1 Getting started: what is midwifery continuity of care? 
Introduction
This chapter discusses the language and concepts used to talk about midwifery continuity of care. The chapter also discusses how this can be designed and implemented. We recognise that continuity has different meanings for different people, so here we address many of the different terms. The glossary also has definitions of some terminology that might also be useful. Chapter 2 then presents the evidence for midwifery continuity of care in relation to outcomes for women and babies, and the organisation of care.
This chapter may be useful to guide your discussions when you are planning a midwifery continuity of care model or if you are involved in reflecting on how things are going in an established model. In our experience, midwives engage in an ongoing process of discussing how they provide continuity of care. It is not unusual, particularly in the first couple of years of a model, for midwives to experiment with how they arrange their service in order to maximise continuity while promoting flexibility regarding time when they are not on-call. Flexibility is the key, as is designing services to fit your local context. While there are differences in some aspects across countries, there are many common considerations when developing midwifery continuity of care and these are highlighted.
Starting with terminology
When we refer to ‘midwifery continuity of care’ we mean care that usually begins in early pregnancy (sometimes following pre-conceptual care) and continues through pregnancy, labour and birth, to the end of the postnatal period (defined by the World Health Organization as six weeks following birth) (WHO 1999).
Throughout this book, midwifery continuity of care is taken to mean that care is provided by the same midwife or by a small group of midwives who the woman is able to get to know throughout this pregnancy. However we know of situations where the term has been used to describe a philosophy of care employed by large groups of people. For example, there are reports of some ‘team midwifery’ projects where as many as 20 midwives—or more—are organised into a ‘team’, sometimes grouped under a consultant obstetrician who heads the team. ‘Midwifery continuity of care’ is also used in some places to describe situations where midwives only provide continuity of care during pregnancy, such as in a ‘Midwives’ Clinic’. Some people refer to situations where women see different midwives in pregnancy from those who provide care in labour and birth and/or the postnatal period as ‘fragmented care’ or ‘standard care’. Midwives who work in hospitals are sometimes referred to as ‘core midwives’. Many midwives describe the important role that core midwives play in supporting midwives who bring women into hospital, particularly if there are complications.
To aid clarity and provide distance from loose definitions of continuity of care, the phrase ‘continuity of carer’ is sometimes used when referring to situations where a primary midwife provides the majority of the woman’s care through pregnancy, labour and birth and the postnatal period. This type of care is also referred to as ‘one-to-one midwifery’, ‘caseload midwifery’ or ‘midwifery caseload practice’. Continuity of carer is also used sometimes to describe ‘independent midwifery’ where midwives work in self-employed practice outside of the public health service. The concepts of a ‘known’ midwife and a midwife who you have ‘met before’ are drawn from the woman’s perspective and are often difficult to define clearly. Some women will say that they had a midwife they knew even though they only met her once. We have tried not to use these terms as they are often confusing and mean different things to different people. Sometimes ‘community midwifery’ is organised so that midwives have individual caseloads. Community midwifery was the term chosen by the Australian consumer group, Maternity Coalition (2002), in their vision for maternity services that would provide one-to-one midwifery care based in the community. However it is worth noting that the majority of community midwives in the United Kingdom do not provide a caseload practice service, and ‘community midwifery’ can sometimes refer to a system involving antenatal clinics in the community and postnatal home visits, with minimal or no continuity of carer during labour.
A group of midwives working alongside each other with individual caseloads, providing back-up and support for each other, is often referred to as working in a ‘midwifery group practice’. Midwives in a midwifery group practice tend to construct on-call arrangements and annual leave to maximise the opportunity for them to be present at the labours of the women for whom they are the primary midwife, while ensuring they also ‘have a life’! ‘Midwifery group practice’ is different from ‘team midwifery’ where a team of midwives take responsibility for an agreed number of women each month. Midwives in team midwifery models tend to work shifts where they are on-call for the labours and births of all the women booked by the team. We will discuss how team midwifery and caseload practice are organised later in this chapter.
Some controversies regarding terminology
Generally when people use the phrase ‘one-to-one’, they are highlighting the essential characteristics of a model that is also called ‘midwifery caseload practice’ or ‘caseload midwifery’. Some would argue that this model is midwifery since it describes continuity of carer from a primary midwife—as opposed to continuity of care from an indeterminate number of people with a common philosophy. Where there is direct government funding for midwifery, as in New Zealand, some provinces in Canada, the Netherlands and some other European countries, continuity of carer is synonymous with ‘midwifery’, and there is therefore less need to use defining terms or talk about different ‘models’. Indeed, in some countries, the word ‘models’ is seen as counterproductive to pursuing a pure version of what midwifery is—or should be. It has also been suggested that the terms ‘models’ and ‘models of care’ are borrowed from fragmented role descriptions within nursing, and these terms are inappropriate when applied to midwifery. Some people question the use of the terms ‘caseload’ and ‘group practice’ since ‘case’ and ‘load’ may have negative connotations.
