“Every woman needs a midwife, some need a doctor too” ¹

Up to 25% of women start pregnancy with at least one chronic medical condition (e.g., epilepsy or high blood pressure).² This is important because chronic medical conditions may increase the risk of pregnancy complications (e.g., pre-eclampsia) and surgical birth.² Furthermore, chronic health conditions add to the likelihood that women will experience perinatal depression and/or anxiety.³ Little is known about how these women experience of maternity care and therefore how well tailored it is to suit their needs.

New research

A trial is underway to test the effect of a multifaceted intervention to improve experiences and outcomes for childbearing women with a chronic medical condition.⁴ To help design the intervention, researchers undertook in-depth interviews with 14 women who had been referred to a tertiary centre for specialist maternity care.⁵ Women were recruited from antenatal clinics and the inpatient ward. Two women were interviewed during late pregnancy, while 12 were postpartum. Data were analysed by two researchers, who had both conducted the interviews, using a well-known 6-step process of thematic analysis.

Challenging experiences with maternity care

Reducing the woman to her medical condition

Women interpreted that their medical condition determined their maternity care (Hansen et al., 2021). For example, it made them worry about the pregnancy (“a constant state of alert”); while diminishing their choices (e.g., place of birth).⁵ At times, women felt reduced to their medical condition, or to being a vessel for their fetus.⁵

Lack of collaboration between providers

Women described intense fragmentation of care between midwifery, obstetrics, and their medical specialist. This led to situations where women tried to piece together information from different professionals that was confusing or conflicting.⁵ One woman said, “I told them to call each other” so they could come to an agreement on their recommendations. In other instances, women felt responsible for transferring information between health professionals: “all that communication had to go through me…it was a mess”.⁵

Lack of personalised and normalised approach

Women felt they missed out on developing a relationship with the midwife.⁵ When women did see the same doctor or midwife, they described this facilitated trust and relieved pregnancy-related anxieties.⁵ Participants perceived midwives did not allow enough time to talk about the normal aspects of their pregnancy; nor did they meet women’s expectations about explaining and translating complex information.⁵

Lack of postnatal support and debriefing

Women who had been so highly monitored during pregnancy, felt abandoned postnatally.⁵ Participants described they had not been well-prepared for the postnatal period by their antenatal care providers. Furthermore, postnatal consultations tended to focus on their medical condition, with no space for discussion of their birth experience.⁵ There was one contrasting experience where a woman felt “allowed” to tell her story and have her experiences acknowledged by the midwife.⁵

What does this mean for maternity care?

How the maternity workforce is organised impacts the quality of care.¹ 

Midwifery continuity of carer across the continuum

Midwifery-led continuity of care across pregnancy, birth and postpartum provides the best outcomes and experiences for mothers and babies.⁶ For women with risk factors, midwifery continuity of carer provided in collaboration with obstetric and medical specialists, offers women similar or better outcomes;⁷ alongside higher levels of emotional support, increased involvement in decision-making, and overall higher care quality.⁸ Midwifery continuity of carer models are becoming increasingly accessible to women of ‘any risk’, including those with chronic medical conditions. However, access to midwifery continuity of carer in Australia is severely restricted. Therefore, setting meaningful targets to increase the availability of midwifery continuity of carer is urgently required.

Midwifery and obstetric continuity during pregnancy

Compared to fragmented care, continuity of midwife during pregnancy is a valuable and acceptable model.⁹ Continuity of relationship with both the midwife and the obstetrician is foundational to well-coordinated, woman-centred care for women whose pregnancy is complicated by a medical condition. In addition, collaboration between midwifery, obstetric and medical providers is critical women receiving coherent and consistent recommendations.

Midwifery role

Regardless of pregnancy complexity, women want midwives to incorporate primary health information and social support during her transition to motherhood. Women appreciate it when their known midwives are empowering and endorphic.¹⁰ Midwives can help women to make sense of complex information, navigate the health system, reduce their pregnancy-related anxieties, and assist them to focus on the normal and joyful aspects of their pregnancy.

Highlighted article

Hansen, M. K., Midtgaard, J., Hegaard, H. K., Broberg, L., & de Wolff, M. G. (2021). Monitored but not sufficiently guided – A qualitative descriptive interview study of maternity care experiences and needs in women with chronic medical conditions. Midwifery, 104, 103167. Advance online publication. https://doi.org/10.1016/j.midw.2021.103167

Blog written by

Dr Jyai Allen and Professor Kathleen Fahy

References

1. Sandall, J. (2012). Every woman needs a midwife, and some women need a doctor too. Birth, 39, 323-326. https://doi.org/10.1111/birt.12010
2. Kersten, I., Lange, A.E., Haas, J.P. et al.  (2014). Chronic diseases in pregnant women: prevalence and birth outcomes based on the SNiP-study. BMC Pregnancy Childbirth14,  https://doi.org/10.1186/1471-2393-14-75
3. Brown, H. K., Qazilbash, A., Rahim, N., Dennis, C. L., & Vigod, S. N. (2018). Chronic medical conditions and peripartum mental illness: a systematic review and meta-analysis. American Journal of Epidemiology, 187, 2060-2068. https://doi.org/10.1093/aje/kwy080
4. de Wolff, M.G., Johansen, M., Ersbøll, A.S. et al. (2019). Efficacy of a midwife-coordinated, individualized, and specialized maternity care intervention (ChroPreg) in addition to standard care in pregnant women with chronic disease: protocol for a parallel randomized controlled trial. Trials,20,  https://doi.org/10.1186/s13063-019-3405-5
5. Hansen, M. K., Midtgaard, J., Hegaard, H. K., Broberg, L., & de Wolff, M. G. (2021). Monitored but not sufficiently guided – A qualitative descriptive interview study of maternity care experiences and needs in women with chronic medical conditions. Midwifery, 104, Advance online publication. https://doi.org/10.1016/j.midw.2021.103167
6. Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. The Cochrane database of systematic reviews, 4, CD004667. https://doi.org/10.1002/14651858.CD004667.pub5 
7. Tracy, S. K., Hartz, D. L., Tracy, M. B., Allen, J., Forti, A., Hall, B., White, J., Lainchbury, A., Stapleton, H., Beckmann, M., Bisits, A., Homer, C., Foureur, M., Welsh, A., & Kildea, S. (2013). Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial. Lancet (London, England), 382(9906), 1723–1732. https://doi.org/10.1016/S0140-6736(13)61406-3
8. Allen, J., Kildea, S., Tracy, M. B., Hartz, D. L., Welsh, A. W., & Tracy, S. K. (2019). The impact of caseload midwifery, compared with standard care, on women’s perceptions of antenatal care quality: Survey results from the M@NGO randomized controlled trial for women of any risk. Birth, 46(3), 439–449. https://doi.org/10.1111/birt.12436
9. Cummins, A., Griew, K., Devonport, C., Ebbett, W., Catling, C., Baird, K. (2021). Exploring the value and acceptability of an antenatal and postnatal midwifery continuity of care model to women and midwives, using the Quality Maternal Newborn Care Framework. Women and Birth.
10. Allen, J., Kildea, S., Hartz, D. L., Tracy, M., & Tracy, S. (2017). The motivation and capacity to go ‘above and beyond’: Qualitative analysis of free-text survey responses in the M@NGO randomised controlled trial of caseload midwifery. Midwifery, 50, 148–156. https://doi.org/10.1016/j.midw.2017.03.012