Caseload – verloskunde is duurzame verloskunde: een persoonlijk relaas

A blog a wrote in May 2016 about my personal experience in sustainable caseloading in midwifery has been translated by a colleague, Tine Oudshoorn, into Dutch.

Er is veel gesproken op sociale media en diverse internationale fora over caseload – verloskunde en werken met persoonlijke continuïteit van zorg (gehele proces) die het model nastreeft. Er bestaat nogal wat opwinding over; veel mythes, misvattingen en ongegronde bezorgdheid gaan rond. Ik had het genoegen in verschillende geboortezorg systemen te werken in het Verenigd Koninkrijk en erbuiten. In het Verenigd Koninkrijk werkte ik in een groepspraktijk met standaard verloskundige zorg en als zelfstandige verloskundige. De standaard verloskundige zorg, waarbij de 1e- en 2e-lijnszorg gescheiden zijn appelleerde eenvoudigweg niet aan mijn behoeften.

De groepspraktijk regelingen in de praktijk van het Chelsea en Westminster ziekenhuis, waar ik werkte in de jaren ’90, hoewel leuk in het begin, waren ook frustrerend en putte mij uit. Zelfstandig werken in het Verenigd Koninkrijk was geweldig, maar wel erg stressvol, doordat het niet volledig geïntegreerd is in het zorgsysteem en de noodzaak bestaat om betaling te vragen voor je diensten.

In Nieuw-Zeeland waar ik werkte, is de vrijgevestigde verloskundige volledig geïntegreerd in het zorgsysteem, waarbij vrouwen een verloskundige rechtstreeks boeken, zonder betaling als ingezetene of burger van Nieuw-Zeeland. Ik heb het Nieuw-Zeelandse verloskunde systeem al eerder elders beschreven.

Ik ga hier niet opnieuw de onderbouwing van caseload – verloskunde opsommen, die vindt je elders. Wat ik hier eerst ga beschrijven is wat persoonlijke continuïteit van zorg voor mij is. Het is ‘het meest’ ter zake doende en meest belangrijke in de contacten tussen de vrouw en de verloskundige tijdens de zwangerschap, de bevalling en het kraambed. Zorg wordt alleen overgedragen aan anderen, als ik op vakantie ben, een weekend vrij heb, bij ziekte of studiedagen en als er twee vrouwen tegelijk gaan bevallen! De zorg die ik verstrek doorkruist risico’s en de gekozen plaats bevalling. Ik volg vrouwen naar de haar geprefereerde plaats bevalling. De regeling is flexibel. Er wordt doorlopend op gelijkwaardige wijze (in partnership) tussen vrouw en verloskundige overeengekomen wat de volgende stap is.

Om te werken als caseload – verloskundige had ik nodig:
• Een uitstekende ondersteunende structuur (netwerk) met collega ‘s.
• Gelijkgestemde collega’s die qua filosofie en visie op dezelfde lijn zitten.
• Eerlijke vergoeding voor het werk dat ik deed, afgestemd op- en overeenkomend met het niveau van mijn vaardigheid. De betaling georganiseerd door het ministerie van volksgezondheid en gratis voor vrouwen.
• Regelmatige verlofregeling in overleg met een vaste praktijkpartner.
• Zelfregelend en autonoom werken, zoals het zelf bepalen wanneer prenatale zorg en postnatale zorg gedaan worden. Zelf het aantal volledige begeleidingen per jaar bepalen en de jaarlijkse rustperiode en vrije weekenden in overleg met de vaste praktijkpartner regelen.
• Eén volledige maand onafgebroken vrijaf zijn per jaar, plus een week vrijaf in overleg met de vaste praktijkpartner.
• Werken in partnerschip met vrouwen, dat wederkerig sensitief was en tegemoet kwam aan beider behoeften.
• Gelegenheid en tijd om ‘geen dienst te hebben’ als dat dringend nodig is.
• Genereuze open sfeer en goede communicatie tussen collega’s.
• Uitstekende werkrelaties met ziekenhuiscollega’s (verloskundigen en artsen).
• Regelmatige ondersteuning en begeleiding van de Midwifery Councel en College of Midwives (organisatie van verloskundigen).
• Begripvolle familie die ondersteunend is aan mijn manier van werken.
• Goede verstandhouding met iedereen (de gemeenschap) in de vestigingsplaats waar ik werkte.
• Betrouwbare auto en telefoon!

