The contribution of continuity of midwifery care to high quality maternity care

A report byProfessor Jane Sandall

for theRoyal College of Midwives

2

3The contribution of continuity of midwifery care to high quality maternity care

The contribution of continuity of midwifery care to high quality maternity careProfessor Jane Sandall

Womens access to quality midwifery services has become a part of the global effort in achieving

the right of every woman to the best possible health care during pregnancy and childbirth.

1.0 What does high quality maternity care look like?

National policies addressing maternity services have often ignored the centrality of the midwifery

workforce and how it contributes to high quality and safe care. The dimensions of care quality

often used in UK country policies draw upon a definition in Crossing the Quality Chasm as safe,

effective, patient-centred, timely, efficient, and equitable care 1. Thus high quality maternity

care should: do no harm to people who use the service or those that provide it; is responsive and

creates no delay when complications occur; is organised to maximise efficient use of resources

including the maternity care workforce; provides evidence based care; is women and family

centred which involves facilitating informed decision making, women and families feeling safe,

respected, treated with dignity and having their voices listened and responded to; is organised

so that services that some women find hard to reach are accessible and equitable. In addition,

a high quality maternity care system should provide optimal maternity care that follows the

principle of effective care with least harm and supports the beneficial practices that support

womens own innate capacities or the physiologic process of childbirth.

2.0 Current Policy in the United Kingdom

Continuity of care has been at the heart of maternity policy in England since 1993 with the

publication of Changing Childbirth 2 and an emphasis on Choice, Continuity and Control, in the

NSF Maternity Standard 3 and Maternity Matters 4. Ambitions regarding continuity of midwife

care are also expressed in Scottish 5, Welsh 6 and Northern Irish Policy 7.

The current English Government has stated its commitment to choice in maternity services 8.

One of the ambitions of the current NHS Mandate is to help give children the best start in

4life, and promote their health and resilience as they grow up. A long-standing problem with

maternity services has been concerns about coercive and disrespectful behaviour experienced by

women and families, in particular by ethnic minorities 9. Thus the NHS Mandate aims to improve

inequalities faced during pregnancy and maternity, and to improve the experience of women

and families during pregnancy and in early years.

Through giving women the greatest possible choice of providers, building better relationships between women and midwives by personalising their care and reducing

postnatal depression through earlier diagnosis as well as better support.

Specifically stating that every woman has a named midwife who is responsible for ensuring she has personalised, one-to-one care throughout pregnancy, childbirth

and during the postnatal period, including additional support for those who have a

maternal health concern (p17) 10.

Current National Institute for Health and Clinical Excellence (NICE) antenatal and postnatal

quality care standards both state women should have a named midwife 11. In the postnatal period

this person is referred to as a named healthcare professional 12. NICE intrapartum care guidelines

incorporate the importance of 1 to 1 care in labour and birth in their recommendations for

support in labour 13.

However, the level of implementation of continuity of care models and how many women have a

named midwife who cares for them throughout their pregnancy and birth is unknown. In the last

national survey of 25,488 womens experiences of maternity care in England in 2010, 43 per cent

of women did not see the same midwife every time or almost every time during pregnancy, 8 per

cent did not have the name and phone number of their midwife, 23 per cent reported that when

they contacted their midwife they were not given the help they needed, 75 per cent of women

had not met any of the staff who cared for them during their labour and birth before, 27 per

cent reported they did not have definite confidence and trust in staff caring for them in labour.

Continuous support in labour from a person other than the womans partner or family member

has been shown to be effective 14.

In busy maternity units, it is often difficult for midwives to give such one-to-one support and 22

per cent of women reported being left alone in labour and shortly after the birth and unhappy

about it 15.

5The contribution of continuity of midwifery care to high quality maternity care

3.0 What is the difference between midwife-led continuity models of care and care in midwife-led settings?

Midwife-led continuity of care can be provided through continuity models of care which provide

a named midwife who follows women throughout pregnancy, birth and the postnatal period to

all women, both low and high risk and in all settings including obstetric units.

Midwife-led care can also be provided in midwife-led settings such as home, freestanding and

alongside hospital birth centres for women for women defined as having a low clinical risk.

