Midwife to midwíf : a study of caseload midwifery
This thesis explores the implications of individual caseload practice for midwives. Over the past fifty years childbirth in England has become predominantly hospital oriented, with midwives forced to meet the needs of the institution rather than those of childbearing women. In 1994, a change in government policy for the maternity services attempted to address the dissatisfaction felt by mothers and midwives. The model for caseload midwifery was developed from their recommendations. Midwifery retains an ideology of independent practice yet the reality of working in a subservient position to obstetricians and controlled by the dictates of an institution have been seen in some studies to have undermined midwives' practice. However, their willingness and ability to work in a more independent manner was questioned. This study explored the implementation of caseload midwifery within a highly medicalised inner-city NHS maternity service. Working in partnership, within small groups, each midwife carried a caseload of 40 women per year. No longer based in the conventional hospital or community services, the midwives worked where and when appropriate, to meet the needs of their women. The research was undertaken over 46 months using an ethnographic approach and a variety of data collection methods. The prolonged study period facilitated an understanding of the development of caseload practice from its implementation into an established service. This thesis explores the adaptations the midwives needed to make on moving from conventional practice into caseload practice. Comparison of the difference services offers an understanding of the ways in which organisational features can influence the practice and meaning of midwifery. The control over and uses of time emerged as an important theme in this regard. Of particular note was the high level of job satisfaction expressed by the caseload midwives and their consideration that this model enabled them to practice "real midwifery", phenomena which are explored within the thesis. In working 'with' women, it is argued, the midwives developed a form of authority that had not been facilitated with the conventional services, and which contributed towards a new form of professionalism for the midwives. Although considered by many to be independent and 'isolationist', the strengths of caseload practice were seen to be in the context of group and inter-professional relationships, and the relationships midwives formed with mothers and their families as their work became re-embedded in the society in which childbirth occurred and had its meaning.