Achtergrond
De caseload was 4 – 6 bevallingen per maand. Dat genereerde redelijke inkomsten, iets meer dan collega’s die in ploegendiensten in het ziekenhuis werken. De betaling van caseload – verloskundigen in Nieuw Zeeland zet momenteel aan tot nadenken. Aanpassing is nodig om te voldoen aan inflatie en de mate van de verantwoordelijkheid. Op het moment dat ik dit schrijf staan 4 – 6 bevallingen per maand voor een adequate beloning, maar dit is nog niet verhoogd met de inflatie en daarmee een actuele uitdaging.
Ik werkte samen met 8 andere caseload – verloskundigen, opgesplitst in partnerschips van twee collega’s die elkaars partner zijn en waarnemer bij vrije weekends, vakantie- en studiedagen of ziekte. De tweede verloskundige is ook beschikbaar voor primi para bevallingen, of hulp bij langdurige bevallingen of als twee vrouwen tegelijk gaan bevallen! Spreekuur tijden, huisbezoeken en kraamvisites bepaal ikzelf in overleg met de vrouwen. Ik verzet afspraken in overleg met de vrouwen als dat nodig is. Flexibiliteit is de sleutel.

Sommige caseload – verloskundigen prefereren het om alle prenatale zorg op één bepaalde dag te plannen en bij voorbeeld nieuwe aanmeldingen, kennismaking en volledige intake, op een andere dag te doen.

Partnerschap is van essentieel belang tussen de vrouwen en mezelf, mijn praktijkpartner/waarneemster, de groepspraktijk waar we deel van uitmaken en de bijbehorende ondersteunende diensten, zoals de huisartsen, de geboortehuis staf en de plaatselijke ziekenhuiscollega’s.

Hoe ziet een maand werken als caseload – verloskundige eruit? Was ik overwerkt na die maand? Was de doorlopende aanwezigheidsdienst een constante verstoring van- of druk op mijn privé leven? Maakten vrouwen misbruik van mijn constante aanwezigheid en belden ze mij voortdurend?
Hieronder één maand van activiteiten uit het dagboek van mijn praktijk. Alle namen en plaatsen zijn verwijderd. Iedere maand was anders, maar dit voorbeeld geeft je een momentopname.

Daar gaan we …

Week één

• Maandag, dienst. Prenatale zorg in de praktijk 8.00 – 12.00 uur (8 dames). Drie kraamvisites en 1 nieuwe aanmelding, kennismaking en intake aan huis van de vrouw (2 uur). Thuis om 16.30 uur. Geen telefoontjes of oproepen.

• Dinsdag, dienst. Vier kraamvisites in de ochtend. Praktijk administratie bijgewerkt in de middag. Geen telefoontjes of oproepen.

• Woensdag, dienst. Drie kraamvisites in de ochtend. ‘S middags vrij. Geen telefoontjes of oproepen.

• Donderdag, dienst. Prenatale zorg in de praktijk (8 vrouwen). Twee kraamvisites. Praktijk vergadering geannuleerd omdat iedereen bezig was. Om 15.00 uur thuis en om 22.00 uur gebeld voor een bevalling. De volgende ochtend (vrijdag) om 08.00 uur thuisgekomen.

• Vrijdag, dienst. Ochtend vrij om te slapen. In de middag 4 kraamvisites. Thuis om 17.00 uur. Mijn praktijkpartner neemt de dienst over van 18.00 – 23.00 uur, zodat ik buiten mijn werkgebied naar een afspraak kan.

• Zaterdag, dienst. Eén kraamvisite. Geen telefoon of oproepen.

• Zondag, dienst. Eén kraamvisite. Geen telefoon of oproepen.

Totaal aantal uren weg van huis en aan het werk = ca 36 uur.

Buiten de werkdagen, maandag tot vrijdag, – één maal gebeld.

Week twee

• Maandag, dienst. Prenatale zorg in de praktijk 08.00 -12.00 uur. Vier kraamvisites. Thuis om 16.00 uur.

• Dinsdag, dienst. Nieuwe aanmelding, kennismaking en intake 09.00 – 11.00 uur. Drie kraamvisites. Thuis om 14.00 uur. Geen telefoontjes of oproepen.

• Woensdag, dienst. Geen telefoontjes of oproepen. Geen pre- of postnatale zorg. Administratie bijwerken (2 uur).

• Donderdag, dienst. Prenatale zorg in de praktijk 08.00 -12.00 uur. Praktijk vergadering tijdens de lunch. Vier kraamvisites. Thuis om 16.00 uur. Neem waar voor mijn praktijkpartner, zodat zij een avond vrij is.