3.1 How does it differ to standard care?

The philosophy behind midwife-led continuity models includes: an emphasis on the natural

ability of women to experience birth with minimum intervention and monitoring the physical,

psychological, spiritual and social wellbeing of the woman and family throughout the

childbearing cycle. A package of care includes: continuity of care throughout pregnancy, birth

and the postnatal period; providing the woman with individualised education and counselling;

being cared for by a known and trusted midwife during labour; and the immediate postpartum

period; and identifying and referring women who require obstetric or other specialist attention.

Midwife-led continuity of care is provided in a multi-disciplinary network of consultation and

referral with other care providers. Midwife-led continuity of care can be provided through

a team of midwives who share the caseload, often called team midwifery. Another model

is caseload midwifery, which aims to ensure that the woman receives all her care from one

midwife or practice partner. Midwives follow women across the care pathway and provide

antenatal care in community and hospital settings, intrapartum care in the home, midwife-led

units and obstetric units and postnatal care in hospital and at home to women who are both low

and high risk. This contrasts with shared-care models, where responsibility is shared between

different healthcare professionals and women may not know their care providers or have met

who is caring for them in labour previously 16.

There is some evidence around what factors are important for midwife-led models of care to

be sustainable and avoid burnout. Low job control and long working hours are associated with

higher levels of burnout in midwives 17. Ways of working that engender greater job control,

6meaningful relationships with women 18 and collegial support help midwives maintain work/life

balance 19 20. Although there is greater agency for midwives in midwife-led models and settings,

there can be a problematic interface with host units, and a clash of models and culture 21. Key

areas affecting midwifery morale identified, in particular have been staffing levels, working

relationships and organisational issues 22 23.

3.2 Why is continuity important to providers and users of health services?

Midwife-led continuity models of care have generally aimed to improve continuity of care over

a period of time. Continuity has been defined by 24 as having three major types - management,

informational and relationship. Management continuity involves the communication of both

facts and judgements across team, institutional and professional boundaries, and between

professionals and patients. Informational continuity concerns the timely availability of relevant

information. Both are important to managers and health care users 25.

Relationship continuity means a therapeutic relationship of the service user with one or more

health professionals over time. Relationship/personal continuity over time has been found to

have a greater effect on user experience and outcome 26 27. Thus the models of care that are the

foci of this briefing are those that offer relational continuity across the maternity episode of care.

3.3 What is the effect?

3.3.1 Clinical outcomes

A substantial body of evidence now exists showing that care provided by midwives in continuity-

of-care models (defined as care where the midwife is the lead professional in the planning,

organization, and delivery of care throughout pregnancy, birth, and the postpartum period)

contributes to high-quality and safe care in high-income countries. A Cochrane review of 13 trials

involving 16,242 women that compared women who received midwife-led continuity of care

with shared or medically led care found midwife-led care was associated with significant benefits

for mothers and babies, and had no identified adverse effects 16.

Women who had midwife-led continuity models of care were less likely to experience

regional analgesia (average risk ratio (RR) 0.83, 95 per cent confidence interval (CI) 0.76 to

0.90), episiotomy (average RR 0.84, 95 per cent CI 0.76 to 0.92), and instrumental birth (average

7The contribution of continuity of midwifery care to high quality maternity care

RR 0.88, 95 per cent CI 0.81 to 0.96). Women were more likely to experience no intrapartum

analgesia/anaesthesia (average RR 1.16, 95 per cent CI 1.04 to 1.31), spontaneous vaginal birth

(average RR 1.05, 95 per cent CI 1.03 to 1.08), attendance at birth by a known midwife (average

RR 7.83, 95 per cent CI 4.15 to 14.80), and a longer mean length of labour (hours) (mean

difference (hours) 0.50, 95 per cent CI 0.27 to 0.74). There were no differences between groups

for caesarean births (average RR 0.93, 95 per cent CI 0.84 to 1.02).

Women who were randomised to receive midwife-led continuity models of care were less likely

to experience preterm birth (average RR 0.77, 95 per cent CI 0.62 to 0.94) and fetal loss before

24 weeks gestation (average RR 0.81, 95 per cent CI 0.66 to 0.99), although there were no

differences in fetal loss/neonatal death after 24 weeks gestation (average RR 1.00, 95 per cent CI

0.67 to 1.51) or in overall fetal/neonatal death (average RR 0.84, 95 per cent CI 0.71 to 1.00).

