ARTICLE IN PRESS

Midwifery 26 (2010) 435–441

Contents lists available at ScienceDirect

Midwifery
journal homepage: www.elsevier.com/midw

An evaluation of the satisfaction of midwives’ working in

midwifery group practice
Carmel T. Collins (RN, RM, NICC, BSSc, GDPH, PhD) (Dr)a, Jennifer Fereday (Dip App Sci (Nursing), BN,
MEd(Mgt), PhD) (Dr)b, Jan Pincombe (BA (Psychology), M App SC, RM, PhD) (Professor)c,
Candice Oster (BA(Hons), PhD) (Dr)c,, Deborah Turnbull (BA(Hons), MPsych(Clin), PhD, MAPS)
(Professor)d
a
Faculty of Health Sciences, Child Nutrition Research Centre, Women’s and Children’s Health Research Institute, and Discipline of Paediatrics, Flinders Medical Centre,
The University of Adelaide, Bedford Park, SA 5042, Australia
b
Research & Practice Development, Department of Nursing & Midwifery Research & Practice Development, Children, Youth and Women’s Health Service, 72 King William Road,
North Adelaide, SA 5006, Australia
c
School of Nursing and Midwifery, University of South Australia, North Terrace, Adelaide, SA 5000, Australia
d
School of Psychology, The University of Adelaide, North Terrace Campus, Level 4, Hughes Building, SA 5005, Australia

a r t i c l e in fo abstract

Article history: Objective: to examine changes in midwives’ attitudes to their professional role following the
Received 30 June 2008 introduction of midwifery group practice (MGP) (a caseload model of midwifery continuity of care
Received in revised form provided to women of all risk levels) and to explore aspects of the model that were working well and
25 September 2008
those that were not working well.
Accepted 27 September 2008
Design: the questionnaire ‘Attitudes to Professional Role’ was used to measure midwives’ satisfaction in
terms of professional satisfaction, professional support, client interaction, and professional develop-
Keywords: ment. Open-ended questions were also included to offer an opportunity for midwives to expand on their
Caseload midwifery experiences of working in the MGP model. The questionnaire was administered at five time points over
Satisfaction
the 18-month evaluation period. Round 1 was prior to the implementation of MGP, Rounds 2–4 were at
Midwives’ satisfaction
three-month intervals, with Round 5 six months later. Analysis of the structured part of the
questionnaire was undertaken by comparing mean scores of satisfaction ranging from 2 (very
negative attitudes) to +2 (very positive attitudes), and the open-ended questions were analysed using
qualitative content analysis.
Setting: the Women’s and Children’s Hospital, Adelaide, South Australia.
Participants: questionnaires were distributed to all midwives (n ¼ 15) working in MGP in Rounds 1, 2
and 3, and to the 12 midwives remaining from the original sample in Rounds 4 and 5. Fourteen
questionnaires were returned in Round 1, 12 in Round 2, 10 in Round 3, nine in Round 4, and 10 in Round
5.
Findings: overall, a positive change in attitudes to professional role was reflected in all sub-scales in the
period between start-up and 18 months later; a reduction in scores occurred in Round 3. The mean
increases were significant for all sub-scales apart from professional development. Five main themes
were identified across the rounds in the content analysis: ‘continuity of care’, ‘working pattern’,
‘working environment’, ‘collegiality’ and ‘issues relating to midwifery practice’. Midwives gained
particular satisfaction from providing continuity of care and building relationships with women and
their families, and through practising autonomously as a midwife. While there was a struggle to manage
the hours worked and being on call, high levels of professional satisfaction were maintained.
Key conclusions: while there were aspects of MGP that midwives were not satisfied with and wanted to
change, overall they were satisfied with the model.
Implications: there is a need for ongoing evaluation in order to monitor the short- and long-term impact
on midwives of working in a caseload model of continuity of midwifery care.
& 2009 Published by Elsevier Ltd.

 Corresponding author.
E-mail address: candice.oster@unisa.edu.au (C. Oster).

