Implementing managers in Australia – A national …...managers in Australia – A national cross-sectional survey Kate Dawsona,b,*, Helen McLachlana,b, Michelle Newtona,b, Della

Women and Birth 29 (2016) 214–222

ORIGINAL RESEARCH – QUANTITATIVE

Implementing caseload midwifery: Exploring the views of maternitymanagers in Australia – A national cross-sectional survey

Kate Dawson a,b,*, Helen McLachlan a,b, Michelle Newton a,b, Della Forster b,c

a School of Nursing and Midwifery La Trobe University, Bundoora 3086, Australiab Judith Lumley Centre, La Trobe University, 215 Franklin St, Melbourne 3000, Australiac The Royal Women’s Hospital, 20 Flemington Road, Parkville 3052, Australia

A R T I C L E I N F O

Article history:

Received 24 August 2015

Received in revised form 22 October 2015

Accepted 22 October 2015

Keywords:

Caseload midwifery

Sustainability

Maternity workforce

Continuity of care model

Australian maternity service

A B S T R A C T

Background: The benefits of caseload midwifery care are clearly documented, and many policy

documents in Australia support its expansion. Despite this, little is known about the availability of

caseload across Australia, nor about what proportion of women have access to a caseload model. This

paper describes caseload midwifery in the public maternity system in Australia; its prevalence, and

factors associated with implementation and sustainability.

Methods: A cross-sectional online survey of maternity managers of public hospitals that provide birthing

services throughout Australia.

Findings: Sixty-three percent (149/235) of eligible participants responded. Respondents were from all

states and territories, metropolitan, regional and remote areas, and from hospitals with very small to

very large birth numbers. Only 31% reported that their hospital offers caseload midwifery, and an

estimated eight percent of women received caseload care at the time of the survey, most of whom were

considered to be of ‘low obstetric risk’. Many respondents were planning to implement or expand

caseload. Key factors associated with the implementation of caseload were funding to establish the

model, the interest and availability of staff to work in the model, organisational support and perceived

consumer demand.

Conclusion: This is the first study to explore caseload implementation at a national level. Although the

number of services offering caseload midwifery care has increased nationally, access remains relatively

limited. Women who live in metropolitan areas and who are considered at ‘low obstetric risk’ are most

likely to be able to access this model. Funding and support for establishing new models are the main

barriers to implementation.

� 2015 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Contents lists available at ScienceDirect

Women and Birth

jo u rn al h om ep age: w ww.els evier .c o m/lo c ate /wo mb i

Summary of relevance:

Problem

Little is known about the availability of caseload across Australia

and the enablers and barriers to its further introduction and

expansion.

What is already known

The many benefits of providing caseload midwifery care are

clearly documented, and many policy documents in Australia

support its expansion.

* Corresponding author at: Judith Lumley Centre, La Trobe University,

215 Franklin St, Melbourne 3000, Australia. Tel.: +61 03 9479 2203.

E-mail address: [email protected] (K. Dawson).

http://dx.doi.org/10.1016/j.wombi.2015.10.010

1871-5192/� 2015 Australian College of Midwives. Published by Elsevier Ltd. All right

What this paper adds

This paper provides a snapshot of caseload midwifery in the

public maternity system in Australia, including its prevalence,

factors associated with its implementation and sustainability,

and potential factors that enable or hinder implementation of

the caseload model.

1. Background

Maternity care policies in Australia recommend providingwomen with continuity of care for pregnancy and birth.1–5 Thesepolicies reflect the large body of evidence that has demonstrated

s reserved.

K. Dawson et al. / Women and Birth 29 (2016) 214–222 215

that women who receive continuity of care have fewer childbirthinterventions (e.g. caesarean section), increased satisfaction withcare,6,7 and in the context of caseload midwifery,7,8 no evidence ofadverse outcomes associated with providing caseload care towomen, even among women of mixed obstetric risk.8 Continuity ofcare incorporates models such as team midwifery and caseloadmidwifery. Caseload midwifery care (also known as Midwiferygroup practice (MGP), Know your midwife (KYM) and one to onemidwifery) aims to provide women with care from a knownmidwife throughout pregnancy, labour, birth and into thepostnatal period.

Given the evidence of improved outcomes for women, it is alsoimportant to consider staff views of this model of care. Theliterature discusses issues associated with caseload work includ-ing, burnout9,10 and work life balance.9,11–15 Conversely a recentAustralian study found that midwives working in continuity ofcare models may benefit from caseload, with increased profes-sional satisfaction and lower burnout scores when compared totheir non-caseload colleagues.16

Despite the evidence of the benefits of continuity of care, accessto this model of care is still limited.5 Potential benefits of thecaseload model are not limited only to improved clinicaloutcomes; it has also been suggested that caseload midwiferycould assist in keeping smaller maternity services open in the ruraland regional areas and possibly enable some maternity servicesthat have closed to re-open.17,18 However, there is limitedinformation on the availability of caseload midwifery acrossAustralia, and no studies were identified that have explored, at anational level, issues related to sustainability and potentialexpansion of the model.

