Relationship-based continuity of carer: informed choice for women and midwives

Written by Professor Lesley Page CBE Visiting Professor at King’s College London and Adjunct Professor at UTS and Griffith University, Australia

There can be no doubt that we should be implementing relationship-based continuity of carer for most women and their babies. The evidence has been mounting over years and is compelling: there are few developments that offer so much benefit, with fewer risks (click here to read more on this evidence)

It is difficult to understand why this evidence is still seen as contentious, and why even – or perhaps especially – professionals can say that they do not ‘believe in’ continuity of carer.

Relationship-based continuity of carer should be the default for women

Given the evidence and the policy mandate in Better Births England and Best Start Scotland, we should be heading for continuity of carer as the default structure of care for most women.

Perhaps it is because (despite good information being available about what works) relationship-based continuity of carer has often been set up badly – or misunderstood – that resistance is felt. It is certainly a fundamental change that needs carefully-considered implementation and operation.

Following the Facebook live session run by myself and Michala Marling through All4Maternity  on the 12^th December 2017, it became clear that information (on how working in this way might be supported to create sustainable approaches for midwives) is still needed. If you missed this you can watch this here

It is important to note that what works for women will often be best for midwives, too. We should be creating woman-centred midwife-friendly services. Not every midwife will want or will need to work in continuity-of-carer schemes, one-to-one midwifery, neighbourhood midwifery, caseload midwifery or team midwifery. Midwives may also choose to change their style of practice according to their personal circumstances. But we should be scaling up relationship-based continuity of carer eventually, serving all women in this way, in a stepwise manner, over the next five years.

It is important to realise that without continuity of carer, safety and quality of care are badly compromised. The current fragmented services that most women pass through in maternity create many unnecessary risks.

What makes relationship-based continuity of carer work?

So how do we make this approach to practice work for midwives and for women, making it sustainable? It is critical that policy makers, change agents, leaders of services and midwives understand and reflect that it is the development of relationships over time that is associated with the benefits of this approach. There can be many ways of setting up and running relationship-based continuity, as long as there is fidelity to this principal. Each and every woman, her baby and family, should be cared for by a named midwife who co-ordinates her care and provides most of her care, working with a small number of ‘buddy’ midwives. The aim is for women to get to know and trust a midwife – and a small number of other midwives, over time – so that each has the opportunity to get to know and trust the other. This is a reciprocal relationship in which both benefit. It can be achieved through what I will call group practices that are situated in the community for women with all levels of care, from the most complex to straightforward. Always the woman is followed by her midwife/midwives wherever her care is situated. It can also be achieved through group practices working in the hospital, perhaps with women who have highly complex medical needs, or through group practices that attend home births. The ideal number in a group practice is six-eight. Numbers of births for each midwife vary between 35-40 per year, depending on complexity and geography.

On call – or availability, autonomy and enabling support, rather than control

The system of on-call or availability should be established by the group practice, which will be expected to ensure their ‘caseload’ – or ‘patch’ – is covered effectively. It should not require 24/7 on call or very long stretches of care. Having women contact midwives directly with mobile phones that can be switched between the team members works best for the service, for women and for the midwives.

The group practice requires autonomy to maintain the numbers in their team, to organise their own workload, to maintain standards through meetings, reflection and audit of care and outcomes. Management of these group practices should be enabling and not controlling. Annualised hours are essential.

Support may be needed to develop time management skills and flexible approaches as well as effective and authentic team working. If relationships in such small groups break down, it can have an extremely damaging effect. Facilitated meetings may help in this authentic rather than pseudo team-work, and can be one of the joys of working in such a way, sharing and enacting philosophies of care together with like-minded midwives.

While the satisfaction of developing relationships with women is one of the factors that protects against burnout while giving relationship-based continuity, if there are adverse outcomes, this can be devastating for the professionals involved, and there should be an immediate pathway of support for midwives in this situation.

Many successful group practices have been destroyed by calling on midwives to help in shifts on top of their caseloads. Midwives in group practices may choose to contribute to core services at times, and this will help integration of the group practices with core services, but this should not be expected.

Avoiding the us and them divide

One of the problems identified repeatedly is the development of us-and-them mentalities when there are two or more systems of care in place. This is a leadership challenge for all and requires approaches that ensure there is integration of all, respectful relationships with clear pathways for referral.

The avoidance of myths, rumours and misunderstandings requires compassionate and strong leadership. The highest ethical standards are required, to follow and investigate rumours, and to avoid misperceptions.

Students’ and newly qualified midwives’ needs

For the next generation of midwives, being able to work in relationship-based continuity of carer practices offers a very rich way of learning, and better supervision and support than being in acute wards and departments. Opportunities need to be presented for at least some newly qualified midwives to make this their first rotation. All students should have the opportunity to follow women through in each year of their midwifery education.

Ensuring sustainability and that midwives have a choice

Fundamentally, the establishment of sustainable relationship-based continuity requires careful implementation, and commitment to maintaining the model. To close such developments is unethical and unwise, and commissioners should be advised to avoid this.

To be able to practise in this way offers many benefits to midwives, and every service ought to ensure that midwives, as well as women, can choose their style of care and have the opportunity to work in this way. Care mediated through human relationships, given by skilled, knowledgeable compassionate midwives, is the best gift we could give to the next generation. For their sake, let’s do 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 continuitymatters@gmail.com