0266-6138/$ - see front matter & 2009 Published by Elsevier Ltd.

doi:10.1016/j.midw.2008.09.004
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436 C.T. Collins et al. / Midwifery 26 (2010) 435–441

Introduction time on call, cover for sick leave, annual leave and study leave
within the framework of the industrial agreement under which
The past two decades have seen a growing recognition of the they were employed.
importance of continuity of maternity care for women (Turnbull
et al., 1999; Andrews et al., 2006). Models of midwifery continuity
of care have been introduced both in Australia and internationally.
These include team midwifery, where a team of midwives provide Methods
antenatal, intrapartum and postnatal care (Biro et al., 2000;
Waldenstrom et al., 2000), and caseload midwifery, where a Aims
midwife works in a group practice, taking responsibility for the
main provision of care for an agreed number of women (Andrews The aim of this study was to examine changes in midwives’
et al., 2006). attitudes to their professional role following the introduction of
There is high-level evidence in the form of randomised MGP, and to explore aspects of the model that were working well
controlled trials for the efficacy of midwifery continuity of care and those that were not working well. The evaluation took place
(Waldenstrom and Turnbull, 1998; McLachlan et al., 2000). over a period of 18 months from the introduction of the MGP
However, what is less understood is the impact of continuity of model in January 2004.
care models for providers. These models of care necessitate a
change in midwives’ roles and responsibilities to encompass the
full scope of their practice, caring for women antenatally through Participants
to postnatally. Flexible working patterns and time on call are
required (Sandall, 1998). The extent of the changes required raises The sample consisted of all the midwives (excluding the nurse
the question of how midwives fare when they practice within a manager) employed at the commencement of the MGP model of
continuity of care model. care (n ¼ 15).
Higher levels of job satisfaction, increased autonomy and
positive changes in the attitudes of midwives towards their
professional role have been reported in survey studies (Hundley
Questionnaire
et al., 1995; Turnbull et al., 1995; Sandall, 1997; Freeman, 2006).
However, higher levels of burnout (Sandall, 1999; Andrews et al.,
The questionnaire ‘Attitudes to Professional Role’ was used to
2006), concerns about being on call and the disruption of family
assess midwives’ satisfaction with the MGP model (Turnbull et al.,
and social life have also been reported (Todd et al., 1998; Freeman,
1995). The questionnaire was developed by Turnbull et al. (1995),
2006).
and used in their study of changes in midwives’ attitudes to their
In 2004, a midwife-led model of maternity care was introduced
professional role following the implementation of a midwifery
to the Women’s and Children’s Hospital in Adelaide, South
development unit in Glasgow, UK. Four domains of satisfaction
Australia. The model, called midwifery group practice (MGP),
were identified via a series of focus groups with midwives:
offers a midwife managed, caseload model of care to women of all
professional satisfaction, professional support, client interaction
pregnancy risk levels. The success of a new model is partly based
and professional development. A pool of 20 items was developed
on the attitudes of midwives to their professional role and their
to measure these domains. The questions are structured as
enjoyment of the new model (Hundley et al., 1995; Turnbull et al.,
completed statements with a five-point Likert response format
1995). It was important, therefore, to evaluate the impact of MGP
ranging from ‘strongly agree’ (point 1) to ‘strongly disagree’ (point
on the professional role of midwives working within the model.
5). To reduce response bias, half of the items within each domain
This study offers an important contribution to our knowledge
are negatively worded (Turnbull et al., 1995). The discriminant
about the impact of caseload models on midwives given that MGP,
validity of the questionnaire was assessed using a modified Q-sort
as implemented at the Women’s and Children’s Hospital, is one of
procedure (Turnbull et al., 1995).
the few models of continuity of midwifery care in Australia to
Two open-ended questions were also included, which offered
offer care to women at all levels of pregnancy risk. The study also
midwives an opportunity to expand on their experiences of
included a relatively long follow-up time of 18 months, and
working in the MGP model. Prior to the implementation of MGP,
incorporated a qualitative component in the form of open-ended
midwives were asked what they were excited about and what
questions to add an extra depth to the analysis.
concerns (if any) they might have. Following implementation,
midwives were asked what was and what was not working well
The MGP model for them in the MGP.