A number of Australian reports describe factors that havecontributed to the successful introduction of caseload pro-grams.19–21 Factors identified in relation to the sustainability ofcaseload include, engagement and support at all levels within thehospital/service; strong support from the community; keystakeholder engagement and support, including ‘champions’who will drive implementation; a belief in woman-centredmidwife-led care; support for midwives to be able to sustainautonomy and flexibility including occupational and personalsupport; clear boundaries within the model; adequate cover forextended leave; adequate remuneration; and a clear role formanagers within this new way of working.19–21

Given the lack of national data, we conducted a study (ECO –Exploring CaselOad midwifery in Australia) which explored theintroduction, expansion and sustainability of caseload in Australia.The views of maternity managers, midwives, and midwiferystudents have been sought, and aspects explored included enablersand barriers to the implementation, expansion and sustainabilityof caseload midwifery, as well as an exploration of existingcaseload models across the country, and how the models areconfigured. This paper presents data from one component of theECO study; the survey of maternity managers. It aims to provide asnapshot of caseload midwifery in the public maternity system inAustralia (where two thirds of maternity care is provided22),including its prevalence, factors associated with its implementa-tion and sustainability, and potential factors that enable or hinderimplementation of the caseload model.

2. Methods

This study used a cross-sectional survey design.

2.1. Participants

Public maternity hospitals in Australia were identified usingthe ‘My Hospitals’ website,23 an Australian Government website

which provides information on public hospital services through-out Australia, and lists the number of admissions for childbirthat each hospital. ‘My Hospitals’ was searched in early March2012 to determine which hospitals had births in 2011. Publichospitals which provided ‘planned’ birthing care to women wereincluded, thus, hospitals with a maternity service but without abirthing service were excluded from the study, with theexception of one hospital that was reintroducing a birthingservice through introduction of a caseload model. For hospitalswith a low number of births (less than 50 as per the ‘MyHospitals’ site), phone contact was made to determine if therewas actually a birthing service at the hospital, as very smallbirth numbers could have been the result of births occurring en-route to another hospital where the birth had been ‘planned’. Alleligible hospitals were contacted by phone to obtain the emaildetails of the maternity manager, in order to invite them toparticipate.

2.2. Data collection tools

An online survey tool was developed specifically forthe study, informed by the data tools and findings of aprevious study of midwives’ experiences of caseload.24 Thesurvey explored the characteristics of the hospital, existingmodels of midwifery-led care, respondents’ views and inten-tions regarding caseload, and where caseload models alreadyexisted, the operation, structure and functioning of themodels. The survey contained open- and closed-ended questionsas well as Likert-type scales where respondents were requiredto select from a five-point response scale. Response optionsused were: ‘Strongly agree’, ‘Agree’, ‘Neither agree nor disagree’,‘Disagree’, ‘Strongly disagree’. The survey was designed tohave embedded skips, enabling the completion of the surveyto be responsive to certain questions about caseload, thusenabling appropriate questions to hospitals with or without thatmodel.

Four rounds of piloting of the survey were undertaken withresearchers, midwifery academics and midwifery managerswithin the research team’s professional network. Changeswere made following each round of piloting, then the surveyfinalised.

The survey was distributed by an email with an embeddedlink to Survey Monkey.25 The email was sent to maternitymanagers of the eligible public maternity hospitals betweenFebruary and April 2013. Reminders were sent by email at twoand four weeks following the initial invitation to participate.Return of the survey was considered consent to participate in thestudy.

2.3. Data management and analysis

Data were downloaded from Survey Monkey25 into an Excelspreadsheet26 and then transferred into STATA version 11.27 Datacleaning included range and logic checks, and where possibleinaccuracies that were identified were corrected. Descriptiveanalysis was undertaken and frequencies and proportions pre-sented. Open-ended questions were analysed using contentanalysis.28 The responses were coded then collapsed into categoriesand then into themes. Agreement on coding, categories and themeswere undertaken by two of the authors. Ethics approval was grantedby the institutional ethics committees, in September 2012.

3. Results

An overview of results is presented first, then the findingsdiscussed in three sections; hospitals not intending to set up a

Table 1Characteristics of responding hospitals (n = 149).

Responding

hospitals

Hospitals with a

caseload model

n % n %

State/Territory (n = 135)ACT 1 0.7 0/1 0

NSW 41 30.4 9/41 22.0

NT 3 2.2 2/3 66.7

QLD 22 16.3 9/22 40.9

SA 17 12.6 6/17 35.3

TAS 2 1.5 1/2 50.0

VIC 36 26.7 15/36 41.7

WA 13 9.6 1/13 7.7

Hospital location (n = 144)Major city 23 16.6 14/23 60.9

Inner regional 31 20.1 10/31 32.3

Outer regional 48 34.5 12/48 25.0

Remote 39 26.6 7/39 17.9

Very remote 3 2.2 1/3 33.3

Births in 2012 (n = 142)1–100 28 19.7 8/28 28.6

101–500 54 38.0 9/54 16.7

501–1000 20 14.1 5/20 25.0

1001–2000 16 11.3 7/16 43.8

2001–9000 24 16.9 15/24 62.5

Existing midwifery led maternity models of care (n = 143)Midwifery-led antenatal care 79 55.2 – –

Caseload 44 30.8 – –

Team midwifery 41 28.7 – –

Birth centre (within a hospital) 11 7.7 – –

Public home birth

(within a caseload model)

8 5.6 – –

Public home birth

(not within caseload)

5 3.5 – –

Free standing birth centre 2 1.4 – –

K. Dawson et al. / Women and Birth 29 (2016) 214–222216

caseload model, hospitals planning to set up a caseload model inthe future and hospitals with a caseload model at the time of thesurvey.

