Continuity of carer during pregnancy, birth and beyond
- In Bradford, A Better Start is establishing greater continuity in the relationship between women and their families and the people who care for them during a pregnancy.
Current Government policy aims to ensure that women and their families receive continuity in the person caring for them during their pregnancy journey. This was one of several key recommendations in the Better Births report, part of the National Maternity Review published in 2016.
The evidence contained in the Cochrane Review (Sandall, Soltani et al 2016), based upon the experiences of 17,674 women and reported in 15 high quality studies, reported that women cared for in models prioritising continuity reduced their risk of pre term birth by 24%. They were also less likely to have an epidural and more likely to have a spontaneous vaginal birth, and had fewer episiotomies and instrumental births and reported positively about their experiences. Better Start Bradford is leading the way on developing the continuity of carer model in Bradford.
A requirement the continuity of carer model is for each woman to have a personalised care plan, built on the decisions she makes with her midwife. The plan is required to include what is important to the woman and her family, including her values and expectations about being pregnant, giving birth and becoming a mother, her home and work life and support networks, her previous experiences of pregnancy and childbirth, and any fears or concerns she may have. Importantly, the plan is intended to be owned by the woman with access by midwives and obstetricians as required in collaboration with her.
All of this provides the basis for an assessment of the health needs of the woman and baby, is essential for safety, and underpins the decisions she makes about the care and support she wants. In addition, it provides evidence of her choices and information provided by her healthcare providers. Fundamental to all of this is the relationship the woman has with her named midwife.
This is an enormous transformation for maternity services. Targets are in place to increase the numbers of women being cared for on continuity models by 20% each year from March 2019. There is a parallel target for 75% of BAME (Black, Asian, Minority Ethnic) women to be cared for on continuity models by 2024.
The nationally predominant model for maternity care at present sees an over stretched community and hospital service with little or no continuity for women, the majority of births taking place in hospitals with virtually same day discharge home and a skeleton postnatal service based on the ability of the mother to get herself and her baby to a clinic.
The complex health needs of some pregnant women mean accessing hospital antenatal clinics for multidisciplinary care where waiting times are long and continuity a challenge to achieve. The national picture is grim with several maternity services scandals over the last few years including Morecambe Bay(Kirkup 2015), Shrewsbury and Telford Hospitals (Guardian Newspaper 2019) and most recently in Margate, East Kent (BBC 2020).
A continuity model which supports mainstream maternity services is that of the volunteer doulas. A trained doula is matched with a woman and begins supporting her from around 28 weeks to up to 6 weeks postnatal, including at her birth. Private doulas also exist but have to be paid for by the woman. Volunteer doulas provide this service free, and Better Start Bradford has a Doula project in its portfolio.
Here in Better Start Bradford, we have collaborated with our local maternity services provider and commissioners of services to initially create a team of midwives and support workers to provide continuity during the ante and postnatal periods – the Opal Team – and more recently a subsequent team to provide additional continuity at the birth event – the Clover Team via our Personalised Midwifery Care project.
Our evaluation is reporting on the process of implementation and the impact on midwives and women. No evaluation of outcomes is required as this already exists in the form of the Cochrane Review (Sandall, Soltani et al 2016) and most service providers are keen to understand how a team like this can work, be successfully sustained and how it is experienced by midwives, women and their families.
Feedback has been collected and has provided insights into what women have appreciated about being cared for on a continuity model. Having a midwife who is easily contactable, appointments at home, a personal touch leading to less worry and anxiety, feeling more confident, having a known midwife at their birth, feeling empowered and becoming positive about the whole experience, and having flexibility around their own commitments have all been reported repeatedly.
A self reported shy mum told how lovely it was to see the same midwife and be able to build a relationship. Another mum said she was able to discuss her concerns which meant she was more relaxed and had a better birth experience. Mothers also speak about how good it feels that the midwife knows all her issues and challenges, and that repetition is not required when new midwives are met for the first time. One mum told of how she felt really special during her experience, and partners reported feeling confident discussing their worries.
Student midwives have also provided feedback about their learning experiences with the team, remarking that this has reminded them about why they came into the profession, and that the passion and enthusiasm demonstrated by all the team members is inspiring.
The formal evaluation from the midwives is currently being collected, however, the midwives in the Opal Team reported positively on job satisfaction specifically in relation to the benefits of additional time for appointments, being able to be flexible and visit women at home, having a support worker to undertake a pre booking home visit and creating a service vision around women and families. Having professional autonomy is also important for these midwives, and the model enables them to use their midwifery skills to the fullest extent.
Some of our key learning up to present includes:
- Working with local maternity service providers and commissioners supports the development of continuity models.
- Midwives, women and support staff value continuity, it makes a positive difference to everyone’s experience.
- Maternity support workers can be trained and utilised to the benefit of mothers and midwives.
- Flexibility and the ability to exercise professional autonomy is valued by midwives.
- Women and families have increased confidence as they begin their parenthood journey.
- Kirkup B (2015) The Report of the Morecambe Bay Investigation. The Stationary Office. London. www.gov.uk/government/news/morecambe-bay-investigation-report
- Margate and East Kent Hospitals Scandal (2020) www.bbc.co.uk/news/health-51193332
- NHS England (2016) National Maternity Review: Better Births – Improving outcomes of maternity services in England – A Five Year Forward View for maternity care. NHS England. London
- Sandall J, Soltani H et al (2016) Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2016, Issue 4.
- Shrewsbury and Telford Hospitals Trust – https://www.theguardian.com/society/2019/nov/23/hospital-in-worst-maternity-scandal-to-hit-nhs
About A Better Start
A Better Start is a ten-year (2015-2025), £215 million programme set-up by The National Lottery Community Fund, the largest funder of community activity in the UK. Five A Better Start partnerships based in Blackpool, Bradford, Lambeth, Nottingham and Southend are supporting families to give their babies and very young children the best possible start in life. Working with local parents, the A Better Start partnerships are developing and testing ways to improve their children’s diet and nutrition, social and emotional development, and speech, language and communication.
The work of the programme is grounded in scientific evidence and research. A Better Start is place-based and enabling systems change. It aims to improve the way that organisations work together and with families to shift attitudes and spending towards preventing problems that can start in early life. It is one of five major programmes set up by The National Lottery Community Fund to test and learn from new approaches to designing services which aim to make people’s lives healthier and happier
The National Children’s Bureau is coordinating an ambitious programme of shared learning for A Better Start, disseminating the partnerships’ experiences in creating innovative services far and wide, so that others working in early childhood development or place-based systems change can benefit.
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