Maternity care is a subject always in the news, and in recent years this has been for the wrong reasons. One example that springs to mind is the Morecambe Bay investigation published in 2015.
There were concerns over serious incidents in the maternity departments of the Furness General Hospital, part of the University Hospitals of Morecambe Bay. Covering 2004-2013, the report revealed 20 significant failures of care which resulted in the deaths of three mothers and 16 babies.
This is just one case of where maternity care has failed. It is situations like these that triggered the NHS to start changing the model for maternity care.
In 2016, the NHS released its five-year plan, and within that came a lot of changes around the subject of midwifery. Better Births is a national maternity programme brought in to implement the vision for safer and more personalised care across England. This programme included the national ambition of halving the number of still births, neonatal and maternal mortality, and brain injury, by 2025.
One prominent aspect of this transformation is called the Continuity of Carer model (CoC), and as the name suggests, the aim of this is for women to have the same midwife throughout her pregnancy, and right through to labour. This move isn’t just happening in England, internationally it is these midwife-led CoC models that are being recommended.
What this changes mean is that a woman would have a consistent midwife or small team of midwives for the three stages of maternity – pregnancy, labour, and postnatal care.
One named midwife is responsible for coordinating the woman’s care and has to make sure all her needs are met; this is the lead midwife. She is supported by a ‘buddy’ midwife, essentially her substitute. There is then the team midwives, which is aimed to be between four and eight midwives. This structure results in an ongoing relationship between the mother and her midwife, so that when the time comes, she will have a carer that she knows at the birth of her baby.
The timescale for these changes can be difficult to pin down, but in the original plan it was aimed for that by March 2021, most women would be receiving the continuity of carer model. However, due to Covid-19, these aims may be significantly different now.
The outcomes of this model aren’t just about giving a more personal and positive experience to the mother. Many studies have found that it leads to a better result for mother and baby – the need for an epidural decreased, chances of a natural vaginal birth increased, and there was a clear benefit for preventing preterm babies and stillbirths.
Obviously, there are a lot of advantages to this model from the side of the mother, and ideally this is how maternity care would be for everyone, but is it realistic?
I spoke to a number of midwives; some that are working under the CoC model, others that are yet to, and one of the midwives in charge of implementing the changes at a hospital in North Yorkshire.
These women had a range of opinions on the new model, and how it is set to change the traditional form of maternity care.
Bev, one of the senior midwives leading the way for the changes, stressed that the evidence that has come from the studies means that, for her, there should be no question that continuity of care is the way forward.
“If there is anything that could be done to prevent a stillbirth happening for one family, then there should be no question – it should be considered.”
The stats do stack up, with evidence showing that mothers are 16% less likely to lose their baby if cared for under this model. None of the midwives I talked to were disputing this point. All of them agreed that in terms of care quality and results, it is the best option.
One midwife working under the model now, who wants to remain anonymous (hereafter referred to as Anon) supports that the model means an “improved outcome and experience for women, better job satisfaction for midwives, and better flexibility and teamwork.”
Rachael, who has been a midwife for nine years now, said how it could be “an amazing opportunity for midwives to provide bespoke care to women and their families.”
The point here is that there is no denying that on paper, continuity of care is the better structure. The problems come when you move the model from plans on paper, to hospital wards.
Jane, a midwife yet to work under the model, said: “Continuity of Care – know your midwife – it sounds wonderful. In reality I can’t help thinking that we are building upon women’s expectations and we are the ones that will not be able to deliver.”
She touched on the expectations of the midwives, and whether it is really possible for them to be able to achieve what these plans lay out.
Numbers are the heart of the issue, there simply aren’t enough midwives. The Royal College of Midwives (RCM) confirmed last year that NHS England is short of 2,500 full-time midwives.
Bev noted: “We have a large cohort of midwives who are eligible to retire soon, and we don’t want to change their working practices” and whilst there are new midwives coming in, she said that this group don’t see midwifery as a vocation in the same way that previous generations have.
The attitudes towards careers have become more inter-changeable and flexible – qualities that don’t necessarily go hand-in-hand with the CoC model. To this, she said that “the role needs to be adapted to suit the future midwives.”
