8 Sustaining midwifery continuity of care: perspectives for managers 
Introduction
In Chapter 1, the principles and definitions of midwifery continuity of care were explored in some detail, highlighting the importance of having clear and agreed principles for organising the way midwives work in these models. These key principles prioritise and value the following elements as being essential to the way midwives can sustain their roles over time:
In this chapter, we explore these principles in terms of the myriad of challenges and difficulties that have been encountered in diverse settings in the United Kingdom, New Zealand and Australia. Continuity of care fulfils both women’s and midwives’ expectations and needs to be supported and upheld by the profession so that it will remain viable. Supporting midwives and evolving ways in which to manage the high levels of demand encountered professionally is a collective responsibility. For many of us, it has been a matter of starting out on the right foot and getting established through the making of good decisions early on in the development and implementation phases. Sometimes the right steps are serendipitous and just good luck, but it is important to make the most of the opportunities that present themselves.
The first pivotal steps are described in detail in Chapter 4, including the building blocks and strategies for success. In Chapter 6 we looked at the practical actions and processes necessary in the implementation phase of midwifery continuity of care, using one experience in Australia as an example. In this chapter, we take the process one step further to identify what principles, actions and strategies are essential if midwifery continuity of care models are to be viable and sustainable in the long term. Experience has shown us the reality of how difficult it is sometimes to sustain new models and how much creativity, energy and strategic thinking is required. It is important the model is revisited regularly so that difficulties that only become apparent as it evolves can be addressed. An appreciation of the wider challenges in health service innovation, including the ‘big picture’ issues such as health policy, workforce sustainability, resources constraints and the different industrial relations and regulatory frameworks, is necessary as all play a part in enabling or threatening viability.
In this chapter we draw on our experiences of establishing and sustaining effective models of midwifery continuity of care across several different contexts: a large tertiary referral hospital in London (King’s College), England; a free standing midwifery-led unit in an urban district hospital (Belmont) in regional New South Wales, Australia; an urban teaching hospital in Sydney, Australia (St George Hospital); and an independent midwifery service in New Zealand. It is also apparent from conversations with midwives providing care in other areas (such as South Australia, United States of America, Canada, Great Britain and Ireland) that the challenge of sustaining midwifery continuity of care as a viable option is a global one. Our method of introducing change has been to establish an overall philosophy of care and clarity of vision, grasp the available opportunities and work with the enthusiasts whenever possible. We are of the view that a rapid massive reorganisation of services is unlikely to be sustainable and would lead to significant disruption and unhappiness for all involved.
As we share these experiences and ideas we are mindful that ensuring sustainability is not a concrete or finite outcome. It is an evolutionary process, and our ways of working and ensuring long-term viability are continuously changing as we learn, adjust and integrate new understandings about how to act in order to achieve the best from our model over time.
In this chapter we present two specific stories in boxes. One is from King’s College in London where Cathy Warwick has led the development of midwifery continuity of care. The other is from a free-standing midwifery-led unit in an urban district hospital (Belmont) in regional New South Wales, where Carolyn Hastie has led the implementation of an innovative model of care—one that was, and is, challenging for an Australian context.
This chapter describes the process that we took—separately but with similar principles—to put our ideas about what midwifery continuity of care really means into practice. Each of us, in our own way, had a vision about what midwifery continuity of care could look like in our own services. We had done the groundwork (as described in Chapters 3, 4 and 5) and were ready to embark on the process of actually ‘making it happen’. Our challenges were to put our theoretical model into practice.
Vision, philosophy and values
We recommend that, early in the process of developing midwifery continuity of care, there needs to be meetings where all the key players come together to explore visions, values and philosophy. In our experience, the ownership or embedding of these at the outset is critical to the survival and sustainability of new midwifery continuity of care projects. These principles form the framework and support much of what is decided and subsequently acted upon. When challenged, undecided or unsure of how to adapt the model or solve a problem, one can return to the core values and philosophical principles. For example, working arrangements continue to evolve, but these and other evolutionary changes are always negotiated with the vision in mind. It is really useful to articulate your vision, philosophy and values early on in the process and to incorporate them into your proposal and terms of reference for your working groups and other committees.