• Vrijdag geroepen voor een bevalling om 07.00 uur. Thuis om 13.00 uur. Nieuwe aanmelding, kennismaking en intake 15.00 – 17.00 uur. Gebeld om als 2e verloskundige bij een bevalling aanwezig te zijn 19.00 – 23.00 uur.

• Zaterdag, dienst voor mijzelf en mijn praktijkpartner. Haar vrije weekend. Geen telefoontjes of oproepen. Eén kraamvisite.

• Zondag, dienst. Twee kraamvisites. Klaar tegen lunchtijd. Gebeld om 17 uur voor een borstvoeding probleem.

Totaal aantal uren weg van huis en aan het werk = ca 35 uur met 1 – 2 uur telefonische contacten en de administratie bijwerken.
Buiten de werkdagen, maandag tot vrijdag, – tweemaal gebeld.

Week drie

• Maandag, dienst. Prenatale zorg in de praktijk 08.00 -12.00 uur. Vier kraamvisites en één nieuwe aanmelding, kennismaking en intake. Thuis op 17.00 uur.

• Dinsdag, dienst. Twee kraamvisites. Niets te doen vanaf 11.00 uur. Geen telefoontjes of oproepen.

• Woensdag, dienst. Gebeld om een inleiding te begeleiden (over tijd) om 11.00 uur. Thuis om 23.30 uur.

• Donderdag, dienst. Prenatale zorg in de praktijk 08.00 -11.00 uur. Drie kraamvisites. Praktijk vergadering tijdens de lunch. Thuis om 15.00 uur. Geen telefoontjes of oproepen.

• Vrijdag, dienst. Vier kraamvisites. Nieuwe aanmelding, kennismaking en intake 13.00 – 15.00 uur. Overdracht aan praktijkpartner om 18.00 uur. Vrij weekend.

• Zaterdag en zondag, geen dienst.

Totaal aantal uren weg van huis en aan het werk = ca 38 uur met 1- 2 uur telefonische contacten en de administratie bijwerken.
Buiten de werkdagen, maandag tot vrijdag, – eenmaal gebeld.

Week vier

• Maandag vanaf 08.00 uur dienst. Prenatale zorg in de praktijk 08.00 -12.00 uur. Vier kraamvisites. Gebeld voor bevalling om 16.00 uur. Thuis om 21.00 uur.

• Dinsdag, dienst. Gebeld voor ondersteuning van praktijkpartner bij een thuisbevalling, van 07.00 – 11.00 uur. Drie kraamvisites. Nieuwe aanmelding, kennismaking en intake 15.00- 17.00 uur. Geen andere telefoontjes of oproepen.

• Woensdag, dienst. Geen werkzaamheden of gesprekken. De administratie in 2 uur bijgewerkt. Geen enkel telefoontje of oproep.

• Donderdag, dienst. Prenatale zorg in de praktijk 08.00 -12.00 uur. Praktijk vergadering tijdens de lunch 12.00 – 14.00 uur. Daarna twee kraamvisites.

• Vrijdag, dienst. Drie kraamvisites. Nieuwe aanmelding, kennismaling en intake (2 uur). Perinatale sterfte vergadering in plaatselijk ziekenhuis 13.00 – 15.00 uur.

Dienst vanaf 18 uur voor praktijkpartner, haar vrije weekend.

• Zaterdag, dienst. Om 6.00 uur gebeld voor assistentie van een collega (lid van de groepspraktijk die we samen voeren). Thuis om 16.00 uur.

• Zondag, dienst. Eén kraamvisite. Geen andere telefoontjes of oproepen.

Totaal aantal uren weg van huis en aan het werk = ca 35 uur met 1 – 2 uur telefonische contacten en de administratie bijwerken.

Buiten de werkdagen, maandag tot vrijdag, – tweemaal gebeld.

Ik hield ervan en floreerde met deze manier van werken. De voldoening die ik had van het relationele model van zorg resoneren nog altijd door in mijn perspectieven op de verloskunde. De relaties gaven mij energie en inspireerde me. Ja, soms was ik moe en wilde niets anders dan mijn telefoon afzetten. Maar dat werd steeds opnieuw goedgemaakt bij de volgende geboorte, het volgende imponerende moment; dat wij als verloskundigen het privilege hebben geïnviteerd te worden een bevalling te begeleiden.

Laat de caseload – verloskunde en persoonlijke continuïteit van zorg je geen zorg geven of bang maken. Het was een prachtig deel van mijn werk als verloskundige, dat ik vaak mis, nu ik ben ingebed in de academische wereld. Het plezier van zo te werken, overtrof altijd de momenten van kwetsbaarheid of twijfel. Zorgen voor vrouwen en hen adviseren en uit de eerste hand zien en horen hoe het werkt of niet werkt voor hen, geeft vorm aan praktijk besluitvorming. Het steeds opnieuw vrouwen ontmoeten die gezinnen vormen is een genot.