The Women’s and Children’s Hospital has an annual birth rate

of approximately 4000, and provides several options for preg-
nancy and childbirth care, including: medical (traditional)
antenatal care, midwives’ antenatal clinic, shared antenatal care
with a general practitioner, private obstetrician and MGP. Women
choosing to birth at the Women’s and Children’s Hospital self-
select their preferred model of care.
Within MGP, women are provided with midwifery care
throughout pregnancy, birth and up to six weeks postpartum.
Each midwife has an annual caseload of 40 women. At the time of
the evaluation 13 full-time-equivalent (FTE) midwives were
employed and formed two group practices of six FTE, with one
FTE manager position. Within the two groups, the midwives were
largely self-managing with regard to working patterns, days off,
Data collection
The questionnaire was administered at five time points over
the 18-month evaluation period. The first questionnaire (Round 1)
was circulated prior to the implementation of MGP in order to
obtain a baseline. A further three questionnaires (Rounds 2–4)
were distributed at three-month intervals, with the final ques-
tionnaire (Round 5) sent six months later. The questionnaires and
a covering letter were mailed to each midwife’s home address,
and followed three weeks later by a reminder letter to all. A
research support person, not involved with the MGP or evaluation
team, undertook the mail out and data entry, and separated
demographic data from the remainder of the questionnaires.
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C.T. Collins et al. / Midwifery 26 (2010) 435–441 437

Ethical considerations Findings

Return of a completed survey was taken as consent. Con-
fidentiality was maintained throughout the evaluation process.
Demographic data collected from the first questionnaire were
separated from the remainder of the questionnaires prior to
analysis, and no responses have been linked to particular
individuals.
Analysis
Questionnaires in Rounds 1–3 were distributed to all midwives
working in MGP (n ¼ 15). Fourteen (93%) questionnaires were
returned in Round 1, 12 (80%) in Round 2, and 10 (67%) in Round 3.
By Round 4, three midwives had resigned from the MGP. One
midwife left due to complications in her own pregnancy, and two
left as a result of the impact of being ‘on call’ on their personal
lives. This left a sample of 12 midwives who had been with the
MGP since the first round. Nine (75%) questionnaires were
returned in this round. In Round 5, questionnaires were sent to
the 12 midwives and 10 (83%) were returned.

Analysis of the four domains of satisfaction followed the

The midwives
process as described by Turnbull et al. (1995). First, the scoring of
negatively worded items was reversed. Second, all the response
All midwives were female. The majority were aged between 25
codes were recoded as follows: 1 was scored as 2, 2 scored as 1, 3
and 39 years and reported having 10 or more years of experience
scored as 0, 4 scored as 1, and 5 scored as 2. Mean scores were
as a midwife (Table 1). The majority were working in the labour
obtained for each of the four sub-scales by adding the responses
and delivery areas immediately prior to joining MGP. All were a
and dividing by the number of items answered. This produced
member of the midwives’ professional body. The majority
four mean scores for each individual ranging from 2, signifying
received their midwifery qualification through hospital-based
very positive attitudes, to 2, signifying very negative attitudes.
training (n ¼ 9). All midwives held at least one undergraduate
A process of qualitative content analysis was used to analyse
degree or diploma, and eight had postgraduate qualifications
the open-ended questions (Graneheim and Lundman, 2004).
(Table 2).
Responses were coded within the N-Vivo data management
system (QSR International Pty Ltd, 2002), and the responses
under each code were quantified according to their frequency. The Attitudes to professional role
codes were then clustered into themes.
The midwives’ overall satisfaction with the MGP model is
demonstrated in the analysis of their attitudes to professional
role. The mean scores for all sub-scales over the five rounds are
Table 1
The midwives. shown in Fig. 1.
Overall, the midwives had a positive change in attitudes
Variable Number of midwives following implementation of the MGP. Mean scores for Round 1
reflect attitudes prior to implementation when the level of
Age (years) n ¼ 14
25–39 9 (64%)
satisfaction was lowest, particularly in relation to professional
40–54 5 (36%) satisfaction and client interaction (with a mean of 0.01 and 0.5,
respectively, indicating a negative attitude).
Previous job
There was an overall positive change in attitudes from Round 1
Birthing centre 5 (36%)
Delivery suite 2 (14%) to Round 2. The highest mean score for professional satisfaction
Pool A (rotational position) 5 (36%) and client interaction was in Round 2 (three months after
Casual 2 (14%) implementation). Professional satisfaction then decreased slightly
Number of years as a midwife n ¼ 14 in each subsequent round, whereas a negative change in attitudes
2–9 5 (36%) was evident in Round 3 for client interaction followed by a
10–19 7 (50%) positive change in subsequent rounds. The highest mean score for
20 or more 2 (14%) professional development was reached in Round 3; this was
Qualifications n ¼ 15 followed by a negative change in attitudes in Round 4. Attitudes to
Hospital midwifery training 9 (64%) professional support remained fairly consistent and scored the
Undergraduate degree/diplomaa 15 (100%) lowest of all the sub-scales until a positive change by Round 5.
Postgraduate certificate, diploma or mastersb 8 (53%)
Overall, there was a positive change reflected in all sub-scales
Note: One midwife did not respond to the demographic questions. between start-up and 18 months later (Table 4). There was a
a
Four of the 15 midwives had two undergraduate degrees or diplomas. statistically significant mean increase for all sub-scales apart from
b
Two of the eight midwives had two postgraduate qualifications. professional development.