3.1. Availability of caseload models in Australia

Of the 331 public hospitals in Australia that were identified ashaving had births in 2011, 79 hospitals did not have a birthingservice, leaving 252 hospitals eligible to participate. Followingdistribution of the invitation to participate in the study a further17 hospitals were excluded; 13 because they no longer had abirthing service, and four were campuses of larger hospitals. Thisleft a total of 235 eligible hospitals invited to participate (Fig. 1).The response rate was 63% (149/235).

Respondent hospitals were from all states and territories(including approximately half of all eligible hospitals in each stateand territory invited to participate), every geographical region, andrepresented a variety of sizes throughout Australia (as representedby birth numbers). Over half were located in regional areas (55%),29% in remote or very remote areas and 17% in major cities.Hospitals with less than 100 births represented 20% of the sample,38% were hospitals with 101–500 births, 14% with 501–1000births, 11% with 1001–2000 births, and 17% with annual birthsgreater than 2000 (Table 1).

We asked all respondents about the midwife-led models of carethey offered within their hospital. Over half provided midwife-ledantenatal care, and caseload midwifery was the next mostcommon midwife-led model reported, with approximately onethird (31%) of the responding hospitals offering this model of care(Table 1).

In addition to hospital-based care services, antenatal care wasprovided in a range of settings outside the hospital (n = 149). Theseincluded general practitioner (GP) clinics (81%), obstetricians’rooms (36%), Aboriginal health services (35%), community midwifeclinics (including remote and outreach clinics) (31%), otherhospitals (15%), and in women’s homes (14%).

Forty-three (31%) of the responding hospitals had a caseloadmodel at the time of the survey (Fig. 2). The proportion with acaseload model differed by hospital location and size; 63% of

Fig. 1. Recruitment of ‘participants’.

hospitals with large birth numbers (2001–9000) and 61% ofhospitals in a major city had a caseload model, compared with justunder one third (28%) of hospitals with low birth numbers, and18%-33% of hospitals in areas other than a major city (Table 1).Twenty-three percent of those without a caseload model were inthe process of implementing the model (85% of these within thenext 12 months) and 36% of those without a model wereconsidering it for the future (Fig. 2).

3.2. Hospitals NOT planning to implement a caseload model

Of those hospitals without a caseload model, over one third ofrespondents (36/96, 38%) indicated that they were not consideringimplementing a caseload model. Respondents were asked thereasons for their response and 32 responses were received (89%).The vast majority (31/32) of those not planning on implementingcaseload were from a regional or remote area, and 78% (25/32) hadless than 500 births in 2011. The main theme related to staffingissues, including a lack of medical and midwifery staff support,insufficient midwifery staff availability and absence of funding forthe model.

Half of the respondents (16/32, 50%) indicated that staffing themodel was an issue.

‘‘. . . we have a chronic shortage of midwives’’ (id 50, outerregional)

‘‘Midwifery resources currently stretched. . .’’ (id 124, outerregional)

‘‘Lack of midwives’’ (id 26, remote)

Fig. 2. Caseload availability (n = 139).

K. Dawson et al. / Women and Birth 29 (2016) 214–222 217

Others raised the issue that the midwifery workforce was neededto staff other areas of the hospital (particularly noted in the remotesetting, with 10/15 hospitals from a remote area commenting onthis issue).

‘‘Midwives work in combined medical, surgical and midwiferyward so difficult to work around this component’’ (id 113,unknown area)

‘‘The current midwives also participate in the general roster. . .’’(id 117, outer regional)

‘‘Midwife is required to take a general patient load as well as hermaternity load’’ (id 86, remote)

Almost half (15/32, 47%) indicated that midwives were notinterested in working in this way.

‘‘No interest from midwives; midwives here prefer shift workand are not prepared to have their work life balanceinterrupted. . .’’ (id 22, outer regional)

‘‘Midwives working here support caseload models however ingeneral are not prepared to work in a caseload model due to thecall requirements’’ (id 82, outer regional)

‘‘Staff were not interested, as they are all part time staff’’ (id 60,remote)

A further one quarter (8/32, 25%) cited lack of medical staff supportor availability, with a medical model of care currently in operationat the hospital.

‘‘The hospital is run on a VMO model and all women are caredfor by GP obstetrician within the community’’ (id 52, major city)

‘‘Most antenatal care given by GP in private practice orobstetrician in private practice, there would be objection forcaseload midwifery as this would affect their care of thepatient’’ (id 124 outer regional)

Nearly one quarter (22%) cited cost and funding as an obstacle tointroduction of the model.

‘‘Cost factor to staff both caseload and on ward staff isprohibitive’’ (id 64, outer regional)

‘‘We do not have the resources to support [this model]. . ..Resourcing would be required to implement a caseload model’’(id 117, outer regional)

3.3. Hospitals CONSIDERING implementing a caseload model in the

future

At the time of the survey, 35 organisations (36% of thosewithout caseload at the time of the survey) were considering

implementing caseload in the future. We asked respondents tocomment on the reasons influencing their decision to implementcaseload, and 33 responded. Similar to the themes from organisa-tions not intending to implement a caseload model, support for themodel, staffing issues, and funding to support implementationwere all identified as factors influencing their decision.