Ik moet zeggen dat caseload – verloskunde echt de kunst en de magie van de verloskunde door vroedvrouwen benadrukt, die mij altijd na aan het hart zal liggen. Wees niet bang voor caseload – verloskunde, het is duurzaam, aangenaam en goed uitvoerbaar met de juiste ondersteuning en flexibiliteit. Ik ken collega’s die na 20 jaar zo werken, het nog altijd even boeiend en inspirerend vinden. Net als collega’s met kinderen, collega’s die net afgestudeerd zijn en collega’s die nooit zo hebben gewerkt in een vrije praktijk. De belemmeringen om op deze wijze te werken worden overwonnen met steun- en de wens- en inspiratie te willen slagen.

Wat anderen ervan denken? Zou deze aanpak werken in het Verenigd Koninkrijk? Zou deze aanpak werken als nationale aanpak in bijvoorbeeld Schotland (of Nederland)? Heb je er ervaring mee?
Go well ……

Dr. Susan Crowther is hoogleraar verloskunde aan de Universiteit van Aberdeen, UK.

Vertaling Tine Oudshoorn, verloskundige, n.p. MA.

UK Hermeneutic Phenomenology course & symposium

Course and symposium bookings now open. The 2018 April event is in Aberdeen, Scotland hosted at Robert Gordon University. As at the 2017 event Dr Gill Thomson from UCLAN co-facilitates with me! The 2017 event in Preston was fantastic and we are both looking forward to the 2018 one…. see you there. Information on how and where to book a place for the course/symposium is on the attached posters.

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Ecology of Birth

Last week I spent a day at the University of Humanistic Studies, Utrecht, The Netherlands  attending a symposium:

“Concerning maternity: ethical and existential questions at the beginning of life” hosted by Dr. Inge van Nistelrooij & Dr. Joanna Wojtkowiak.

Every human is brought into the world through the woman’s body, however, there is surprisingly little research conducted on mothers’ perspectives on good care at the beginning of life. The symposium focused on existential concerns at the beginning of life from the perspectives of those closely involved in the care of new life: mothers, fathers and professional caregivers. This symposium was the first part of a two-piece expert-meeting of a new program of research. This 1st symposium posed the question

‘What are existential concerns at the beginning of life?’I was invited to share some of my insights about spirituality, childbirth and existential experience. Needless to say i resonated with this theme! Part of the key note I gave explored the following taken from my chapter  ‘Birth as a Sacred Celebration’,  In (Crowther, S & Hall, J. 2017 Eds.) Childbirth and Spirituality: meaning and practice at the start of life. pp. 15-16. I want to share this excerpt from the chapter and presentation in the hope it will generate some dialogue.

Ecology of birth

There is a wholeness about childbirth which I to refer to as an ‘ecology of childbirth’ which unfolds at each birth (Crowther 2016, Crowther 2014). Yet we need to be cautious of naming something. The notion of an ‘ecology of childbirth’ (see figure 1) and its implications for how childbirth occurs within contemporary maternity systems is used here as a point of departure in our explorations and is not intended to be taken as a fixed and inflexible notion.

An ecology of birth

According to Haeckel (1986) ecology is the science of relationship of living things/beings and their environments. What is key in this definition of ecology is the significance of relationships. I would contend that ecology in relation to childbirth is concerned with multiple relationships. It is an interrelated phenomenon comprising an embodied quality [i], a spatial quality that includes felt-space and physical places of birth, a quality of relationality or being with others, a quality of temporality that incorporates Kairos time (explored later in chapter), a dynamic quality of social-political and cultural context e.g. changing policies and practices informing childbirth. Simultaneously every birth includes a mysterious unspoken quality unfolding in and around the occasion. This ‘ecology of birth’ incorporates ALL types of birth in ALL circumstances.

An ecology of birth is a notion built upon the enigmatic description of Heidegger’s fourfold [ii] (Heidegger 1971/2001), Smythe et al’s (2016) interpretation of the ‘good birth’ and my own research in relation to the existential qualities of lived-experiences of being at the time of birth (Crowther 2014). Reawakening our collective cognisance of an ecology of birth can bring remembrance of how each birth is potentially a joyful celebration of life and our shared natality. I infer a ‘reawakening’ as I fear we have forgotten or covered up our original knowing. In this chapter I adopt a phenomenological and philosophical hermeneutic lens informed by the works of Heidegger (1927/1962), Gadamer (2008/1967), Arendt,(1958) Dilthey, (2002) and O’Byrne, (2010) to present a philosophical interpretation of birth as spiritually meaningful.

