Historical perspectives on midwifery continuity of care

Since the 1980s in many Western countries there has been a movement to build services or practices that enable midwives and women to get to know each other and develop a relationship of trust and confidence (Sandall 1995). This move to regain ‘continuity of care’ has been an important part of the renaissance of midwifery in recent decades. Continuity of care was seen as a fundamental aspect of midwifery practice that had been lost in the move to fragmented, hospital-based care.

Whereas the development of midwifery continuity of care schemes has been seen as a departure from the norm, it should be remembered that the roots of midwifery actually lie in the relationship of ‘being with’ the woman. Until relatively recently, midwives were a part of a woman’s community; they were often kith or kin and were likely to have had some prior relationship with her and her family, and thus continuity was a part of the practice of midwifery (Page 2003).

Although the development of continuity of care reverts to an early principle of midwifery, it has required major shifts in organisation in modern, highly complex institutions and health services, with practitioners often having no previous experience of this way of organising midwifery services. It is significant that the earliest developments of continuity of care schemes were undertaken by midwives who had already practised in continuity of care, many of them as independent or community midwives. Perhaps because there was an experiential understanding of what this meant, the importance of the purpose of continuity was not always made explicit (Flint et al. 1989, Weatherston 1985).

Perspectives on the relationship between women and midwives

The purpose of midwifery continuity of care is to allow women and their midwives to get to know each other over time. This involves not only a personal knowledge of each other, but also the ability to be able to work out, investigate, talk about and consider the complex decisions that need to be made together, bearing in mind understandings about the woman’s needs and expectations, her social situation, and her current and previous experiences of health and health care. Continuity of care is about developing a partnership to provide mutual support, and a psychological contract that is necessary for the best care of the woman during all the phases of childbirth. Aspects of this relationship have been described in a number of publications (Leap & Edwards 2006, Leap & Pairman 2006, Pairman & McAra-Couper 2006).

The relationship between a woman and her midwife is not purely instrumental, and women have described it as being important in itself (Wilkins 1993). There is, however, no point in having a good relationship if the midwife is not skilled and knowledgeable. The relationship has a professional purpose, which is the provision of safe effective midwifery care. This has been described as a ‘professional friendship’ (Pairman & McAra-Couper 2006). Continuity is necessary but not sufficient alone. In addition, midwives practising in this way are helped by an organisational model that should support them in their practice, not only by positive attitudes in colleagues but also through systems of care, consultation and referral.

Midwifery continuity of care should be the right of all women. Inherent in this statement is the notion that collaboration is important. Often midwifery continuity of care has been developed only for healthy pregnant women (so called ‘low risk’ women). This is reflected in much of the evidence presented in this chapter. We believe that midwifery continuity of care should be the right of all women since it is highly likely that all women will benefit from midwifery continuity of care, especially those who have complex pregnancies due to physical, social or emotional factors. It is important to bear this in mind when looking at evidence in order to set up a practice or service. We suggest we should work towards a time when all women can have access to midwifery continuity of care, regardless of ‘risk status’.

Policy supporting midwifery continuity of care for all women

The move towards all women being able to access midwifery continuity of care was spelt out in a recent United Kingdom maternity service policy document ‘Maternity matters: choice, access and continuity of care in a safe environment’ (Department of Health 2007). The report states that maternity services should ensure that women are able to refer themselves straight to a midwife when they first know they are pregnant. The section on ‘Continuity of midwifery care’ (2.12) states:

Elements of continuity of care will include:

If midwives’ roles encompass these elements, it is likely they will have a higher level of job satisfaction too (Department of Health 2007, pp 15–16).

The importance of addressing such policy documents when making the case for midwifery continuity of care cannot be overestimated. Often the recommendations in policy documents are based on international as well as local evidence; they can be a useful source of information particularly when writing funding proposals.

Questions raised by health care reviews of ‘continuity of care’

A number of approaches and methods have been employed in the evaluations of continuity of care in health care. Different questions have been asked and diverse hypotheses have been tested. As such, outcome measures have also differed. Research on whether continuity of care is effective has measured outcomes, such as behaviours and outcomes of recipients and caregivers; adherence to advice; use of services; clinical sequelae; clinician knowledge of patient’s condition; costs; and patient and staff satisfaction.

Reviews of continuity in health care raise some interesting questions when we apply the findings to maternity care in general, and midwifery specifically:

Given the complexity of the redevelopment of standard fragmented maternity services, such questions are appropriate. The evaluation of such changes requires a very specialised form of research, that is the evaluation of complex interventions (Campbell et al. 2007). It requires an understanding of the processes of organisational change as well as a literacy with different forms of evaluation: this is time consuming and expensive (Freeman et al. 2001).