Resources and funding for the model were considerations for45% (15/33) of respondents.

‘‘Funding is the biggest issue, if funding was available caseloadcould be implemented’’ (id 79, major city)

‘‘Financial support’’ (id 149, outer regional)

‘‘Financial support for a project person’’ (id 78, outer regional)

A number of respondents (n = 15/33, 45%) also discussed issuesrelating to staffing a caseload model.

‘‘Retain[ing] and recruitment of rural midwives to ensure aviable service delivery. . .’’ (id 144, inner regional)

‘‘Midwives interested in working in that model’’ (id 73, outerregional)

‘‘. . ..enough midwives to ensure adequate time off’’ (id 12, outerregional)

A further 24% (8/33) reflected on the medical support required toimplement the model.

‘‘VMO’s would have to be supportive’’ (id 29, outer regional)

‘‘This model would require strong support by the local GPObstetrician and Specialist Obstetrician. . .’’ (id 126, outerregional)

A small number of respondents also discussed the support neededfrom hospital executive (n = 3/33), while 15% (5/33) citedconsumer support as another consideration.

3.4. Barriers and facilitators to setting up caseload midwifery

In order to explore similarities and differences between thethree groups that did not have a caseload model at the time ofthe survey, a series of statements regarding perceptions about

4.5

77.3

95.5

95.5

81.8

15.2

94.1

88.2

81.8

41.2

33.3

83.8

48.6

37.8

24.3

Believe t here is li �le consumer dema nd for case load

Nee d a n ini�al block of fund ing to esta bli sh a m odel

Midwives i ntesterested to wo rk i n caseload

Midwives i n hospita l supp or�ve of caseload

Med ical staff wo uld be supp or�ve of caseload

Do not h ave a c aseload model pla nnedConsider ca selo ad in f uturePlanning to impleme nt ca selo ad

Fig. 3. Requirements for implementation of caseload (percentage ‘Agreed’ or ‘Strongly agreed’).

K. Dawson et al. / Women and Birth 29 (2016) 214–222218

implementation was presented. While all groups indicated thatthere is consumer demand for the model, this was stronger in thegroup planning to implement the model (Fig. 3). Agreement wasstrong in all groups in regard to needing funding to initiate acaseload model. Midwifery and medical support for caseload wasperceived to be strongest in the group planning to implementthe model, and least in the group not planning a model; andmidwifery interest in working in a caseload model was perceivedto be weaker in the hospitals not planning to implement acaseload model.

3.5. Hospitals with a caseload midwifery model

Hospitals that already had an established caseload model(n = 44) were asked a series of questions about the modelestablishment and operation. The first model was established in1995, and the number of models increased to 44 by 2013 (31% of allrespondents), indicating a substantial increase in caseload modelavailability in Australia over time (Fig. 4).

Antenatal care was provided in a range of settings within thecaseload model. The vast majority offered antenatal care withinthe hospital (90%). Other options included community-basedclinics (56%); antenatal care at home (more than one visit (44%) orone visit only (12%)); and care within a GP clinic (5%).

0

5

10

15

20

25

30

35

40

45

1995

1997

*199

8*1

999

*200

0*2

001

*200

2*2

003

*200

420

0520

0620

0720

0820

0920

1020

1120

1220

13

Num

ber o

f hos

pita

ls

Annual total (ne w mod els)Cumula�v e total* No new mod els established betwee n 1998-2004.

Fig. 4. Year caseload models established.

Thirty-six of the 44 hospitals indicated that ‘seed’ funding wasreceived to set up the caseload model within their hospital. Thisfunding came from a variety of sources and special initiatives (suchas the ‘Rural Maternity Initiative’ (n = 10), Closing the Gap,Towards Normal Birth, Chronic Disease Prevention, New Direc-tions), one-off grant funding (e.g. Department of Health funding,funds allocated by Regional Board), and in one case from fundstransferred from a community health budget.

3.5.1. Eligibility

Respondents were asked to indicate what eligibility criteriathey applied to their caseload model (Table 2). The majority ofhospitals accepted women considered to be at ‘low obstetric risk’at the time of booking (81%), and one third offered caseloadmidwifery care to women in an all risk model. Forty percentaccepted women aiming for a vaginal birth after caesarean section.Some caseload models targeted specific groups of women, such aswomen of Aboriginal and/or Torres Strait Islander background(37%) and young women (30%). By calculating the reported birthnumbers and the percentage of women receiving caseload at eachof the responding hospitals, we estimated that the overallpercentage of women receiving caseload among respondinghospitals across Australia at the time of the survey was eightpercent.

3.5.2. Midwifery workforce

We asked how many midwives were employed in caseload interms of numbers and FTE (full time equivalent). Respondents

Table 2Eligibility criteria for women for caseload midwifery models (n = 43).

Criteriaa n %

‘‘Risk’’ level accepted for caseloadAccept women low risk and follow through even if risk

level changes

21 49

Accept low risk and transfer out if risk level changes 19 44

Accept women aiming for a VBAC 17 40

All risk model 14 33

Women targeted for caseload careAboriginal &/or Torres Strait Islander 16 37

Young mums 13 30

Women with alcohol or drug issues 6 14

Minority ethnic groups 5 12

Refugee women 2 5

Women with high body mass index 2 5

a Respondents could tick more than one response.