[i] Embodied experiences refers to how the body is the medium of our perceptions (Merleau-Ponty 1962/2002). Experience and bodily sensorial sensations are thus inseparable. For example a joyful experience is both our material body, such as tears of joy, as well as the lived experiencing of the joy. As Heidegger (2001) contends we body our experiences, that is to say we embody them.

[ii] Heidegger’s philosophical notion of the fourfold is a central aspect of how we dwell as human beings in all situations we find ourselves. The fourfold has four components: earth and sky, divinities and mortals which are an inseparable unity that cannot be divided into separated components. Each component is interconnected and in the interiority of the other. Heidegger claims that human beings are not only a being in the world, but are always part of this fourfold. For further description read Heidegger’s (2001) Poetry, Language, Thought

(full references given at end of chapter).

Finishing First Year Midwifery

This is such a lovely blog from a 2nd year student midwife at RGU – I just felt compelled to share! Emma, midwifery is privileged to have you join the profession!

RGU Student Blog

This September I finished the first full year of my midwifery course, and so much has happened in that time. I sat an exam, I failed essays and passed essays, I moved into a new flat with 3 fantastic girls, I’ve worked in 3 different hospitals during 4 clinical placements, I set up my own Netflix account and I have delivered 10 beautiful babies.

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Spirituality and Childbirth: meaning and care at the start of life

It is now published! Available on Amazon – that was quite a journey. Made wonderful by a team of amazing chapter authors and my lovely friend and colleague Dr Jenny Hall as Co-editor. The official launch will be at the Normal labour and Birth research conference early October at Grange over Sands, UK. We hope it brings this conversation to the table or at least begin a conversation. To find oneself, in whatever capacity, in and around childbirth, is to be moved and transformed by an event in human life that is significant on so many individual and societal levels. Enjoy the read and let me know your thoughts.

A four-day Hermeneutic Phenomenology Methodology Course (3-6th April, 2017)

School of Nursing and Midwifery Blog

A four-day Hermeneutic Phenomenology Methodology Course (3-6th April, 2017)

The University of Central Lancashire and Robert Gordon University are delighted to invite you to attend the following:

A four-day Hermeneutic Phenomenology Methodology Course (3-6th April, 2017) aimed at postgraduate research students, researchers and academics working within health and social care areas who are new/novices in this theoretical and methodological approach.  During the course, participants will receive an introduction to, and beginning experience in, designing hermeneutic phenomenology studies, collecting and analysing data, and reporting themes, qualities and patterns.  (Please note this event includes a three-day methodology course and attendance at the one-day symposium detailed below)

A one-day Hermeneutic Phenomenology Symposium (6th April, 2017) aimed at postgraduate research students, researchers and academics working within health and social care. This is an exciting opportunity to listen to experienced researchers who have used a hermeneutic phenomenological approach to a) highlight some of the challenges…

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Hermeneutic Phenomenology Symposium April 2017

Hi all. Dr Gill Thomson and I have finalised the program for the 4th day of a hermeneutic Phenomenology methodology course (see previous blog). The 4th day is an exciting and inspiring symposium open to all. So even if you cannot join us for the week come along for the symposium. Attached is information to wet your interpretive appetites. A great line up of hermeneutic phenomenological scholars. See you there for a day of dialogue! Looking forward to a feast of thinking!

Compassion in midwifery, maternity and childbirth

Last week I had the wonderful opportunity to be part of an interactive event in Dundee. It was the 2nd Scottish Improvement Science Collaborating Centre (SISCC). A wonderful liberating and inspiring day. I just want to share some insights that came during the day which focused on care and compassion.
I was confronted by a series of questions that arose both within myself and in communication with others: 

  • What is compassion? 
  • Where does it come from? 
  • Does it dwell within us or outside of us? 
  • Can compassion be taught and learnt? 
  • Is compassion an innate human quality?
  • How can compassionate care be spread to places where it may not yet be realised?

My personal life experience is that compassion is a quality and energy that manifests, and awakens between us within relationship. Such relationship is born of communications both silent and spoken. It is in the richness of a reciprocal dialogue that the possibility of empathy and compassion awakens. For me it is a way of being in the world and being with others. 