As you implement and sustain midwifery continuity of care, new challenges and difficulties will present. Along with increasing awareness of the challenges comes the responsibility to stay focussed on the vision of the service and how you want your service to be. Continually revisiting the vision and discussing how you are putting that vision into action ensures that everyone acts towards making it a reality. In this way relationships between the midwives, with their colleagues and with the women, are kept in the centre of your thinking and actions. We will outline each of the core values and principles that we identified below, starting with the foundational premise of woman-centred care.
A clear sense of vision needs to be juxtaposed with the question: what is the everyday experience of practising as a continuity of care midwife? For example, in New Zealand there are independent midwives who have practised in a continuity of care model for many years, who now tell us that trying to live out the vision and values, striving to ‘be there’ for every woman, was for them too high a price to pay. The extent and degree of the personal cost that some midwives have paid in trying to meet their profession’s ideology needs recognition and calls for the development of professional strategies to protect midwives from such events in the future. We therefore write this chapter trying to hold the balance of what is best for women but also works for midwives.
The notion of ‘woman-centred care’ has been the dominant discourse related to midwifery continuity of care in recent times. It evolved as a distinct contrast to a traditional mode of care where institutional policies and practices dictated the experience of individual women. In a traditional mode of care, a woman was expected to behave, conform, be compliant and unquestioningly trust the judgement of health professionals. In other words, the care was centred on what suited the maternity service rather than on what would work best for her. The call of midwives and woman to put the focus back on the woman herself arose from stories of women feeling ignored, powerless and vulnerable.
In the early 1990s, midwifery literature began to talk about partnership in the context of woman-centred care (Guilliland & Pairman 1995). Experience in New Zealand, where midwives have been offering continuity of care since 1990, is beginning to reveal the price that some midwives have paid by not recognising their own needs while providing continuity of care. We are aware of extreme situations where midwives tell of severe burnout, to the point of feeling suicidal. They stayed on-call for the women for too long; gave of themselves too tirelessly; and, they sacrificed their own right to be with family and friends too many times. Some of these midwives saw their inability to meet the rigours of the demands of continuity of care as a personal failure rather than the need for the professional demands to be revisited (Young 2006). It is important we understand and learn from these experiences and develop models and systems that work for both midwives and women.
We have come to see that unless a relationship is established that identifies the needs of both woman and midwife, midwifery continuity of care will not be sustainable. To consider only the needs of the woman is to negate the personal and professional commitment of the midwife. Woman-centred care must focus on the woman’s individual, unique needs, expectations and aspirations, while at the same time accommodating the needs and values of the midwife and recognising the responsibility and accountability carried by the midwife. Compromises must sometimes be made. Continuity with one midwife is not necessarily sustainable nor in the woman’s best interests if the midwife is obligated to continue providing care when she can no longer ensure that such care is effective or safe because of her own circumstances. In addition, midwifery continuity of care involves collaboration with other health professionals when necessary. At times it may be more appropriate for the woman to receive care from midwives within specific services. We also recognise the woman’s expertise in decision making, while not discounting the expertise of the midwife and other health professionals. Optimal decision making is collaborative. When a midwife believes a woman’s decision seriously places the wellbeing of herself and her baby at risk, she makes a professional stand to demonstrate her concern.
Throughout this chapter we have included stories from midwives and managers who are working in midwifery continuity of care. Our first story is from Carolyn Hastie, the midwifery manager of the Belmont Birthing Service in New South Wales, Australia.
Box 1 Belmont Birthing Service
Our model of maternity care rose out of the ashes of the Belmont District Hospital’s obstetric and gynaecology services which closed because of the lack of anaesthetists and paediatricians. The local women wanted birthing services in their community and put pressure on the area health service, so after rigorous community-wide consultation, key stakeholder involvement and risk assessment, Belmont Birthing Service was conceived and born on 4 July 2005.