Similarly, it has been argued that the term ‘group practice’ may be seen to mask the concept of individual care from a primary midwife. It may be worth understanding the origin of these terms since there were strategic, political reasons why they were chosen in the early 1990s by midwives in the South East London Midwifery Group Practice (SELMGP)1 (Leap 1996b). This group of independent midwives had previously specialised in providing homebirth services in pairs when they came together to try and ‘contract in’ to the National Health Service (NHS) in the United Kingdom. They secured premises in the Albany Community Centre in Deptford, south-east London, and were committed to working with women who were unable to access or afford independent midwifery services. The midwives were looking for inclusive and familiar words to describe how their model would ‘fit’ within the NHS. The word ‘independent’ was seen as counterproductive when trying to convince NHS policy makers of the value of funding an integrated, community midwifery model involving self-employed midwives. Everyone was used to the idea of general practitioners working autonomously and collaboratively as self-employed practitioners within the NHS in community-based ‘general practitioner group practices’, so it seemed logical to talk about ‘midwifery group practices’. The term ‘caseload’ was also familiar to health service planners, since health visitors and social workers used it to describe the way they had an agreed number of clients for whom they took individual responsibility. Thus the concept of midwives with individual responsibility for providing continuity of carer to a specified number of women per year, working within a supportive group of midwives, became defined in terms of ‘caseload practice’ and ‘midwifery group practice’. Subsequently ‘caseload midwifery’ was adopted as shorthand in many Western countries to describe this way of providing individualised midwifery care from a primary caregiver. The phrase ‘caseload practice’ was to play an important role in identifying the difference between continuity of ‘carer’ and the continuity of care provided by a team of people in ‘team midwifery’. We will return to this discussion later.
Midwifery continuity of care: basic characteristics
No matter what the particular circumstances, midwifery continuity of care is generally organised to include the antenatal, labour and birth, and postnatal periods so that the woman has known midwives providing her individualised care.
In some countries, access to a known midwife has been recognised in formal government policy. For example, in England and Wales, there is a policy mandate that women should be able to access maternity care through a local midwife. The policy document, Maternity Matters (Department of Health 2007), also states that ‘every woman will be supported by a midwife she knows and trusts throughout her pregnancy and after birth’ (p 5). The policy recognises that ‘for some women, care from a team of maternity professionals, including midwives, obstetricians and other specialists, or from others will be the safest option. For others with complex social needs, maternity care can best be provided in partnership with other agencies including children’s services, domestic abuse teams, illegal substance use services, drug and alcohol teams, youth and teenage pregnancy support services, learning disability services and mental health services’ (p 14). Examples of the different ways midwifery continuity of care might be provided are presented in Box 1.
Box 1 Ways of organising midwifery continuity of care
Antenatal care
Antenatal care can be provided in a range of venues—at the local hospital, in the community or in the woman’s home. In some cases, midwives encourage early access to their service by providing free pregnancy testing with pregnancy counselling and appropriate referral. Where the woman also wishes to have antenatal care from her general practitioner, the primary midwife ensures that a ‘shared care’ arrangement is implemented.
Antenatal support and information sharing
There are a number of ways that midwives provide and facilitate information sharing and support. Antenatal groups—as opposed to traditional ‘classes’—can play a crucial role in midwifery continuity of care. (Antenatal groups are discussed in more detail later in this chapter.)
Planning for birth and the postnatal period
When the woman reaches her 36th week of pregnancy, her midwife or midwives often offer a home visit for discussion with her, her family and friends about her individual needs and requirements in order to prepare for the birth and establish the practical support required in the postnatal period.
Labour and birth care
Labour and birth will occur in whichever setting is appropriate to the individual needs and wishes of the woman, and depending on the local services available. Importantly, the woman will know the midwives who attend her.
Postnatal and newborn care
After the woman has given birth, midwifery postnatal care will be negotiated with the woman. If she has given birth in hospital, the woman’s midwife will facilitate her transfer home and continue to visit her for up to six weeks, the frequency of visits being determined by the woman’s needs. This ensures adequate time to support her as she establishes lactation and builds confidence in caring for her baby and herself.
The midwife who knows her community will be able to encourage women to access services in the community, for example a ‘new mothers’ group, and services offered by the child–family health nurse or health visitor. This assists women to establish contacts and networks with other women and to access services and opportunities that can build family and community capacity.
Referral and consultation
Where necessary, midwives collaborate with medical practitioners and others to ensure the woman is able to access appropriate services and agencies. Any midwifery continuity of care project will use guidelines for consultation as a useful aid to guide decision making and support safe and effective care.
Guidelines for care, including criteria for referral and consultation and frequency of visits, are developed according to current evidence, and, ideally, are developed locally and agreed to by everyone involved in the multidisciplinary team. Guidelines will suggest that, in many instances, a midwife should initially discuss the situation with another midwife and decide if consultation or referral to a medical practitioner is appropriate. As an example, the Australian College of Midwives ‘Midwifery Guidelines for Consultation and Referral’ (ACM 2004) can be downloaded.
Variations in midwifery continuity of care
Midwifery continuity of care occurs in a myriad of different ways across different countries as can be seen from examples throughout this book. There are also differences within countries, with models and services varying from one region, state, health trust or province to the next. This is largely due to the factors listed in Box 2.
Box 2 Factors influencing midwifery continuity of care
Midwifery continuity of care: key principles
Despite variations in the way midwifery continuity of care is organised, there are a number of key principles to ensuring it is effective, appropriate and sustainable. These have been identified by Sandall (1997) and are highlighted in Box 3.
Box 3 Key principles of sustainable midwifery continuity of care
Sandall demonstrated that, where these key principles were in place, midwives did not experience burnout. The converse was also true. We have found these three simple principles are crucial considerations when developing sustainable midwifery models. We return to them regularly when reviewing projects or where issues have arisen.
