Ali Monaghan is an American Midwife and a British Student Midwife. In the first part of her story she shares her experience of providing continuity in the USA and having her first baby at home with 2 midwives whom she had got to know throughout her pregnancy.
What if I told you that there was a new, magic intervention that was guaranteed to lower the rate of epidurals, cesarean births, instrumental deliveries, preterm births, miscarriages and even neonatal deaths? Sounds too good to be true, right? This intervention is so miraculous, though, that not only does it reduce all of those risks above, but it also increases the likelihood of having a normal, uncomplicated vaginal delivery. It even shortens the duration of labour, and women across the board not only feel more positive about their births, but also more satisfied with their care in general. Sounds incredible, right? If you were a pregnant woman, you’d definitely want to make sure that you received this intervention, right? You would be clamouring to get your hands on it!
But here’s the rub—this intervention already exists. It isn’t new—it’s been studied for decades and all of the evidence is quite clear. It’s something that the RCM and RCOG both agree on! The magic intervention? Relational continuity with your health care provider during your pregnancy, labour, birth and postnatal period. That’s it. Continuity of care and carer. Meaning that every time you have an antenatal appointment, it’s with the same midwife. When you go into labour, the midwife you know and trust is the one supporting you at your birth, and she continues to care for you during the first several weeks after the delivery as you weather the normal postnatal ups and down during your transformation into a mother. Continuity of care and carer. That’s all we need for better outcomes across the board. That’s the magic bullet.
And women don’t just need this, but midwives need this as well. Study after study has shown that when midwives are able to provide continuity of care to women (known as case-loading midwifery here in the UK), there is less burn-out, more job satisfaction and more autonomous practice. Continuity of care is the one magic intervention which will improve maternity services across the board, in all areas, for women AND midwives. It really is that simple.
Except that it’s not. Very few NHS trusts provide a case-loading model of care for their maternity services. In fact, unless you’ve hired an independent midwife or a midwife through a company like Neighbourhood Midwives, who offer both private and NHS services, chances are good you won’t receive continuity of care in your NHS trust. Which means that the majority of women in the UK aren’t receiving this amazing, life-changing, magical intervention. Because of this, increased continuity of care is a priority in both Midwifery 2020 and the Better Births Initiative.
I first experienced continuity of care as a brand new midwife working in Brooklyn with some of New York City’s most vulnerable women who were attending a Medicaid-only public hospital for their care. It wasn’t complete continuity of care and carer, but it was pretty close. In the antenatal clinic, when you did an initial booking visit with a woman, she would then follow-up with you for all of her future visits (assuming she was appropriate for midwifery care; any women in need of obstetrical care were transferred to the obstetrical team). Which meant that as her pregnancy progressed, you really got to know her, even though you only had 15 minutes per visit. In many cases, towards the end of the pregnancy, when you were seeing her on a weekly basis, you knew her so well that you recognised her name on sight, and knew all of her history without needing to consult the notes. You knew her birth plans, her hopes and desires for her birth, as well as her concerns and fears. You often also knew the names of her older children that she always brought with her to the visits, and in many cases, you knew her partner too. You could greet her with a familiar smile, answer her questions, and pick up conversations that you had left off the week before. It also meant that there was time for the relationship to grow and for trust to develop between you. In some situations, this meant that as she got to know you, she would finally feel comfortable enough to confide in you about domestic violence, substance misuse or other issues going on in her pregnancy—things she hadn’t been comfortable discussing at the earlier visits, and things she probably would never have mentioned if she was seeing a different provider for each antenatal appointment.
It wasn’t a perfect system by any means—the visits were still too short, and while there was continuity in the antenatal and postnatal setting, there wasn’t continuity on labour ward, which meant that we worked shifts on labour ward and delivered whoever happened to be in labour that day, rather than being called in for our own clients when they went into labour. However, sometimes, when I was lucky, one of the women I’d cared for in the antenatal clinic would be in labour during my shift, and then I was able to provide her with complete continuity. The look of joy lighting up her face when I would first come into her room as she laboured was always priceless—and it was a look of joy that was always mirrored in my own face as well, since it was an absolute pleasure to be able to care for women that I knew well and had formed a relationship with. In fact, many of my clients would inquire about my schedule during the weeks around their due date, and in some cases would try their best with acupuncture and spicy food and lots of sex to go into labour on the same days as my shifts.
I also had an opportunity to provide complete continuity of care briefly during a 5-month stint as an independent home birth midwife in Brooklyn. I was a younger midwife joining the established practice of an older midwife who had been providing continuity of care on her own for years. Unfortunately, she and I never really gelled as a team and the partnership was very short-lived, but the experience of providing care for women that I had an opportunity to really get to know well during (luxurious!) hour-long antenatal visits at their homes was indelible. As each woman approached her due date, at each visit, there was growing anticipation leading up to the birth, and when the phone call finally came that she was in labour, my first thought was often excitement and joy for her, rather than disappointment that I would have to leave my warm bed or whatever activity I was currently doing. This made the on-call slightly easier to bear, despite the fact that it was pretty brutal (we had to take on six births a month in order to be able to cover our salaries and our indemnity insurance, which, trust me, is A LOT of work in a month). I missed Thanksgiving, Christmas and New Year’s that year, and was sometimes away from my 1 year old son for up to 30 hours at a time. It wasn’t sustainable, but the continuity did provide enough joy to almost (almost) balance it out.
I was also lucky enough to be on the receiving end of continuity of care with both of my pregnancies. With my first pregnancy in the States, I knew from the very beginning that I wanted to have a home birth, so this automatically meant that we were going to have to seek out private midwifery services, since home birth is not provided in the US through any hospital-based system. My husband and I interviewed several midwives providing private services and finally settled on a two-midwife team that lived fairly close to us, and who seemed to click with us on every level.
Over the course of my pregnancy, my visits were split between the two of them, so that I had an opportunity to get to know both very well, and by the time I went into labour, I felt equally comfortable with both of them. These two midwives took turns with the call, meaning that one of them would always be available by phone at any point in my pregnancy, and while I didn’t have to avail myself of their on-call services much during the pregnancy (except for one really bad case of the flu around 20 wks), it was a tremendous comfort to know that I could speak to my midwives at any point, whenever I felt like I needed them. It was also a tremendous comfort to know that when the big day finally arrived, it would be someone who knew me and my pregnancy well who would be picking up the phone to answer that call.
And thank goodness for that!
My first labour was a 56 hour marathon, during which time I lost hope on several occasions. However, because I knew and trusted my midwives and had a relationship of trust and respect with them, I believed them when they told me that things WERE progressing, that everything was normal, that we didn’t have to transfer to the hospital (in my labour-haze I had determined that hospital augmentation, or possibly cesarean birth, was the only way I was going to deliver). If I hadn’t known them and trusted them as much as I did, I don’t know that their words would have carried as much weight with me at a time when I was seriously doubting my ability to give birth. And lo and behold, they were right: 56 hours later, I did indeed give birth in my living room, surrounded by this loving circle of support!
In the next post Ali will go on to talk about moving to the UK, her experience of continuity in the UK with her 2nd baby and retraining as a midwife. 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