Case Loading in Midwifery Education – a student’s perspective

Originally posted on Jul 2009

Student Caseload Story – MIDIRS Essence > July 2009 > Student/Tutor feature

'Our case loads have taught us how to be true advocates for women and their families, and many of us have had to actively defend their rights to other professionals in order to support them in making informed choices. Most importantly, it has taught us as a group that the small changes we are all capable of making can impact hugely on a woman's experience, and that it is the subtle changes that really make a difference'.

Kristen Goodall reflects on her experience of case loading in midwifery during her third year as a student at University of Nottingham.

Case loading in midwifery is not a new concept; it was fundamental to the ‘Know Your Midwife’ scheme (Flint et al 1989) and was highlighted in Changing Childbirth (Department of Health 1993) as the ‘ideal’ for maternity care. It strongly promotes the importance of women receiving continuity of care by a known carer throughout pregnancy, labour and the postnatal period.

These core values are stressed once again in Maternity Matters (Department of Health 2007) and echoed in Darzi (2008) with women and their families being put at the forefront of maternity services, being supported by a midwife they know and trust throughout their pregnancy and after birth. However, at the University of Nottingham it is a new part of the curriculum and as a third year student about to qualify, I was part of the first cohort of students to progress through the new curriculum with case loading integrated into the course. Bournemouth University pioneered this approach to midwifery education and with encouragement from the Nursing and Midwifery Council (NMC) many institutions have since followed suit.

We are encouraged to embrace case loading from the very start of the course. In the first year we select women, guided by our mentors, who have chosen midwife led care and follow them through the service. As the course progresses we continue to select women to follow but have the freedom to choose more complex cases as we become more experienced. As a group we have found case loading to be both rewarding and challenging. As many of our placements are short, the insight into maternity care can often be fragmented, and case loading has enabled us to see a woman’s journey through the maternity service. It has provided us with invaluable skills in communication, professionalism and time management, and has given us experience in taking the lead in maternity care. We have found our management skills developing, particularly when balancing lectures, a work placement, exams, assignment deadlines and the appointments of our case load. We have experienced the complexities of being on call as we were all encouraged to be on call for the births from 37 weeks onwards. Together, these skills have been of immense benefit when it has come to applying for jobs, interviews and writing our personal statements, and we have been able to reflect upon our experiences when completing our portfolios. Our case loads have taught us how to be true advocates for women and their families, and many of us have had to actively defend their rights to other professionals in order to support them in making informed choices. Most importantly, it has taught us as a group that the small changes we are all capable of making can impact hugely on a woman’s experience, and that it is the subtle changes that really make a difference.

Perhaps one of the biggest revelations to us all was that, through handling a case load as a student, it has highlighted weaknesses in the current maternity system - something that I hope we will all continue to strive to improve on upon qualification. As a group the feedback we received from the women involved in the process had one overwhelming theme: that the women felt they could talk to us about things they couldn’t talk to their midwife about, particularly with emotive subjects such as breastfeeding, and that they often felt let down by the lack of continuity of care. As midwives, we are perhaps the most constant contact a woman has with a health care professional at any time in her life. We have training in counselling and health promotion, and are trusted with handling extremely sensitive aspects of a woman’s life such as domestic violence and sexual abuse, and yet we are failing them if they feel they cannot talk to us. One of my cohort received this letter from one of her case load women:

‘The hardest thing for me during pregnancy was knowing that the midwife who you build up a relationship with, trust and who knows you and all your worries, is not the midwife going to be there when you give birth. Having you follow me made such a difference in how I felt about giving birth knowing that you would be there. I was so scared about labour but having you there, knowing that you knew me and knew how I felt about things like not being shouted at etc put me at so much at ease. During labour I felt it was much easier to talk to you and ask you things than the others and I felt you were able to explain things better and reassure us more then the professionals could, but again I think that is because you understand us. Also as it is such a personal private time having you there to share the birth instead of a bunch of strangers made the experience more special and something I will be able to tell my baby as he gets bigger. We feel that you did so much more than ‘just your job’ being there for me during surgery, visiting us afterwards, all those things mean such a difference through the whole pregnancy and labour. We never thought of you as a student, you were totally professional and knowledgeable and it was easy to forget you were still learning. Another point I would say is something my friend said, having a student follow her pregnancy would have been so much nicer for her as she only saw her named midwife twice and felt that she spent so much time in her appointments going through how she felt and her problems again and again with different people, having a student would have helped with that so much.’

I think this letter is an expression of the feedback in general that many of us were receiving. It is extremely difficult to provide a perfect service but as students, through having a case load, we are able to witness first hand the frustrations that women have and are able to strive to provide the ideal when we start practising. Many of us will be managers of the future and I hope we don’t forget our experiences through this process when shaping the services of tomorrow.

As a group through case loading we have cared for two sets of twins (who both had vaginal births!), a lotus birth, home births, pool births, stopped dads from fainting and given them tissues when they’ve cried. We’ve cared for a sports star and driven 30 miles in the wrong direction when attending appointments. Together, we have experienced early and late miscarriages and a termination for congenital abnormality. We have even had students care for the same woman twice and each time on their second pregnancy the women have specifically requested the care of her case loading student – a true testament to the service. Whilst case loading does not carry any academic credit at our university at present, it is fundamental to the curriculum. It pieces together everything we learn in class, all the theory we study and write assignments about, and applies them to practice and more importantly the role of the midwife. Whilst case loading has had its own challenges it has also been an immensely rewarding experience and keeps the passion for midwifery burning in all of us as we begin our careers.

References

·  Flint C, Poulengeris P, Grant A, (1989). The ‘Know Your Midwife’ scheme – a randomised trial of continuity of care by a team of midwives. Midwifery 5(1): 11-6.

·  Department of Health (1993). Changing Childbirth. Part 1: report of the Expert Maternity Group. London: The Stationery Office.

·  Department of Health (2007). Maternity Matters: choice, access and continuity of care in a safe service. London: The Stationery Office.

·  Darzi, Department of Health (2008). High Quality Care for All: NHS next stage review final report CM7432. London: The Stationery Office.

Kristen Goodall, BA (Hons), University of Nottingham - with information and assistance from the 06/09 cohort.