No trial included models of care that offered out of hospital birth at home or in a free-standing

unit. All intrapartum care was provided either in an obstetric unit or a alongside midwife unit.

The review includes trials that included women classified as low risk and trials that included

women who were classified as both high and low risk. It also includes models of team and

caseload midwifery. The effects were the same across team and caseload midwifery models and

whether caseloads were low or mixed risk.

3.3.2 Womens experience

Women receiving midwife-led continuity of care models were almost eight times more likely to

be attended in labour by a known midwife. Women in the midwifery-led continuity care models

reported higher ratings of maternal satisfaction with information, advice, explanation, venue of

delivery, preparation for labour and birth, choice for pain relief and behaviour of the carer and

control. Other studies have found that women who carry social complexity and find services hard

to access, particularly value midwifery continuity models of care 28 29. Women also experienced

increased agency and control, and more empathic care 21.

3.3.3 Efficiency

Based on scant existing evidence, there appears to be a trend towards a cost-saving effect for

midwife-led continuity care compared to other care models 21. The estimated mean cost saving

for each eligible maternity episode is UK12.38. This translates to an aggregate saving of 1.16

8million per year, if half of all eligible women avail of midwife-led care. This equates to an

aggregate gain of 37.5 quality adjusted life years (QALYs) when expressed in terms of health

gain using a NICE cost-effectiveness threshold of 30,000 per QALY. The uptake of midwife-

led maternity services affects results on two levels, first by its role in determining caseload per

midwife and thus mean cost per maternity episode, second at the aggregate level by determining

the total number of women who switch to maternity-led services nationally 30.

9The contribution of continuity of midwifery care to high quality maternity care

4.0 Midwife led birth settings

Evidence with respect to birth settings is also increasing, where women are normally classified as

low risk. A Cochrane review of midwife units located alongside an obstetric unit compared with

conventional hospital labour wards found increased likelihood of spontaneous vaginal birth,

labour and birth without analgesia or anaesthesia, breastfeeding at 6 to 8 weeks postpartum,

satisfaction with care, and decreased likelihood of oxytocin augmentation, assisted vaginal birth,

caesarean birth, and episiotomy. Although no difference occurred in infant outcomes, substantial

numbers of women were transferred to standard care either before or during labour, because

they no longer met eligibility criteria for the alternative setting 31.

Less evidence is available about freestanding midwife units and birth centres, but what does

exist results in similar findings 32. A recent prospective study in Denmark which has a similar

public maternal health system to the UK found important benefits, such as improved experience,

reduced maternal morbidity, reduced use of birth interventions including caesarean sections,

and increased likelihood of spontaneous vaginal birth compared with women who planned

to give birth in an obstetric unit. No differences were observed in perinatal morbidity among

infants of low-risk women who intended to give birth in the freestanding midwife unit or birth

centre compared with infants of low-risk women who intended to give birth in the obstetric unit.

However, 37 percent of primiparas and 7 percent of multiparas were transferred during or less

than 2 hours after birth 33.

Birth experience and satisfaction with care were rated significantly more positively by FMU than

by OU women. Significantly better results for FMU care were also found for specific patient-

centred care elements (support, participation in decision-making, attentiveness to psychological

needs and to wishes for birth, information, and for womens feeling of being listened to).

Adjustment for medical birth factors slightly increased the positive effect of FMU care for high

risk women 34. Furthermore, women without post-secondary education intending to give birth in

an FMU had comparable and, in some respects, more favourable outcomes when compared to

women with the same level of education intending to give birth in an OU. In this sample of low-

risk women, the effect of intended place on birth outcomes did not differ with womens level

of education 35.

10

A similar pattern has been found with planned out of obstetric unit birth for low-risk women.

A recent observational study in England assessed outcomes by intended place of birth for women

at low risk in midwife units and birth centres located alongside an obstetric unit, a freestanding

or stand-alone midwife unit and birth centre, home, and obstetric units 36. For low-risk women,

the overall incidence of adverse perinatal outcomes was low in all birth settings. For low-risk

multiparas, no differences were reported in adverse perinatal outcomes between settings.

