Should I stay or should I go? Case-loading midwives' perceptions of transfer of midwifery care for epidural
Author: Bronwyn Carpenter
Should I stay or should I go? Case-loading midwives’ perceptions of transfer of midwifery care for epidural
Bronwyn Marie Carpenter
2 October 2018
Abstract
New Zealand has a world-leading and unique maternity system. Case-loading midwives known as Lead Maternity Carer (LMC) midwives may care for a woman from pre-conception through to six weeks postnatally. The LMC midwife (or her backup) provides continuity of care in a partnership model throughout this period, sharing responsibility with the woman for maternity care. This service is funded by the government via The Primary Maternity Services Notice (Section 88) of the New Zealand Public Health and Disability Act, 2000, which outlines the responsibilities of the LMC along with the payment schedule for services provided.
The Ministry of Health (MOH) produces guidelines that outline levels of referral for different conditions in the childbearing year. A request for epidural anaesthesia during labour calls for an LMC to recommend a consultation with a specialist. This guideline, and the New Zealand College of Midwives Transfer Guideline, recommend that a conversation takes place between the LMC and specialist about ongoing responsibilities of the midwife in the event of such consultation. Lead Maternity Carers are required, within the terms of their access agreement, to inform the District Health Board (DHB) of their scope of practice with regard to their epidural certification status. The transfer guidelines suggest that the LMC can reasonably expect to continue providing care until the facility has a core (hospital-based) midwife available to take over. The LMC may also choose to stay with the woman in a support role following transfer of clinical responsibility. This statement infers a co-operative approach which may or may not be a reality.
This study used a qualitative descriptive approach in order to explore LMC midwives’ perceptions and experiences in relation to transfer of midwifery care for women whose labour choices or needs include epidural anaesthesia. Two focus groups were conducted; one with a group practice who provide continual labour care for women with an epidural, and the other with a group practice where the midwives transfer midwifery care for epidural to the core midwives at the facility.
The research question was “How do case-loading midwives feel about providing ongoing care when a woman has an epidural in labour?”
The midwives who chose to provide epidural care, expressed a growing sense of disillusionment with the perceived inequity in payment for providing what they saw as secondary care as a primary-funded midwife, and therefore - in effect - subsiding the District Health Board (DHB) services by providing epidural care in the interests of continuity with the woman.
Midwives who had chosen not to provide epidural care articulated their joy in being with women having a normal childbirth experience and their ways of keeping a safe space for women to birth. Both groups intimated that payment issues and inequity have created disharmony and tensions regarding this aspect of midwifery care provision, by challenging the philosophy of continuity and questioning some basic concepts about what it means to be a case-loading midwife.
Keywords: epidural, continuity of care, case-loading midwives, Lead Maternity Carer, transfer of care, midwifery philosophy, focus groups, qualitative descriptive
Bronwyn's thesis was supervised by Suzanne Miller and Karen Wakelin.
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