With such questions in mind, it is easy to see that more research needs to be done on:

Effect of continuity of care on pregnancy and childbirth outcomes

Sadly, despite so much development work around the world to provide midwifery continuity of care, there are few evaluations with many being marred by inadequate descriptions of the ‘intervention’ and different approaches to the change process and organisation of care. Recent international work has attempted to address this situation and ensure consistency in evaluations of midwifery continuity of care by developing a core set of outcome measures (Devane et al. 2007).

In considering the evidence on midwifery continuity of care, we may need to use information from a number of sources to understand the context of care. These include the experience of women being cared for and those providing care; how changes worked and whether or not they achieved goals set out for them; the processes and outcomes of changes, both intended and unintended; and what the economic and human costs and benefits may be. While this qualitative information is vital, the first place to go when looking for evidence that carries ‘weight’ when making the case for midwifery continuity of care is the Cochrane Collaboration Database of Systematic Reviews.

A recent Cochrane Review, soon to be published, compared trials of midwife-led models of care with other models of care for childbearing women and their infants. It aimed to determine whether the effects of midwife-led care were influenced by models of midwifery care that provide differing levels of continuity, risk status and setting of care. Studies where midwives provided care antenatally and during labour were compared with models of medical-led care and shared care by Hatem et al. (under review).

Continuity of care during pregnancy and following birth

In situations where continuity of care in labour is not an option, there are still benefits for women in receiving midwifery continuity of care during pregnancy and the postnatal period. Understandably, women do not want continuity enhanced in one area of care to the detriment of continuity in another. Building trust with a midwife through continuity of care during pregnancy is important to women. In the Audit Commission study (1998), 23 women commented voluntarily on continuity of care in the antenatal period, although there were no questions related to this in the survey. Quite a few of these comments about continuity referred to the difficulties of having to explain things to different members of staff, as well as to women’s worries that clinical care might not be as good when many caregivers were involved (Garcia et al. 1998).

There is evidence that continuity of care can impact on the experience of women with risk-associated pregnancies. A study in Australia compared levels of worry during pregnancy for women with risk-associated pregnancies (most commonly hypertension) and those who had uncomplicated pregnancies and were receiving standard care (Homer et al. 2002b). A multidisciplinary team, known as the Risk Associated Pregnancy (RAP) team, provided continuity of care for the women with risk-associated pregnancies. The team included a small number of midwives, an obstetrician and a physician. The continuity of information and support is hypothesised to have contributed to the lower levels of worry in the women who experienced care from the RAP team.

While labour and birth is a critical time for women, the postnatal period may also be a distressing time and supportive care at this stage is also crucial. As Garcia et al. (1998) comment, lack of continuity at this time may lead to conflicting advice, something that many parents find very difficult. Postnatal care is an area where many women feel dissatisfied with the support they receive, especially in hospital (Garcia et al. 1998), whereas women who have continuity of care from a small team or caseload tend to feel supported throughout (Beake et al. 2001).

Impact of midwifery continuity of care on costs

It is often assumed that midwifery continuity of care is likely to cost more. The evidence we have indicates that it may cost no more, and may even cost less than standard or traditional models with fragmented care. This is in part because midwives providing continuity of care tend to practise more flexibly, responding to demand. They are not waiting in the maternity unit for women to come into the system during quiet times. Consequently, the per capita number of women per midwife may be more than in standard care. In addition, intervention rates, length of stay and readmission rates may be decreased, all of which reduce costs significantly.

There are limited studies that address the costing of caseload models. In Australia, the Ryde Midwifery Group Practice evaluation included a costing analysis and in the United Kingdom, the One to One Midwifery Group Practice Model has undertaken a series of evaluations including a costing analysis. Some significant cost savings associated with midwifery continuity of care were evident in both evaluations, however more evidence is needed from multiple sites.

The Ryde Midwifery Group practice is a caseload model, where midwives provide total care for a defined caseload of women. For midwives who work full time, a caseload involves being the primary midwife for 40 women and back-up midwife for another 40 women. The primary midwife provides antenatal, labour and postnatal care for the same woman and works with a back-up midwife to cover for time off. There is a defined mechanism for consultation, referral and transfer to the tertiary hospital. Midwives are paid an annualised salary based on their caseload (Tracy & Hartz 2005). The model is described more fully in Chapter 7.

The evaluation included a cost analysis that examined the impact on direct costs and included salaries, activity, transfer, and goods and services before and after implementation of the new model of care. This analysis indicates a significant saving per woman of $A927 (19.0%) in 2004–2005 terms, which equates to an absolute saving of $A259,000 on the basis of 280 women per year.