We are a stand-alone, woman-centred, midwifery-led, comprehensive maternity service, and a satellite of the tertiary referral hospital’s obstetric and gynaecology division. While we are operationally networked with the services of the obstetric and gynaecology division of the John Hunter tertiary referral hospital in Newcastle, NSW, we are physically separate and located within the grounds of the urban district hospital which is 16 kilometres from the referral hospital. If any woman requires medical assistance, she is transferred to the referral hospital’s delivery suite. Her midwife accompanies her to the referral hospital.
The midwives work autonomously, have primary responsibility for the women they are allocated to, and work cooperatively with their midwifery colleagues in the service. The midwives have all moved from a fragmented model of midwifery care to a holistic, integrated, continuity model of relationship-based midwifery care. This sounds simple, which it is not, and very desirable, which it is. In reality it has been exciting and rewarding, although a big challenge for everyone. Each of the midwives is committed to the women they care for and the service, and say they love what they do and can’t imagine working any other way. Many of the women choose to give birth to their babies through water. The normal birth rate is over 93% and most of the women choose to give birth to their placentas physiologically with minimal blood loss. The women are relaxed and happy and their babies are calm. The midwives say they rarely even see the traditional ‘third day blues’.
Caring for midwives from a management perspective
A foundation in the philosophy of care is that it is as important to look after the staff as it is to look after the women. This is pivotal to sustainable practice and fundamental to the principle of woman-centred care in that it embraces not only the cared for but also the caregiver to enable them to fulfil their role. By this we mean that recruitment and retention of midwives within the service is going to be enhanced if midwives can:
In our experience, midwives who choose to work in midwifery models of care have several features in common. The first most common feature is that they have a deep belief in the capacity of women and the healthy normality of their body processes. The second is they seek professional autonomy and desire to work in a way that they believe is best. The third is a belief that if they can work the way they really want to, they can make a real difference in the lives of the women and families they are working with. Other features include an open mind and a willingness to explore what is possible and go beyond what is expected. Such passionate enthusiasts need to be supported, validated and understood, so it is essential that managers and those who support midwives have an appreciation of these occupational issues.
A strong belief in the capacity and potential of midwifery is critical to the sustainability of working in, and being a manager of, midwifery continuity of care. Moving from a fragmented model of care to a holistic, woman-centred model is an enormous growth process for most midwives and many managers. Access to education, information and opportunities to explore practice within a safe and supportive environment is essential. As practice changes from a ‘managed’ model to an autonomous model of working with women, midwives are challenged in their long held beliefs and ways of working that positioned them as clinical ‘expert’. As one midwife said recently ‘now I know why I had to get so good at managing postpartum haemorrhages … we were causing them!’
As a manager, it is thrilling to watch the midwives become confident and competent in working with normal physiology; working out what they can do to support the woman’s process safely. It is also important for the manager to provide a safe space in which the midwives can test things out, come up with their own ideas and find ways to advance their practice. The manager has to be able to ride through the inevitable criticisms and frustrations as the midwives struggle with new ways of practising. By doing so, their roles and effectiveness can be sustained over time and they avoid the pitfalls of occupational stress and burnout (Deery & Kirkham 2000, Kirkham & Morgan 2006, Kirkham et al. 2006, Sandall 1995, 1997).
Along with new ways of working, comes the unpredictability and disruption of 24-hours on-call instead of the discrete timeframe of a 7-day shift-work roster. Such a requirement causes all sorts of complexities in personal relationships, midwives covering each other for on-call, and workload management. These changes have required shifts in perceptions, beliefs, attitudes, values and behaviours for midwives, their peers and managers alike, which all takes time to settle and adjust to. Shifts will inevitably occur in individual private and professional lives as well as self image and identity, so midwives need time, understanding and support from their peers and managers if their roles are to be effectively developed and maintained. As a manager, having a roster of midwives where none are actually in the maternity unit on any given day can take some getting used to. It is likely that if no women are in labour and no other care is occurring, the midwives will be at home on-call. This can be challenging for managers used to seeing their staff at the start of the shift and knowing what they are up to all day long. It takes courage and trust in the model and the midwives to let go of this traditional way of managing.