K. Dawson et al. / Women and Birth 29 (2016) 214–222 219

indicated that a total of 311 midwives were working in caseloadat the time of the survey, and this was calculated asapproximately 276 full time equivalent midwives based on thetotal number of midwives working in caseload and the FTE ofmidwives currently working in caseload for each hospital. Therewas a large variety of employment classifications for midwivesworking in caseload for each state and territory; a total of21 different classifications were reported for midwives workingin caseload models. This is due in part to the differentclassifications systems in each jurisdiction, but demonstratesthe diversity even within states (Fig. 5).

Of the 42 hospitals responding to questions regarding themethod of remuneration for midwives working in caseload,36 (86%) paid caseload midwives an annualised salary (i.e. theywere paid a certain percentage ‘loading’ above the base rate fortheir classification each fortnight in an attempt to capture thevaried work patterns of a caseload midwife), and the remaining sixrespondents paid midwives as per the local industrial award (i.e.they were paid for the hours and type of work performed inaccordance with the midwives’ contract and enterprise/industrialagreement in place). Of the 36 hospitals that paid an annualisedsalary, 30 reported the loading that they paid; 12 (40%) paid aloading of 29% above base rate, seven paid 30%, seven paid 35%, twohospitals 27%, one hospital 28% and one paid 32%. It should benoted that in South Australia and Queensland, a loading isstipulated in the state-wide industrial award for midwivesworking in caseload, and is set at 35%. In states such as Victoria,a local agreement is made with individual hospitals and no state-wide agreement exists. The majority who paid midwives as per theenterprise agreement/industrial award (n = 6) were in a smallhospital (<100 births) (4/6) and/or in a remote area (3/6) or outerregional area (2/6).

Managers were asked about current staffing vacancies in thecaseload model. The majority (71%) indicated that they currentlyhad no vacancies in their model, although a few of these also notedthat staff were needed to provide relief in times of extended sickleave, annual leave, and to fill some on call periods.

Of the responding hospitals with a caseload model there were39/311 (13%) reported resignations from midwives working incaseload over the previous 12 months. The majority of thoseleaving caseload work remained working in midwifery; 12 mid-wives returned to shift work, two to ‘9 to 50 work, nine toother midwifery work, and six no longer worked in midwifery.When managers were asked if there were ‘usually’ enoughsuitable applicants for vacant positions, 51% either ‘Agreed’ or‘Strongly agreed’ with this and 28% ‘Disagreed’ or ‘Stronglydisagreed’.

3.5.3. Community demand

Respondents were asked if there was enough caseload places tomeet community demand, and the majority (28/43 (65%)) notedthat more women wanted caseload than there were placesavailable. Three indicated that they had more places available intheir caseload models than women wanting the model, 10 indicat-ed that places available in the model met the current demand, andtwo were unsure.

All 43 responding hospitals considered that their caseloadmodel was sustainable into the future; 19 indicated that theircaseload models would be staying the same size, while 21 plannedon expanding. One hospital was planning to reduce the size of itsmodel.

3.5.4. Advantages and challenges of a caseload model

Managers from hospitals with a caseload model were asked inan open-ended question if they had any comments regarding theadvantages and challenges of caseload.

Twenty-eight respondents commented on the advantages ofcaseload. The main themes were improved outcomes andsatisfaction for women, and increased job satisfaction for mid-wives.

Benefits to women were the most common theme, and 82%(n = 23) commented to this effect.

‘‘Continuity of care by a known midwife is really important forwomen and improves birth outcomes’’ (id 5, major city)

‘‘. . ..The birth outcomes are excellent’’ (id 9, outer regional)

‘‘All women should be in a caseload model, our women love it.It’s important to consolidate education and increase [women’s]self-esteem’’ (id 103, major city)

‘‘Increased satisfaction for women and their families’’ (id 65,outer regional)

Job satisfaction for midwives also emerged as a theme, with 14/28(50%) respondents making a comment.

‘‘This is an excellent model for midwives as they work acrosstheir scope of practice’’ (id 5, major city)

‘‘Midwives practising autonomously and really fully exploringtheir roles leads to great job satisfaction’’ (id 74, outer regional)

Twenty-nine respondents commented on challenges associatedwith the caseload model. The overall theme to emerge from thecomments was that of ‘acceptance and integration’ of the model,that is, how it was accepted by the whole organisation and how itwas integrated into the functioning of the hospital.

Comments about working relationships and support were themost common, with 59% (n = 17) of respondents making acomment on this.

‘‘Getting buy-in from executive was tough’’ (id 121, remote)

‘‘Integration with core midwives remain an ‘us and them’situation with some staff’’ (id 148, major city)

‘‘. . . not handing over, want to stay and wait for the birth’’ (id 10,inner regional)

Workforce management reflects issues such as recruitment andretention of staff, burnout, coverage of sick and annual leave, andmaintaining a skilled workforce, and was apparent in thecomments. These were all seen as challenges in caseload bynearly half of hospitals with a caseload model (48%, n = 14).

‘‘Covering sick leave/annual leave etc. is one of the mainchallenges’’ (id 42, remote)

‘‘Just starting the model and dedicating time to organising’’ (id111, major city)

‘‘Recruiting and retaining a skilled workforce. Ensure strategiesare in place to reduce the risk of burnout’’ (id 65, outer regional)

In summary, although respondents clearly noted benefits towomen and to midwives working in caseload care, obstaclesremain from an operational perspective in terms of acceptance andintegration of the model within the organisations.

