Caseload midwifery services expanded in industrialised countries during the late twentieth century in response to childbearing women's acknowledged need for continuity of care, humane care, more judicious use of intervention, and more control over management of their maternity care. Caseload midwifery practice is built on the assumption that receiving full maternity care from a designated midwife, or pair of midwives, enhances continuity of care and women's participation in their care and decision-making, reduces unnecessary obstetric intervention, and increases women's satisfaction with care. How these processes of care operate in practice, within the relationship between women and their midwives, is the focus of this study. This thesis explores the expectations and experiences of women and their midwives of the woman-midwife relationship within a caseload midwifery service.
An interpretive approach was used to examine the relationship over time between six women and their midwives in a service using individual and paired midwifery caseload. The service was located in a birth centre in a large metropolitan hospital in Australia. Data collection comprised four to five in-depth, individual interviews of participants from before the relationship commenced until after the birth, observation of one to two woman-midwife consultations per dyad, and general observation in the birth centre. While the small size of the sample precludes generalisability of the findings, the inclusion of both women and their midwives provided rich data from both parties to each dyadic relationship. The collection of data at multiple points in time enabled the exploration of expectations, how those expectations were enacted or modified, and the women's reflections on their experience of the relationship four months later.
Both client and midwife participants enjoyed the relationships and actively participated in them. The three main themes reported were a sense of personal connection between the woman and her midwife, mutual trust, and shared decision-making. These relational elements developed iteratively over time and were deeply intertwined and context-dependent. Time was important in enabling relational processes to develop with ongoing reflection. Important aspects of the context of the relationship include the birth centre's active birth philosophy and inclusive physical and social environment. The active role of clients in their childbearing and inclusion in their maternity care was central to the midwives' practice.
Clients and their midwives experienced inclusion in slightly different but complementary ways. To clients, inclusion largely meant being actively involved in a relationship with one or two midwives who were friendly and interested in them, who supported their personal needs and wishes regarding care, and whom they trusted to keep them safe and informed. To midwives, inclusion primarily meant clients being fully informed of their situation and options, and either included in, or solely responsible for, decision-making regarding their care. The term inclusion is used, therefore, to signify the inclusion of the childbearing women in all aspects of their care, including the working out of how to share decision-making. While the sense of personal connection and trust were important to the midwives, they were somewhat a means to inclusive decision-making and personal growth for the women, whereas the personal connection and trust were important to the clients more for their own sake. The considerable mass of positive relational aspects of each relationship, developed and enacted over time and in an inclusive environment, enabled the relationships to accommodate some difficulties such as occasional challenges to trust.
This thesis contributes insights into the process of the caseload midwifery relationship. Knowledge generated has implications for midwifery education, practice and research, and the structure and evaluation of maternity services. The findings may help midwives and midwifery students prepare for caseload practice and may help midwives practising caseload understand and further develop their relationships with clients. Further research could explore the implications for development of the relationship in various service models including caseload and team practice, in particular the relative importance and core processes of personal connection, mutual trust and inclusion. Finally, as various service models are introduced, health service providers require empirical knowledge of the implications of the various models to inform client and midwife satisfaction and staff retention in various models.