Table 2
Changes in midwifery group practice (MGP) midwives’ attitudes prior to start-up of MGP and 18 months latera,b.

Mean score pre MGP Mean score 18 months after Mean change 95% CI for change in P value
(n ¼ 9) start-up (n ¼ 9) mean score

Professional satisfaction 0 0.8 0.8 0.37–1.23 0.001

Professional support 0.04 0.64 0.6 0.30–0.89 0.0006
Client interaction 0.62 1.13 1.76 1.15–2.36 o0.0001
Professional development 0.19 0.59 0.39 0.04–0.84 0.07

a
Only midwives who responded at both time periods are included in the analysis.
b
Note: Round 1 occurred prior to the implementation of MGP.
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438 C.T. Collins et al. / Midwifery 26 (2010) 435–441

Open-ended questions Excited about. Six themes were identified. Midwives were excited
about a range of ‘issues relating to midwifery practice’ (n ¼ 13
Five main themes were identified across the rounds: ‘continuity midwives) and providing ‘continuity of care’ (n ¼ 9). They were
of care’ ‘working pattern’, ‘working environment’, ‘collegiality’ and excited about the ‘collegiality’ they felt would occur with the MGP
‘issues relating to midwifery practice’. Other themes identified in (n ¼ 5), and the sense of ‘new beginnings’, both professionally and
one or more rounds include: ‘new beginnings’, ‘acceptance’ and personally (n ¼ 4).
‘women’s commitment to active birth’. The themes are summarised Issues relating to midwifery practice. This was the dominant
in Tables 3 and 4, including a count of the number of respondents theme (n ¼ 13) and had two aspects, namely professionalism/
identifying each theme across Rounds 1–5. autonomy and promoting midwifery/role models. A number of
comments were made about professionalism/autonomy; for
example, having control over working hours. The midwives also
Round 1 (prior to commencing MGP) looked forward to expanding their midwifery skills and having
The open-ended questions focused on what midwives were ‘broader responsibilities’. The midwives considered it exciting to
excited and concerned about in starting their new role in the MGP. be able to be role models for a new form of midwifery practice and
to promote midwifery.
Continuity of care/woman-centred care. Providing ‘continuity of
professional satisfaction care’ and ‘holistic woman-centred care’ was an aspect of the MGP
professional support model that many of the respondents (n ¼ 9) were excited about.
client interaction This was seen as allowing them to provide ‘better care for the
1.5 professional development women’.
Collegiality. The main aspect of collegiality that midwives
(n ¼ 5) were excited about in starting their new role was within
1.0
MGP; comments focused on things like ‘team work’, ‘camaraderie’,
working with ‘like-minded midwives’ and working with midwives
Mean Score

0.5 they ‘like and respect’.

