Pregnant women with substance dependency are more likely to lead multi-layered, psychologically and socially complex lives and can be distrustful of mainstream services. Dr Elaine Moore, a retired midwife from Ayrshire, Scotland, shares some findings from her recent study exploring midwifery continuity of care and its impact on midwife/mother relationships.
_______________________________
This article aims to discuss how midwives providing care via a midwifery-led continuity of care model build and maintain relationships with pregnant women with substance dependency.
I recently completed a Doctorate in Professional Studies, using Interpretative Phenomenological Analysis (IPA) to explore how safeguarding midwives built and maintained relationships with pregnant women with substance dependency.
Safeguarding Midwives are midwives with a specialist interest in and knowledge of supporting pregnant women with vulnerabilities, for example, substance use, mental health challenges, and learning difficulties. Pregnant women with substance dependency can lead complex, chaotic and challenging lives with interdependent issues such as poverty, partner violence, and a family history of drug misuse (Latuskie et al., 2019), and most are involved with social services through unborn child protection referral pathways.
In the following paragraphs, for ease, I will refer to safeguarding midwives as midwives and pregnant women with substance dependency as women. Also, as one of the purposes of IPA is to examine the experiences of individuals of the phenomena, I will use midwives’ quotes to reference points of interest. The midwives provided community-based maternity care using a Midwifery-Led Continuity of Care (MLCC) model to a caseload of women who were designated as vulnerable, some of whom were substance dependent. They provided continuity of midwifery care in the antenatal and postnatal periods. The midwives were also present in addiction clinics, social services or child protection meetings to support women in their care.
In the core document ‘Professional Framework for Midwifery (2021)’, the International Confederation of Midwives (ICM) defined MLCC as a care model ‘in which a known midwife or small group of known midwives supports a woman throughout the antenatal, intrapartum and postnatal continuum’ (ICM, 2021). Therefore, it could be argued that, technically, the midwives in the study did not provide true MLLC. Nevertheless, for midwives in the study, this midwifery-led continuity was integral to building relationships with the women in their care.
When the midwives were asked about their thoughts on delivering intrapartum care for women, they intimated that this would be wonderful in an ideal world. However, they considered this not practical for women in their caseload as some led chaotic lifestyles requiring the midwives’ support at unpredictable times. Therefore, providing intrapartum care would reduce the midwife’s ability to be available to support women in crisis. Midwives felt strongly that the women they cared for preferred to have their known midwife support them when attending addiction clinics or advocating for them in child protection meetings rather than having them present at their birth. Therefore, future service provision should consider the midwives’ views on where continuity is the most effective for this specialist care group, i.e. in the antenatal and postnatal periods.
MLCC enhances the relationship between midwives and women (Sandall et al., 2016). However, this study demonstrated how it could improve relationships between midwives and multiagency services such as social work. Midwives worked with designated social work teams within specific local authority areas, building multiagency connections and networks. This facilitated the creation of mutual understanding and respect for multiagency roles, enhancing care provision and protecting women.
Midwives indicated a distinct difference in how they perceived women from before to after they joined the safeguarding midwifery team. Before joining the Midwifery Safeguarding Team (MSGT), midwives articulated mixed feelings towards women. They had some empathy; however, this was tempered with the feeling that women were in control of their addiction and didn’t understand why they couldn’t stop for the baby or themselves. They also discussed how working in busy hospital settings, with competing demands on midwifery time, was detrimental to building meaningful relationships with women in their care.
Along with midwifery continuity, midwives articulated the importance of time: time to listen to women and time to build relationships with the multi-disciplinary and multiagency teams. Once the midwives joined the MSGT, they had smaller caseloads and autonomy in managing their workload. These facilitated the opportunity to listen to women, get to know them and understand their lifeworld. This transformed how the midwives perceived the women in their care. This is best described through a quote from one of the midwives.
‘I had just joined safeguarding, and I went out with one of the midwives. She took me to a girl, and I actually sat. The girl told me her full story about her childhood, everything that happened to her. I came out…and…she was in my mind, you know, for a good few weeks after. I kept going over her story, and I kept thinking, you know …it could be any one of us; that could have been anybody. If I had been born into that family…the things that poor girl was exposed to, nobody really cared about her, she was abused by everybody her whole life, you know, physically, sexually everything…and she spoke about using the drugs, you know and how it helped block things out. I feel as if I had a lightbulb kinda situation at that point…and I kinda guessed that…People don’t always pick their path….No one would pick to become that heroin addict.’
This midwife, through having the time to sit and listen to the woman’s story, gave them an insight into a real person. This woman, instead of being a pregnant addict, became a woman who was pregnant with a disease called addiction.
‘you start to see the person rather than the addiction.’
However, transformational change can be challenging as it asks us to confront long-held beliefs and attitudes, which can be uncomfortable. Through reflection and reflexivity, midwives highlighted regret for their perceptions of women, with one quote displaying the depth of regret.
‘I’m quite ashamed of it, actually.’
Although the midwives spoke about the importance of listening and verbal communication several times throughout the study, they also highlighted the significance of non-verbal communication. They described how women appeared to have a heightened sensitivity to non-verbal cues. Women could discern subtle non-verbal cues that may indicate judgemental attitudes of members of the maternity service team. This is significant for all staff working in maternity services who have contact with women. As a midwifery manager, many of the complaints I received were around staff attitudes, including non-verbal and verbal communication. I would encourage all who read this blog to be mindful of the lifeworld these women have, to reflect on how they interact with women and how their preconceptions may subliminally affect the care they give. As the midwife intimated, no one knows what has brought a woman to addiction; ‘it could be any one us.’
Maternity Care in Scotland is being re-evaluated now with a focus on introducing Trauma Informed Maternity Services (TIMS) (Scottish Government, 2023). This study suggests The National Trauma Transformation Programme: Trauma-Informed Maternity Services Pathfinders – Learning Report (Scottish Government, 2023) is on the correct trajectory. The report suggests maternity services should introduce specialist support teams, increase continuity of care provision, provide holistic assessment person-centred care plans and improve multiagency communication/working. As the study demonstrates, the MSGT meets and enhances these recommendations. Therefore, the expansion of this model of care, which supports not only the midwife/woman but also midwife/multiagency relationships, is crucial to the success of the introduction of TIMS.
References
International Confederation of Midwives (2021): Professional Framework for Midwifery (2021) https://internationalmidwives.org/resources/professional-framework-for-midwifery-2021/
Latuskie, K. A., Andrews, N. C. Z., Motz, M., et al (2019) ‘Reasons for substance use continuation and discontinuation during pregnancy: A qualitative study’, Women Birth, 32(1), pp. e57-e64.
Sandall, J., Coxon, K., Mackintosh, N., et al (2016) Relationships: the pathway to safe, high-quality maternity care; Report from the Sheila Kitzinger symposium at Green Templeton College October 2015, Oxford: (writing on behalf of the Sheila Kitzinger symposium) Green Templeton
College, Oxford.
Scottish Government, Mental Health Directorate and Directorate, C.a.F. (2023) National Trauma Transformation Programme: Trauma-Informed Maternity Services Pathfinders- Learning Report. https://www.gov.scot/publications/national-trauma-transformation-programme-trauma-informed-maternity-services-pathfinders-learning-report/
Dr Elaine Moore, DProf, MM, BSc, RM, Retired midwife, Ayrshire, Scotland
February 2024