Midwifery clients with complex care needs

Understanding the changing profile of midwifery clients between 2000-2018

Luba Butska, Kathrin Stoll, and Alison Campbell received funding in January 2020 to undertake a mixed methods study about midwifery clients with complex care needs. This study involves retrospective analysis of provincial perinatal data to examine the changing profile of midwifery clients over the past 20 years, outcomes of midwifery clients with complex care needs, and focus groups with midwives who care for clients with complex medical, emotional and psycho-social needs. We hope that the study results will help us understand how best to prepare midwifery trainees to work with clients with complex needs and how best to support midwives to care for these priority populations. This project might also include a shadow-billing pilot with selected midwifery clinics. Some employed nurse practitioners do shadow billing to document what types of patients they look after and to justify increased funding. As part of this project, we are also conducting a scoping review of the literature to better understand how complex needs and complex care are defined during pregnancy. The review will inform a concept analysis on the topic.

A preliminary review of midwifery births between 2000-2018 shows how different, on average, midwifery practice was in 2000 versus 2018: in 2000 close to one in three clients had a home birth, 75% of clients with prenatal midwifery care also delivered with a midwife, and intervention rates were low. In 2018 some interventions have doubled (e.g. the proportion of multiparas with a CS or instrumental vaginal birth increased from 9-19%), the home birth rate is half of what it was in 2000 (14 % versus 27%), midwives deliver 10% fewer babies than in 2000 (as a proportion of clients with a midwife involved in care) , and one in two clients have an obstetric risk factor. These changes impact how midwives practice, their compensation, and their levels of job satisfaction and burnout.

Supporting midwives to care for clients with complex needs

In BC, there are currently no formalized mandates or supports to care for clients who face discrimination and/or those with complex care needs. In provinces where midwives are employed by health authorities they are usually expected to look after a certain proportion of clients with complex care needs (up to 50%) and the definition of what constitutes a complex client is broad. In Alberta, midwives can bill for an additional 7 courses of care, to cover additional time spent working with clients from priority populations and those residing in rural areas. One course of care equals 48 hours and midwives track the additional hours they spent providing care and reaching clients. In Ontario, midwives can access additional funding for caseload variables or CVs. When BC midwives were asked in 2018 which strategies would reduce burn out and enhance job satisfaction, higher pay per course of care and higher pay for more complex clients were high on the list.