Midwifery Continuity of care: Imperative to Change

Developing maternity services to provide continuity of care is national policy across the four countries of the United Kingdom. In this article Trixie McAree, National lead for Continuity of Carer with Alana Hunt, regional lead for Continuity East of England, they explore the background for this policy and how the process is being supported. They share a case study demonstrating  the effectiveness of implementation.

 

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Midwifery Continuity of care: Imperative to Change

 

Headlines about maternity services have been rolling in for months, portraying midwives and maternity services in a poor light. We have the shocking statistics that women of certain ethnicities are more likely to die or be damaged during the childbirth process and that, in general, women are not being listened to or receiving care that it is personalised.  Over the past 17 years, we have examples of services, such as Northwick Park, Morecambe Bay, Shrewsbury and Telford that were put on special measures and went under investigation, resulting in reports outlining what went wrong and what we should do to prevent it ever happening again.  The issues identified have remained similar over the years:

• Organisational culture
• Concerns around clinical incompetence
• Lack of ability to care plan and risk assess

 

The reports over the years have offered similar solutions but this does not seem to have prevented other maternity services experiencing disfunction with women and families experiencing poor care. Therefore, the problem needs to be viewed differently if we are to achieve the improvements desired.

 

It should be acknowledged that, for the most part, issues encountered are not because midwives or obstetricians don’t care, or that they lack appropriate  knowledge rather that the current “one size fits all” model of service delivery, that has been in place since at least the 1970s, inhibits our ability to  provide care that is safe and personalised due to the way it is resourced and delivered.  This has been understood for some time; Better Births heralded the start of the transformation programme outlining the changes required. However, two years of a pandemic, staffing shortages and lack of knowledge/understanding of the changes needed (especially around Midwifery Continuity of Carer (MCoC) and how to implement such a complex, far reaching change has hampered progress.

 

If we agree change is required, the key steps to managing this well are:

1. Understand and pursue the vision: “the ambition for the NHS in England is for MCoC to be the default model of care for maternity services, and available to all pregnant women in England – with rollout prioritised to those most likely to experience poorer outcomes
2. Be clear around the evidence and why the service needs to change in this way: there are not only three recent Cochrane reviews for continuity of carer but also literature from other disciplines that all point to improved clinical outcomes as well a benefits for maternity staff. A lived example is given in the case study below.
3. We are mandated to proceed: DHSC has said this intervention is appropriate and should be expedited.
4. Access the tools and teams to support MCoC roll out. Building blocks that need to be in place for a safe service should be employed regardless of model of care and are set out in the NHS England guidance.

 

Case Study:

Midwifery Continuity of Carer at the James Paget University Hospital NHS Trust

 

The James Paget University Hospital (JPUH) NHS Trust is situated in the East of England and have approximately 2000 births per year. Demographics include a high proportion of women living in the lowest decile of deprivation (IMD, 2019) with a high number who are non-English speaking. In February 2021, the JPUH launched 3 geographical, mixed risk teams based in the areas of highest deprivation. There are around 7 WTE midwives per team, each providing  all 3 elements of care with a live caseload of 1:27. A Quality Improvement approach and PDSA cycles were utilised, continually gaining feedback and testing what works best, listening to women and staff to optimise the model locally.  To model our teams and draw up our plan we used the NHSE/I Continuity workforce tool Home (continuityofcarer-tools.nhs.uk)

We now provide Maternity care to approx. 85% of women using the MCoC model.  Recent data collected from staff and service user surveys have shown overall improvements in maternity outcomes, midwives job satisfaction and service user satisfaction. A snapshot of 3 months of maternity outcomes for women cared for under the MCoC model has shown marked improvement against those cared for under the traditional model:

 

• preterm birth rates were 4.2% lower
• miscarriage rates were 0.9% lower
• ELCS rates were 3.4% lower
• EMCS rates were 3.4% lower
• episiotomy rates were 1.1% lower
• 3/4^th degree tear rates were 1.6% lower
• unassisted vaginal delivery rates were 6.7% higher
• breast feeding initiation rates were 11.6% higher

 

Through staff and service user surveys we have seen an overall increase in job satisfaction and service user satisfaction:

“It’s so much nicer now, I have really enjoyed my pregnancy and birth experience from start to finish, I am gutted it’s all over. The way it’s all done now with the continuity model is so much nicer, I was fortunate enough to see my lovely midwife at every appointment and was able to build up a rapport. However, when at the appointments if another [team] Midwife was free [my midwife] would kindly introduce me to them and say that they may deliver your baby, which was nice, so I knew a few more names and faces, luckily enough for me my midwife was on call the night I went in to labour so delivered my son for me”                                                                                     

MCoC service user, MVP survey

 

“My job satisfaction has massively improved. It makes so much sense to me to care for the whole family, educate over time and the family understand that you are there for them and they can come to you as a professional friend that has their interests at the forefront. Seeing families flourish or supporting them in times of need throughout the whole journey has been such a privilege. I am excited to go to work and see them and ensure they’re doing well. I can also see that women are benefiting from us understanding their history/background/birth experience and feel heard which has made me feel that I am doing my job well.”                                              

MCoC midwife, staff survey

 

The JPUH are working towards ensuring all women are cared for under the MCoC model, with plans in place to achieve this by the end of November this year.

 

There are other services across England that are reporting similar results unfortunately we don’t have room to share all of them here. NHS England are undertaking a national evaluation that will contribute significantly to our understanding of both impact (clinical and other) and implementation that will support maternity services moving forwards to become they best can be. NIHR is also funding research to review this approach for women who are most likely to have poor outcomes.

 

In conclusion we see that we have the imperative to change and that there is support available to help the building process. Local changes should link with the Equity strategy, Core 20plus5 which will be well supported by MCoC. You can contact  me (trixie.mcaree2@nhs.net) or the regional leads for MCoC and also access the toolkit for ideas and support.

 

Trixie McAree National lead for Continuity of Carer with Alana Hunt, regional lead for Continuity East of England and Better Births lead Norfolk and Waveney LMNS

 

June 2022