Paper: Life in Midwifery: Managing Work-Life Balance Through Alternative Call Models

The benefits of midwifery care are well known.  Women enjoy the relationship that they develop with their midwife, and report greater satisfaction compared to other models of care. (1:901, 2:12-13).  Clinical benefits have also been documented for women receiving midwifery care, including lower rates of labor interventions such as induction of labor and epidurals. (3:6) Midwives enjoy their professional autonomy and the relationships that they are able to develop with their clients. (4:436, 5:5, 6:10, 7:36)  

Midwifery itself is often a calling, something that had been dreamed of for years before pursuit.  It can be described as more of a lifestyle than a job, something that becomes entwined with one’s sense of identity. (8:24, 7:36) The nature of midwifery work is selfless, yet its demands can cause an upset of work-life balance that can be problematic. (4:439, 6:10,7:30, 8:26) Working on call as a midwife often means sustaining very long hours, sometimes with no breaks for meals or rest. It also means being in a constant state of anticipation, having to leave at a moment’s notice without knowing when you will be returning. The demands of being on-call can disrupt midwives abilities to meet their most fundamental needs, such as nutrition, sleep, and interaction with family and friends. (7:38, 6:10) The passion that midwives have for their work fuels them through many of these challenges.(8:25, 7:36-40) Yet many midwives still struggle to balance their lives. Their struggles can continue to mount, resulting in feelings of social isolation or declining mental health. (6:10, 7:38) Without careful attention, this can easily lead to burnout, which is the main reason that midwives discontinue practice.(8:26, 6:13) This burnout is reflected in the attrition rate for Ontario midwives, which was found to be 21% between 1994 and 2008. (8:23)  Midwives approaching retirement, and those with young children, are at particular risk of suffering from burnout, yet these women make up the bulk of the workforce in midwifery. (7:30, 7:42, 9:314-315) Such a high attrition rate is unacceptable in a profession that seeks to grow to match maternity care needs. 

There is no lack of evidence to justify the fact that midwives need a more realistic workload. Some Ontario midwives may work in excess of 80 hours per week, which can only lead to exhaustion and questionable safety of care delivery.(10:3)  There is a clear need for revision of policy to enable midwives to find solutions, which is best undertaken at a regulatory level. The College of Midwives of Ontario (CMO) has responded to this need by creating a policy review plan that is currently in execution.(11:1)  This plan has included a thorough literature review with extensive client and member surveys and interviews in order to represent midwifery in Ontario.  Their review of client feedback has revealed a client base that continues to value continuity of care.(12)  Clients in all Ontario call models report equal levels of satisfaction, and while they persistently express the desire to know anyone who will be at their birth, the nature of birth itself makes this an issue that may never be universally resolved.(12) Consultations with CMO members have been undertaken to determine how regulations are currently being interpreted and practiced, and the degree of member support for change. (11:1) Other studies with similar objectives have indicated an “overwhelming” support to increase flexibility in the current model of care. (7:39)  The most prominent suggestions from Ontario midwives have included revising the requirement that two midwives attend every birth, and modifying continuity of care requirements.(7:39) The CMO has echoed their members’ support for increasing flexibility, while also responding to concerns from other members about the risk of change that could compromise the quality of care that women are currently receiving. (13:2-6)  The CMO’s goal is to allow for more opportunities to prevent burnout by increasing flexibility, while strongly maintaining all of the existing tenets of Ontario midwifery care. (14:2, 13:2-3-6) 

Alternate approaches to care

 