Job satisfaction for midwives in any situation tends to be based on the ability to develop ‘meaningful relationships’ of mutual trust and partnership (Guilliland & Pairman 1995). This was referred to by Stevens as ‘reciprocity’ in the study of the One-to-One midwifery group practices operating through Queen Charlotte’s Hospital in London (McCourt et al. 2006, Stevens & McCourt 2002). Continuity that builds relationships also enables midwives to facilitate effective access to services, advocate for women when they are unable to advocate for themselves, and prevent some women ‘falling through gaps’ in the service. In addition, a situation is fostered where midwives can listen and act on women’s wishes offering humane, personal care. This is linked to midwives assuming greater responsibility and accountability for their actions (McCourt et al. 2006).
The next section of this chapter will explore how these principles can be addressed when introducing midwifery continuity of care.
Designing and planning midwifery continuity of care
An important initial challenge when designing and planning midwifery continuity of care is actually ‘selling’ the idea of midwifery continuity of care to financial managers. The cost-effectiveness argument will need to be outlined in any discussion about implementing new services, and it is only reasonable that the people responsible for financial management will want to see this evidence. Chapter 2 of this book has a section on cost effectiveness of midwifery continuity of care and will provide some useful references.
Box 4 contains a basic list of initial considerations when considering setting up a midwifery continuity of care project. These will be discussed in more detail in subsequent chapters.
Funding arrangements
In some countries, self-employed midwives can claim funding directly through government or health insurance schemes. Where maternity services are organised through hospital services, funding for midwifery continuity of care projects usually needs to come from within the maternity service budget. Midwives are employed within such projects, although there are examples of self-employed midwives ‘contracting in’ to the health service (see Becky Reed’s story in Chapter 2).
Where midwives have to re-negotiate their funding with a health service on an annual or regular basis, they are often left being vulnerable to being ‘closed down’ if there are budget cuts or changes. The same applies with any project that is not embedded within mainstream service provision. There are also sorry tales regarding ‘death by pilot project’!
Access for women
Sometimes it is easier to secure funding for a new project if the majority of women are from vulnerable or socially disadvantaged groups. If health planners can see the links between midwifery as a public health strategy and the potential for health gain, they are more likely to be interested in directing new funding to midwifery services. Some examples are outlined in Box 5.
Premises or location
When considering premises, the ideal is for midwives to have their own base in the community where they are visible and easily accessed by women. Other advantages include ready access to other community-based services and agencies. Where women come for antenatal care to a venue in the community, they are able to access support groups and meet other pregnant women and new mothers. There is also the bonus of increasing the chance of meeting other midwives if the woman is booked in a group practice or team midwifery program.
There are cost and time management arguments for basing most antenatal care in one site rather than providing all of it in women’s homes. Having antenatal care in one site includes reducing travelling time for midwives, which is likely to reduce costs and increase efficiency. However some midwives who work in a small geographical ‘patch’ enjoy fitting antenatal and postnatal home visits around each other and would prefer (and argue it is more efficient) to visit women’s homes. There will sometimes be women who will only receive antenatal care if the midwife visits them at home. The other group of women who often have all their antenatal care in their home are women who choose independent midwifery. Some independent midwives also provide antenatal care in their own home. Box 6 highlights some premises that midwives have used.
The decision around the most appropriate venue should be made after consideration of the community, the needs of the women and the available resources. The mapping process outlined in Chapter 3 of this book may assist in making these decisions.
Geographical area and local population
In a publicly funded maternity service, midwives based in the community often have a defined geographical boundary. In the United Kingdom, this may be defined by only taking referrals from certain general practitioners. Geographical boundaries are used to ensure that local women are the first to access the service. This can be important if the midwifery practice is the only service providing continuity of care or homebirth services, or if the midwives have a particularly good reputation. A ‘first in, first served’ system can sometimes mean a service can be swamped with bookings from women from outside of the area, to the disadvantage of local women who may not be as good at getting their needs met. Some midwifery projects cope with this by having a waiting list for women who live outside of the area, who will be taken on if local women have not accessed the number of places reserved for local ‘late bookers’.
Geographical considerations are also important in terms of the practicalities of postnatal visiting. Ideally there should be a network of midwifery services for identified geographical areas. This is sometimes not an option in rural areas but again, local services benefit women in terms of the opportunities for networking with local women and attending nearby antenatal and postnatal groups.
Type of service including place of birth
There is increasing pressure on maternity services to include the option of homebirth in their range of services, as a strategy to promote choice and normal birth. Linked to this will be the decision to offer first stage labour care at home. This enables a decision to be made in labour as to whether it is a good idea to stay at home and give birth or whether to go to hospital. This ‘wait and see’ system is advocated by the Albany midwives who have a homebirth rate of over 50% in an NHS project in London—all women who want to are prepared for giving birth at home with the option of going to hospital if they ‘need help’ or if this is their choice (Reed 2002a, 2002b). For women in uncomplicated labour who decide they want to go to a hospital or birth centre to give birth, there are many benefits in having a midwife provide labour care at home in terms of not going to hospital too early.
Subsequent chapters will provide detailed suggestions for planning the type of service provided. This will include examples of insurance arrangements and industrial relations issues. Chapter 5 also addresses the issue of obstetric support and collaboration.
Supporting midwives in midwifery continuity of care
The imperative for midwives to be supported through the implementation of midwifery continuity of care is reinforced in the work of Deery and Kirkham in the United Kingdom (2006). Midwives cannot work in models such as caseload practice in public maternity services without explicit support systems in place. In our experience, this support needs to come from the service leader or manager, who requires many of the personal skills and attributes outlined in Box 7.