Effective leadership of services and supportive care of midwives also requires attention to appropriate working conditions and adequate remuneration. Industrial arrangements and regulations will vary from country to country, however there are important principles to consider if models are to remain viable for the midwives working within them. Some of these are outlined in Chapter 4 and they remain specific to each country and each health care system.
In terms of midwifery continuity of care, there are some simple principles that will help maintain the model’s effectiveness and long-term viability. These include:
These simple principles form the foundation for effective support and ‘management’ of autonomous midwives working in midwifery continuity of care.
Self care for midwives
We believe it is vital to personal health and wellbeing for all midwives working in a continuity model of practice to consider:
It is often said to us that midwives with young children cannot work in this way. We believe that it is possible to juggle midwifery continuity of care and a family life although it takes flexibility and, at times, compromises.
Leonie Hewitt, one of the midwives from the Ryde Midwifery Group Practice described in Chapter 7, tells of her typical week to demonstrate this flexibility.
Box 2 A week in the life of a midwife in a midwifery group practice in Sydney
Monday
The alarm goes at 0630. I have been on-call over the weekend. It was a quiet weekend however: no births, a few phone calls and two postnatal visits.
I organise breakfast, coffee and my family off to school and work. I then walk my youngest child to primary school, hoping to catch the teacher for a chat before school. My phone rings three times on the way, two of the calls are from my colleagues checking on what happened on the weekend and another was from a woman who had a ‘show’ last night and was letting me know. I chat to my son until we get to school, see the teacher and walk home for exercise. Once home I have a shower and get ready for the day.
My first visit is an antenatal visit with a woman who I looked after with her third child. As she is now pregnant with her fourth child it is much easier to see her in her own home. At 1100 I pick up some shopping for home and take two phone calls from women; one enquiring about vaginal mucous and the other cancelling her appointment with me at 1230. I then do the postnatal visit and go to Ryde (where our service is based) and find a colleague to have lunch with since my next appointment has cancelled. I then do a booking appointment, some paper work and two antenatal visits until I go home at 1600.
Once home it’s back to being a ‘mum’: run children to dance classes, cook dinner, help with homework, ensure clothes are ready for school tomorrow, notes are signed and lunches ready. My ‘call out clothes’ (in case I need to go to attend a labour in the night) are still in the pile next to my bed and so I put my phone on charge and go to bed.
Tuesday
I get up and organise the family as usual. I have meetings all day today starting at 0930. I get a phone call on the way to work from a woman who is contracting irregularly. We discuss how to manage this phase and I go to my group meeting. We meet once a week to talk about our week, reflect and debrief on our births and plan the next week. We then allocate women wanting to book in to our service and discuss the items on the agenda. This meeting is a really important part of the group practice and we all try to attend.
At lunchtime I go out to the community to do a postnatal visit then come back for an education session at 1330. This is followed by peer review where we discuss and review all the women who required transfer. I then attend an antenatal visit at 1600 and go home and take my daughter to ballet. At 1900 I get a call from the woman who had been contracting, we discuss her contractions and she is happy to have a bath and try to sleep. I go to bed after tea, homework and organising the next day.
Wednesday
At 0200 I have a phone call from a woman who has ruptured her membranes and is contracting strongly; it is her second baby. We meet at Ryde and she has a lovely birth in the shower an hour later. I then receive another phone call from the woman who has been contracting all day as she wants to come in to the hospital.
The core midwife (the core midwives work alongside the caseload midwives working shifts but not being on-call) helps me clean up after the birth and cares for the first woman while I care for the second woman. She is in established labour and gives birth by 0700. The first woman goes home and, by the time I finish my paper work, it is 1000. I ring up the two women I was going to book in today. I explain the situation, apologise and change their appointments to next week. I ask my colleague to see the women who gave birth this morning later this afternoon. I then divert my phone and go home to bed. Although it’s been a busy night I feel pleased that next week might be quiet, having attended two births last night.