4. Discussion

This study explored the caseload midwifery model throughoutAustralia from the maternity managers’ perspective; including its

Fig. 5. Position classifications of midwives working in caseload by state and territory (y-axis = n, x-axis = classification). CMC – Clinical Midwife Consultant; CMS – Clinical

Midwife Specialist; AUM – Associate Unit Manager. (This figure aims to highlight the diversity of classifications of the midwives working in caseload, not to be a comparison of

actual salaries or levels.)

K. Dawson et al. / Women and Birth 29 (2016) 214–222220

prevalence, and factors associated with its implementation andsustainability. This is the first study to explore these issues at anational level, and to describe the elements of the caseload modelsin existence.

There is evidence of growth of the model throughout thecountry, both in terms of hospitals establishing the model for thefirst time and planned expansion in organisations where caseloadalready exists. These findings also indicate there is strongconsumer demand for the caseload midwifery model, with themajority of hospitals with a caseload model having more womenwanting caseload care than there are places available, andcommunity demand evident in sites where caseload was beingconsidered. Key factors regarding the implementation of caseloadrelated to the interest and availability of staff to work in the model,as well as organisational support and consumer demand. These key

themes are congruent with the literature and documents thatguide organisations in establishing new caseload models,19–21

where factors such as engagement and support at all levels withinthe hospital/service, strong support from the community, and abelief in women centred midwife-led care have been identified.

While there are many recent state and national policydocuments in Australia regarding the promotion of the caseloadmodel,1–5 it is evident that not all services have responded to thesepolicy directions, with 28% of respondents not consideringimplementing the model. The majority of these was from regionalor remote settings and had annual birth numbers less than500. Barriers to the implementation of caseload in these settingsincluded lack of interest from staff, staff shortages, and hospitalsneeding midwifery staff to work across both nursing andmidwifery practice areas. Many of these sites also indicated that

K. Dawson et al. / Women and Birth 29 (2016) 214–222 221

their maternity care was predominantly medical (i.e. did not haveexisting midwifery – led care models). A perception of lowconsumer demand was also discussed by these respondents. Giventhese factors it would require a significant change to the waymaternity care is provided in these settings and significantcommitment from management and staff in order to enable asustainable caseload model to be established. It has been discussedelsewhere that ‘buy-in’ from all levels of the hospital is critical forthe sustainability of caseload models, and that each model needs tobe adapted to suit the needs of each organisation.17 Given thevariety of settings and differences in the organisation of maternitycare around Australia, the model may not be sustainable at all sitesall the time, however, it has been suggested that caseload couldassist in sustaining a rural midwifery service.17,18 Closure ofmaternity services is an issue that impacts on women andmidwives, and it is concerning that over one quarter of all thehospitals identified as having births in 2011 no longer provided abirthing service at the time of this study. It may be that with carefulconsideration of their identified issues, and with negotiation,caseload could assist in these rural maternity services re-establishing birthing services. Data have also been collectedregarding the operational aspects of caseload including workpatterns and model logistics, and will be reported elsewhere.

In contrast, hospitals that would consider implementingcaseload in the future were more focused on elements of supportwhich would enable the model to be established rather than thebarriers to implementation. Support came in many forms; the mostcommon was the requirement of financial support that would helpin the establishment of the model (e.g. enabling the appointmentof a midwife into a project role). These hospitals also identified thatboth medical and midwifery staff would be supportive ofestablishing a caseload model, factors that have been reportedelsewhere as being key to successful implementation of themodel.17,19–21,29

Increased availability of the caseload model is evident in ourfindings; from 2004 the model has seen significant growththroughout Australia, and this is the case in all states andterritories, in urban and regional areas, and in hospitals of varioussize (NB: there was no respondent from ACT with a caseload model,but we are aware that there is a caseload model in operation). Thelargest proportion of hospitals with a caseload model were locatedin metropolitan areas. Further growth of the model is alsoexpected, with 16% of respondents implementing caseload atthe time of the survey and 25% considering it in the future. Withinhospitals that had an established caseload model, half (49%) wereplanning on expanding the model within their organisation. It istherefore timely to be investigating factors associated withsustainability, and encouraging to see that all hospitals thatcurrently have a caseload model believed that their model wassustainable into the future.

Funding of caseload models was identified by respondents inthis study as a challenge, particularly during the establishmentphase. Although studies have demonstrated that the cost ofrunning caseload is either equivalent or slightly cheaper thanstandard care,30,31 the majority of respondents in this study notedthat start-up or seed funding would be necessary in order toestablish a caseload model. Hospitals with a caseload modelreported receiving funding to set up the model from a wide varietyof sources; where funds were not sourced externally they weresometimes redirected or realigned from other areas within theorganisation, a strategy that was also suggested by QueenslandGovernment20 in their discussion regarding establishment costs ofa caseload model. Maternity care funding in Australia is complex,with some components of care being funded by state governmentand in others federal funding is used, and different arrangementsexist even within individual states, in relation to pregnancy care.

This adds to the complexity of introducing a model such ascaseload. This is an issue which may require consideration bypolicy makers to enable further implementation of the caseloadmodel to occur.