Box 7 Supporting midwifery continuity of care: qualities of a manager
Support from service leaders as a key to sustainability of midwifery continuity of care in the long term is discussed further in Chapters 5, 6 and 8.
Midwifery continuity of care in rural areas
In rural areas, midwifery continuity of care will vary according to the setting and funding arrangements; the nature of the population; the availability and range of skills of staff; the qualifications and commitment of general practitioners and others to provide supportive maternity care with midwives; and the current services already provided and requested by local women. In some rural and remote areas, the local midwife is also the local nurse with a range of challenges associated with this dual role. In some settings, while it may be difficult for rural midwives to provide antenatal care, midwives have decided to run antenatal groups as a way of getting to know women who they will be caring for during labour. This has the added benefit of bringing women together for social support. Chapter 10 has some other examples of midwifery continuity of care in rural and remote settings.
In Australia in 2006 a new federal government initiative has created significant debate in relation to the provision of antenatal care in rural and remote communities. This has been initiated as a means to attract and retain general practitioners in rural areas and also to ensure more women have access to some form of antenatal care. General practitioners and obstetricians in rural and remote areas receive public funding (known as Medicare) to employ midwives (and others, including nurses) to provide antenatal care on their behalf. While on one hand this is a positive step as it could increase the potential for increased access to midwives and midwifery continuity of care for rural women, alarm has also been expressed that it will enable nurses and others without midwifery or obstetric qualifications to provide antenatal care. The leading national organisations for nurses, midwives and obstetricians have voiced concerns about the safety of this policy (ACM 2006).
Other strategies to consider when designing your project
In planning how you set up antenatal care for women in your midwifery continuity of care project, you may like to think about two important strategies pioneered by the Albany midwives in south-east London: the ‘birth talk’ home visit at 36 weeks of pregnancy, and antenatal groups women can access at any stage of their pregnancy as opposed to a set of ‘classes’ with a predetermined agenda (Kemp 2003, Leap & Edwards 2006, Reed 2002a, 2002b). You may also like to consider providing group antenatal care as pioneered by Sharon Rising in the ‘CenteringPregnancy’ model. This next section provides an overview of these initiatives, each of which has the potential to enhance your ability to provide a social model of care (Leap & Edwards 2006).
The 36 week home visit and ‘birth talk’
The approach of the Albany midwives includes a visit to each woman in her home when she is around 36 weeks pregnant by her primary and secondary midwife (Reed 2002a, 2002b). All the people likely to be supporting the woman during labour are encouraged to attend. This ‘birth talk’ visit provides an opportunity for the woman’s supporters (family and friends) to meet the midwives. Showing photographs can encourage discussion about normal birth and any particular wishes the woman has for labour and birth. A range of important issues can be discussed including:
Discussion of these issues promotes the involvement of the woman and her family in decision making that enhances a sense of independence and control (Kemp 2003). The mustering of support from within the woman’s own family or social network plays an important role in creating situations where she can feel emotionally, as well as physically, ‘safe’. The 36 week birth discussion has been seen as an integral part of the ongoing dialogue and relationship of mutual trust that occurs between a woman and her midwife throughout pregnancy, where the same midwife or midwives will be with the woman during labour (Kemp 2003).
Antenatal groups
As suggested by Mavis Kirkham, ‘linking women with others makes them stronger’ (1986 p 47). A model of antenatal education and support where women set the agenda (as opposed to being taught what the midwife has decided they should know about) can have far reaching consequences for both women and midwives.
Women learn from each other and build their own support network, thus potentially minimising dependency on health professionals. This process was described by women who attended a group in Deptford, south-east London, in a video they made with Nicky Leap (1991):
I think it’s the only place I go where people don’t try to tell you how you’re supposed to feel … It sort of makes me feel like I’m the one that’s got the power and I used to think that everyone else had the power over me … It wasn’t about ‘experts/novices, women/us’… we were all seen as having a valuable contribution to make; we were seen as having our own expertise … The group helps you sort out what you want to do. It helps you to make your own decisions …
Learning to work in this way is a challenge to the idea that the midwife is the ‘expert’ whose role is to educate women. Instead of ‘classes’ where the midwives instruct the women, antenatal groups can be organised so that each week someone comes back to the group with their new baby to tell their story. This triggers discussion and women can ask questions relevant to their needs and interests. Pregnant women can go to the group as often as they like, starting in early pregnancy, so they will hear lots of different stories. As one of the women in the video says: ‘Because you hear so many different stories from so many women, it’s very rich information that you’re getting’.
Another woman in the video described how information is assimilated differently when it arises from the stories of women in the group: ‘It stayed in my head because it was attached to real people. It wasn’t abstract information you were getting. It was associated with women in the group so it got absorbed differently.’
Women are highly motivated to continue the friendships they have made in the antenatal groups. Women in the video described the postnatal group they attended as ‘a life line’ in breaking down the isolation of new motherhood:
Just being able to ring someone up in the middle of the night … just the fact that you’ve had a conversation with someone means that you’re not there as an island trying to cope on your own.
I think they’re probably friends that you’ll have for life, even though we’re all so different. I would have been very isolated otherwise … we formed a network of women who met up outside of the group and carried on meeting for years.
