Our Updates

Overcoming barriers to obstetric support for midwifery continuity of care models

by Midwives Siubhan McCaffery and Professor Jenny Gamble, with Obstetrician Kirsten Small

One of the frequently mentioned barriers to the expansion of midwifery continuity of care models is a lack of support from obstetricians. There is a small body of research that sheds some light on this lack of support. These studies have shown that the issues include differing birth-related philosophies between maternity care providers, medical dominance of the maternity-care landscape, medical officers’ misunderstanding of what midwifery is, and the impact of maternity reform on medical maternity care providers.

One study reported on a cohesive and accepting culture across midwifery and obstetrics which was created through strong knowledge of the model and acceptance of the associated evidence relating to midwifery continuity of care (Styles, et al., 2020). While this was the exception, rather than the norm, it does show that it is possible to overcome the challenges and generate multi-professional teams that support midwifery continuity of carer models.

We have both worked in a variety of maternity care settings and have our own first-hand experience of setting up and working in midwifery continuity of care models. It is our belief that many of the concerns of obstetricians can be addressed through education or through exposure to well-functioning models of care. Here we explore and address three common concerns.

Concern #1 Uncertainty about professional roles

Historically, obstetricians have by default been considered as the leader of any maternity care team. When midwives move into the role of primary care provider, this necessitates a shift in role for the obstetrician as well. This can cause discomfort simply because it is unfamiliar but provides a valuable opportunity for obstetricians to reflect on what they want to contribute to maternity care and how they would like to structure their role.

The obstetricians’ role shifts from being primarily about supporting the birthing woman, and the midwife supporting the obstetrician to do that; to the obstetrician supporting the midwife as they support the birthing woman. The primary relationship the obstetrician has in a midwifery continuity of care model is with the midwives, rather than birthing women. The concept of measuring good obstetric practice changes from being chiefly about whether the woman was happy with the obstetrician’s care (though that remains important), to being about whether the midwife was happy with the support provided by the obstetrician.

As obstetricians shift into this new role, there is also an opportunity to negotiate with midwives who will make up the team about how members of each profession work with one another. We take for granted that we understand our own and each other’s roles, yet this is often not accurate. Rather than representing a threat to obstetric practice, role clarity for both professions can reduce workload and anxiety, and improve the safety of practice.

Concern #2 Uncertainty about professional responsibility

Tied to the concept of the obstetrician as the leader, is the sense that obstetricians are ultimately responsible for the actions of every member of the healthcare team in producing good outcomes. There is no basis for this assumption in law, which is clear that clinicians are responsible for their own actions and not that of others. Along with providing an opportunity to renegotiate roles, shifting to midwifery continuity models of care provides a chance to be clear about lines of responsibility.

The most effective way for obstetricians to be clear about their risk exposure is to not take on care responsibilities for women until a midwife escalates care to them. This is easy to achieve in a midwifery continuity of care model where the only time an obstetrician becomes involved in woman’s care is when they are asked to do so by a midwife who has the woman’s agreement. Hybrid models, where obstetricians review healthy women at some point, make the lines of responsibility fuzzy and don’t improve outcomes. They should therefore not be used.

Concern #3 Lack of forewarning

While the suggestion that obstetricians don’t take on care for women until requested reduces workload and medicolegal risk, this can generate concern that they will need to step into a care role without forewarning. Many obstetricians feel more comfortable when they have had the opportunity to meet and assess women during the antenatal period, on the assumption that they might be able to prevent complications from arising during or after birth.

Evidence shows that the outcomes of midwifery continuity of care are at least as good as they are for obstetric led care (Sandall et al., 2016). This is only possible because midwives are at least as good as obstetricians at risk assessment and management. The circumstances under which midwives request the input of obstetricians are clearly set out, ensuring that obstetric involvement is achieved before a clinical situation has evolved into a major complication, when this is possible to do so.

It is important to acknowledge, that even with significant levels of obstetric input in an obstetric led model of care that unexpected emergencies still arise. It is therefore a myth that having a check-up with an obstetrician can avoid these. Being able to respond to an emergency situation without being forewarned will always be a feature of the work required of obstetricians, regardless of the model of care. This should not be used as a reason to limit access to midwifery continuity of care models.