Thursday
My day starts the usual family way, I then go off and visit the two women at home who gave birth the day before and discharge another woman who is day 16 postpartum and doing beautifully. I catch up with some paperwork, and attend three antenatal visits before going home.
Friday
After getting children off to school, I go into Ryde and say hello at the consumer group ‘Mums at Ryde’ meeting. I then see women for antenatal visits and talk to different labs and GPs on the phone. I see the two women who have recently given birth and hand over for the weekend to my colleague who would take my calls for the weekend. Once home its back to being a mum and wife.
Leonie’s story illustrates that it is possible to integrate family life with a caseload practice. Not all midwives will be able to manage a caseload with a family life, especially one that involves small children. However, depending on the individual social situations and levels of support, a caseload practice may well provide midwives with more flexibility to fit around their family life than a conventional rostered model of care. The importance is to develop midwifery continuity of care models that meet the needs of women and midwives.
Midwives’ self-awareness and mindfulness
A commitment to woman-centred care and to supporting midwifery colleagues dovetails nicely with self-awareness. In our view, working in an intense and personal way with women and colleagues requires a highly evolved emotional intelligence, the foundation of which is self-awareness. This requires reflection on behalf of the midwife, both in the moment of action and after, to see if the action was the best to take at that particular time. Lesley Page’s Five Steps of Evidence-based Midwifery is useful in this process—the fifth step is reflecting on what happened with the woman and with colleagues (Page 2006). Reflection involves looking at a particular circumstance over and over again and with different perspectives, while checking on one’s own response to the different aspects and ideas. The ability to become more mindful and self-aware, while taking action, becomes an evolutionary developmental process as it enables even more creative and conscious behaviour. Personal awareness is a sophisticated concept and may be challenging to many. In terms of ensuring sustainability of midwifery continuity of care, it is a vital aspect of establishing greater understanding of both professional and personal issues associated with working in this way. Midwives and managers who are self-aware and have the capacity to reflect are likely to be creative and successful in addressing the challenges and difficulties as they arise.
It is important that midwives are engaged in some form of practice review regardless of the setting in which they practise. The imperative to review and assess quality of care and outcomes for women leads us into multiple ways of evaluating and critiquing the care we provide. This should include an opportunity to acknowledge good practice and an affirmation of midwifery skills, as well as learning opportunities.
We would also recommend the uptake of regular ‘clinical supervision’7 or formal reflection sessions as a part of professional development, which can assist the long-term sustainability of midwifery models of care. Clinical supervision provides an opportunity to reflect on, explore and practise workplace issues and generate ideas in a facilitated forum (Hawkins & Shohet 2006). Such supervision can occur with an individual or a group. The facilitator asks questions about topics under discussion that may not have occurred to the group or the individual. The knowledge and skill level necessary to maintain woman-centred, safe practice and continuity of care brings a myriad of potential stressors and issues. These may not be adequately addressed through the more common quality and professional development programs conducted in most health services. Service managers and leaders may also benefit from the outcomes of effective clinical supervision to assist them to provide support and to facilitate woman-centred care.
Supervision for employed midwives should be funded and not something the midwife has to pay for herself. If the midwife pays for it, she may see it as optional and possibly even indicative of professional inadequacy if she engages in it. Midwives are not only exposed to stress and at times trauma within their practical work, but through the stories of the women for whom they provide care. For example, they may hear stories of stressful situations such as addiction, abuse and domestic violence. Midwives are often bound by confidentiality to ‘process’ these on their own.
Supervision may also provide a means for a more personal counselling type relationship that explores issues such as levels of stress, impact on family of on-call lifestyle, as well as general health and wellbeing issues for those who need it. The very nature of on-call work means that the personal–professional divide becomes very blurred. Therefore, we suggest it is vital that the midwife’s personal wellbeing is supported. Burnout is insidious and often hidden by the midwife who strives to show her colleagues she is coping. The midwife may be unaware of her increasing vulnerability, and perceive herself as being inadequate rather than in need of support and revisiting her professional demand. There needs to be a way of early signs being recognised and addressed (for example, not sleeping, dreading calls, always feeling tired, irritable, stressed, a diminished passion for midwifery or concern about the impact of stress on their family). Sleep deprivation is an ongoing factor for many midwives working in continuity of care, and a reality of the model that needs to be recognised by the midwifery profession as well as the individual midwife.
