the continuity of carer ideal is unachievable in a system based on teams of seven or more. Attendance at the delivery may be a luxury provided at the expense of antenatal and postnatal continuity. Implications: midwives recommended remedial measures: reducing team sizes, reducing caseloads, ensuring teams were fully staffed, reducing ‘on call’ and labour ward hours. It remains to be seen whether these will have the desired effects on continuity of care.

Team midwifery: the influence of the midwife-woman relationship on women's experiences and perceptions of maternity care.

The need to provide woman-centred maternity services which take account of womens' views and specifically address their need for choice, control and continuity has been advocated and team midwifery has been suggested as one of the ways to achieve these objectives. This paper explores women's descriptions of their maternity care experiences in England, specifically focusing on: their experiences of communication; being informed and making choices; being involved in the process of care; and their own perceptions of care. It is suggested that the midwife-woman relationship is an important aspect of satisfaction which needs greater recognition. Analysis of the data highlighted the importance of the quality of women's relationships with caregivers. Findings revealed how positive relationships facilitated conditions which influenced satisfaction with care and suggest that, for the development of genuine woman-centred services where women exercise informed choice, and are involved in, and have some control over, the process of care, the nature and quality of the midwife-woman relationship must be accepted as an integral and crucial aspect of the service.

Working with team midwifery: health visitors' views of one team midwifery scheme.

The fragmented nature of maternity services in the UK has led to the introduction of various forms of team midwifery scheme. The aim of such schemes is usually to increase continuity through the provision of antenatal, intrapartum and postnatal care to women by a small team of midwives. Few published studies of this organization of midwifery care exist, and even fewer consider the impact of such schemes on related health professionals. This paper presents the results of an independent survey of health visitors working alongside one team midwifery scheme in the south-east of England. Eighty per cent of the health visitors thought that team midwifery was a good idea in theory; however, just 27% thought it was working well locally and 70% reported that they would like to go back to working in the way they did before the introduction of team midwifery. The survey highlighted the health visitors' concerns in relation to team midwifery locally. Two issues were paramount: firstly a reported deterioration in interdisciplinary communications, and secondly a perceived loss of continuity for the women. Thus team midwifery, as implemented in this locality, may not attain the goals aimed at by the organization of care in this way.

Planning midwifery services to deliver continuity of care

This paper describes a simulation model of maternity services which was developed to support the planning of midwifery services to meet demands for continuity of care. A Government report of maternity services in 1992 emphasised the need to replace the fragmented care offered to pregnant women by a more personalised type of approach. One way of doing this is by the implementation of team midwifery in which care is provided, antenatally, during labour, and then postnatally by either the same midwife or, more usually a small team of midwives.The model described in this paper attempts to assess the effects of team size upon the continuity of care provided to pregnant women under different implementations. Continuity is measured in terms of the percentage of occasions a team midwife will be available to meet the health care demands of pregnant women. The model may be used not only for the evaluation of services already in use, but also for the planning of alternative and better services.

Misplaced values: in fear of excellence

Over the last few years, a shift to a new midwifery, and the renewal of the midwifery profession seemed certain. Now, a constant resistance to success, a ‘fear of excellence’, casts doubt on this renewal. The new midwifery, which is explicitly woman and family centred, started in the 1980s with the development of team midwifery.

The demise of the traditional community midwife

As Changing Childbirth brings new initiatives into the midwifery profession the personal and financial cost of continuity of carer schemes requires urgent review. An enhancement of the role of the traditional community midwife could provide a care system of the highest quality. If so, there is a need to change the indicator of success advocating a known midwife for delivery which necessitates the establishment of team or caseload midwifery.

Trial of scar-team midwifery makes a difference

‘Once, and certainly twice, a caesar always a caesar.’ Where is the evidence to support this often expressed belief? As discussed by Roberts (1991) this is simply an opinion and not based on any form of scientific inquiry. This article describes two women requesting a vaginal delivery, one having had two, and the other, three previous Caesarean Sections. The doctors they had approached were unwilling to support them in their request and they had been told they would be unable to have a vaginal delivery. Both women decided to utilise the hospital's Team Midwifery service for their antenatal and intrapartum care and found the team, together with one of the hospital Registrars, sympathetic to their wishes. Carefully coordinated communication between these groups, and a supportive working relationship, enabled both women to have their vaginal delivery, one of which involved a twin birth. These are the type of services and support that should be available to all women.

Midwives and general practitioners: to be or not to be a team?

We hear a lot about teams in maternity care: hospital teams, midwifery teams, consultant teams and primary health care teams, to name but a few. Why, when the basis of such care is the one-to-one carer-patient relationship, based on the consultation?

Changes in midwives' attitudes to their professional role following the implementation of the midwifery development unit

Objective: to examine changes in midwives' attitudes to their professional role following the implementation of the midwifery development unit (MDU). Design: prospective cohort study. Setting: the MDU is based at a major teaching hospital in Glasgow, UK. The MDU midwives provide care via a new self-rostering system which is intended to improve continuity of care. Midwives aim to provide total care for each woman from the antenatal period through delivery and the postnatal period. Participants: 21 midwives who joined the MDU were compared with a group of 64 midwives at the hospital who were also eligible and who continued in their usual pattern of work (non-MDU midwives). Measurements: an audit questionnaire was distributed to MDU and non-MDU midwives prior to the implementation of the unit and about 15 months afterwards. In addition, the MDU midwives were sent the questionnaire every three months. Extra questions were added at each time period in order to identify specific problems. This information was then fed back to the midwifery management team to aid in the planning and implementation of the care programme. Findings: the MDU midwives experienced a significant positive change in attitudes; no significant change was evident for the non-MDU group. There was no evidence of increased stress in the MDU midwives. In general, both groups of midwives had positive attitudes towards the unit and felt that MDU-style care had a role to play in the future provision of maternity care. A number of areas of concern were also highlighted, such as the sytem of liaison with colleagues. Conclusions: innovative models of midwifery care such as an MDU can have a positive impact on midwives' attitudes towards their professional role. Implications for practice: if change is managed in a systematic manner which involves the midwives, it may be possible to increase midwives' professional satisfaction, while at the same time minimising any negative effects such as increased stress.

Midwifery team approach with the coffee morning network

In an attempt to provide mothers-tobe with better antenatal care, and to encourage greater interaction between midwives and patients, Southlands Hospital set up a coffee morning network. This article discusses how the scheme has fared.

Book Review: Midwifery Teams &amp; Caseloads

Book Review: Midwifery Teams &amp; Caseloads

Mapping midwifery employment patterns.

Studies suggest that team midwifery should not he seen as a panacea, reports James Buchan

Book reviews

Midwifery Teams and Caseloads You can Teach your Child to Read Contraception—Your Questions Answered (2nd edn)

Changing childbirth. Domino schemes preferable to team midwifery.

Changing childbirth. Domino schemes preferable to team midwifery.