Following last week I am left wondering how do institutions and organisations in which we work enable and disable the potential for compassion to be revealed? Do our organisations ensure relationships can flourish? I am thinking of organisational structures that resonate at a particular tone or mood of fear and control that may not value human connection in which compassion can thrive. 

What does the organisation you work for value most? I’m not speaking of written policy, guidelines and organisational rhetoric but coalface interactions between and through all layers of an organisation. Does the context you work for allow the magic between people to unfold and energise compassion? Are the the conversations we have with colleagues and users of services based on a democratic dialogue, that is to say, does our use of language create a level playing field between us? 

For compassion to thrive and inform our connections with others a particular mood is required. A mood of congeniality, openness, transparency, care and tenderness. If we understand that we have to be in one mood or another and that we cannot be without a mood then the mood of a places and persons are significant. If a mood permeating your place of work is largely fear based then that is how that environment comes to be understood and how all interactions in that environment become interpreted. I would contend that in that mood a maternity (or any health environment) unfolds into a risk orientated experience. That can feel threatening and stressful.

I remember transferring a women into a hospital from community. I was happy to see an old colleague on duty in the hospital yet the communication between us was uneasy. I was confused and disoriented. I was met by a host of questions about the care I had provided prior to admission. This was all necessary yet it was the tone of the communication that left me feeling uneasy. The obstetrician then entered and the mood drifted into antagonism which translated into a barrage of risk discourse that awakened anxiety both for me and the family I was working with. I remember becoming overly judgemental of my own decision making, second guessing myself and feeling defensive. I was on guard and felt no sense of connection between the staff and myself. I went quiet. 

My relationship with the mother and partner became challenging as they too were being pulled into this new mood since being admitted. Suddenly everything became dangerous and risky. We transferred in for slow progress of labour and maternal request for analgesia. It felt we had arrived just in time to stop a terrible outcome! I felt that no one was having a good day in that environment. 

On the other hand I have admitted from a homebirth with a woman having a retained placenta and been met with congeniality, respect and a listening ear. The admitting midwife made me a coffee whilst I admitted the woman and spoke to the doctor. The admitting doctor was friendly and professional. The mood on both occasions was startlingly different. Although the outcomes both times were positive for mother and baby in terms of physical needs there was a tangible felt difference postnatal in my relationships with the mothers. In the first story I went home exhausted, questioning my abilities and feeling frustrated. The postnatal care did not flow easily in the way I had hoped. In the second story I felt connected to my colleagues and went home feeling part of a team and that I had done a good job. The compassion in the second story left me sustained and nourished my relationship with the mother throughout the postnatal period.

Compassion is a quality awaiting a fertile ground to awaken and grow. Once compassion and care takes root it can nurture the possibility of compassionate connections in each moment. So for me compassion requires the right ground, a freeing type of resonance. Once the mood of an organisation shifts from one that narrows potential, for example when fearful, to one that opens to possibility something enlightening between us awakens. A spark of compassion, once a spark of a potential flame awakens it can be fanned into a roaring fire warming and bringing brightness to all our encounters.

Let us think about how our leadership is attuned? Our colleagues? Our policy makers? Our researches? Our educators? Our new graduates? 

Maternity and midwifery have been shown repeatedly to be based on relationships. Indeed it is the relationships that keep care safe. Midwives are the ambassadors of maternity care and have a responsibility to safeguard what is precious in childbirth and ensure its continuance is holistically orientated. Facilitating and turning to moods that enable compassion to flourish between us is therefore worthy of our efforts. We may or may not have innate compassion, in a certain sense that does not matter. However we can be accountable to the moods which we contribute to and choose to awaken and we can also decide the moods we choose to turn away from. We just need to be aware of moods and take notice of the affects certain moods have on ourselves and others.

For me the good news is that compassion awaits us all. It is not dependent on whether you or your colleague next to you has a good amount of innate compassion! The notion of compassion being inside or outside creates a kind of false objective -subjective dichotomy that is antithetical to compassion. Compassion wants to gift us all those wonderful experiences that come from giving and yielding to each other. Compassion is thus realised and expressed in our relational encounters. Compassion for me is thus unfolding moments between us in the reciprocal play of our interactions. Without the play between us compassion finds no ground to take root and grow. Compassion only asks for a fertile ground to grow and come forth. The delight of feeling compassion once awakened between us reminds us of our shared human needs of wanting to be understood to feel loved and to feel safe.