The advantages for women in attending antenatal and postnatal groups are manifold, but for midwives providing continuity of care the groups can become the nucleus of practice. Some of the advantages for midwives in facilitating groups can be summarised thus:
Group antenatal care
Where the focus of antenatal groups centres on antenatal care as well as information sharing and support, significant improvements in outcomes have been identified in disadvantaged communities in the United States through the concept named ‘CenteringPregnancy’ (Ickovics et al. 2007, 2003, Rising 1998). Longer pregnancies and better weight gain for preterm infants were demonstrated where women due at the same time received antenatal care in group sessions lasting two hours (Massey et al. 2006). CenteringPregnancy provides group antenatal care that is relationship centred and nurturing for women, their families and health care professionals. Box 8 provides an overview of the essential elements of CenteringPregnancy (Rising et al. 2004).
Considerations when setting up groups
If you are planning to provide antenatal groups or group antenatal care as part of your continuity of care project, you may need to organise for some training in group facilitation for the midwives who will be running these groups. If you are organising this training yourself, you could start by using the video about the Deptford antenatal and postnatal groups to promote discussion about how you might adapt this model in your own context (Leap 1991). You will also have to consider an appropriate venue and whether you are able to offer crèche facilities for toddlers. Such groups are best situated in the community but have also been run successfully in hospital antenatal clinics as an alternative to classes, and on antenatal and postnatal wards for women who are hospitalised. You may also like to think about how you could collaborate with local child health nurses, health visitors, or a youth or community organisation in setting up a postnatal group that they might facilitate, or when looking for a suitable venue for your antenatal group sessions.
Challenging issues for long-term sustainability
Providing midwifery continuity of care is not without its challenges. We do not want the reader to think that implementing and sustaining midwifery continuity of care is all rosy. We have been working in challenging systems for long enough to know that there are times when it does seem to be too hard and not worth the effort. If you feel like this sometimes, do not despair and do not give up. We encourage you to read the evidence, especially in Chapter 2 of this book, to remind yourself about why midwifery continuity of care is good for women and why it can be good for many midwives too.
We have heard of stories from midwives who, while they embrace the ideology of continuity of care, at times struggle with the reality. We know some midwives have become burnt out but have hidden their distress, thinking that they themselves have failed. We recognise that many midwives who work in midwifery continuity of care make considerable personal sacrifices when adopting an on-call lifestyle, on top of taking full responsibility for the care of women. Family life is impacted on by being on-call so it is important to have an understanding family. There may be times when partners and families may not always be so understanding, especially if they are also tired. This is a challenge many midwives have to face as they work out strategies and alternatives in order to get through the hard times.
It is essential to have time away from work. This is necessary to balance work and family responsibilities and to ensure that, as a midwife, you also ‘have a life’. Deciding to work in a model of care where periods of on-call are needed or in the more structured work patterns offered by a team midwifery model are decisions that should be made while considering all the factors important to the individual midwife. Everyone needs to have time off-call otherwise they will get tired and burnt out. We do recognise that ‘time off’ or ‘time out’ is essential, and midwives should not feel guilty or selfish about taking care of themselves.
The lack of adequate sleep is an issue that also faces many midwives who work on-call for long periods of time. While we recognise that there is often an excitement about ‘getting up and attending the labour of someone you know’, there are times when the pager or mobile phone going off in the middle of the night brings dread and despair. The midwife who groans when the phone rings in the night feels she is a failure instead of recognising that she is simply exhausted. Again, it is essential to work with a supportive group of midwives so that there is support to take time out when needed. We return to these important aspects of the working life of midwives in Chapter 8.
In our experience, we have found that most women understand and support their midwives to avoid burnout, particularly where they have an ongoing relationship. Women are unlikely to call their midwife during unsociable hours unless there is a good reason, especially if this has been discussed. There will, sadly, always be instances where this is not the case and this needs to be identified and addressed. We have heard stories where midwives say they felt some women took advantage of their availability. Midwives taking on a continuity relationship need to recognise from the outset the importance of creating professional boundaries to keep themselves safe, and that creating dependencies is unhelpful to both themselves and the women. Midwives cannot assume that women will always be able to recognise the boundaries. Talking with women about these at the outset is essential. We must remember that ‘we cannot be all things to all people all the time’.
We now move onto the practicalities of actually designing a midwifery continuity of care model. The rest of this chapter explores issues related to both midwifery caseload practice and team midwifery, drawing on examples.
Caseload midwifery
We will use the phrase ‘caseload midwifery’ to encompass ‘one-to-one’ and ‘continuity of carer’ since these terms all denote a system where each midwife has a ‘caseload’2 of women for whom she is the first point of reference through pregnancy, labour and birth, and the postnatal period. As well as being the primary midwife for an agreed number of women each year, each midwife may also be a second or ‘back up’ midwife for women who have another midwife as their primary caregiver. Most independent midwives work in a caseload practice model, often in pairs or threes.
As a starting point, it is probably worth reflecting on the fact that not all midwives can, or want to, work in this way at all times. In our experience, we have seen midwives move out of a caseload model because of their personal circumstances, for example the birth of their own children, a lack of flexible support at home, or the need for more time with a sick parent. This is often temporary and many midwives move in and out of caseload practice over a period of years as their personal and professional circumstances evolve.
There are many examples of newly qualified midwives working in caseload practice with support from other midwives. It is generally recognised that all midwives in a group practice bring different skills and experiences, and this is one of the strengths of working in a group where midwives come together frequently to confer with each other and to discuss their practice.