In closing

As a midwife and an obstetrician, we have both experienced the benefits of working in midwifery continuity of care models. Not only are the clinical outcomes excellent, but the restructuring of working relationships between midwives and obstetricians that occur with the shift in model enhance professional relationships and help to make our professional lives more meaningful. There is joy and reward to be found in working in multi-professional teams with clear understanding and respect for each other’s roles and responsibilities.

 

Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016.) Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, 4(11), CD004667.

Styles, C., Kearney,L., & George, K. (2020). Implementation and upscaling of midwifery continuity of care: The experience of midwives and obstetricians. Women and Birth, in press.

Preventing stillbirth: What works best?

Preventing stillbirth has been, and continues to be, a major focus in both practice and research in maternity care. Reducing rates of stillbirth in high-income countries has proven challenging, with little significant change over the past two decades. One of the current approaches to tackle stillbirth has been to routinely and regularly encourage women to focus on the movement pattern of their fetus and report any changes to their maternity care provider. Is this the best approach, or might midwifery continuity of care be more effective?

Earlier this year Bellussi et al. (2020) published a systematic review of literature which addressed the question of whether heightened awareness of fetal  movement patterns reduces stillbirth. On the basis of the research available at that time, the answer was no – increasing awareness of fetal movements didn’t reduce the rate of stillbirth. Several large trials remained unreported at the time they conducted their analysis, and one of these has just been published.

The latest addition to the pool of evidence is the Mindfetalness study (Akselsson et al., 2020). Conducted in 67 maternity services in Sweden, individual clinics were randomly selected to provide either routine care, or to provide women written and verbal information about an approach they called Mindfetalness. Starting from 28 weeks of gestation, women were asked to spend 15 mins at rest daily, during a period of fetal activity, being mindful of the pattern of movements. Women were encouraged to “trust their intuition” and seek care if they were worried about the movement pattern.

A cluster-randomisation process was used to ensure that socio-economic status and the number of births conducted at the clinic didn’t influence the outcome. In total, 19,639 women were registered for care at clinics where Mindfetalness was used, and 20,226 in the control clinics. Stillbirth is a (fortunately) rare outcome, so astonishingly large studies are needed to examine any change in the outcome. Because of this, the more common occurrence of low Apgar scores (under seven at five minutes of age) was chosen as the outcome of interest, and the size of the study was planned to be big enough to confidently find an improvement of 4 fewer babies in every 1000 births having better Apgar scores, if this effect was present. Data were collected from women who gave birth after 32 weeks of gestation.

The rate of babies born with low Apgar scores was the same regardless of whether Mindfetalness was recommended or not (11 in every 1000 births). While the primary aim of the trial was not to look at deaths, they did collect this information. There was a slightly higher rate of stillbirth (2 in 1000) in the Mindfetalness group, than the control group (1.4 in 1000). No statistical measure was offered to judge whether this was a chance finding or not. Neonatal death was extremely low in both groups (1 and 2 in 10,000 respectively – not statistically different).

The abstract of the article highlights two benefits of the Mindfetalness approach. There was a statistically significant reduction in the caesarean section rate, from 20% to 19%. This is far from being a clinically significant difference, and it is far less than has been seen in other interventions proven to be effective for reducing the rate (for example introducing midwives into obstetric only maternity care models reduced the rate by 7% – Chen et al., 2018). The other benefit was a reduction in the rate of babies born under the tenth centile. This fell from 107 per 1000 to 102 per 1000. However, there was no difference in the more clinically relevant measure of the rate of babies born under the fifth centile.

The authors argue that “increasing women’s awareness of fetal movements is not harmful” (p.835). While this is true within the context of their research findings, widespread adoption of programs focusing on fetal movement as a means to reduce the stillbirth rate comes with an opportunity cost. Maternity systems have finite resources in terms of money, people, and time. Focussing efforts towards an ineffective but not harmful approach to care directs effort and people away from other approaches to care which are already known to be effective.