It may only take a kindly moment of eye contact, perhaps a smile and some gentle verbal acknowledgement of the others you meet and work with. Such moments can be the fan that ignites the flame of compassion between us.

taken from collective notes board at SISCC in Dundee 2016:Sept

New book early 2017 “Spirituality and Childbirth: meaning and care at the start of life”

kali-squatting
Co-editors – Susan Crowther and Jenny Hall.
Publishers: Routledge: Taylor & Frances Group.

The book will draw attention to the beginning of life; a poignant human journey that holds meaning and significance within and beyond current maternity care systems.

For more information click here.

Your examples of Caseload continuity of carer midwifery practice?

Hi all. I have received a variety of comments and feedback about caseload, continuity of carer midwifery practice. Would love to hear more. So vital to share our examples. There is a lot of misconceptions and fears about this way of providing midwifery. Also if you received care from a caseload midwife and want to contribute you are welcome! Let us have a conversation. My example was previous blog…..

Kind regards, go well

Susan

Feeling safe being free

img_0083-1

Safe and free

Focus on safety safety safety breeds fear,

fear then attunes us to more fear and then

the situations we find ourselves in, like childbirth,

become coloured by more fearful feelings ….

then it all feels even less safe!

Being constantly fearful is an unsafe place to dwell, function and be human,

we are simply not free when we are fearful!

Needing to feel safe is a human need yet it need not imprison us

let us not cover over what it means to be human in the pursuit of safety;

find ways of being and doing that awaken our potential to

flourish and feel safe and free

Susan Crowther 2016

Caseload midwifery is sustainable: personal example

There has been a lot of conversations across social media and various fora about caseload midwifery and working towards a continuity of carer model. There is a lot of anxiety and myth, misperceptions and unfounded concerns. I have had the pleasure to work across various systems in the UK and overseas. In the UK I worked in a group practice, standard maternity care and as an independent midwife. The standard fragmented care in which primary and secondary services are separately staffed simply did not resonate with me. The group practice arrangements I worked in at Chelsea and Westminster hospital in the 90s, although fun at the start, also were frustrating and exhausted me. Working independently in the UK was wonderful yet very stressful at times due to not being fully integrated into the system and the need to ask for payment. When I worked in New Zealand it was a fully integrated system in which women booked a midwife directly without having to pay when they were a resident or citizen. I have described the NZ system elsewhere. 
I am not going to re-state the supporting research evidence for caseloading, you can find that elsewhere. What I want to do here is first describe what continuity of carer is for me. It is being the main point of contact for a women through pregnancy, labour and birth then postnatal. Care is only handed to others when I am on holiday, weekends off, sick, study days or have two women go into labour at the same time! The care I provide traverses risk and chosen location for birth. I follow the women where she intends to birth. The arrangement is flexible and agreed in partnership at each step of the journey.

For caseloading to work I needed:

  • Excellent support structure with colleagues
  • Like minded colleagues who were philosophically aligned
  • Fair remuneration for the work I did that was equitable and matched the level of skill. Payment to be organised through ministry of health and be free at point of delivery to women.
  • Regular time off arranged with practice partner.
  • Self determine my ways of working, e.g. When to do clinics, postnatal visits, Case load numbers, organising annual leave and weekends off call in liaison with practice partner.
  • One full month off for AL per year in one go, plus another week decided amongst group practice.
  • Partnership working with women that was reciprocally sensitive to each other’s needs
  • Time to be off call when needed urgently.
  • Generosity of spirt and good communications amongst colleagues
  • Excellent relationships at interface with hospital colleagues (midwives and medical)
  • Regular support and guidance from the midwifery council and college of midwives
  • Understanding family who supported my way of working
  • Great rapport with everyone in my local community where I was working
  • Reliable car and phone!

Background

Caseload 4-6 per month. Reasonable living wage that was slightly more than colleagues working shift work in the hospital. The payment for caseload midwives in NZ is presently being challenged to meet inflation and degree of responsibility. At the time of this diary entry the 4-6/month booked women provided an adequate pay yet this had not increased with inflation hence current challenge.
I worked with 8 other caseload midwives split into partnerships for weekend off call, holidays, SDs, sick, 2nd midwife for primary births and when need support for long labours or when two women go into labour at the same time! Clinic times and postnatal visit times decided by myself and confirmed with women as needed. Key is flexibility. Some midwives prefer to do all clinics in one day, all bookings another day for example. Partnership is essential between the women and myself as well as with practice partner, group practice and associated support services such as GPs, primary birth unit staff and local hospital colleagues.
So what did a month look like? Was I over worked? Was being on call a constant intrusion in my life? Did women abuse the on call system and call me constantly?