Jane reflected on this new wave of midwives too: “Employing newly qualified midwives makes up for numbers but not experience” and that the retiring cohort are taking “valuable experience” with them.
Surely you could say this for any element of change – it takes getting used to, but eventually it becomes the new normal – however, this isn’t always the case.
Anon stressed that: “We know that larger caseloads lead to burnout in midwives.” Failing to have enough midwives will lead to more caseloads– stretching midwives too thinly, which will reduce the level of care given.
“We have only been doing it a few months and are already feeling the strain. Pregnancies are becoming more complex, the procedures and protocols we are expected to be able to remember number in the dozens. There is a lot to be said for being a specialist in one area.”
This leads me to the next prominent issue that came up – training. Under the traditional model, midwives know what they’re doing in their certain area, whether that is as a community midwife or one on the wards. This new model would essentially see midwives doing a bit of everything because they’re involved with their cases from start to finish. So rather than the women moving through the system with different midwives at each point, the midwife moves with the patient, needing to know all the stages at all times.
Jane compared this to midwives having to become “Jack of all trades, masters of none.” She said the worry is that “midwives will lose some of these skills and with it their confidence.” This aspect, teamed with the increase in complex cases, means that the stats supporting the move might not end up being the reality of the change.
Rachael touched on this too, saying how the model could put midwives “in areas they are not familiar with. Potentially moving a lot of midwives to CoC could affect this balance of skill.”
Anon worries that “safety could be compromised by pushing midwives to work across all areas.”
As well as this, the organisation and administration of a team was something that the midwives mentioned. The personal aspect of the care means that the team of midwives are the ones to organise when they are all working, rather than a computer dictating shifts.
Bev said how “midwives can hold their own diary, working more flexibly” and she argued that moving away from the “rigidly rostered shifts” means that midwives have more choice. “I have had numerous experiences of feeling compromised if one of my children needed me, but I’ve been rostered to work a 13-hour day.” This suggests that the new model is an improvement in the work/life balance for midwives.
Claire, who works under the CoC model, vouched for this: “I manage my own diary and holidays, which is great working in a small team as our holiday requests can be honoured. I can work more autonomously and fit my workload around my time.”
However, these attitudes were not shared. Vicky, who is yet to work under the model, said how “it demands more time from the midwife. The nature of labour and birth means not knowing when one of the women will labour so the midwife may have to cover two or more nights a week on call,” something that could impact home life.
Rather than having 12-hour shifts, the CoC model could spread the work over much shorter shifts depending on what your cases are doing – but is that really any better?
Vicky continued: “Once the midwife is with a labouring woman there would be an expectation to be there until delivery, this can impose on the midwife's own commitments due to no fixed finish time.”
Midwives will be working when their women need them, causing shift routines they’re used to now, to change considerably.
Additionally, Jane argued that midwives having to organise their own shifts “is a job in itself” and rather than making life easier, it actually takes up more time outside of the shift for the midwife.
She added: “I would expect greater pressure and stress levels upon individual midwives. More on calls and this will affect the work/life balance with midwives finding they have no down time. I personally do not want to be available for women at all times.”
Bev is fully aware of the lack of enthusiasm the changes are seeing: “It is disappointing that my own profession is really negative about something which is proven to be a significant improvement. I believe it is the right things to do, and with greater understanding we will get there together!”
Claire added: “I expected there to be resistance from staff” and because of this “the model will evolve to fit around the team and women.”
Anon was clear that she isn’t against the measures, she just believes that: “it should be up to midwives to choose to work this way, it should not be imposed on them.”
Vicky also believes in the changes but stressed: “I don’t feel it’s a model that will mould to all midwives.”
Whilst Jane simply sees it as a “rose-tinted” view of maternity care, and questions what the cost will be to the individual midwife.
This split in opinions isn’t going to fade away any time soon, especially now that the transition will be slowed down further because of the effects of Covid-19, which has stretched the NHS in all areas, including maternity care. Change always brings conflict, and this subject area definitely has that.
The only answer to this is time. See where we are in a few years – will the traditional model still be a prominent structure serving as a backup plan, or a distant memory?
*Original article can be found in the British Journal of Midwifery*