Much attention has focussed on reducing stillbirth close to the end of pregnancy. The relationship between gestational age and stillbirth is a ‘U’ shaped curve (Ibiebele et al., 2016). The rate rises beyond 36 weeks of pregnancy, but we often forget that it also is high prior to 24 weeks of gestation. Fetal movement monitoring will be entirely ineffective for this population of fetuses, as it presumes that achieving the birth of the baby will prevent death. This is not true in the time prior to viability.

We already have sound research evidence that the rate of deaths prior to and after birth before 24 weeks of gestation can be reduced – a 19% reduction from 32 deaths per 1000 births to 23 – which is both statistically and clinically significant. This can be achieved through midwife-led continuity of care (Sandall et al., 2016). In other words, by ensuring that each pregnant woman has her own midwife. It’s time we did something about making this the universal standard of care with the same level of enthusiasm that clinicians describe for fetal movement monitoring programs.

Dr Kirsten Small

Implementing continuity of midwifery carer – just a friendly face?

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.

Meet Associate Professor Kathleen Baird – TMCC collaborator and researcher

Kathleen Baird
Associate Professor Kathleen Baird – Board Member of Queensland Domestic Violence Implementation Council 2015-2019

“Midwives have an important role to play in addressing domestic and family violence.”

I wear a range of hats that inform my perspective on Queensland’s domestic and family violence reform program. I have been a midwife for over two decades, and most days, you will find me working as an academic in the field of midwifery at Griffith University or as the Director of Midwifery and Nursing Education, for the Women Newborn & Children’s Services at the Gold Coast University Hospital. As a member of the Council and Deputy Chair of Queensland’s Domestic and Family Violence Death Review and Advisory Board, I have been particularly interested in reforms directed at comprehensive and integrated services with a special interest in the role of midwives and the health services to identify, empower and effectively support those experiencing domestic and family violence to escape violence and safely rebuild their lives.

These reforms include the integrated service response trials in Beenleigh, Mount Isa and Cherbourg that aim to ensure the safety of victims and manage the risk posed by perpetrators through a collaborative multiagency process. Fundamentally, this approach is about breaking down the silos which have so often been identified as a barrier to protecting victims of domestic violence. But identifying those experiencing domestic and family violence is the first critical step in engaging the service responses necessary to help them to safety. As a midwife, I have long been passionate about improving the health response to domestic and family violence and advocated for routine screening by midwives. The trusting relationship women form with their midwives throughout pregnancy, labour and after her child is born makes midwives ideally placed to enquire about the nature of a woman’s relationship, her sense of safety and available support and to provide appropriate support and referrals if domestic violence is disclosed.

Hospitals are often the first point contact for those experiencing domestic and family violence and are uniquely placed to identify victims and survivors and then offer appropriate support and referrals. In October this year, I was incredibly proud that the Council had the opportunity to see firsthand the response we have developed at the Gold Coast University Hospital. We have worked hard to embed a culture that domestic and family violence is everyone’s business and all hospital staff have a role in identifying and supporting victims and perpetrators of domestic and family violence whether they are pregnant women, patients, children or fellow staff members. Gold Coast Health was the first public health service in Queensland to appoint a specialist and dedicated Domestic and Family Violence Coordinator. The Coordinator ensures that all hospital staff understand their roles, and that our frontline health workers are well trained and supported to sensitively ask the right questions to identify potential domestic and family violence victims, and then to open pathways towards assistance for them.

Experienced social workers work across the health services’ emergency and maternity departments and with the Homeless Health Outreach Team. The Emergency Department is supported by an in-house forensic unit, an active elder abuse support worker, improved platforms for information sharing and a multidisciplinary team to support patients affected by domestic and family violence. Midwives are trained to not only ask the right questions, but to look out for particular signs of domestic and family violence, and to respond and refer accordingly. A partnership with the Women’s Legal Service Queensland has made free and confidential onsite legal services available for women experiencing domestic and family violence who present to the hospital.

