Professor Rhona McInnes led a research team in Scotland as they closely examined the process of implementing a midwifery continuity model. In this post, Professor McInnes provides some details about this recently published research.
You can access the full paper here.
We know from published studies that, compared to other models of care, midwifery continuity of carer has better clinical outcomes for women, higher satisfaction with care and provides a better caregiving experience for midwives. Despite the evidence for midwifery continuity, large scale and sustainable implementation has not been achieved. Our study aimed to explore how a government policy for midwifery continuity might be enacted in one area of Scotland to determine how continuity works and what might inform wider scale up and sustainability.
Midwifery continuity of carer is a relationship-based model of care that provides greater opportunities for midwives and women to get to know each other across the maternity care journey. In our study we used quality improvement methods to support the implementation of initially one midwifery continuity team. The first team comprised eight midwives each aiming to achieve care for 35 women (pro-rata) at any one time. The team was located in one geographical area and served a mixed-risk population within public sector (National Health Service) maternity services. Each midwife provided all antenatal care for her caseload and as much postnatal care as possible. Midwives were on call for their team’s births and might or might not attend the birth of their caseload women. Women could choose to have their care provided in their home or in a primary care facility and were supported to birth in hospital, in the alongside birth centre or in the home. Good information sharing was developed to ensure the midwives knew the team’s women and so that women felt known by the midwife attending their birth.
We used a research approach known as realist evaluation in order to determine what worked for whom, in what context. Our findings were informed by published studies and reports, audit and quality improvement data, field work, reflective discussions and interviews with midwives and key stakeholders. We began by reviewing policy documents alongside the published literature to identify theories of how continuity might work or be supported to work. This identified 3 key theories: relationships, how midwives practise, and leadership. We tested these theories in the real time implementation context where we were acting in the roles of researchers, evaluators and facilitators. Audit and quality improvement data showed what was working well, what might be improved, and enabled us to identify strategies that might support on-going implementation.
In our context we identified effective leadership as key to enabling the implementation. This comprised having a shared vision that was consistently communicated across all levels of the organisation; and building trust between midwives in different models of care, across the multidisciplinary team and between different organisational levels. Midwives in the continuity team needed to feel they were trusted to be professional and able to make decisions that would be supported by management, other midwives and the multidisciplinary team without feeling micromanaged, constrained by organisational structures or that ‘no-one had their back’. Likewise, management needed to feel able to relinquish control and trust to the continuity midwives. Good leadership enabled trusting relationships to develop, made staff feel safe and able to engage with the new model of care and also acted as a buffer against external, and at times unrealistic, pressures to succeed.
Much of the focus in the literature is on the positive relationship between the woman and her continuity midwife. In our study this was highly valued by women for supporting them and making them feel relaxed and confident about their care. In addition, this relationship sustained the midwives’ wellbeing, motivated them to provide high quality care and changed how they practiced. Across the organisation other relationships were important for sustaining the model of care; for example, positive relationships within the continuity team offset negative encounters with others in the multidisciplinary team. Trusting relationships with other midwives (not in continuity) and the wider multidisciplinary team were sustaining and supported safe practice but were more commonly experienced as challenging where team midwives felt under pressure to perform well. The combination of the team midwives’ sense of responsibility to provide women with a good care experience in the context of feeling watched and judged was an additional pressure that served to disempower midwives during the implementation.
Midwives working to full scope of practice across women’s care journey is recognised as key to continuity of care. We found this to be important for woman-centred care, confidence in their midwifery role, sense of empowerment and job satisfaction but that this was affected by the practice context meaning that the midwives needed to genuinely be in control of their workload and style of practice. This required the organisation to relinquish control which, in the public health service setting, proved difficult. Midwives in our study recognised that they had changed the way they worked which supports continuity changing the midwife rather than midwives who choose continuity being intrinsically different. Our evaluation also highlighted that to support continuity it was essential for practice to change right across the organisation because a lack of change here prevented continuity from flourishing.
To summarise, the implementation of continuity is enabled within a context of effective leadership which builds trusting relationships across all organisational levels and boundaries. It can’t be a small localised change at the women-midwife interface but needs to be embedded and supported within the organisation. This is achieved through shared vision, service reconfiguration and a changed management style that actively and genuinely supports woman centred care and empowered and confident midwives.