New beginnings. Four midwives identified ‘new beginnings’ as
0.0 something they were excited about in starting in the MGP,
1 2 3 4 5 including having a ‘fresh challenge’, ‘working with new people’
Round and ‘new leadership’.
-0.5

-1.0 Concerned about. Four themes were identified in response to the

question of what the midwives were concerned about in starting
Fig. 1. Summary of ‘Attitudes to Professional Role’, Rounds 1–5. in the MGP. These included: ‘conflict and acceptance’ (n ¼ 11),

Table 3
Summary of themes from all rounds—positive aspects.

Theme (positive aspects of midwifery Round

group practice)
1 (n ¼ 14) 2 (n ¼ 12) 3 (n ¼ 10) 4 (n ¼ 9) 5 (n ¼ 10)
February 04 May 04 August 04 November 04 June 05

Continuity of care 9 11 7 9 9
Working pattern 0 7 4 5 3
Working environment 0 0 0 0 3
Collegiality 5 12 7 9 8
Midwifery practice 13 5 5 5 6
New beginnings 4 0 0 0 0
Acceptance 0 0 0 2 0

Data are presented as number of respondents identifying each theme.

Table 4
Summary of themes from all rounds—negative aspects.

Theme (negative aspects of midwifery Round

group practice
1 (n ¼ 14) 2 (n ¼ 12) 3 (n ¼ 10) 4 (n ¼ 9) 5 (n ¼ 10)
February 04 May 04 August 04 November 04 June 05

Continuity of care 0 2 1 0 2
Working pattern 7 11 8 6 3
Working environment 3 6 7 10 4
Midwifery practice 4 2 2 0 0
Acceptance 11 0 0 0 0
Collegiality 0 0 0 0 5
Active birth 0 0 0 0 3

Data are presented as number of respondents identifying each theme.

