4 ways to create sustainable and satisfying midwifery continuity

Women and their babies have better outcomes and experiences when they receive care from a known midwife across the continuum of pregnancy, birth, and the postnatal period (Sandall et al., 2016; McLachlan et al., 2016). Therefore, it is troubling that most women cannot access this model of care. Some have argued it is unethical. But various organisational leaders claim that transition from the dominant model of fragmented care, to individualised care from a known midwife, is not possible. Why not? Because midwives largely do not want to work in these models and the on-call commitments contribute to stress, anxiety, and burnout. That is the claim. But what does the evidence say?

Stress, anxiety, burnout 

Since the introduction of the national accreditation standards in 2006, Australian midwifery education programs have had a clear focus on preparing graduates to provide continuity of care. As a result there is increasing evidence that midwifery graduates would prefer to work in a continuity model than do shiftwork (Carter et al., 2021; Carter et al., 2020; Evans et al. 2020; Kuliukas et al., 2021).  Similarly, there is growing international evidence that midwives who work in a continuity model are less likely to experience stress, anxiety and burnout, and experience a greater sense of empowerment and job satisfaction (Dixon et al., 2017; Fenwick et al., 2018; Jepsen et al., 2017; Newton et al., 2021). But what factors are needed to draw midwives to continuity of care, satisfy and sustain them? Results from a recent literature review provide guidance on the structures, processes and philosophy required.

Creating a sustaining and satisfying work environment

Hanley, Davis & Kurz (2021)conducted a literature review to identify “the factors which contribute to job satisfaction, and therefore the sustainability of practice, of midwives working in caseload models of care.” The review includes 22 research articles from Australia, Denmark, United Kingdom, Netherlands, New Zealand, and Sweden. The included articles used quantitative or qualitative methods (e.g., surveys, interviews) to identify factors that enhanced or undermined job satisfaction, contributed to burnout, and improved or undermined sustainability from midwives and/or managers perspectives. The researchers extracted data from the articles, analysed the findings, and synthesised them to identify common themes and sub-themes.

4 key factors

  • Ability to build meaningful relationships with women

When midwives know the women they care for it offers a sense of joy at work, it “makes the job fulfilling and meaningful” (Hanley et al., 2021).

  • Flexibility and control

When midwives can choose and manage their own hours, this flexibility is seen as more desirable than shiftwork, and is a primary motivator for working on-call (Hanley et al., 2021).

  • Sense of professional autonomy and identity

When midwives can work autonomously across the full scope of practice, and be accountable for each woman’s care, they have enhanced feelings of self-worth and professional fulfilment (Hanley et al., 2021).

  • Facilitative practice arrangements

When caseload size is manageable and equitable, time-off is valued and protected, and staffing allows cover for sickness/fatigue, midwives have higher job satisfaction and sustainability (Hanely et al., 2021).

Practice implications

This review provides a useful guide to those planning to implement a continuity model and provides a framework to assess current models for sustainability factors. For example, managers and caseload midwives can reflect on whether antenatal care arrangements facilitate or hinder meaningful midwife-woman relationships. When midwives can manage and plan their work around the woman’s needs, whilst maintaining control of their own lives, they are more likely to enjoy and sustain their practice.  Determining an appropriate caseload size and providing midwives with the key support structures and the resources needed to enable them to focus on their work with women are strong predictors of success.


Midwifery continuity of care is critical to achieving the best possible outcomes for women, babies, and their midwives. However, to achieve these benefits organisations must apply the evidence to support and empower midwives to work in a sustainable and balanced way. Leadership plays a key role (Adcock, Sidebotham, & Gamble, 2021) – see our recent blog Equipping Midwifery Leaders to Drive Reform.

Highlighted article

Hanley, A., Davis, D., Kurz, E. Job satisfaction and sustainability of midwives working in caseload models of care: An integrative literature review, Women Birth,

Blog written by

Professor Mary Sidebotham and Dr Jyai Allen


Adcock, J. E., Sidebotham, M., & Gamble, J. (2021). What do midwifery leaders need in order to be effective in contributing to the reform of maternity services? Women and Birth.

Carter, J., Sidebotham,M., Deitsch,E. (2021). Prepared and motivated to work in midwifery continuity of care? A descriptive analysis of midwifery students’ perspectives. Women and Birth

Carter, J., Dietsch, E., & Sidebotham, M. (2020). The impact of pre-registration education on the motivation and preparation of midwifery students to work in continuity of midwifery care: an integrative review. Nurse Education in Practice, 102859.

Dixon, L., Guilliland, K., Pallant, J., Sidebotham, M., Fenwick, J., McAra-Couper, J., Gilkison, A. (2017). The emotional wellbeing of New Zealand midwives: Comparing responses for midwives in caseloading and shift work settings. Journal of the New Zealand College of Midwives, 53.

Evans, J., Taylor, J., Browne, J., Ferguson, S., Atchan, M., Maher, P., … & Davis, D. (2020). The future in their hands: Graduating student midwives’ plans, job satisfaction and the desire to work in midwifery continuity of care. Women and Birth, 33(1), e59-e66.

Fenwick, M. Sidebotham, J. Gamble, D. Creedy. (2018). The emotional and professional wellbeing of Australian midwives: a comparison between those providing continuity of midwifery care and those not providing continuity. Women Birth 31, 38–43.

Jepsen, I.,S. Juul, S., Foureur, M., Sørensen,M. (2017). Is caseload midwifery a healthy workform? – a survey of burnout among midwives in Denmark. Sexual & Reproductive Healthcare, 11, 102–106.

Kuliukas, L., Bayes, S., Geraghty, S., Bradfield, Z., & Davison, C. (2021). Graduating midwifery students’ preferred model of practice and first job decisions: A qualitative study. Women and Birth, 34(1), 61-68.

McLachlan, H. L., Forster, D. A., Davey, M. A., Farrell, T., Flood, M. M., Shafiei, T., & Waldenström, U. (2016). The effect of primary midwife-led care on women’s experience of childbirth: Results from the COSMOS randomised controlled trial. BJOG: An International Journal of Obstetrics and Gynaecology123(3), 465-474.

Newton, M., Dawson, K., Forster, D., McLachlan, H. (2021). Midwives’ views of caseload midwifery–comparing the caseload and non-caseload midwives’ opinions. Across-sectional survey of Australian midwives. Women and Birth, 34(1).

Sandall et al. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, 4. CD004667. 14651858