One such approach is enlisting the help of nursing staff to act as second birth attendants, rather than requiring a second midwife to attend every birth. This has the potential to alleviate midwifery resources and save costs on the healthcare system by utilizing the services of a nurse who is already being paid. It may also facilitate closer relationships with hospital staff, an issue that has been identified by a number of midwives. (8:26, 7:40) A rural hospital in British Columbia implemented such a model, whereby nurses provide second attendant care and assistance through the first stage of labour as needed. The nurses in this setting were interviewed after the integration process was considered complete, and the arrangement appeared to be working well for everyone. (15:13) Such an arrangement may provide additional support for midwives to take meal or sleep breaks during long labours. This type of integration can, however, result in role confusion because the nurse assumes a much different role in a midwifery-led birth than she does in a physician-led birth.(15:6) Obstetric consultation and transfer of care are already challenging situations in many settings, as each discipline attempts to determine what role to play, and this certainly has the potential to be compounded when there are two sets of expectations depending on whether the most responsible provider has changed in labour.(15:12) Differences in philosophy of care, which can come up during routine care or emergency situations, can also create tension.  This can be anticipated and alleviated by identifying and explaining differences in practice styles. The most significant advice gleaned from the British Columbia example of collaborative care was to facilitate clear, frequent and direct communication about client care, and the roles and scope of each player on the team.(15:13)   Nurses and midwives can grow to respect one another a great deal when given time and the opportunity to work together and observe each other in practice.(15:12)

Another approach to interprofessional collaboration is sharing clients between physicians and midwives.   This is especially beneficial in rural and remote areas where care can be shared between physicians and midwives to enhance back-up coverage. This form of maternity care has been endorsed by a number of Canadian health care organizations. (16:8) It should be considered with caution, however, for the urban Ontario population. The United Kingdom has a vastly different system from that in Canada, and midwives there often work within such a context. Many midwives in the UK have become employed by the centres in which they work, sometimes providing only clinic or hospital care to women of all levels of risk. For this reason, their care styles and philosophy of midwifery, including continuity and low intervention birth, are different than Ontario’s midwives. Many who work in these settings claim a lack of professional autonomy due to the institutional nature of their hospital-based job. (1:905-907, 17:221, 5:5) Further study has hinted that these models only produce high levels of job satisfaction when the institution subscribes to similar values as the midwives working within it. (18:332) Physicians and midwives also have different scopes of practice and legal responsibilities. This means that if both disciplines are regularly sharing the same client base, liability issues have the potential to alter care and interprofessional relationships. It must be stressed, then, that any jurisdiction considering interprofessional models consider the ramifications it may have on practitioner autonomy and satisfaction.

Hospital or birth centre-based midwifery that revolves around shift work has also been suggested as a solution to the stresses of on-call work. Predictable shift work could bring a number of benefits to midwives as well as the benefit of eliminating the chance of midwife exhaustion for the client. This practice, however, comes with a number of drawbacks.  Continuity of care is one issue that could get severely compromised if midwives are working shifts in any setting.  This system may also require midwifery management teams, which leaves the potential for a hierarchical system of division between midwives with greater seniority and authority than others. (18:329) It will most likely also require employment within the institution, which could have an impact on practitioner autonomy, an aspect of care that midwives in Ontario value a great deal. (7:41) Some midwives that the CMO has consulted with have warned of the potential for conflict between midwives if the college were to adopt a more flexible guideline for models of care such as this one, highlighting the potential for two different “kinds” of midwives to emerge. (12) For these reasons, consideration of this option must be very detailed before it is determined that continuity and autonomy can be preserved before proceeding with a model that could significantly alter the tents of care received by clients.

Practice Considerations

            Regardless of the transferability of these options to current settings, it is imperative that midwives find ways to practice that promote the longevity of their career and the continued satisfaction of their clients. Certainly work-life balance is not upset for all working midwives, and so we can take lessons from those who have found a positive work-life balance.  We also, however, need to learn from the voices of midwives who were not able to achieve this balance and subsequently left practice. 