 ARTICLE IN PRESS
C.T. Collins et al. / Midwifery 26 (2010) 435–441
‘working pattern’ (n ¼ 7), ‘working environment’ (n ¼ 3) and ‘is-
sues relating to midwifery practice’ (n ¼ 4).
Conflict and acceptance. The majority of the midwives (n ¼ 11)
were concerned about conflict and acceptance, both within the
hospital (n ¼ 8) and within the group practice (n ¼ 3). The
midwives expressed concern about how MGP would be accepted
within the hospital, particularly given that the MGP is ‘new
therefore issues will arise which will cause conflict and tension’. It
was anticipated that there might be ‘resistance from other staff’
and ‘sabotage by other maternity care providers’, as well as ‘lack of
support if not direct opposition from other staff in hospital’.
Some concerns were also raised about conflict within the MGP
itself. Two comments were made about possible conflict regarding
care that is given to women and babies. Here the midwives were
concerned about ‘poor management of labour by another group
member’ and that ‘concerns about maternal and infant health and
safety may not be shared by others in my group’.
Working pattern. Another concern for midwives (n ¼ 7) was
the working patterns within MGP. These included, for example,
‘being on call’ and that ‘compensation for using car [may be]
inadequate’. A further aspect was concern about balancing work
and home commitments.
Working environment. Concerns about working environment
(n ¼ 3) included not having a designated area for the MGP
practice within the hospital, and potentially not having access to
facilities, such as a birthing room with a bath.
Issues relating to midwifery practice. Four midwives were
concerned about various aspects of midwifery practice, including
their own skills and knowledge. There was particular concern
about the potential loss of the philosophy of the Birthing Centre
(BC), which was discontinued with the implementation of MGP.
Statements were made about ‘limits placed on scope of practice’
and ‘deterioration in outcomes which we have worked so hard to
achieve in (BC)’. Concerns were also raised about not being skilled
enough to work in the MGP model. One midwife expressed
concern about ‘not enough knowledge, lack of confidence’, while
another comment was made regarding ‘not being as skilled as
midwives in delivery suite with high-risk women’.
Rounds 2–5 (3–15 months after commencement of MGP)
This section discusses the similarities and differences in
responses to the open-ended questions across the final four
rounds.
What is working well?. Responses to this question were similar
across the final four rounds. Five themes were identified: ‘con-
tinuity of care’, ‘collegiality’, ‘working patterns’, ‘working en-
vironment’ and ‘issues relating to midwifery practice’.
Continuity of care. The theme attracted a high number of
respondents in all four rounds (see Table 3). Midwives identified
that MGP enabled them to establish ‘good rapport with the
women’ (Round 3) and to build ‘meaningful relationships with
women’ (Round 4). Midwives also enjoyed the ability to work with
women across the antenatal and postnatal periods.
Collegiality. Collegiality within MGP was another aspect that
was working well for them. Collegiality with other health-care
professionals was also positively identified:
I enjoy the way that the MGP is supported by the wards–
without the other midwives’ support, it would be difficult–we
are learning to work together (Round 2).
Working patterns. An important positive aspect of the MGP
working patterns was the ‘flexibility’ (Round 3) of working hours.
Midwives identified ‘flexibility of working hours with planned
work’ (Round 2), ‘to a certain extent being able to work when it
439
suits me’ (Round 2), and ‘having rostered days off’ (Round 4) so
that work does not consume all of their time, as valuable aspects
of the MGP. Work/family/life balance was also identified within
this theme, with midwives making comments such as:
Being available (most days) for my children when needed i.e.
drop off, pick up and bedtime (Round 2).
Concerns about flexibility and work hours raised in earlier
rounds (see following section on what is not working well for
midwives) appear to have been resolved for some midwives by
Round 5, as seen in the following comment:
Initially [concern] over hours—now hours are appropriate to
contract.
Work environment. Round 5 saw the first mention of work
environment as a positive aspect of the MGP, with three midwives
mentioning administrative aspects. This is in contrast to the
earlier rounds (see following sections), where these were men-
tioned as aspects of dissatisfaction. This shift reflects the
introduction of clerical support for midwives.
Issues relating to midwifery practice. The final theme identified
in responses to the question of what is working well for them is
that of midwifery practice. This included the ability to develop
and use all their midwifery skills and knowledge, for example:
Looking after low-and high-risk women good for expanding my
knowledge base (Round 5).
Professional ‘autonomy in providing midwifery care’ (Round 3)
was also identified as working well in MGP.
What is not working well?. Six themes were identified in response
to this question: ‘working patterns’, ‘working environment’,
‘continuity of care’, ‘issues relating to midwifery practice’, ‘colle-
giality’ and ‘women’s commitment to active birth’ (see Table 4).
The themes ‘working pattern’ and ‘working environment’ were
broadly similar across the rounds. Continuity of care was referred
to in Rounds 2, 3 and 5, and issues relating to midwifery practice
were referred to in Rounds 2 and 3 only. Round 5 also saw the first
appearance of a new theme relating to ‘women’s commitment to