The development of increasing self-awareness, together with the ability to examine and if necessary change long-held beliefs and attitudes, can help midwives expand their personal capacity to manage a complex and changing role and lifestyle. We believe that when midwives are supported to grow and develop their practice in this way, confidence increases and they give themselves permission to engage in self-care strategies, acknowledge their own needs and accept the reality of physical limitations in providing effective 24-hour care.
Developing confidence usually means a greater ability to manage the complexities of contemporary midwifery practice in diverse environments. This leads to a strong sense of self and increases belief in the self. As our belief in ourselves and our capacity increases, we move away from a ‘them and us’ mentality. This is important when as we negotiate the care for a woman we transfer to our colleagues into secondary or tertiary care. We recognise that what everyone does is important. From this standpoint, as midwives, we are more able to be of assistance to our colleagues and more willing to be grateful for their assistance when we need to transfer a woman during labour. This may also require a shift in how other health disciplines view midwifery input in order to enable a mutually cooperative and collegial relationship to evolve. These personal insights and an awareness of how conflicts arise are useful in the implementation phase as well as being an adjunct to the challenge of ensuring sustainability of midwifery continuity of care in the long term.
Communication and commitment
If midwifery continuity of care is to be sustained for the long term, it appears self evident that there has to be wholehearted commitment from all key stakeholders. The way we continue to generate commitment to the way we work, and to each other, is to ensure everyone is involved at every step of the way in the development and evolution of the service. In that way we have ‘buy in’ from each midwife and other members of the team as to what is decided. We recognise that from time to time individual midwives may need to ‘buy out’ of the on-call lifestyle. It is vital they can do this in a supportive manner. When there is dissent we discuss the various perspectives and seek consensus. When people drift from the decided pathway or activities, they are gently reminded of the decision-making process and encouraged to realign themselves. If the decision requires revisiting, we put the item on the agenda for team discussion and start the cycle all over again. It is essential that everyone has their say and contributes to the discussion and decision-making process.
We recommend weekly team meetings to ensure effective communication. These meetings are facilitated by the midwives. Topics might include: the women who are due in the next 2 weeks; births that have occurred; postnatal events; and any issues or concerns with any of the women or events in the practice. At the team meetings, information about educational opportunities can be discussed, including updates on the various portfolios of education and development; weekly in-service activities (such as some aspect of maternity emergency or neonatal resuscitation practice) and occasional specific guest speaker in-service (for example, lactation or contraception). Practice development is a key feature of such meetings. Time is allocated so that midwives can discuss their approaches, insights and understandings of the research on a particular aspect of practice. For example, practice development topics might include ways of helping babies move from a posterior position; breastfeeding issues when babies have tongue-tie; and how to facilitate third stage when women choose to give birth in water. Some midwifery group practices start team meetings with a round of ‘how are we?’ to encourage personal sharing before getting to the nitty-gritty of the practice discussion.
In the beginning, midwives may become impatient and intolerant of the team meeting time and think they are wasting time. That is a function of the old way of working which valued ‘tasks’ above ‘relationships’ and ‘doing’ above ‘being’. It is interesting to see that as midwives become more attuned to the social model of health and the primary health care way of working, the focus on completing tasks dissipates. That too has its downside as regular ‘checks’ (say, of equipment or supplies) are at risk of being omitted. This is also an aspect of growth and development as the midwives move into a more balanced sense of taking responsibility and commitment to keeping the whole service functioning on all levels.