However, the risk of an adverse perinatal outcome appeared to be significantly higher for

nulliparas who planned to give birth at home compared with those who planned to give birth

in an obstetric unit. For all women, the incidence of major interventions was significantly lower,

including intrapartum caesarean section, and normal birth increased in all settings outside the

obstetric unit. The overall intrapartum transfer rate ranged from 21 to 26 percent for all women,

but was higher for nulliparas (3645 per cent). The study also found that the cost to the National

Health Service of intrapartum and related postnatal care, including costs associated with clinical

complications, was lower for birth planned at home, in a freestanding midwife unit and birth

centre and in an alongside midwife unit compared with planned birth in an obstetric unit 37.

11

The contribution of continuity of midwifery care to high quality maternity care

5.0 Summary

Thus, overall, both the model of care and the place of birth are important influences on a range

of health and clinical outcomes for mothers and babies, and have economic implications for the

health system. It is also clear that the possibility always exists that women will need to transfer

into an obstetric unit from an out-of-hospital setting, and that systems need to be in place to

allow safe and timely transfer to obstetric care and expertise without financial, professional, and

organisational barriers.

Midwife led continuity models of care contribute to improving quality and safety of maternity

care at no additional cost. Women who receive care in these models are more likely to have

effective care, a better experience, improved clinical outcomes, and with some evidence of

improved access to care by women who find services hard to reach and better co-ordination of

care with specialist and obstetric services. Midwife-led continuity models provide services for all

women across all settings, whether women are classified as high or low risk and current evidence

shows improved outcomes with no adverse effects in populations of mixed risk. In addition

improved birth outcomes result where care is provided in obstetric units, although it is clear that

women planning to give birth in midwife led birth settings have fewer intrapartum interventions

including caesarean section.

Approximately 45 per cent of women are classified as low risk at the end of pregnancy and

the challenge is to provide a choice of midwife led settings for this group of women, whilst

improving quality of care for women are higher risk or with social complexity. It is with this

group of women that midwife-led models of continuity of care have the potential to improve

quality and safety of care , several models already exist such as caseloading for women classified

as vulnerable, or midwife caseloading as part of a multi-disciplinary hospital based team for

women with serious medical and obstetric complications and further research is needed on the

potential for midwifery continuity models to improve quality of care for this group of women

who arguably need intensive midwifery support and care.

12

1. Institute of Medicine. Crossing the Quality Chasm. Washington: National Academy

Press, 2001.

2. Department of Health. Changing childbirth. Report of the Expert Committee on

Maternity Care. London: HMSO, 1993.

3. Department of Health. National Service Framework for Children, Young People and

Maternity Services: Maternity Standard 11. London, 2004.

4. Department of Health Partnerships for Children Families and Maternity. Maternity

Matters: Choice, access and continuity of care in a safe service: Department of Health,

Partnerships for Children, Families and Maternity, 2007.

5. Scottish Government. A Refreshed Framework for Maternity Care in Scotland. In: Group

TMSA, editor. Edinburgh, 2011.

6. Welsh Government. A Strategic Vision for Maternity Services in Wales, 2011.

7. Department of Health SSaPS, . A Strategy for Maternity Care in Northern Ireland 2012-

18. Belfast, 2012.

8. Department of Health. White Paper, Equity and Excellence: Liberating the NHS, .

London, 2010.

9. Centre for Health & Social Care Research. Life and Health: An evidence review and

synthesis for the EHRCs triennial review 2010: Sheffield Hallam University, 2010.

10. Department of Health. The Mandate: A mandate from the Government to the NHS

Commissioning Board: April 2013 to March 2015. In: Department of Health, editor:

Crown Copyright, 2012.

11. National Institute for Health and Care Excellence. Quality standard for antenatal care,

QS22. London, 2012.

12. The National Collaborating Centre for Primary Care. Postnatal care: Routine postnatal

care of women and their babies. London, 2006.

13

The contribution of continuity of midwifery care to high quality maternity care

13. National Institute for Health and Care Excellence. Intrapartum care: Care of healthy

women and their babies during childbirth, CG55. London, 2007.

14. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C, Weston J. Continuous support for women

during childbirth. Cochrane Database Syst Rev 2011(2):CD003766.

15. Care Quality Commission. Womens experiences of maternity care in England; Key

findings from the 2010 NHS trust survey. London: Care Quality Commission, 2010.

