What if I told you that there was a new, magic intervention that was guaranteed to lower the rate of epidurals, cesarean births, instrumental deliveries, preterm births, miscarriages and even neonatal deaths? Sounds too good to be true, right? This intervention is so miraculous, though, that not only does it reduce all of those risks above, but it also increases the likelihood of having a normal, uncomplicated vaginal delivery. It even shortens the duration of labour, and women across the board not only feel more positive about their births, but also more satisfied with their care in general. Sounds incredible, right? If you were a pregnant woman, you’d definitely want to make sure that you received this intervention, right? You would be clamouring to get your hands on it!
But here’s the rub—this intervention already exists. It isn’t new—it’s been studied for decades, and all of the evidence is quite clear. It’s even something that the RCM and RCOG both agree on! The magic intervention? Relational continuity with your health care provider during your pregnancy, labour, birth and postnatal period. That’s it. Continuity of care and carer. Meaning that every time you have an antenatal appointment, it’s with the same midwife. When you go into labour, the midwife you know and trust is the one supporting you at your birth, and she continues to care for you during the first several weeks after the delivery as you weather the normal postnatal ups and down during your transformation into a mother. Continuity of care and carer. That’s all we need for better outcomes across the board. That’s the magic bullet.
And women don’t just need this, but midwives need this as well. Study after study has shown that when midwives are able to provide continuity of care to women (known as case-loading midwifery here in the UK), there is less burn-out, more job satisfaction and more autonomous practice. Continuity of care is the one magic intervention which will improve maternity services across the board, in all areas, for women AND midwives. It really is that simple.
Except that it’s not. Very few NHS trusts provide a case-loading model of care for their maternity services. In fact, unless you’ve hired an independent midwife or a private midwife through a company like Neighborhood Midwives, chances are good you won’t receive continuity of care in your NHS trust. Which means that the majority of women in the UK aren’t receiving this amazing, life-changing, magical intervention. Because of this, increased continuity of care is a priority in both Midwifery 2020 and the Better Births Initiative.
I first experienced continuity of care as a brand new midwife working in Brooklyn with some of New York City’s most vulnerable women who were attending a Medicaid-only public hospital for their care. It wasn’t complete continuity of care and carer, but it was pretty close. In the antenatal clinic, when you did an initial booking visit with a woman, she would then follow-up with you for all of her future visits (assuming she was appropriate for midwifery care; any women in need of obstetrical care were transferred to the obstetrical team). Which meant that as her pregnancy progressed, you really got to know her, even though you only had 15 minutes per visit. In many cases, towards the end of the pregnancy, when you were seeing her on a weekly basis, you knew her so well that you recognised her name on sight, and knew all of her history without needing to consult the notes. You knew her birth plans, her hopes and desires for her birth, as well as her concerns and fears. You often also knew the names of her older children that she always brought with her to the visits, and in many cases, you knew her partner too. You could greet her with a familiar smile, answer her questions, and pick up conversations that you had left off the week before. It also meant that there was time for the relationship to grow and for trust to develop between you. In some situations, this meant that as she got to know you, she would finally feel comfortable enough to confide in you about domestic violence, substance misuse or other issues going on in her pregnancy—things she hadn’t been comfortable discussing at the earlier visits, and things she probably would never have mentioned if she was seeing a different provider for each antenatal appointment.
It wasn’t a perfect system by any means—the visits were still too short, and while there was continuity in the antenatal and postnatal setting, there wasn’t continuity on labour ward, which meant that we worked shifts on labour ward and delivered whoever happened to be in labour that day, rather than being called in for our own clients when they went into labour. However, sometimes, when I was lucky, one of the women I’d cared for in the antenatal clinic would be in labour during my shift, and then I was able to provide her with complete continuity. The look of joy lighting up her face when I would first come into her room as she laboured was always priceless—and it was a look of joy that was always mirrored in my own face as well, since it was an absolute pleasure to be able to care for women that I knew well and had formed a relationship with. In fact, many of my clients would inquire about my schedule during the weeks around their due date, and in some cases would try their best with acupuncture and spicy food and lots of sex to go into labour on the same days as my shifts.