active birth’, and concerns about ‘collegiality’ in terms of lack of
recognition and communication with other areas in the hospital.
Working patterns. It was clear that midwives were struggling
with the change to the working patterns of the MGP model,
particularly in the early rounds. This theme drew the most
respondents in Rounds 2–4 (Table 4). By Round 5, some of the
issues had been resolved, as discussed previously, and the number
of respondents in this theme fell.
There were many aspects of the MGP working patterns
commented on by the midwives, including managing the hours
worked and ‘on call’. Adjusting to being on call continued to be a
problem for some midwives six months later in Round 5, as the
following comment shows:
‘still have difficulty with relaxing when I am on call—I feel
consumed by my job at times’.
Other issues identified included long travel times, increased
workload when midwives were on leave, working too many hours
due to too many high-needs women, time spent in meetings and
the volume of work. The midwives also had some difficulties
managing the work/home balance, and effectively juggling time
with friends/family and being available for work.
Some aspects of the theme ‘working patterns’ were not
referred to in all rounds, although this does not necessarily mean
that these were not issues at the time of the other rounds.
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440 C.T. Collins et al. / Midwifery 26 (2010) 435–441
One midwife in Round 2 and four midwives in Round 3 also
expressed concerns about remuneration, particularly in relation to
decreased pay and increased childcare costs, and covering costs
associated with using their own car. One midwife identified time
for ongoing professional development as an issue, stating:
‘I find there is a lot of work—I find it hard to get time to study’
(Round 2).
Working environment. The MGP working environment was the
second most common concern identified. The midwives were very
concerned about the absence of a dedicated physical space in the
hospital to put their personal belongings, conduct appointments
and do administrative tasks. Not only did this make it difficult for
them to work, they also felt it made them look unprofessional.
This concern with physical space continued through all four
rounds.
The midwives’ concerns about administration related to both a
lack of clerical support and the amount of time involved in
administration duties. It was felt by some that this took time away
from the ‘real’ midwifery work. By Round 5, midwives no longer
mentioned the need for clerical assistance, as this issue had been
resolved with the provision of access to clerical support.
Continuity of care. Issues relating to continuity of care were
presented in Rounds 2 and 5. In particular, these midwives were
concerned about not being available when women were in labour,
and caring for women they did not know when covering for other
midwives.
Issues relating to midwifery practice. Two midwives in Round 2
and two midwives in Round 3 identified issues relating to
midwifery practice as not working well for them. For example,
in Round 2, midwives stated they were concerned about ‘doing
medically based routine care’ that was felt unnecessary by the
midwife and the ‘need to increase my knowledge’. In Round 3, the
issue related to professional relationships with non-MGP mid-
wives whose care did not follow best practice, such as: postnatal
ward midwives offering babies artificial milk and undermining
women’s breast-feeding confidence.
Collegiality. While collegiality was generally mentioned as a
positive aspect of MGP, concerns about lack of collegiality
emerged in Round 5 in relation to lack of recognition from the
organisation, communication with other areas and feeling under-
valued.
Lack of commitment to active birth. An issue raised for the first
time in Round 5 by three midwives was the lack of ‘commitment’
by some women to active birth. All three midwives suggested that
some clients wanted the continuity of care associated with MGP,
and had a stated desire for active birth, but in reality the
expectation was of a more interventionist approach to birth, as
exemplified by these two quotes:
Women who say they are committed to birthing actively just to
get continuity when they want [elective caesarean section].
Women who say they are committed to active birth but are not
really—in fact want lots of technology with personalised care
MGP brings.
One midwife stated that this was at the expense of women
who really did want active birth:
women wanting active birth missing out for elective epidural/
LSCS women.
Discussion
The evaluation of the midwives’ satisfaction with the MGP
model of care demonstrates that MGP midwives are highly
satisfied with working in this model, with an increase in
satisfaction on all dimensions of professional satisfaction from
the baseline level established in Round 1. Responses to the open-
ended questions also generally reflect the high levels of satisfac-
tion. This supports the findings of other studies of midwifery
continuity of care models (Hundley et al., 1995; Turnbull et al.,
1995; Todd et al., 1998; Freeman, 2006).
There was an interesting trend in the mean scores for the
dimensions of professional satisfaction, client interaction and
professional support, with lower scores in Round 1 followed by a
sharp increase in Round 2. In Round 3 (after six months of
working in the model), the scores on these dimensions dropped,
followed by a general trend towards levelling out (or increasing)
in Rounds 4 and 5. A similar trend was found in Turnbull et al.’s
(1995) study of change in midwives’ attitudes to their professional
role following the implementation of a similar model of
midwifery continuity of care. In their study, the drop in