It took a great deal of hard work by many dedicated people, supported by strong commitment from our health service executive and managers and a broader integrated service network across the Gold Coast, to deliver a responsive, compassionate and integrated support system for patients and staff affected by domestic and family violence. The hospital continues to refine its systems and processes, but I hope that our experience will encourage and support other health services to develop integrated services that focus on the safety of those experiencing domestic and family violence.

Access the November 2019 Full Council Report here

TMCC welcomes Professor Rhona McInnes

Transforming Maternity Care Collaborative (TMCC) has welcomed Professor Rhona McInnes to its growing team of researchers.

Professor McInnes shares the team’s commitment to improving the outcomes for women and babies and brings more than 32 years of practical and research experience to her role as Professor of Maternal & Child Health and Clinical Chair at the Gold Coast University Hospital School of Nursing and Midwifery and as an important collaborator of TMCC.

With a background in infant feeding, focusing on improving breastfeeding outcomes, and with more recent experience evaluating and implementing continuity of care models in Scotland, Professor McInnes will now have the opportunity to bring both of her interests together in a mission to improve the outcomes for midwives, women, babies and their families here in Australia.

“I was really drawn to the team at TMCC for their strong sense of teamwork and their genuine determination to make a real difference in the health services and for women and babies,” Professor McInnes said.

“I am looking forward to combining my research background with clinical connections in the hospital, supporting the midwifery workforce and the broader health profession to ultimately improve care outcomes and make the system more resilient.”

TMCC is thrilled to have Rhona on-board and is looking forward to seeing the outcomes this collaboration brings.

 

Praise for midwifery-led continuity of care

Midwife Dawn Reid with mother Samantha Love and her baby boy

Gatton mother of two, Samantha Love, gave birth to her second child using the continuity of care model and had one midwife from start to finish.

“I met my midwife at 12 weeks pregnant and had her on call 24/7 until six weeks following the birth of my son,” Mrs Love said.

“During this time, I was able to get to know my midwife and she got to know me – she spent time understanding my birth intentions, anxieties and beliefs.

“When it came to labour and birth, I felt so empowered and in control and knew that my midwife was there for me and looking out for my best interests.”

Director of Lockyer Valley Midwifery, Dawn Reid, was Samantha’s midwife and said women who have been through this service will swear by it.

“Women and families who have had their children through a midwifery-led continuity of care model can’t speak more highly of it,” Mrs Reid said.

“Continuity of midwifery care is not just about managing labour and pain during birth, it’s about holistic care, covering all aspects of pregnancy, birth, antenatal and postnatal whilst supporting the entire family and extended family to make the entire experience the most beautiful, empowering and memorable of your life.”

Mrs Reid has spent the last 7 years working in a continuity of care model prior to spending the last 30 years of her career in various other models of care.

“The benefits for women, babies and midwives is undeniable and cannot be overlooked,” she said of the continuity of care model.

“As a midwife, we go into this profession because we want to support women to be empowered and we can only do this when we have the opportunity to build a relationship with women and their families.

“Knowing the woman and the family you’re supporting is also critical to ensuring the health and wellbeing of the mother and their newborns.”

Maternity continuity of care model changing lives

Our workforce studies show working in continuity of care is better for midwives and women and helps retain this very important workforce. Our collaborator and Lead Author of the study Mary Sidebotham was interviewed for this Channel 7 News story that demonstrates the benefits of a Continuity of Maternity Care model for midwives and women.

Watch the full news story here.

Transforming Maternity 2020

Transforming Midwifery Practice Through Education 2020 Conference

Join the world leaders and key influencers in midwifery education to generate and share educational approaches that transform practice, policy, and research.

Amazing keynote speakers include Professor Jean Rankin, and Marni Tuala, CATSINaM President.

Hosted by the Trans-Tasman Midwifery Education Consortium, this conference provides an opportunity to debate the critical education issues and the challenges in growing and sustaining the current and future midwifery workforce. Join us in Auckland, New Zealand on 16 & 17 April 2020. Information about the conference is available on transtasmanmidwife.org/