I also had an opportunity to provide complete continuity of care briefly during a 5-month stint as an independent home birth midwife in Brooklyn. I was a younger midwife joining the established practice of an older midwife who had been providing continuity of care on her own for years. Unfortunately, she and I never really gelled as a team and the partnership was very short-lived, but the experience of providing care for women that I had an opportunity to really get to know well during (luxurious!) hour-long antenatal visits at their homes was indelible. As each woman approached her due date, at each visit, there was growing anticipation leading up to the birth, and when the phone call finally came that she was in labour, my first thought was often excitement and joy for her, rather than disappointment that I would have to leave my warm bed or whatever activity I was currently doing. This made the on-call slightly easier to bear, despite the fact that it was pretty brutal (we had to take on six births a month in order to be able to cover our salaries and our indemnity insurance, which, trust me, is A LOT of work in a month). I missed Thanksgiving, Christmas and New Year’s that year, and was sometimes away from my 1 year old son for up to 30 hours at a time. It wasn’t sustainable, but the continuity did provide enough joy to almost (almost) balance it out.
I was also lucky enough to be on the receiving end of continuity of care with both of my pregnancies. With my first pregnancy in the States, I knew from the very beginning that I wanted to have a home birth, so this automatically meant that we were going to have to seek out private midwifery services, since home birth is not provided in the US through any hospital-based system. My husband and I interviewed several midwives providing private services and finally settled on a two-midwife team that lived fairly close to us, and who seemed to click with us on every level. Over the course of my pregnancy, my visits were split between the two of them, so that I had an opportunity to get to know both very well, and by the time I went into labour, I felt equally comfortable with both of them. These two midwives took turns with the call, meaning that one of them would always be available by phone at any point in my pregnancy, and while I didn’t have to avail myself of their on-call services much during the pregnancy (except for one really bad case of the flu around 20 wks), it was a tremendous comfort to know that I could speak to my midwives at any point, whenever I felt like I needed them. It was also a tremendous comfort to know that when the big day finally arrived, it would be someone who knew me and my pregnancy well who would be picking up the phone to answer that call. And thank goodness for that! My first labour was a 56 hour marathon, during which time I lost hope on several occasions. However, because I knew and trusted my midwives and had a relationship of trust and respect with them, I believed them when they told me that things WERE progressing, that everything was normal, that we didn’t have to transfer to the hospital (in my labour-haze I had determined that hospital augmentation, or possibly cesarean birth, was the only way I was going to deliver). If I hadn’t known them and trusted them as much as I did, I don’t know that their words would have carried as much weight with me at a time when I was seriously doubting my ability to give birth. And lo and behold, they were right: 56 hours later, I did indeed give birth in my living room, surrounded by this loving circle of support!
With my second pregnancy, here in the UK, I was really excited by the fact that home births were a service provided by the NHS, and something that wasn’t viewed as inherently risky or completely crazy—what a relief to be in a country that valued evidence, had a thriving midwifery presence, and a long history of midwifery care as the norm for all pregnant women! However, when I began to inquire into what the NHS home birth service looked like in my trust, I was very disappointed. Yes, the NHS would absolutely support my desire to have a home birth, but the majority of my care would be provided at the antenatal clinic at the hospital, following the usual schedule (and since I was a multip, this meant fewer visits with midwives than I would have been having as a primip). I would meet the community midwifery team for the first time at 28 weeks for one visit, and then again at 36 weeks, but this meant that I wouldn’t have much of a chance to get to know them at all, or even meet everyone on the team. Since there were 6-8 midwives on the team, chances were good that when I did go into labour, a complete stranger would be answering the call and coming to our house. I also learned that sometimes if the ward was very busy, the on-call community midwives were asked to come help out on the ward, and that when I went into labour, if the community midwife was on the ward at that moment, she would ask me to come to the ward for my birth. Not ideal! Even though it was absolutely within my right to put my foot down and insist that the midwife come attend me at home instead, the thought of having to make a decision like that while in labour (and to selfishly pull a midwife away from a busy ward where she was caring for other women) filled me with dread. Having had a taste of true continuity of care, it’s hard to settle for anything less than that the second time around. So in the end, we decided to hire an independent midwifery team for our second birth as well, and he was born in our downstairs loo into the loving hands of our midwives, whom we had gotten to know and adore through 9 months of unhurried antenatal visits in our home. It was expensive, but we were lucky enough to be able to afford it, and to my way of thinking, it was worth more than every pence we paid for it, especially when my son became very sick with a bout of viral meningitis on Day 5 and we ended up in the hospital with him—being visited daily by our independent midwives, whose familiar faces and support made such a difference to us during such a stressful time in our lives!