Many midwives working in a group practice identify the importance of all midwives having the same status, that is, being paid the same salary. Caseload practice is a great leveller and all the midwives in a group practice share responsibility for decision making about how the practice is organised. Although important leadership roles have been described in setting up and supporting caseload practice in maternity services (see more about this in Chapter 8), problems can arise where one person is paid more than the others to have a management role. We know of situations where the responsibility of midwives has been compromised because one person takes on, or is given, more responsibility for decisions and tasks and this negatively affects all the midwives in the practice.
The role of the primary midwife
Depending on how the model is set up, each midwife’s caseload may be restricted to the following criteria:
Whatever the defined caseload, the primary midwife coordinates the woman’s care from booking through to the early weeks following birth. The midwife works in partnership with the woman, identifying her individual needs and ensuring that she has access to safe and supportive services. This includes ensuring that all investigations, consultations and referrals occur in a timely fashion.
As in any midwifery practice, the primary midwife will consult with other practitioners in partnership with the woman and according to her situation and needs. Where it is necessary for a woman to attend a consultation with an obstetrician, the primary midwife sometimes attends with the woman to facilitate communication and a coordinated approach to her care.
Midwifery group practice
Many midwives working in caseload practice organise themselves into a group or structure known as a midwifery group practice. Within the group there is ample opportunity to organise being on-call for individual women, back up, cover during days off and annual leave, and support for each other. In many countries, independent midwives who work in solo practices or pairs are looking at how they can continue to provide one-to-one midwifery services while working within a supportive group.
A midwifery group practice usually consists of four to eight midwives.3 Each midwife has an annual individual caseload of women for whom she is the primary midwife. This number varies according to several factors, for example, whether she works full time or not, the level of need of the group of women or the distance to be travelled. Annual caseloads for midwives working full time are typically 36 to 40 women per year (with this number divided proportionally for part-time midwives). Each midwife is the primary midwife for her ‘own’ 36 to 40 women and provides back up for her midwife partner’s women. Midwives working in caseload practice operate on a 24-hour on-call system through a paging and/or mobile phone system. To enhance the possibility of the woman having access to midwives she knows, each woman usually has an opportunity to meet any midwives in the group practice who provide back up to her primary midwife.
There are many different ways midwives organise how they manage to provide care to individual women, particularly regarding how they plan being on-call. Some work in consistent pairs or triplets, others work in different pairs for different women—but however the midwives organise this, each woman receives most of her care from her primary midwife with back-up care from one or two other midwives who she gets to know during pregnancy.
Midwives in group practices find many different ways to ensure they have appropriate leave, including dedicated days off and adequate annual leave throughout the year. The primary midwife works with her colleagues in the group practice to organise this. Throughout this book there are many examples of the ways midwives have organised their practice to ensure that they do not experience burnout.
Managing being on-call in caseload practice
Being on-call for labour and birth is often a major concern that midwives have when considering midwifery caseload practice. Being on-call for women who you know is very different from being on-call for the whole birthing unit or for all the women booked with a ‘team’ of midwives. It has been suggested that being on-call for ‘known’ women is easier than being on-call for ‘unknown’ women (Farmer & Chipperfield 1996, McCourt et al. 2006). When a woman you know phones you in the night, there is often an excitement about getting up and attending her labour. It may be much more stressful to go out to someone who you do not know.
Caseload midwives are on-call for proportionally fewer women than team midwives so are less likely to be called (Leap 1996a). In a team model, you are on-call for the team’s 30 or so women who are due to labour in any one month. In a caseload model, as a full-time midwife, you are on-call for the labour of only four of your ‘own’ women and as back-up for your partner’s women when she is not on-call. Some midwives in caseload practices report that, in reality, they usually work office hours with most nights in their bed and most weekends free. This was the experience of midwives in the Albany Midwifery Practice in the United Kingdom (Sandall et al. 2001).
Midwives who work in group practices report that in order to maximise control over their working lives, they spend a lot of time negotiating switching their pagers or mobile phones over to each other if they have a social event to attend or if they are feeling too tired to work. Midwives describe a flexible system of ‘swings and roundabouts’, ‘looking after each other’ in order to avoid burnout (Leap 1996a). Women understand and support their midwives to avoid burnout, especially if they can be reassured of the same philosophy and approach from all midwives in the group.
Arranging antenatal visits while being on-call for women in labour can be challenging. One way to do this is to spread visits over the week, rather than all in one session as in a conventional antenatal clinic. Midwives may schedule two or three antenatal visits each day so that they can see all the women they need to during the week. This means if they are with a woman in labour and unable to do the visits, they can ring and re-schedule the two or three women as necessary. Re-scheduling only two or three women is much easier than re-arranging a whole day of clinic visits. Experience shows that re-scheduling is rarely necessary more than once a week. Again, women understand and tolerate the inconvenience of re-arranging visits knowing that one day it may be their turn to be the cause of the disruption.
The amount of continuity of carer that is possible depends on how the midwives organise their time on-call: the longer the span of time on-call, the higher the level of continuity and the less likely the midwife is to be called out for women who have other midwives as their primary midwife. Conversely, if midwives are taking days off each week, they will also spend more time covering for their colleagues, they will be called out more when they are on-call and the proportion of women who are attended by their own primary and second midwife will be lower. Midwives therefore sometimes choose to maximise their time on-call with good breaks in between, for example six weeks on-call followed by two weeks off. Midwives working in pairs sometimes choose to alternate a week on-call with a week off-call. Other midwives choose to shift their days off at the last minute if one of the women for whom they are the primary midwife goes into labour. Importantly, whatever the system, a woman is not booked with a primary midwife who is likely to be on annual leave or a long period of time off-call when she is due to give birth.