Protecting the model
All aspects of communication are important in the long term as individuals build relationships, understanding and trust in both the midwives’ practices and the model itself. Trust and a degree of ownership and protection of the model is a key to sustainability, but not, of course, at the expense of the wellbeing of midwives who commit ‘above-and-beyond’ what is expected of them. A strong feature of the model must be the nurturing of the midwives if it is to be sustainable.
Over the years, we have emphasised the need for new midwifery continuity of care models to be integrated into the mainstream as a way of protecting them and ensuring their survival. While this continues to be true in an organisational and funding sense, it needs to be carefully managed so the models are not integrated in a way that means they become immersed in the complexities of the mainstream service.
Where midwifery continuity of care has sometimes floundered, it has been due to the overwhelming demands of the mainstream service. In this scenario, the team or group practice midwives are often called in to assist due to workforce shortages. While this may be acceptable occasionally, in times of critical shortages it cannot be sustained and the key message of protecting the model from such erosion is critical for managers to understand.
Effective management
While we are writing this chapter from our perspectives and experiences as managers and leaders who have been involved in setting up and sustaining midwifery continuity of care, we are mindful that midwives working in these groups are ideally ‘self managing’. Within this framework, however, there is the opportunity for managers to create a positive working environment in which midwives can feel both supported and safe. We have described the necessary level of commitment and taking of responsibility of the midwives involved, and recognise that such an approach is essential for success. This involves more than clinical responsibility and includes midwives taking responsibility for the effective functioning of the team or group practice on a day-to-day basis.
Some of the other components of effective management include:
Cathy Warwick’s story in Box 3 is an example of effective management and sustainability.
Box 3 Developing and sustaining midwifery group practices at King’s College Hospital in London
I became Head of Midwifery at King’s College Hospital in 1994 just after the publication of the Changing Childbirth Report with its emphasis on the three Cs—Choice, Continuity and Control.
King’s College Hospital is a large teaching hospital in South East London. It serves a local population which is ethnically diverse and among the most disadvantaged in England and Wales. The maternity unit currently looks after just under 5000 women a year, has a fetal medicine unit of international renown, a neonatal intensive care unit caring for medical and surgical neonates, and also a reputation for developing models of midwifery-led care and promoting normality. The unit currently has the highest homebirth rate in London and one of the highest rates in England and Wales (8%).
In 1983 my predecessor as Head of Midwifery had established the Brierley Midwifery Practice—a group of three midwives. This group was set up in response to two apparently very different needs.
First, mental health problems were a significant feature among women booking to have their babies at King’s. It was felt that if their care was to be optimised they should have continuity of midwifery care throughout their pregnancy, birth and postnatal care, and that the midwives providing this care should have expertise in this area and in particular be able to liaise with other members of the perinatal mental health team.
Second, while midwives at King’s were providing homebirths to women who were referred to them by their general practitioner, there was a developing problem where women were registered with general practitioners who were not supportive of homebirth. These general practitioners, apart from positively discouraging this choice among women, were unwilling to give the midwives the support they might need during the pregnancy and birth. This small group of midwives were supportive of homebirth and wished to encourage this choice. Establishing them as a practice meant that women who wanted a homebirth in the area but who were registered with an unsupportive general practitioner could access this group directly. The group were linked to an obstetrician, also supportive of homebirth, to whom they could refer women antenatally if necessary, and who would help develop care plans and protocols.
This was the first ‘stake in the ground’ of a strategy that has been evolving at King’s over period of years. There are now eight small group practices at King’s. Importantly, these practices have thrived in a context where other units have struggled to maintain team or group practice care. The practices are very varied and are significantly different to each other in terms of caseload, organisational arrangements and outcomes.
They have evolved as part of a service strategy not a research strategy, and it is regrettable that this has not been the case as detailed comparative data on their work is not available. However there is little doubt that, in a climate where midwives have been hard to recruit and retain, King’s has never had a problem with recruitment and retention. In 2006, the homebirth rate is 8%. The caesarean section rate is 22.4%. Women consistently have evaluated their care in the midwifery group practices more positively than in the typical hospital system. There are midwives with significant expertise in particular forms of care.