The major sources of savings were due to:

The One to One midwifery group practice model in the United Kingdom was also studied in relation to the economic impact of the model. The One-to-One midwives carry a personal caseload of 40 women per year with a named midwife for each woman. The model caters for women who are both high and low risk, for all stages of care. The midwives are organised in partnerships and group practices. In 1994–1995 a comparative cohort study of over 1400 women indicated positive outcomes associated with One-to-One midwifery including high levels of continuity and lower rates of some obstetric interventions in labour (Page et al. 1999), and the model did not increase the midwifery costs to the service (McCourt & Page 1996). The One-to-One evaluation was repeated in 2001. The economic analysis demonstrated that the positive outcomes of the first cohort had been maintained over a period of time and in some cases had improved. There was a lower rate of all clinical interventions associated with one-to-one care, higher rates of normal birth and rates of satisfaction were higher (Page et al. 2001). The economic analysis examined a number of issues including:

The analysis demonstrated that women receiving One-to-One care:

The evaluation modelled bed occupancy and bed usage. It showed that increasing One-to-One care to 75% of the maternity service’s workload would result in fewer inpatient beds being needed (Piercy et al. 2001). Clearly, the more women who receive this type of care, the more the cost efficiency is evident.

The above studies are not enough to make a sound recommendation on cost effectiveness. A number of other studies have examined the cost implications of ‘new’ models of midwifery care, although none of these are about caseload midwifery per se. All the studies suggest a cost saving effect in intrapartum care, and one study suggested a higher cost of postnatal care when midwifery-led care is compared with standard maternity care. Although there is a lack of consistency in estimating maternity care costs between studies, there seems to be a trend towards the cost saving effect of midwife-led care in comparison with standard care.

It seems evident that ‘more intervention’ costs more than ‘less intervention’. Other economic studies have demonstrated that uncomplicated normal birth costs significantly less than caesarean section in terms of immediate costs as well as community midwifery, re-admissions and general practitioner care (Henderson et al. 2001, Petrou & Glazener 2002, Petrou et al. 2001). Australian research has also shown the relative cost of birth increases by up to 50% for low risk primiparous women and up to 36% for low risk multiparous women as labour interventions accumulate (Tracy & Tracy 2003). Research has also examined the cost effectiveness of early postnatal discharge and midwifery home visits with a traditional postnatal hospital stay, and found that early postnatal discharge combined with midwifery home visits resulted in significant cost savings (Petrou et al. 2004).

A recent economic evaluation of planning place of birth, carried out in the United Kingdom by the National Institute for Health and Clinical Excellence to inform the clinical guidelines for Intrapartum Care (NIHCE 2007), concluded:

The NIHCE Intrapartum Guidelines identify the importance of considering cost-effectiveness in order to maximise health gain within scarce health care resources, and suggest the use of a decision–analytic approach. An example is given in Appendix E of the guidelines (p 271) of a ‘Decision tree modelling framework to assess cost-effectiveness of place of birth’. Using this framework, data on birth outcomes by place of birth can be compared against the Department of Health 2006–2007 National Tariff: NHS Reference Costs (p 273). A chart identifying these reference costs provides useful information, for example, the tariff identifies the reference cost of a normal birth without complications as £467 ($A1100) if it takes place at home and £838 ($A2000) if it takes place in an obstetric unit; the reference cost of an instrumental birth without complications at an obstetric unit is £1175 ($A2800); and the reference cost for an uncomplicated caesarean section is £1912 ($A4500).

Implications of job satisfaction for midwives

Economic analyses in health have considered the financial impact of recruitment and retention, and ways to reduce turnover. It is known in nursing that ‘turnover’ costs can be significant. Evidence from the United States in a recent review of turnover suggests it costs $US42,000 ($A38,000) to replace a medical–surgical nurse and $US64,000 ($A57,000) for a specialty nurse. These figures included recruitment, orientation, mentoring and lost productivity with the latter estimated to be close to 80% of the total turnover cost (Hayes et al. 2006). While this research is from another context and discipline, many of the assumptions around replacement of staff will be similar in midwifery. Therefore cost analyses of caseload midwifery models must consider job satisfaction, retention rates and lost productivity.

Job satisfaction will be one factor that reduces turnover and increases retention and thus reduces costs. The ‘Why do midwives stay’ study in the United Kingdom (Kirkham et al. 2006) found the factors that encouraged midwives to stay included:

The results from ‘Why do midwives stay’ are supported by previous work by Sandall (1997), which showed that similar elements were critically important for job satisfaction for midwives working in midwifery continuity of care. This was especially true for midwives working in caseload models.