The first step to happy and fulfilled midwives is an environment of positivity in the clinic. Midwives within a practice are interdependent upon one another – for call coverage, advice, and consultation, but also for emotional support. (4:438-439, 7:36) Because midwives depend on one another in so many ways, each member of the team has a responsibility to maintain respectful and empathetic relationships. Their sense of support has a strong influence on midwives’ job satisfaction, and their abilities to handle challenging or busy periods of work. (18:332, 9:314)

Yet many midwives have reported a sense of “expectation” or “pressure” to work beyond their capacities in order to pull their own weight. (6:13, 7:39) In some instances this can be the result of peer “bullying”.(7:39) In others, these expectations may never actually be spoken but are anticipated by midwives who know how hard the job already is and do not want to burden their colleagues. Regardless of the reason, this can lead to a sense of obligation to continue working, sometimes to the detriment of physical or mental health, or even to the detriment of client safety. Flexibility and a non-hierarchical nature within the practice for midwives to express themselves and influence the structure of the practice can facilitate the sentiment that everyone is working together, rather than against one another.   Taking even small steps such as matching clients geographically to their midwives can make a big difference in lightening a workload and feeling as though you have been considered as members of a team.(9:316) For those practices who are still striving toward this type of environment, conflict resolution interventions can be an effective way of retaining midwives and facilitating a team mentality. (7:40)  Priority should also be given to meeting often to facilitate clear communication about client cases and individual needs. (14:1) 

Some midwives may be unable to maintain working on call for certain periods of their lives.  Midwives who have young families or who encounter health complications may still wish to be involved in work but unable to maintain on-call responsibilities. (7:42)  These midwives can still be of immense value to the team, through alternate work arrangements. Examples of this include providing clinic care only, or acting as “non-call practice managers”, maintaining aspects of practice such as call schedules and caseload arrangements for the group. (14:1-2) This can work beneficially for everyone in the practice as it lightens the workload for those midwives who continue call work, and provides a continuing means of meaningful paid work for those who are not able to maintain on-call duties. 

            Practices need to evaluate the effectiveness of their call model regularly to ensure that it is working well for everyone. (10:4)  Midwives who have left the profession have reported losing their sense of self in lieu of the priorities that they felt obligated to place on their work. (8:26) This mentality, while perhaps common in midwifery, does not foster a sense of balance or longevity.  Practices need to employ mechanisms for midwives to obtain adequate time off call to sleep and nurture their non-working selves.

The CMO recommends that practices structure protocols to prevent midwives from working more than 24 continuous hours, despite the fact that this many hours awake impairs an individual’s cognitive abilities to a similar degree to alcohol impairment.(10:3-4) One could speculate how few careers require such long hours, particularly in such a litigious field. Care providers who are not adequately rested are at a greater risk of providing suboptimal care, making mistakes, and encountering conflict with their peers. (6:13, 10:3) The 24 hour rule ignores the possibility that work may commence at a time of day when the midwife has already been awake for a number of hours. Clearly a delineation of less than 24 hours would be beneficial for both the client who deserves safe and effective care, and the midwife who has physical needs to be met. Further, the interdependence between midwives can sometimes result in being paged back into work before sleep has adequately been recovered.  Fereday and Oster examine a model of midwifery at a clinic in Australia that provides an exemplary template for practices that are looking for suggestions.  In this model, each midwife is required to have two days per week completely free of all work-related responsibilities. (9:313) Midwives in this model are also required to call in a backup and discontinue working after 12 continuous hours of client contact. (9:313)  Policies such as these provide a baseline for accountability toward one another.  All midwives have to work together to ensure that these requirements are met. In order to implement these, each midwife on this team was on call only 3-4 days per week. (9:316)  While this model may not facilitate the same degree of continuity that Ontario midwives strive toward, a modification of these practices is worth consideration. The midwives who worked in Fereday and Oster’s model had high levels of job satisfaction, and indicated that they did not wish to return to hospital shift work. (9:316) 

Models such as Fereday and Oster’s show that midwives who can feel confident that they will not be overworked and will have adequate time to rest and restore themselves can find good balance. The considerations listed here are an introduction into approaches that can be used within current or future models that may be able to maintain principles of autonomy and continuity while still allowing for self-care and growth.  Each midwife will meet her own challenges to managing work-life balance, and each practice needs to find a flexible way to accommodate the midwives within it.  Ontario midwives need to continue the discussion together about what works, and what does not, so that all midwives can foster happiness and positivity both within themselves and in their work.

 

 

 

References

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