Alongside this we have also always understood that if care is to be of the highest quality it is important that the relationship between midwives and medical staff including obstetricians, neonatologists and anaesthetists is close and mutually supportive, and that protocols and guidelines are utilised across our service.
Perhaps the biggest challenge to the development of the practices at King’s has been the challenge of equity. The argument that is put forward says that: ‘if everyone can’t have this service why should anyone have it?’ How can we tolerate a situation where one woman can come into our labour ward with her own midwife but another woman perhaps has one midwife looking after her and one or two other women. We have tended to counter this argument at King’s in two ways.
First, I have argued that if it is only possible to provide this type of service to some women, wherever possible it should be to those who would appear to benefit from it most. There is little evidence to support this theory but it seems to make sense that if a woman’s needs are complex these will be better provided for by midwives who know her and understand about access to other services. In this group I would include the very socially disadvantaged, women who do not speak English, women who have had a traumatic birth, and young unsupported women.
Second, I would suggest that ‘doing nothing’ is not an option. Service change is in my view evolutionary, and one has to start somewhere. Of course, at the same time as working to develop midwifery group practices we have also worked to improve the core services, and midwifery staffing in the main unit, for example, has increased.
Thus, between 1983 and 2000 eight midwifery group practices developed at King’s. Two of these practices are linked to large general practitioner practices interested in developing a service for the women who attended their surgeries that might be determined as ‘gold standard’. Both of these practices were able to support six midwives with a group caseload of 240 women per year. Three further practices were actually placed by us in three general practitioner practices in areas of highest deprivation. One of these, the Albany midwifery practice, is a group of self-employed midwives. There is also a practice that provides care for young unsupported mothers and a practice that is largely hospital based and cares for women with medical problems in pregnancy and women who are HIV positive. The Brierley practice continues to support a mixed caseload of women planning a homebirth and women with mental health problems.
The fact that the model of change has been evolutionary has meant there have been relatively few industrial challenges to face. The biggest one has been the introduction into our service of a group of self-employed midwives in 1997—the Albany midwives. The midwives who formed the Albany practice had been offering care to women since 1994 as a self-employed, self-managed group who had a contract with a local Health Authority. When the health authority made a decision that they did not want to continue managing this small contract, discussions began about the sub contract moving to King’s.
For me, as an NHS manager, this presented significant challenges. Although it may be argued these were unique to the particular situation, I believe that some of the principles apply whatever change one is trying to manage. In the first place, we had a central philosophy and knew where we were going as a midwifery ‘team’. It was very easy therefore to justify this development as a cornerstone of that philosophy and to counter the ‘why on earth would you want to do that’ type arguments. Second, this was an example of grasping any opportunity that presented itself. Not only was this a group of midwives who were demonstrably delivering on the woman-centred care agenda, but also three of them were to be funded by the health authority. Third, here were a group who wanted to be self-employed but part of our service. My approach to this was not ‘can we do that’ but ‘how can we do that’?
Leadership matters
This chapter draws on our experiences about how to make sure that the hard work of developing and implementing midwifery continuity of care can be embedded and sustained. Many of the examples, strategies and actions reflect our own commitment and belief in the inherent value of the models and their potential to make a difference to outcomes and experiences for women. Woven through this and other chapters are subtle and not so subtle messages about the vital role that leadership plays in making change happen, bringing people along with the change and making the changes acceptable to the majority of stakeholders across the service. Some of these strategies reflect sound management principles while others are about commitment, will, passion and the ability to lead and influence others.
Conclusion
We conclude by summarising the issues discussed in this chapter. For those of you seeking to ensure sustainability and build long-term midwifery continuity of care (as either a manager or a midwife), the following suggestions, which encapsulate the organisational and culture change that is necessary and which have worked for us, are offered.
The next chapter discusses the complexities of evaluating your model of care. Maralyn Foureur and Jane Sandall discuss the ways in which evaluation should be built in from the beginning and highlight different approaches to evaluation that may lead to a clearer understanding of midwifery continuity of care.
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