In Australia women’s access to midwife-led models of care islimited. Only a minority of women are able to access continuity ofcare models5 and this is particularly so for the most vulnerablewomen.32 Despite the benefits of caseload and the increasingavailability of the model nationwide, only eight percent of womenfrom the responding hospitals had access to caseload care at the timeof this survey. Whilst there are models that target sociallydisadvantaged women, the majority of places in caseload wereavailable to a ‘low risk’ cohort of women. In a qualitative study ofcaseload in a multi-ethnic community in the United Kingdom,women from minority groups reported improved outcomes such asfeeling known by the midwives caring for them; receiving person-centred care; having improved social support; experiencing moreflexible care; and feeling more informed and in control when in acaseload model.33 This is also reflected in findings of a study whichinvestigated the introduction of a caseload model for remotedwelling Australian Aboriginal women; women reported a morepositive experience of the health system, and staff also seemed tobecome more culturally aware and sensitive.34 Providing caseloadcare to women of any risk status has been reported as safe.8

However, a recent Cochrane review suggests that further consid-eration should be given to the suitability of this model for womenwith substantial medical or obstetric complications.6

In terms of staffing caseload midwifery, we found that hospitalsplanning to implement caseload midwifery had midwifery staffavailable, and there were midwives interested in working in thisway. However, in a recent study where midwives’ intentions towork in caseload were explored in hospitals where caseload wasalready in operation, it was found that although there was supportfor caseload midwifery, only a small percentage of additionalmidwives were prepared to work in the model at the time of thestudy.24 In the current study we found that approximately onequarter of hospitals had vacancies in their caseload models at thetime of the survey and nearly one third of these hospitals reportednot having enough suitable applicants to fill the vacant positions.However, respondents also noted that they believed working in thisway brought midwives job satisfaction. A further longitudinalinvestigation is warranted to investigate the long term sustainabilityof working in caseload midwifery in terms of midwives’ outcomes.

The advantages and challenges of a caseload model identifiedby respondents in this study are similar to those reportedelsewhere; while improved outcomes for women and increasedjob satisfaction for midwives are commonly reported,7,16,35 thechallenges, such as funding to set up the model, acceptance of andsupport for the model and buy-in and support from stakeholders(maternity management and medical staff) appears vital, not onlyfor the implementation, but also the sustainability of the model.19–21

Variations on how the model is staffed and operates will addvaluable information to this data (to be reported elsewhere).

4.1. Strengths and limitations

This is the first study to evaluate the implementation and statusof the caseload midwifery model in Australia at a national level.The response rate of 63% is similar to other comparable Australia-wide studies of hospital services36 and is higher than the acomponent of the Australasian Maternity Outcomes SurveillanceSystem (AMOSS) study (53%) which mapped maternity services inAustralia.37

In this study, there may have been variable biases andmotivations in responding to the survey for those either with orwithout a caseload model, therefore, although this is a substantial

K. Dawson et al. / Women and Birth 29 (2016) 214–222222

national sample, it does not represent all maternity hospitals inAustralia. It does however give an overview of the prevalence ofcaseload in Australia at the time of the survey, and makes acontribution to understanding the barriers and enablers to the futuresustainability and expansion of the caseload model in Australia.

5. Conclusion

This national cross-sectional survey exploring caseload mid-wifery found that at the time of the survey, 31% of hospitals offeredthe caseload care, and an estimated eight percent of women hadaccess to the model. The number of hospitals with caseloadmidwifery in Australia has increased steadily over the past10 years. Access is still primarily metropolitan-based and forwomen considered low risk at the time of booking for maternitycare. In view of the benefits caseload provides for women and thestrong consumer demand for the model, the potential forincreasing the availability of caseload should be further explored,especially in terms of providing equity and access to the model forall women. Although caseload midwifery appears to be wellsupported, interest and availability of staff to work in the model aswell as seed funding were the main barriers reported to itsimplementation. The issues raised here are important and providea basis for thinking about these issues at a national level, and thedata provide information that can be used at the policy level.

Conflict of interest

We have no conflicts of interest to declare.

Author’s contributions

Study design, data collection tools, study implementation, dataanalysis and manuscript drafting: KD, HMc, MN, DF.

Acknowledgments

We would like to acknowledge all the maternity managers whomade the time to respond to this survey and thanks also to thosecolleagues that assisted with piloting and survey development.

References

1. Department of Health Western Australia. In: Department of Health, editor.Improving maternity services: working together across Western Australia. West-ern Australia: Department of Health; 2007.

2. NSW Department of Health, editor. Primary Maternity Services in Australia – Aframework for implementation. Sydney: Australian Health Ministers’ AdvisoryCouncil; 2008.

3. Queensland Government, editor. Midwifery models of care: implementationguide. 2008.

4. Department of Human Services Victoria. Future directions for Victoria’s mater-nity services. Melbourne: Victorian Department of Human Services; 2004.

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

6. Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuitymodels versus other models of care for childbearing women. CDS Rev 2013;(8).AN CD004667.

7. McLachlan H, Forster D, Davey MA, Farrell T, Gold L, Biro MA, et al. Effects ofcontinuity of care by a primary midwife (caseload midwifery) on caesareansection rates in women of low obstetric risk: the COSMOS randomised con-trolled trial. BJOG 2012;119(12):1483–92.

8. Tracy S, Hartz D, Tracy M, Allen J, Forti A, Hall B, et al. Caseload midwifery careversus standard maternity care for women of any risk: M@NGO, a randomisedcontrolled trial. Lancet 2013;382(November (23)):1723–32.

