Our Updates

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/