How are the midwives reimbursed?
The midwife’s earnings are based on the size of her caseload, not the number of hours she works. Where caseload midwives are employed, they are often on annualised salaries since they do not work shifts. Annualised salaries are negotiated to include recognition of on-call arrangements and the average hours a midwife will spend working at weekends, evenings and at night. In some midwifery group practices, midwives who are part time are compensated for attending meetings and for being on-call full time. For example, a midwife with a 50% caseload may be paid 60% of what a midwife with a full caseload earns, since, although she will be taking responsibility for half the number of women as primary midwife, she is on-call full time for them unless on days off or annual leave.
In some countries there are industrial relations issues associated with implementing caseload midwifery or group practices. This is because much of the regulation that governs midwifery salary rates is based on a ‘per hour’ arrangement with the addition of shift penalties4 and overtime arrangements. Caseload practice does not fit easily into such an industrial model of remuneration. You will need to negotiate through these issues in your particular country. Chapters 6 and 8 provide some real-life examples of how this can be achieved.
Team midwifery
Another way to provide midwifery continuity of care is in a team midwifery model. In this model, a small team of midwives employed by a maternity unit or birth centre provides antenatal, intrapartum and postnatal care for a defined number of women. Care during labour and birth is provided by one of the team midwives. This model has been well evaluated in randomised controlled trials in England (Flint et al. 1989) and in Australia (Homer et al. 2001a, Biro et al. 2000, Waldenström et al. 2000, Rowley et al. 1995, Kenny et al. 1994). It is estimated that a team midwifery model with six midwives may be able to cater for 250–360 women per year, depending on the needs of the women.
There are multiple ways of arranging team midwifery. The model described in this section is based on having six or seven midwives in a team providing care for up to 360 women per year. A model of six midwives will usually have a seventh midwife to provide cover for annual leave. The roster (or rota) in a model such as this covers two antenatal clinic sessions per week (5 hours per session), 24-hour labour care (provided in divided, two 12-hour on-call shifts) and one morning shift each day for hospital and community-based postnatal care.
Enthusiasm for team midwifery models has waxed and waned over the past decade. The limited continuity of carer is one disadvantage as there are reduced opportunities to actually develop meaningful relationships with women. Being on-call for all the women in the team also means they are more likely to be called in for a labour than in a caseload model. Nonetheless, for many midwives, team midwifery is the ideal model as the hours of work may be more predictable especially if the model uses a roster system. In our experience, midwives with young children often find the on-call part of caseload midwifery challenging and would prefer a more regular work pattern. This is completely understandable and it is important to value the contributions of midwives who work in team midwifery. It is important to be flexible in designing your model of care—it must work for the women as well as the midwives. The ideal is to have both team midwifery and caseload practices in a maternity service so that midwives have options about how they provide midwifery continuity of care depending on their individual circumstances and preferences.
Ways of organising team midwifery
There are lots of ways of organising team midwifery in a mainstream service. Box 9 presents one way with a group of seven midwives (one is always on annual leave which leaves six at any one time).
Box 9 One way of organising team midwifery with six midwives
ANTENATAL CARE
The six midwives in the team provide antenatal care to the women identified as being booked for care with the team. In a team midwifery model with six midwives around 30–35 women would be ‘booked’ each month with the aim to have around 28–30 births per month. This will equate to around 340–360 women per year.
It is essential that when women book into a team midwifery model they are fully aware of what is being offered. That is, that they will have six or seven midwives who they may see antenatally and one of these will provide care during labour and birth. Often team midwifery models arrange what is known as a ‘meet the midwives’ evening so that all the pregnant women, their partners and significant others can have an opportunity to meet all the midwives in an informal setting.
Some team midwifery models try to arrange the six midwives into groups of two or three to provide antenatal care. This is a way to increase the possibility of a closer, trusting relationship developing between the midwife and the woman, as she will meet two or three midwives rather than the six that constitute the entire team.
Team midwifery models generally arrange antenatal care in clinics, either based in a hospital or in a community setting. Generally, two 5-hour clinics per week would be able to accommodate the women booked with a team of six midwives.
LABOUR AND BIRTH CARE
One of the midwives from the team is on-call for women in labour or to answer questions. Women access the midwife on-call through a paging system. The midwife will then call the woman and discuss her particular situation and plan of care.
In many team midwifery models, midwives work 12-hour on-call shifts and do not come into the hospital unless required to provide labour care. Once the team midwife’s 12-hour shift is complete, she hands over primary responsibility of the woman to the next team midwife. The first midwife often remains with the woman if appropriate, for example if she is expected to give birth shortly, but the oncoming midwife assumes responsibility. This principle is often in place to ensure that over-tired midwives do not jeopardise the care of the woman.
A team midwifery model means that women have less chance of being cared for in labour by a known midwife, however continuity in the philosophy and approach to care is promoted and the midwives are able to plan ahead around clearly identified shifts and times on-call.
POSTNATAL CARE
Postnatal care can be arranged in multiple ways. Postnatal care is provided in the hospital and in women’s homes, continuing the cycle back into the community.
In some models, a midwife from the team is rostered onto the postnatal ward in the morning to provide care for women from the team who are in hospital and also to provide hospital care to those women who have been discharged home. Other models only provide community-based postnatal care, that is, in the woman’s home. While women are in hospital, they are cared for by the core midwives.