16. Sandall J SH, . Gates S,. Shennan A,. Devane D.,. Midwife-led continuity models versus

other models of care for childbearing women. Cochrane Database of Systematic Reviews

2013(8):CD004667.

17. Sandall J. Occupational burnout in midwives: new ways of working and the relationship

between organisational factors and psychological health and well being. Risk, Decision

and Policy 1998;3(3):213-32.

18. Hunter B. The importance of reciprocity in relationships between community-based

midwives and mothers. Midwifery 2006;22(4):308-22.

19. Sandall J. Midwives burnout and continuity of care. British Journal of Midwifery

1997;5:106-11.

20. Jordan K, Fenwick J, Slavin V, Sidebotham M, Gamble J. Level of burnout in a small

population of Australian midwives. Women Birth 2013;26(2):125-32.

21. Devane D BM, Begley C, Clarke M, Walsh D, Sandall J, Ryan P, Revill P, Normand C.

Socio-economic value of the midwife: A systematic review, meta-analysis, meta-synthesis

and economic analysis of midwife-led models of care. London: Royal College of

Midwives, 2010.

22. Hughes D, Deery R, Lovatt A. A critical ethnographic approach to facilitating cultural

shift in midwifery. Midwifery 2002;18(1):43-52.

23. Kirkham M. Retention and return in the NHS in England. RCM Midwives 2007;10(5):

224-6.

14

24. Freeman G, Woloshynowych,M., Baker,R., Boulton,M., Guthrie,B.,, Car J, Haggerty,J.,

Tarrant,C. Continuity of care: what have we learned since 2000 and what are policy

imperatives now?: National Co-ordinating Centre for NHS Service Delivery and

Organisation R & D (NCCSDO), 2007.

25. Guthrie B SJ, Freeman GK, Haggerty J. Why clinicians and managers should care about

continuity: Continuity matters to patients and requires clinician and managerial

commitment to bridge discontinuities. BMJ 2007:337:a867.

26. Saultz JW, Albedaiwi W. Interpersonal continuity of care and patient satisfaction: a

critical review. Annals of family medicine 2004;2(5):445.

27. Saultz JW, Lochner J. Interpersonal continuity of care and care outcomes: a critical

review. Annals of family medicine 2005;3(2):159.

28. McCourt C, Pearce, A. Does continuity of carer matter to women from minority ethnic

groups? Midwifery 2000;16:145-54.

29. Finlay S, Sandall J. Someones rooting for you: continuity, advocacy and street-level

bureaucracy in UK maternal healthcare. Soc Sci Med 2009;69(8):1228-35.

30. Ryan P, Revill,P., Devane,D,. Normand,C.,. An assessment of the cost-effectiveness of

midwife-led care in the United Kingdom. Midwifery 2013;29(4):368-76.

31. Hodnett ED, Downe S, Walsh D, Weston J. Alternative versus conventional institutional

settings for birth. Cochrane Database Syst Rev 2010(9):CD000012.

32. Walsh D, Downe SM. Outcomes of free-standing, midwife-led birth centers: a structured

review. Birth 2004;31(3):222-9.

33. Overgaard C, Mller AM, Fenger-Grn M, Knudsen LB, Sandall J. Freestanding midwifery

unit versus obstetric unit: a matched cohort study of outcomes in low-risk women. BMJ

Open 2011;1(2).

34. Overgaard C, Fenger-Grn M, Sandall J. The impact of birthplace on womens birth

experiences and perceptions of care. Social Science & Medicine 2012.

15

The contribution of continuity of midwifery care to high quality maternity care

35. Overgaard C, Fenger-Grn M, Sandall J. Freestanding midwifery units versus obstetric

units: does the effect of place of birth differ with level of social disadvantage? BMC

Public Health 2012;12:478.

36. Brocklehurst P, Hardy P, Hollowell J, Linsell L, Macfarlane A, McCourt C, et al. Perinatal

and maternal outcomes by planned place of birth for healthy women with low risk

pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011;

343(d7400):1-13.

37. Schroeder E, Petrou S, Patel N, Hollowell J, Puddicombe D, Redshaw M, et al.

Cost effectiveness of alternative planned places of birth in woman at low risk of

complications: evidence from the Birthplace in England national prospective cohort

study. BMJ 2012; 344:e2292.

www.rcm.org.uk