9. Stevens T, McCourt C. One-to-one midwifery practice. Part 3: Meaning formidwives. Br J Midwifery 2002;10(2):111–5.

10. Wakelin K, Skinner J. Staying or leaving: a telephone survey of midwivesexploring the sustainability of practice as Lead Maternity Careers in one urbanregion of New Zealand. N Z Coll Midwives 2007;37(October):10–4.

11. McCourt C. Working patterns of caseload midwives: a diary analysis. Br JMidwifery 1998;6(9):580–5.

12. Sandall J, Davies J, Warwick C. Evaluation of the Albany midwifery practice.London: Florence Nightingale School of Nursing and Midwifery, Kings College;2001.

13. Tracy S, Hartz D. The Quality Review of the Ryde Midwifery Caseload Practice – aprimary level maternity service at Ryde Hospital, September 2004–October2005. Final Report. Northern Sydney and Central Health Coast; 2006.

14. Fereday J, Oster C. Managing a work-life balance: the experiences of midwivesworking in a group practice setting. Midwifery 2010;26(3):311–8.

15. Collins CT, Fereday J, Pincombe J, Oster C, Turnbull D. An evaluation of thesatisfaction of midwives’ working in midwifery group practice. Midwifery2010;26(4):435–41.

16. Newton M, McLachlan H, Willis K, Forster D. Comparing satisfaction andburnout between caseload and standard care midwives: findings from twocross-sectional surveys conducted in Victoria, Australia. BMC Pregnancy Child-birth 2014;14(426).

17. Brown M, Dietsch E. The feasibility of caseload midwifery in rural Australia: aliterature review. Women Birth 2013;26:e1–4.

18. Yates K, Usher K, Kelly J. The dual roles of rural midwives: the potential for roleconflict and impact on retention. Collegian 2011;18(3):107–13.

19. NSW Ministry of Health. In: Office TNaM, editor. Midwifery Continuity of CareModel Tool-kit. Sydney, NSW: NSW Ministry of Health; 2012.

20. Queensland Government. In: Office NaM, editor. Delivering continuity ofmidwifery care to Queensland women. Brisbane: Queensland Health; 2012.

21. Homer C, Brodie P, Leap N. Midwifery continuity of care: a practical guide.Sydney: Elsevier Australia; 2008.

22. Hilder L, Zhichao Z, Parker M, Jahan S, Chambers GM. In: Unit ANPS, editor.Australia’s mothers and babies. Canberra: AIHW; 2012. p. 2014.

23. National Health Performance Authority. My Hospitals. 2012http://www.myhospitals.gov.au/. [accessed March 2012].

24. Newton M. Implementing caseload midwifery: exploring the views and experi-ences of midwives and key stakeholders. (Unpublished Thesis) Bundoora, Mel-bourne: La Trobe University; 2013.

25. SurveyMonkey I. Palo Alto, CA: SurveyMonkey; 2012.26. Microsoft Corporation Microsoft Office Excel. Microsoft; 2010.27. Stata Corporation. STATA 11.0 Statistics/Data Analysis. TX, USA: Statacorp LP;

2012.28. Liamputtong P, editor. Research methods in health. South Melbourne: Oxford

University Press; 2010.29. Scherman S, Smith J, Davidson M. The first year of a midwifery-led model of care

in Far North Queensland. Med J Aust 2008;188(2):85.30. Tracy S, Welsh A, Hall B, Hartz D, Lainchbury A, Bisits A, et al. Caseload

midwifery compared with standard or private obstetric care for first timemothers in a public teaching hospital in Australia: a cross sectional study ofcost and birth outcomes. BMC Pregnancy Childbirth 2014;14(46).

31. Gao Y, Gold L, Josif C, Bar-Zeev S, Steenkamp M, Barclay L, et al. A cost-consequences analysis of a Midwifery Group Practice for Aboriginal mothersand infants in the Top End of the Northern Territory, Australia. Midwifery2014;30:447–55.

32. Sutherland G, Yelland J, Brown S. Social inequalities in the organization ofpregnancy care in a universally funded public health care system. Matern ChildHealth J 2012;16(2):288–96.

33. Beake S, Acosta L, Cooke P, McCourt C. Caseload midwifery in a multi-ethniccommunity: the women’s experiences. Midwifery 2013;29(8):996–1002.

34. Josif C, Barclay L, Kruske S, Kildea S. ‘No more strangers’: investigating theexperiences of women, midwives and others during the establishment of a newmodel of maternity care for remote dwelling aboriginal women in northernAustralia. Midwifery 2014;30:317–23.

35. McLachlan H, Forster D, Davey MA, Farrell T, Gold LC, Nicolle Oats J. Arandomised controlled trial of caseload midwifery for women at low risk ofmedical complications (COSMOS): women’s satisfaction with care. J Paediatr2012;48(Suppl. 1):41.

36. Rumbold AR, Crowther CA. Guideline use for gestational diabetes mellitus andcurrent screening: diagnostic and management practices in Australian hospi-tals. Aust N Z J Obstet Gynaecol 2001;41(1):86–90.

37. Homer CSE, Biggs J, Vaughan G, Sullivan E. Mapping maternity services inAustralia: location, classification and services. Aust Health Rev 2011;35:222–9.