Other factors associated with costs

As has already been articulated, one of the limitations when considering evidence is the different definitions of the models of care and the inconsistency across models, states and countries. While this diversity is important and necessary—models of maternity care are best locally developed and adapted to meet local need—it also is hard to generalise on cost and draw wider conclusions. Economic analyses need to consider direct and indirect costs as well as the opportunity costs. The political factors that drive decisions also need to be considered. Sometimes the most cost-effective options will not be considered or funded due to political agendas that are unrelated or poorly timed.

While the aim should always be to establish midwifery continuity of care within existing budgets to ensure sustainability, there may need to be a commitment to some start-up funding. This may be required for the purchase of equipment, especially if care is to be provided from community settings or at home. An example of the start-up funding for equipment is offered in Chapter 6. The levels and amount of equipment will depend on the model of care, for example, whether it includes first stage visits at home and/or homebirth. Other resources may include additional time for upskilling and additional training as required, and for regular meetings, practice, peer review and team building. These aspects are essential for sustainability and to ensure ongoing quality and safety and discussed further in Chapters 4, 6 and 8.

We must also consider the longer term impact rather than only concentrating on the short-term costs. Unfortunately our systems are set up to only manage short-term costs. The longer term implications, including less morbidity, increased breastfeeding or lower levels of distress, are usually not factored into the costs of the service as these are not directly impacting on anyone’s ‘cost centre’ or budget.

Midwifery continuity of care: acceptability to midwives

Establishing midwifery continuity of care services often brings about profound and fundamental changes. There are changes in the structure of the service, the processes of ensuring the new way of practice operates smoothly, and there is usually a shift in the approaches, attitudes and ways of working of individual midwives. Perhaps of most importance is the shift from allegiance to the institution to an allegiance with the individual woman and her family (Brodie 1996, McCourt et al. 2006). From the earliest publications midwives talk about this shift, the intense learning that is stimulated, and of feeling that, sometimes for the first time, they felt like a real midwife (Page 1995). Stevens, in her detailed ethnography of midwives working in One-to-One Midwifery, describes ‘a major adjustment of what it means to be a midwife’ (2003, p 188).

Insufficient research has been conducted on the impact of this way of working on midwives themselves, who worry about the impact of on-call working and achieving a work–life balance. Research conducted by a national survey of midwives in England found that some new organisational structures such as team midwifery models were associated with higher levels of staff burnout. They contained factors such as low control over decision making and work pattern, low occupational grade, and longer working hours (Sandall 1998). The implications are that if midwifery is to continue moving towards a more flexible way of working, these predictors of burnout need to be taken into account. However qualitative work found that midwifery continuity of care (caseload midwifery within a group practice) that embodied meaningful relationships with women, occupational autonomy and social support at work and at home all contributed to a sustainable work–life balance (Sandall 1997).

Implementation of midwifery continuity of care

There is evidence of factors that will lead to a more effective implementation: some are detailed below, and they are explored further in Chapters 3 and 4. One of the issues to consider is the cultural changes and clash likely to occur. The inherent clash of the new culture designed to provide more effective but also more humanised care with the prevailing culture, often technocratic in nature, should not be underestimated (Davis-Floyd 2002). This clash of cultures was evident in Stevens’ (2003) ethnographic accounts of the introduction of One-to-One Midwifery within a very medicalised service. It arose despite an effective and vigorous change management process, and despite the fact that the development was officially welcomed. The clash of cultures will often result in resentments, difficulty in the interface between different services, and subconsciously or consciously driven sabotage, such as rumours dwelling on adverse outcomes and misinformation (Stevens 2003).

Midwives moving from traditional roles to continuity of care need to undergo a major adaptation. According to Stevens (2003), this may take 10–12 months. The adaptation requires organisational features including control over and use of time, to managing boundaries in interpersonal relationships with women. These include taking responsibility and managing all aspects of practice rather than the compartmentalised expertise of fragmented care. The new role is very different and often symbolised by being out of uniform, and using filofaxes and mobile phones. In the case of the One-to-One Midwifery study, midwives identified that their work became more embedded in their personal lives; their increased availability to women meant organising their personal as well as their professional lives (Stevens 2003).

In order to make this adjustment, many midwives require support in the form of training and professional development. This training is not only in clinical skills but also in interpersonal and professional relationships, management of self, reflection, and functional group working. While a great deal may be put into management of technical skills in modern maternity services, there is often little or no investment in professional development and professional relationships (Deery & Kirkham 2006).

The development of collegial groups that are the home of the individual named midwife working in continuity of care is crucial if practice and midwives are to feel safe and effective, and if professional growth is to be maintained. Stevens (2003) identifies a number of key elements that make groups work, including: