The evidence for the benefits of continuity of care during pregnancy, birth and during the postnatal period, for both women and midwives is strong (Sandall 2014, Sandall et al 2016a, 2016b, Forster 2016) and repeatedly highlighted in government publications both nationally (Department of Health [DoH] 1993, 2007, 2010, NMR 2016) and internationally (WHO, 2016), it is recommended by both midwifery (RCM 2016) and obstetric trade unions (RCOG 2011), and is within the recommended guidelines for maternity care (NICE 2016, 2017a, 2017b) yet it is still not available in the large majority of the UK.
Prior to 1993 women were recommended to birth in a hospital as it was seen as being safer. The Changing Childbirth report (DoH, 1993) paved the way for a shift in the attitude towards birth and models of care provided to women. The recommendations were that the development of maternity services should be focused on moving away from this medical model of care, because whilst it may be safer for some women, they recognized it was not the safest option for all. It was stated that women should be in control of their choices (and I should think so too, as that is their human right after all) and the decisions made around their pregnancy, including the options to have their baby at home or under midwifery led care. The Maternity Matters report (2007) then put emphasis on the need to improve the care provided to women and their partners by individualising care that focused on choice, easy access to care and the provision of continuity.
In 2010 the Department of Health saw that the new challenges and opportunities facing midwifery needed addressing and there was a need to identify the changes that needed to be made. Subsequently, Midwifery 2020 (DoH 2010) stated that it wasn’t simply continuity that women needed, as this term can mean a number of things, but more specifically continuity of carer. The recent National Maternity Review (2016) stated that care women receive should be based on a relationship of mutual trust and respect, but to ensure this they need continuity throughout pregnancy, during labour and birth, right through the postnatal period. All 3 of these areas are important and we cannot forget that. When a woman has continuity of carer, through either a named midwife or a small group of midwives sharing or caseloading her care, it enables a really special positive relationship to build between the woman and the midwife (Sandall et al 2016b). This is what I would define as true caseload midwifery.
When the provision of maternity care is within the caseload model; emotional and physical outcomes are shown to improve for both mother and baby (Sandall et al 2016b). Women cared for under this model are 24% less likely to have a preterm birth, 16% less likely to experience pregnancy loss and also less likely to need interventions such as instrumental birth, amniotomy, episiotomy and epidural pain relief (Sandall et al 2016a). The Maternity Safety Ambition set out in the Department of Health’s ‘Safer Maternity care’ report (DoH, 2017) is to halve the rates of stillbirths, neonatal deaths, maternal deaths and brain injuries, whilst also reducing pre-term birth, so it seems obvious that introducing continuity of carer will make a large contribution in meeting the Maternity Safety Ambition. The World Health Organisation also [WHO] (2016) recommend caseload midwifery as being the safest model of midwifery care and one that should be available to all throughout antenatal, intrapartum and postnatal care and more recently in their guidelines specifically based around a positive experience in the intrapartum period, recommend midwifery led continuity of carer from a known midwife or small group of midwives (WHO 2018).
Having worked within this model of caseload care as a student, alongside a team that is already doing pretty much all of what The National Maternity Review (2016) recommends, I have seen first hand the job satisfaction that this gives midwives as well as the flexibility they have to fit work around their lives. I have seen and felt the benefits not just for the women but for me, both in a midwifery sense and personally too, as it was something that helped me through grief and PTSD… but that’s for another day!! Experiencing caseload midwifery in its true sense is shown to help student midwives develop emotional intelligence and provide more holistic woman centred care that focusses on empowering women and their partners towards a positive birth experience (Dahlberg & Aune, 2013).
Having this experience of high quality continuity as a student midwife is also shown to help students develop high quality skills and provide a more meaningful practice that supports personal development (Aune et al 2011). The importance of this experience as a student is reflected in it being an important aspect of midwifery education (NMC, 2009), yet for the majority of students, they will never experience true caseload midwifery. If we want to provide women with the caseload model of care, we need the midwives on board too. If we want the midwives on board we should surely address this at student level and support students to complete caseload projects within caseload teams so that they can truly experience this model of care rather than associating it with attempting to provide continuity in a system that doesn’t support it.
Please join the campaign for continuity of carer for all women, for the benefit not just of the women but for babies, for families and for the midwives too. You can do so by following the campaign on Facebook, sharing the campaign on social media using the hashtag #continuitymatters or you can email your story to share on the blog to email@example.com
I would love to hear from people who have experience of working in this model of care, from women and their partners, families, doula’s who have experienced this type of care, from leaders who have set up and managed this model of care effectively… Or if you couldn’t imagine working in this way, get in touch and share your worries and maybe just maybe it’s something someone somewhere might have answers for you…Please get in touch!!
Written by Michala Marling – Midwife, Hypnobirthing Teacher and campaigner
Aune, I., Dahlberg, U., & Ingebrigtsen, O. (2011). Relational continuity as a model of care. British Journal of Midwifery 19 (8) 515-523
Birthplace in England Collaborative Group, 2011, Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011;343:d7400 doi: 10.1136/bmj.d7400 (Published 24 November 2011)
Dahlberg, U. and Aune,I. (2013) The womans birth experience – The effect of interpersonal relationships and continuity of care. Midwifery, 29 (4), 407-415. Available online http://www.sciencedirect.com/science/article/pii/S026661381200174X
Department of Health (1993) Changing Childbirth. HMSO, London.
Department of Health (2007) Maternity matters: choice, access and continuity of care in a safe service. London: DH Publications
Department of Health (2010) Midwifery 2020: Delivery Expectations. Available online https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216029/dh_119470.pdf
Department of Health (2017) Safer Maternity Care: The National Maternity Safety Strategy – Progress and Next Steps. Available online https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/662969/Safer_maternity_care_-_progress_and_next_steps.pdf
Forster, D., McLachlan, H., Davey, M., Biro, M., Farrell, T., Gold, L., Flood, M., Shafiei, T. and Waldenström, U. (2016). Continuity of care by a primary midwife (caseload midwifery) increases women’s satisfaction with antenatal, intrapartum and postpartum care: results from the COSMOS randomised controlled trial. BMC Pregnancy and Childbirth, 16(1).
Haggerty, J. L., Reid, R. J., Freeman, G. K., Starfield, B. H., Adair, C. E., & McKendry, R. (2003). Continuity of care: a multidisciplinary review. BMJ : British Medical Journal, 327(7425), 1219–1221.
Kenny, C., Devane, D., Normand, C., Clarke, M., Howard, A., & Begley, C. (2015). ‘A cost-comparison of midwife-led compared with consultant-led maternity care in Ireland (the MidU study’). Midwifery 31(11): 1032-1038.
McLachlan, H., Forster, D., Davey, M., Farrell, T., Gold, L., Biro, M., Albers, L., Flood, M., Oats, J. and Waldenström, U. (2012), Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial. BJOG: An International Journal of Obstetrics & Gynaecology, 119: 1483–1492. doi:10.1111/j.1471-0528.2012.03446.x
National Institute for Health and Care Excellence (2016) Antenatal Care Quality Standard [QS22]. Available online https://www.nice.org.uk/guidance/qs22/chapter/quality-statement-2-services-continuity-of-care
National Institute for Health and Care Excellence (2017a) Antenatal Care for Uncomplicated Pregnancies. London, NICE. Available online https://www.nice.org.uk/guidance/cg62
National Institute for Health and Care Excellence (2017b) Intrapartum Care for Healthy Women and Babies. London, NICE. Available online https://www.nice.org.uk/guidance/cg190
National Maternity Review [NMR] (2016) Better Births: Improving Outcomes of Maternity Services in England. London. Available online https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf
Nursing and Midwifery Council (2009) Standards for Pre-Registration Midwifery Education. Retrieved from http://www.nmc.org.uk/globalassets/siteDocuments/Standards/nmcStandardsforPre_RegistrationMidwiferyEducation.pdf
Royal College of Obstetricians and Gynaecologists [RCOG] (2011). High Quality Women’s Health Care: A Proposal For Change. Expert Advisory Group Report, London. Available online https://www.rcog.org.uk/globalassets/documents/guidelines/highqualitywomenshealthcareproposalforchange.pdf
Royal College of Midwives [RCM] (2016) Getting The Midwifery Workforce Right. Available online at https://www.rcm.org.uk/sites/default/files/Getting%20the%20Midwifery%20Workforce%20Right%20A5%2024pp_2_1.pdf
Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2016a, Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub5.
Sandall, J., Coxon, K., Mackintosh, N. J., Rayment-Jones, H., Locock, L., & Page, L. (2016b). Relationships: the pathway to safe, high-quality maternity care: Sheila Kitzinger symposium at Green Templeton College, Oxford: Summary report. Green Templeton College, Oxford.
Sandall J (2014) The Contribution of continuity to high quality maternity care. RCM, London. Available online https://www.rcm.org.uk/sites/default/files/Continuity%20of%20Care%20A5%20Web.pdf
World Health Organisation [WHO] (2016). WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. WHO Publications, Luxembourg. Available online http://apps.who.int/iris/bitstream/10665/250796/1/9789241549912-eng.pdf
World Health Organisation [WHO] (2018). WHO Recommendations: Intrapartum Care for a Positive Pregnancy Experience. WHO Publications, Luxembourg. Available online http://apps.who.int/iris/bitstream/10665/260178/1/9789241550215-eng.pdf?ua=1