professional satisfaction following the implementation of the
continuity of care model was accounted for by commencement of
the midwives’ caseload, which required the midwives to adjust to
a new way of working. Their eventual adjustment led to an
increase in satisfaction, which was evident in the results for later
rounds. A study by Fereday and Oster (in press) showed that
midwives changing to caseload and on-call work required a period
of adjustment to achieve a work–life balance, which could take up
to 18 months. These results suggest that midwives new to
caseload models need to be aware that a period of transition,
when job satisfaction may decrease, can occur. Midwifery leaders
also need to be aware that extra support and leadership may be
required during this time.
The trend in scores for professional development differed to
that for the other dimensions. Here, scores dropped in Round 4
after reaching the highest score in Round 3. The increase in scores
in the earlier rounds can be explained by the intensive up-skilling
programme provided for midwives at the beginning of imple-
mentation of MGP. An explanation for the drop in scores after
Round 4 was provided by the midwives who were part of the
evaluation group, who felt that while midwives continued to
engage in professional development, there was comparatively less
time devoted to it compared with the early intensive programme.
An issue emerged in the last round highlighting a philosophical
dilemma for some midwives. MGP was available to all pregnant
women of all risk levels. Many of the midwives worked previously
in the BC caring for low-risk women committed to active birth and
where birthing expectations were clear; for example, if a woman
needed an epidural, they were transferred out of BC care to the
labour ward. Midwives were now faced with caring for women
who chose MGP, but whom some midwives perceived not to be
fully committed to active birth. This creates an interesting
paradox regarding the needs of birthing women and the needs
of midwives. In a model of care that is open to all levels of risk, can
boundaries on types of birth, active or intervention, be pre-
scribed? This issue requires further exploration both from the
midwives’ and women’s view points.
There has been some discussion about the possibility that
participation in midwifery continuity of care models will lead to
increased stress and burnout (Sandall, 1998, 1999). Of particular
concern are the extra demands placed on midwives by being on
call, working long hours and managerial change (Todd et al., 1998;
Sandall, 1999; Freeman, 2006). This is reflected in the analysis of
the open-ended questions, where managing the hours worked and
being ‘on call’ were aspects of MGP that the midwives continued
 ARTICLE IN PRESS
C.T. Collins et al. / Midwifery 26 (2010) 435–441
to struggle with through all rounds. However, while two midwives
left MGP during the evaluation period due to the impact of being
‘on call’ on their personal lives, the majority of MGP midwives do
not appear to be experiencing dissatisfaction, as the high levels of
professional satisfaction indicate.
According to Sandall (1999), three key factors need to be
present in order to sustain models of midwifery continuity of
care:
 occupational autonomy;
 social support; and
 developing meaningful relationships with women.
The apparently low levels of dissatisfaction in the MGP
midwives may be due to the presence of these factors, which
were reported in the responses to the open-ended questions as
being aspects of working in MGP that the midwives liked. In
particular, providing continuity of care, building relationships
with women and their families, and the ability to practice
autonomously and with flexibility were identified as positive
aspects of working in MGP. Midwives were also positive about the
development of collegial relationships with other midwives
working in MGP, and the ability to practice across the whole
scope of their skills (antenatal through postnatal).
Conclusion
This study analysed the impact of the MGP model of midwifery
continuity of care on midwives. While there were aspects of MGP
that midwives were not satisfied with and wanted to change,
overall they were satisfied with the model. This study thus
demonstrates the successful implementation of MGP from the
perspective of midwives.
This study has also highlighted the need for ongoing evaluation
in order to monitor the short- and long-term impact on midwives
of working in a caseload model of continuity of midwifery care.
This includes anticipating a period of adjustment and reduction in
midwives’ satisfaction with their professional role during the first
months. It is also particularly important due to the potential
negative impact of the on-call component of the model. A more
in-depth study of how midwives working in continuity of care
models manage the balance between their work, social and family
lives would be useful to further enhance understanding of the
effectiveness of these models.
Conflict of interest
Dr Jennifer Ferreday and Dr. Candice Oster are employed by the
Children, Youth, and Women’s Health Service, which incorporates
441
the Women’s and Children’s Hospital where the MGP model is
practiced.
Acknowledgements
The authors acknowledge the support and contribution of the
participating midwives. The authors also acknowledge the con-
tribution of the members of the Women’s and Children’s’ Hospital
Midwifery Group Practice evaluation team: Associate Professor
Peter Baghurst, Ms L. Buttery, Mrs C. Cornwell, Mrs C. Donaghy-
Harris, Mrs R. Donellan-Fernandez, Ms A. Nixon, Ms M. Farnhill,
Ms T. Garnons-Williams, Mrs C. Holliday, Mrs K. Stephenson and
Ms L. Thomas.
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