Giving birth with someone you know and trust is transformative, and it makes perfect sense: labour strips you down to an incredibly vulnerable place, by necessity, and it’s much easier to remove your armour and surrender to that vulnerability when you’re surrounded by people you trust. Additionally, labour is hormone mediated, which means that the more relaxed a woman is, the more easily the hormones of labour can unfold, without cortisol (a stress hormone) blocking the effects of the love hormone oxytocin (which is responsible for uterine contractions, among many other things). Women are incredibly sensitive and perceptive when they’re in labour; even small levels of anxiety are sometimes enough to disrupt contractions. Many women experience this when they first transfer to the hospital, discovering that their labour, which was booming along in the comfort and safety of their home, suddenly stalls over the journey and admission to the hospital. Continuity of care can help buffer these effects, though. When a woman is with a team that she knows and trusts, the message her labour brain receives is one of safety and security, rather than stress and anxiety, and this encourages the labour to progress without intervention (and is probably one of the reasons that continuity models have higher numbers of spontaneous vaginal deliveries, and lower numbers of augmentation, instrumental deliveries and cesarean births).
Therefore, with all of this in mind, I was really excited to learn that continuity of care would be part of our learning experience as a student midwife, and I envisioned myself giving care to women as part of the community midwifery team and getting to know them over the months of their pregnancy. However, I quickly learned that in the trust that I’m working at, continuity of care is the exception and not the rule. While a new case-loading model for high-risk women is going to be trialled at our trust over the next year, at the moment, the hospital-based antenatal care is often done by a different midwife at each visit—often midwives who are part of the same community midwifery “team”, but still different midwives. In some situations, there is antenatal continuity, especially in smaller satellite clinics which are run by the same midwife every week, but at the main hospital this is not often the case. And unfortunately, there is no continuity between the antenatal team and the labour ward team. When a woman finally goes into labour and comes to Labour Ward, she is greeted by brand new midwives she’s never met before, who are then tasked with the difficult job of building rapport and learning about the woman’s history and birth plans on the spot, while she’s in labour, which isn’t exactly the ideal time to be doing this crucial relationship-building. (For the record, though, the labour ward midwives work exceptionally hard at immediately building trust and rapport with the women when they come in, and are often able to provide exemplary care in spite of this significant hurdle—kudos to them! It’s not an easy task at all!). Additionally, the home birth on-call schedule is shared between the entire community midwifery department, which again means that when a woman calls to say she’s in labour, the community midwife who attends her birth will most likely be someone she’s never met before. If the woman is lucky, she might be cared for in the community by the same midwife for each of her postnatal visits, but again it’s common for different members of the same community team to visit her on different days, depending on which days they’re working.