Managing being on-call in team midwifery
Many midwives find the on-call requirements in a team midwifery model easier to manage than a caseload model as they are more structured. We know that many midwives are concerned about the amount of on-call time required in midwifery caseload practice. The on-call component of caseload practice is often the factor that midwives find the most difficult to manage if they need more regular working patterns to manage their family commitments and childcare needs. The on-call arrangements in team midwifery involve a compromise. Sometimes it suits the midwives better in terms of their lifestyle, but it means the continuity of care is decreased, which again has disadvantages for both midwives and women.
Midwives working 12-hour on-call shifts in team models report that the transition from a usual 8-hour shift on the ward to being on-call does take time. In the beginning, midwives seem to come into the hospital whenever they are on-call, even if none of their team women are in the labour ward. As midwives settle into this new way of working, they are more likely to come into the hospital only when team women are in labour. Midwives say that they ‘get used to it’ but it does require a high level of personal time management, back-up from other midwives in the team, and monitoring and support from their managers (Brodie 1996). Important elements in managing on-call include taking individual responsibility for the hours worked, having regular team meetings to talk about the issues and having dedicated days off.
Being on-call also enables the development of autonomy and self-management skills. This means midwives can respond to the priorities of each woman, fitting in other responsibilities and routine tasks around the needs of the women. Midwives develop skills in looking after one another, watching out for those who are getting overtired and negotiating the team’s workload effectively. Anecdotally, midwives working in team midwifery say they value the increased flexibility, autonomy and satisfaction that the on-call system offers over a standard rostered system.
Team midwifery in different settings
Team midwifery has been instituted in a number of countries, however there is considerable dispute about what constitutes ‘a small team of midwives’. The randomised controlled trials on team midwifery showed positive outcomes with teams of six to eight midwives (Biro et al. 2000, Flint et al. 1989, Homer et al. 2001, Kenny et al. 1994, Rowley et al. 1995).
The size and composition of teams varies considerably. In some large maternity units in the United Kingdom, there are nine or more teams with perhaps five or six midwives in each team. In others, there may be two teams with 16 or more midwives in each (Seccombe & Stock 1995). In Australia, a number of hospitals have teams of six to ten midwives. Some team midwifery models have been developed for women deemed to be of low risk of complication, while others were designed to provide care to women with varied risk profiles in collaboration with a medical team (Homer et al. 2002).
In some settings, teams are made up of 20 or more midwives who work rotating shifts through the maternity unit, being onsite if their women present. It is hard to see what amount of continuity of carer is possible with teams this size. It is equally difficult to see how the positive outcomes demonstrated in the team midwifery studies could be replicated with teams consisting of 20 midwives.
Designing a team midwifery model
Team midwifery can mean that women have reduced continuity of carer in the antenatal period; thus it is important to put some thought into how the antenatal component of the model is organised. In the early Australian models (Rowley et al. 1995, Kenny et al. 1994), each midwife attempted to meet all the women on the team during the antenatal period. The net result was that women saw six or seven different midwives antenatally and experienced little continuity of carer during this period. The attempt to meet all the women also placed extraordinary demands on the midwives, many of whom would come into the hospital on their days off to ‘meet’ women so they could feel they ‘knew’ them in labour. Despite this difficulty, women reported increased satisfaction with this form of care when compared to the conventional maternity services that were available (Rowley et al. 1995, Kenny et al. 1994).
In other Australian studies (Biro et al. 2000, Waldenström et al. 2000), while there was little antenatal continuity of carer, there were high levels of known midwives in labour and high levels of satisfaction with care. In the Biro study, seven full-time equivalent (FTE) midwives were in the team with 80% of women having a ‘known’ midwife during labour. In the study by Waldenström et al. (2000), eight FTE midwives were involved with more than 60% of women having a ‘known’ midwife in labour. In both these studies, satisfaction with antenatal care was higher for women in the team models than for those in standard care (Waldenström et al. 2000).
Another option is to adapt the team midwifery model and try to increase the probability of women seeing the same midwife during the antenatal period. This can occur by having smaller teams of midwives (perhaps three) within the larger team. Each of these smaller teams is assigned half the women to whom they will provide all of the antenatal care. As women value friendliness, consistency and support in the antenatal period (Homer et al. 2000, McCourt et al. 1998, Morgan et al. 1998), they may find that increased continuity of carer in the antenatal period is beneficial. This option means women have a lower chance of having a known midwife during labour as they receive labour care from one of the six or seven midwives in the wider team. Continuity or consistency of care is still an important focus in this modified team midwifery model.
Being clear about your model
It is essential to be clear about what your model is—hopefully the definitions and descriptions in this chapter will help. Be careful of designing a model that is half caseload and half team midwifery. For example, caseload midwifery will be challenging and probably unsustainable if the midwives are on-call for large numbers of women as in a team midwifery model or if the annual caseload for individual midwives is more than 40 women. Equally, the level of job satisfaction is likely to go down for midwives if they feel that it is rare that they really ‘know’ the women they attend in labour as the caseload is too large or if they are always called out when on-call as they are covering for large numbers of women for whom they are not the primary midwife.
Conclusion
This chapter has provided an overview of different ways that midwifery continuity of care can be designed and implemented, and identified some of the key elements and principles that have been shown to aid sustainability. The next chapter provides an overview of the evidence and subsequent chapters describe how to get started, drawing on examples and experiences from different countries.
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