Here is one month activity from my practice diary. All names and places have been removed. Each month was different but this gives you a snap shot.
So here it is…   

Week one

Monday. On call, Antenatal clinic 8-12noon (8 women). Postnatal visits x3 X1 booking (2 hours). Home by 430pm. No calls

Tuesday on call x4 Post natal visits in morning. Office admin work afternoon. No calls.

Wednesday on call 3 post natal visits in morning. Afternoon free. No calls.

Thursday on call antenatal clinic (8 women). X2 PN visits. Practice meeting cancelled everyone busy. Home at 3pm. Called at 10pm to a birth. Home at 8am Friday morning.

Friday on call. Morning free to sleep. X4 postnatal visits in afternoon. Home by 5pm. Practice partner took my on call 6-11pm so I could go out of area to an event.

Saturday, on call, no calls. X1 PN visit.

Sunday, on call, no calls. X1 PN visit.

(Total hours actually away from home and working = approx 36 hours)

Called out outside of Monday to Friday working days – once
Week two.

Monday on call. Antenatal clinic 8-12. PN visits x4. Home 4pm

Tuesday on call. X1 booking 9-11am. X3 postnatal visits. Home 2pm. No calls

Wednesday on call. No calls, no visits. Admin catch up (2 hours)

Thursday on call. Antenatal clinic 8-12. Practice meeting over lunch. X 4 PN visits. Home by 4pm. Took practice partners on call so she could have an evening off.

Friday called to birth at 7am. Home at 1pm. Booking 3-5pm. Called to be 2nd midwife at birth 7-11pm.

Saturday on call for my own case load and practice partner for her weekend off. X1 PN visit no calls

Sunday x2 PN visits. Free by lunchtime. Called at 5pm for BF problem.
(Total hours approx 35 hours away from home + 1-2 hours phone and admin work)

Called out or working outside working Monday to Friday working hours – twice
Week three.

Monday on call. Antenatal clinic 8-12. PN visits x4. X1 booking. Home at 5pm.

Tuesday on call PN visits x2. Free from 11am. No calls

Wednesday. Called to induction of labour at 11am (post dates). Home at 11.30pm.

Thursday on call Antenatal clinic 8-11am. X 3 PN visits. Practice meeting over lunch. Home by 3pm. No calls.

Friday on call PN visits x4. Booking 1-3. Hand over on call to practice partner at 6pm.

Saturday and Sunday off call.
(Total hours approx away from home 38 + 1-2 hours phone and admin work)

Called out or working outside working Monday to Friday working hours – once
Week four

Monday on call from 8am. Antenatal clinic 8-12. PN visits x4. Called to birth at 4pm, home at 9pm.

Tuesday. Called to be birth support for practice partner at home birth 7-11am. X3 PN visits. Booking visit 3-5pm. No calls.

Wednesday. No calls all day. Did 2 hours of admin.

Thursday Antenatal clinic 8-12. Practice meeting over lunch 12-2pm. Then X2 PN visits. 

Friday x3 PN. Visits. X1 booking. Perinatal mortality meeting at local hospital 1-3pm

On call from 6pm for practice partner also for weekend.

Saturday called to birth at 6am (practice partners caseload). Home by 4pm.

Sunday X1 PN visit. No other calls.
(Total hours approx working away from home 35 hours + 1-2 hours phone and admin work)
Called out outside working Monday to Friday working hours – twice
I for one flourished and loved this way of working. The rewards that I derived from the relational model of care continue to resonate throughout my perspectives on midwifery. The relationships energised and inspired me. Yes at times I was tired and wanted to ‘just turn off my phone’ yet these times were frequently ‘healed’ by the next encounter, the next birth, the next moment of awe; that as midwives we have the privilege to be invited to.
Don’t let caseloading and continuity of carer worry you or cause anxiety. It has been a wonderful part of my work as a midwife which I often miss now embedded in academia. The joys of working that way always outstripped the moments of vulnerability. Providing advice and care to women and seeing and hearing first hand how it worked or did not work so well for them shapes practice decision making. Meeting up with women again and again over the years whilst they make their families is a joy. 
I would say it was being a caseloading midwife that really highlighted the art and magic of midwifery in ways that will always be dear to my heart. Don’t be afraid of caseloading, it’s sustainable, enjoyable and doable with the right support and flexibility. I know colleagues who are still flourishing after 20 years working this way, colleagues with young children, colleagues who just qualified and colleagues who had never worked in the community prior to caseloading. The barriers to this way of working can be overcome with the support, desire and inspiration to succeed.
What do others think? Would this work in the Uk? Would this work as a national approach for Scotland for example? Do you have your own experiences?
Go well