As a student, we’re required to case-load at least one woman every year of our education, but our programme defines case-loading pretty loosely: one antenatal visit, caring for the woman in labour, and then one postnatal visit is all that’s required, although we’re certainly welcome to see the woman/ family more often than that if we can manage it (and if our schedule allows!). Even this minimal requirement is difficult to achieve, though, because we’re not allowed to give the women we’re case-loading our mobile number due to privacy/ confidentiality/ legal issues. Which means that it’s really hard to know exactly when she goes into labour! There are brightly coloured stickers which we put on the outside of the woman’s chart which have our contact details on them, in the hope that the midwives will call us when she arrives in labour at the hospital, but this doesn’t always happen. In fact, I case-loaded four women antenatally, each of whom I was lucky enough to attend two antenatal visits with, but I was never called by Labour Ward when they arrived in labour (despite the stickers on the front of their charts with my name and mobile number on them)— so I missed their births. In the end, to fulfill the requirement for case-loading in my programme, I “case-loaded” a woman who I saw once in triage in early labour, who was then sent home (this counted as my antenatal visit), who then returned to the hospital later that day and was admitted in labour. I attended her birth and helped catch her baby, and then saw her the following day on the postnatal ward (which counted as my postnatal visit). This isn’t exactly true case-loading or continuity of care, by a long shot! But if you’re a student in a trust where true case-loading doesn’t exist, this might be the best you can do in a less-than-ideal situation. If I hadn’t already experienced case-loading in a professional capacity as a midwife in the States, or as a pregnant woman receiving it, I’m not sure I would understand that continuity of care looks a lot different to what is being offered in my trust. Which is by no means suggesting that the care women are receiving in this trust is bad care–on the contrary, I think it’s very GOOD care, all things considered–but it’s not true continuity of care, and there’s plenty of room for improvement in that regard.
Continuity of care is meant to be an integral part of the student experience, but unfortunately it’s nearly impossible to ensure that students are exposed to this model of care. I’ve spoken to many students who have had the blessing of experiencing true continuity of care—Michelle Marling, the author of the Continuity Matters campaign, was lucky enough to discover this early in her student experience, which she has written about before. Once you’ve had a taste of the joys of continuity of care, it’s a lot harder to settle for anything less! But if you’re never exposed to true continuity of care as a student, you never learn that there is another model of care out there. You never learn to treasure it, to seek it out, to make it happen, to fight for it if necessary. You grow up in the system as it stands, learning how it works, growing confident in your skills and competence within that system, and all the while never know that other options exist. And it all boils down to a chicken-and-egg sort of question. If student midwives aren’t exposed to continuity, they won’t want to provide that type of care. They won’t clamour for creating continuity models in their trust, they won’t be keen to sign up for case loading teams, they won’t want to provide that type of care—and then, less of that care will exist, and even fewer students will be exposed to it. And around and around it will go. This is how systems are perpetuated, and why creating systemic change is always so challenging.
Thankfully it does seem like the message of continuity is starting to seep into the system, with the RCM, RCOG, Better Births and Midwifery 2020 all promoting it (and even the World Health Organization recommending it in their most recent intrapartum guidelines). My fingers are crossed that the high-risk case-loading trial at our hospital will be a rousing success, and we can start to roll this type of care out for low-risk women as well. The evidence speaks for itself. What’s more difficult to combat is the perception that case-loading is too difficult, that case-loading midwives never have down-time or chance to see their families, and that case-loading leads to burn-out. In part, I think burn-out occurs because not enough midwives want to case-load (in part because they weren’t exposed to it), which means that too much pressure is put on the few midwives who do. If the work of case-loading is spread out over many midwives, in small teams or in buddy systems, the work is much more manageable (but again, this is easier said than done in a system that’s already 5,000 midwives short). (Better births tries to help prevent this by suggesting caps for case-loading teams, putting a ring-fence around their work so that they can’t be pulled to different units, and allowing the midwives to manage their own schedule and diary.) Nevertheless, despite these challenges, this is the future I long for: a world where all women can receive true continuity of care and the many benefits associated with it, and all case-loading teams are staffed robustly enough to allow each midwife the important down-time and off-duty she needs to recharge her batteries and return to work refreshed and ready to give her all again. This is the case-loading dream! But if students aren’t exposed to this type of care, how will we know to shoot for it?